Postlaparotomy pain management: Comparison of patient-controlled analgesia pump alone, with subcutaneous bupivacaine infusion, or with injection of liposomal bupivacaine suspension
DOI:
https://doi.org/10.5055/jom.2019.0498Keywords:
laparotomy, pain, patient-controlled analgesia, liposomal bupivacaine, opioidsAbstract
Objective: Efforts to achieve balance between effective pain management and opioid-related adverse events (ORAEs) have led to multimodal analgesia regimens. This study compared opioids delivered via patient-controlled analgesia (PCA) plus liposomal bupivacaine, a long-acting local anesthetic with potential to be an effective component of such regimens, to opioids delivered through PCA alone or PCA plus subcutaneous bupivacaine infusion (ONQ), following laparotomy.
Design: Prospective, randomized controlled trial.
Setting: Single, tertiary-care institution.
Patients: One hundred patients undergoing nonemergent laparotomy.
Interventions: Patients were randomly assigned to one of three study treatments: PCA only (PCAO), PCA with ONQ, or PCA with injectable liposomal bupivacaine suspension (EXP).
Main Outcome Measures: Cumulative opioid use, daily mean patient-reported pain scores, and ORAEs through 72 hours postoperatively.
Results: On average, the EXP (n = 31) group exhibited less than 50 percent of the total opioid consumption of the PCAO (n = 36) group, and less than 60 percent of that for the ONQ (n = 33) group. Postoperative days 1 and 3 pain scores were significantly lower for the EXP group as compared to the ONQ and PCAO groups (p ≤ 0.005). Fewer patients in the EXP group (19.4 percent) experienced ORAEs compared to the PCAO (41.1 percent) and ONQ (45.5 percent) groups (p = 0.002).
Conclusions: Laparotomy patients treated with liposomal bupivacaine as part of a multimodal regimen consumed less opioids, had lower pain scores, and had fewer ORAEs. The role of liposomal bupivacaine in the postoperative care of laparotomy patients merits further study.
References
Abdallah FW, Laffey JG, Halpern SH, et al.: Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: A meta-analysis. Br J Anaesth. 2013; 111: 721-735.
Mrunalini P, Raju NV, Nath VN, et al.: Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies. Anesth Essays Res. 2014; 8: 377-382.
Zengin SU, Saracoglu A, Eti Z, et al.: The effects of preoperative oral pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement in patients undergoing laparatomy. Pain Res Manag. 2015; 20: 179-182.
Chou R, Gordon DB, deLeon-Casasola OA, et al.: Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17(2): 131-157.
Cusack SL, Minkowitz HS, Kuss M, et al.: A randomized, multicenter, pilot study comparing the efficacy and safety of a bupivacaine-collagen implant (XaraColl®) with the ON-Q PainBuster® Post-op Pain Relief System following open gynecological surgery. J Pain Res. 2012; 5: 453-461.
Cohen SM, Vogel JD, Marcet JE, et al.: Liposome bupivacaine for improvement in economic outcomes and opioid burden in GI surgery: IMPROVE Study pooled analysis. J Pain Res. 2014; 7: 359-366.
Oderda GM, Evans RS, Lloyd J, et al.: Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage. 2003; 25: 276-283.
Oderda GM, Said Q, Evans RS, et al.: Opioid-related adverse drug events in surgical hospitalizations: Impact on costs and length of stay. Ann Pharmacother. 2007; 41: 400-406.
Wheeler M, Oderda GM, Ashburn MA, et al.: Adverse events associated with postoperative opioid analgesia: A systematic review. J Pain. 2002; 3: 159-180.
American Society of Anesthesiologists (ASA) Task Force on Acute Pain Management: Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012; 116: 248-273.
Bergese SD, Onel E, Morren M, et al.: Bupivacaine extended-release liposome injection exhibits a favorable cardiac safety profile. Reg Anesth Pain Med. 2012; 37: 145-151.
Bergese SD, Ramamoorthy S, Patou G, et al.: Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for postsurgical analgesia. J Pain Res. 2012; 5: 107-116.
Cohen SM: Extended pain relief trial utilizing infiltration of Exparel®, a long-acting multivesicular liposome formulation of bupivacaine: A Phase IV health economic trial in adult patients undergoing open colectomy. J Pain Res. 2012; 5: 567-572.
Dasta J, Ramamoorthy S, Patou G, et al.: Bupivacaine liposome injectable suspension compared with bupivacaine HCl for the reduction of opioid burden in the postsurgical setting. Curr Med Res Opin. 2012; 28: 1609-1615.
Davidson EM, Barenholz Y, Cohen R, et al.: High-dose bupivacaine remotely loaded into multivesicular liposomes demonstrates slow drug release without systemic toxic plasma concentrations after subcutaneous administration in humans. Anesth Analg. 2010; 110: 1018-1023.
Golf M, Daniels SE, Onel E: A phase 3, randomized, placebo-controlled trial of DepoFoam® bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Adv Ther. 2011; 28(9): 776-788.
Haas E, Onel E, Miller H, et al.: A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation. Am Surg. 2012; 78: 574-581.
Kerr DR, Kohan L: Local infiltration analgesia: A technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients. Acta Orthop. 2008; 79: 174-183.
Marcet JE, Nfonsam VN, Larach S: An extended paIn relief trial utilizing the infiltration of a long-acting Multivesicular liposome foRmulation Of bupiVacaine, EXPAREL (IMPROVE): A Phase IV health economic trial in adult patients undergoing ileostomy reversal. J Pain Res. 2013; 6: 549-555.
Vogel JD: Liposome bupivacaine (EXPAREL®) for extended pain relief in patients undergoing ileostomy reversal at a single institution with a fast-track discharge protocol: An IMPROVE Phase IV health economics trial. J Pain Res. 2013; 6: 605-610.
Kalogera E, Bakkum-Gamez JN, Weaver AL, et al.: Abdominal incision injection of liposomal bupivacaine and opiod use after laparotomy for gynecologic malignancies. Obstet Gynecol. 2016; 128(5): 1009-1017.
Cepeda MS, Africano JM, Polo R, et al.: What decline in pain intensity is meaningful to patients with acute pain? Pain. 2003; 105: 151-157.
Olsen MF, Bjerre E, Hansen MD, et al.: Pain relief that matters to patients: Systematic review of empirical studies assessing the minimum clinically important difference in acute pain. BMC Med. 2017; 15: 35.
Cusack SL, Jaros M, Kuss M, et al.: Clinical evaluation of XaraColl®, a bupivacaine-collagen implant, for postoperative analgesia in two multicenter, randomized, double-blind, placebo-controlled pilot studies. J Pain Res. 2012; 5: 217-225.
Alimian M, Pournajafian A, Kholdebarin A, et al.: Analgesic effects of paracetamol and morphine after elective laparotomy surgeries. Anesth Pain Med. 2014; 4: e12912.
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