Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair

Comparison of Different Surgical Procedures with Local Infiltration Analgesia in Day Surgery

Purpose of this study was assessing of local infiltration analgesia (LIA) with levobupivacaine on the trend of acute postoperative pain and outcome in individuals who underwent rhinoplasty procedure and abdominoplasty performed in general anaesthesia. The research was conducted on 60 patients, of which 30 patients underwent rhinoplasty procedure and the other 30 patients underwent abdominoplasty procedure in general anaesthesia with LIA in “Bagatin” Polyclinic in the time period between 01.01.2014. and 01.01.2017. Postoperative analgesics doses on the same day of surgery were noted in 85% of participants who underwent an abdominoplasty procedure and in 45% of participants underwent rhinoplasty procedure. Patients who underwent abdominoplasty were discharged from the facility within 48 hours, while all patients who underwent rhinoplasty procedure were discharged on the same day of the surgery. During the first postoperative day patients who underwent a rhinoplasty procedure did not require analgesics, while only 3% of patients who underwent an abdominal liposuction procedure required an additional dose of analgesics. The research results had shown, when LIA was performed, the manifestation of acute postoperative pain and vomiting did not lead to prolonged stay in day surgery.

Effectiveness of continuous wound infusion of local anesthetics after abdominal surgeries

BACKGROUND

To assess the effectiveness of continuous preperitoneal wound infusion of local anesthetic drug bupivacaine in providing pain relief, reducing opioid consumption, and enhancing postoperative recovery.

METHODS

Eligible patients were randomly allocated to two groups (study group: bupivacaine and control group: normal saline). There were 47 patients in each group. The patients received continuous infusion of either 0.25% bupivacaine or 0.9% normal saline at 6 mL/h, for 48 h, based on their group allocation, through a multiholed wound infiltration catheter placed preperitoneally. All patients also received intravenous morphine through patient-controlled analgesia pump. Pain scores at rest and on cough, morphine consumption, and peak expiratory flow rate were assessed at 12, 24, and 48 h postoperatively. The time to first perception of bowel sounds and first passage of flatus was noted. All patients were assessed for postoperative nausea and vomiting and any local or systemic complications. Chi-square test was used to compare categorical variables. The morphine consumption was compared using Student t-test, the visual analogue scale (VAS) scores were compared using repeated-measures analysis of variance.

RESULTS

The mean total morphine consumption in the study group was significantly lower than the control group (18.8 ± 2.21 versus 30.8 ± 2.58 mg, P = 0.001). The median VAS scores were significantly lower in the study group than those in the control group both at rest (3 [1-4] versus 4 [2-5], P = 0.04) and during cough (4 [3-6] versus 6 [4-6] P = 0.03), except at 48 h, when the median VAS score at rest was similar (3 [1-4] versus 3 [2-4], P = 0.56). Bowel function returned earlier in study group (67.34 ± 2.61 versus 76.34 ± 5.29 h, P = 0.03). Postoperative nausea and vomiting was less in study group. Respiratory function, assessed by peak expiratory flow rate, was better in the study group (192.55 ± 12.93 versus 165.31 ± 9.32 mL, P = 0.03). The incidence of surgical site infection was similar in both the groups (3/47 versus 5/47, P = 0.06). There was no systemic toxicity of local anesthetic.

CONCLUSION

Continuous preperitoneal wound infusion of local anesthetic provides effective analgesia, reduces morphine consumption and its associated side effects, and enhances the postoperative recovery by reducing the incidence of prolonged postoperative ileus.

Analgesic efficacy of ropivacaine wound infusion after laparoscopic colorectal surgery

Purpose

Local anesthetic wound infusion has been previously investigated in postoperative pain management. However, a limited number of studies have evaluated its use in laparoscopic colorectal surgery. This study aims to evaluate whether ropivacaine wound infusion is effective for postoperative pain management after laparoscopic surgery in patients with colorectal cancer.

Methods

This prospective study included 184 patients who underwent laparoscopic surgery for colorectal cancer between July 2012 and June 2013. The patients were grouped as the combined group (intravenous patient-controlled analgesia [IV-PCA] plus continuous wound infusion with ropivacaine, n = 92) and the PCA group (IV-PCA only, n = 92). Efficacy and safety were assessed in terms of numeric rating scale (NRS) pain score, opioid consumption, postoperative recovery, and complications.

Results

The total quantity of PCA fentanyl was significantly less in the combined group than in the PCA group (P < 0.001). The NRS score of the combined group was not higher than in the PCA group, despite less opioid consumption. There were no differences between groups for postoperative recovery and most complications, including wound complications. However, the rate of nausea and vomiting was significantly lower in the combined group (P = 0.022).

Conclusion

Ropivacaine wound infusion significantly reduced postoperative opioid requirements and the rate of nausea/vomiting. This study showed clinical efficacy of ropivacaine wound infusion for postoperative pain control in colorectal cancer patients undergoing laparoscopic surgery.

Magnesium Versus Bupivacaine Infiltration in Controlling Postoperative Pain in Inguinal Hernia Repair

Background:

Postoperative pain is one of the most common problems after hernia repair. Decrease in postoperative pain accelerates functional recovery, decreases duration of hospital stay and postoperative morbidity.

Objectives:

To compare postoperative analgesic effect of infiltration of magnesium versus bupivacaine into incision of inguinal hernia repair.

Patients and Methods:

In a double blind clinical trial, 80 patients’ candidates for elective inguinal hernia repair were enrolled. Right before closure of incision, in Bupivacaine group 5 mL Bupivacaine 0.5% added to 5 mL normal saline and in Magnesium group, 10 mL Magnesium sulfate 20% was infused subcutaneously. Pain score was measured using numeric rating score (NRS) at 1, 3, 6, 12 and 24 hours postoperatively. If NRS was above 3, 1 mg morphine was administered as rescue analgesic until patient felt comfortable or NRS < 3.

Results:

Postoperative pain scores at 1 and 3 hours were not significantly different between bupivacaine and magnesium groups (P = 0.21, 0.224; respectively). However, at 6 (P = 0.003), 12 (P = 0.028) and 24 (P = 0.022) hours postoperative, pain score (NRS) was significantly lower in bupivacaine group. Number of patients needed at least 1 dose of rescue morphine (P = 0.001), mean number of episodes asked for morphine during next 24 hours (P = 0.001) and total dose of morphine requirement (P = 0.01) were significantly lower in bupivacaine group.

Conclusions:

Magnesium infiltration did not decrease total dose and number of episodes needed for morphine rescue analgesic. Bupivacaine infiltration into surgical site was more effective than magnesium sulfate infiltration in postoperative pain control.

The value of continuous wound infusion systems for postoperative pain control following laparoscopic Roux-en-Y gastric bypass: an analysis of outcomes and cost

BACKGROUND

Current health-care reform is focusing on improving patient outcomes while cutting health-care costs, and as such, surgeons should consider that postoperative pain management techniques can contribute to the overall value of care delivered to patients. The current study aims to evaluate the value of continuous wound infusion systems (CWIS) in patients following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Records of all consecutive patients who underwent elective LRYGB by a single surgeon from January 2008 until June 2010 were reviewed. The presence of CWIS, patient pain scores, postanesthesia care unit (PACU) times, postoperative narcotic and antiemetic requirements, postoperative complications, and hospital length of stay (LOS) were recorded. Clinical data were subsequently linked and correlated with hospital financial data to determine overall hospital costs.

RESULTS

Forty-four LRYGB patients were reviewed; 24 (54.5 %) received CWIS for postoperative pain control. There was no significant difference in PACU times, postoperative LOS, or postoperative complications. Patients with CWIS required significantly less narcotics (36.7 vs. 55.5 mg IV morphine equivalents for total LOS; p = 0.03) and antiemetics (5.0 vs. 12.4 mg ondansetron for total LOS; p = 0.02); however, patients with CWIS did not report better pain control and had slightly higher hospital costs ($13,627.00 vs. $13,395.05, p = 0.68).

CONCLUSIONS

Data from the current study suggest that the value of CWIS for postoperative pain control following LRYGB is limited. As the environment for hospital reimbursement is changing to be one which is value driven, surgeons should consider analyses such as this when making decisions on which treatments to offer their patients.

Comparison of continuous local anaesthetic and systemic pain treatment after axillary lymphadenectomy in breast carcinoma patients - a prospective randomized study

Background

Acute pain after axillary lymphadenectomy is often related mainly to axillary surgery. The aim of the prospective randomized study was to find out if continuous wound infusion of local anaesthetic reduces postoperative pain, consumption of opioids and the incidence of chronic pain compared to the standard intravenous piritramide analgesia after axillary lymphadenectomy in breast carcinoma patients.

Methods

Altogether 60 patients were enrolled in the prospective randomized study; half in wound infusion of local anaesthetic and half in the standard (piritramide) group.

Results

In the recovery room and on the first day after surgical procedure, the wound infusion of local anaesthetic group reported less acute and chronic pain, a lower consumption of piritramide and metoclopramide, but their alertness after the surgical procedure was higher compared to the standard group.

Conclusions

After axillary lymphadenectomy in breast carcinoma patients, wound infusion of local anaesthetic reduces acute pain and enables reduced opioid consumption, resulting in less postoperative sedation and a reduced need for antiemetic drugs. After wound infusion of local anaesthetic there is a statistical trend for reduction of chronic pain.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery

Background

Open inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery.

Methods

Randomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity.

Results

Of the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia.

Conclusion

Field block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request.

Continuous elastomeric pump-based ropivacaine wound instillation after open abdominal aortic surgery: how reliable is the technique?

INTRODUCTION

We aimed at quantifying the impact of continuous wound infusion with ropivacaine 0.33% on morphine administration and subjective pain relief in patients after open abdominal aortic repair in a double-blind, placebo-controlled study.

METHODS

Before closing the abdominal wound, 2 multihole ON-Q® Soaker Catheters™ (I-Flow Corporation, Lake Forest, California, USA) were placed pre-peritoneally in opposite directions. Either ropivacaine 0.33% or saline 0.9% was delivered by an elastomeric pump at a rate of 2 mL/h for 72 hours in each of the catheters. Postoperative pain and morphine administration were assessed using the numerical rating scale (NRS) in 4-hour intervals. Total plasma concentrations of ropivacaine, unbound ropivacaine, and α1-acid glycoprotein (AAG) were measured daily. Mean arterial pressure, pulse rate, oxygen saturation, total amount of morphine administration, ventilation time, and length of stay in the intensive care unit (ICU) were recorded. At the end of the study period, the wound site and the condition of the catheters were assessed.

RESULTS

The study was terminated prematurely due to a malfunction of the elastomeric balloon pump resulting in toxic serum levels of total ropivacaine in 2 patients (11.4 μmol/L and 10.0 μmol/L, respectively) on the second postoperative day. Six patients had been allocated to the ropivacaine group, and 9 patients had been allocated to the control group. Demographic and surgical data were similar in both groups. During the first 3 postoperative days, no difference between the ropivacaine and the control group was found in NRS (P = .15, P = .46, and P = .88, respectively) and morphine administration (P = .48). Concentrations of unbound serum ropivacaine (0.11 ± 0.08 μmol/L) were below toxic level in all patients.

CONCLUSION

Continuous wound infusion of ropivacaine 0.33% 2 mL/h using an elastomeric system was not reliable and did not improve postoperative pain control in patients after open abdominal aortic surgery.

Continuous local analgesic therapy reduces pain after radical inguinal/iliacal lymph node dissection

BACKGROUND

To optimize postoperative pain therapy after a radical inguinal/iliacal lymph node dissection (RILND), we investigated the influence of a continuous application of a local anaesthetic via a subfascial wound catheter in the abdominal wall in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Between July 2007 and December 2009, 50 patients with stage III/IV of melanoma disease received, in an observational study, a systemic analgesic therapy. Of these patients, 30 were additionally treated with a subfascial catheter. Main outcome criterion was the pain under mobilisation at the first postoperative morning registered via a visual analogue score. Minor criteria were the analgesic requirement, the specific (surgical) complications and the day of discharge.

RESULTS

Patients treated with the subfascial catheter had significant less pain at the first postoperative morning in rest (p = 0.02) and after mobilisation (p = 0.03) without increased morbidity (p = 0.45). Less patients of the treatment group needed a supplementary analgesic medication (p = 0.01) and were able to leave hospital earlier than patients of the control group (p = 0.01).

CONCLUSIONS

A subfascially placed pain catheter enhances postoperative pain therapy after RILND.

Parecoxib sodium in the treatment of postoperative pain after Lichtenstein tension-free mesh inguinal hernia repair

PURPOSE

This prospective, randomized, double-blind study compared the analgesic efficacy and safety of parecoxib sodium versus lornoxicam and diclofenac, after Lichtenstein tension-free mesh inguinal hernia repair.

METHODS

Patients were randomly assigned to receive parecoxib 80 mg daily i.v. (Group A), lornoxicam 16 mg daily i.v. (Group B) or diclofenac 150 mg daily i.m. (Group C). Rescue analgesia in all groups consisted of pethidine 25 mg i.m. Pain was measured with an analogue scale (pain intensity score).

RESULTS

Patients treated with parecoxib 80 mg reported significantly lower summed pain intensity scores compared with lornoxicam and diclofenac-treated patients. Duration of analgesia was also significantly longer with parecoxib than with lornoxicam and diclofenac. Adverse events were significantly less common in the parecoxib and lornoxicam group, compared with diclofenac group.

CONCLUSIONS

Multiple-day administration of parecoxib 40 mg twice daily is more effective than equivalent doses of lornoxicam and diclofenac, and generally better tolerated than diclofenac after Lichtenstein tension-free mesh inguinal hernia repair.

Brief report: improved pain relief using intermittent bupivacaine injections at the donor site after breast reconstruction with deep inferior epigastric perforator flap

BACKGROUND

Deep inferior epigastric perforator flap surgery usually results in postoperative pain from the donor site requiring opioids.

METHOD

We examined the effect of bupivacaine 2.5 mg/mL, 20 mL given every third hour for 72 hours postoperatively through 2 thin catheters placed on the donor site in a double-blind placebo-controlled study consisting of 2 x 20 patients.

RESULTS

The bupivacaine group had significantly reduced pain at rest and during coughing. The placebo group needed 2 to 3 times more opioids in the 72-hour observation period. No difference was seen in the frequency of nausea or the consumption of antiemetic drugs.

CONCLUSION

We conclude that intermittent delivery of bupivacaine at the abdominal donor site significantly reduces the postoperative pain and need for narcotic rescue medication.

[Efficiency of bupivacaine wound subfasciale infiltration in reduction of postoperative pain after inguinal hernia surgery]

INTRODUCTION

The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique.

METHODS

This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed.

RESULTS

Concerning demographic parameters, ASA class and secondary effects, we didn't find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain.

DISCUSSION

Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.

Intermittent wound perfusion for postoperative pain relief following upper abdominal surgery: a surgeon's perspective

BACKGROUND

Although there are many methods for postoperative pain management, implementation may be limited in some settings due to practical or financial constraints. Simple, inexpensive and easily implemented analgesic methods may improve access to effective pain relief.

METHODS

Fifty patients undergoing truncal vagotomy and gastrojejunostomy for pyloric stenosis secondary to chronic duodenal ulceration were studied in this prospective randomized trial. Subjects were assigned to receive either wound perfusion with 8 mL of 0.25% bupivacaine every 5 hours through a catheter placed subcutaneously or intravenous pethidine 0.2 mg/kg on demand for postoperative pain relief. Postoperative pain scores at rest were measured by visual analog scale and the opioid requirement at 0-12 hours, at 12-24 hours and at 24-36 hours were compared. Changes in respiratory parameters were also compared between the two groups.

RESULTS

Pain scores at 0-12 hours were significantly lower in the wound perfusion group compared with the intravenous pethidine group (5.7 +/- 1.3 vs. 4.3 +/- 1.2, mean +/- SD; P < 0.001). The number of doses of analgesic required in the wound perfusion group was significantly lower compared with the controls during the 36 hours of study (3.5 +/- 1.3 vs. 1.4 +/- 1.0, P < 0.001). There were no differences in respiratory parameters, vital capacity, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate between the two groups. The FEV1:FVC ratio, however, was significantly higher in the intravenous pethidine group. There were no wound complications due to catheter placement or systemic toxicity due to the anesthetic.

CONCLUSION

Intermittent wound perfusion with 0.25% bupivacaine is a safe and efficient method to reduce pain scores and opioid requirement in the early postoperative period. Wound perfusion, however, had no beneficial effect on the postoperative respiratory function.

Postoperative continuous paravertebral anesthetic infusion for pain control in lumbar spinal fusion surgery

STUDY DESIGN

A retrospective, case-control study was conducted to analyze postoperative outcomes in patients who received local anesthetic infusion pumps after lumbar spinal fusion procedures. Data were collected prospectively via nursing protocol and third party assessment, and analyzed retrospectively.

OBJECTIVE

To review the safety and efficacy of continuous infusion of local anesthetic into the subfascial aspects of the wound after lumbar fusion surgery for treatment of postoperative pain, and to determine whether other outcome measures such as postoperative nausea and vomiting, ambulation and length of hospitalization were affected by the presence of the device.

SUMMARY OF BACKGROUND DATA

Patients who undergo lumbar spine fusion procedures frequently experience significant, debilitating pain related to their surgery. This pain may delay postoperative mobilization, increase length of hospitalization, and require prolonged use of high doses of narcotics. Use of a local anesthetic continuous-infusion pump after surgery may lead to improvements in these outcome variables.

METHODS

After posterior lumbar spine fusion procedures, 26 consecutive patients received the ON-Q PainBuster, which infused 0.5% marcaine via an elastomeric pump into the subfascial aspects of the wound. Retrospective analysis compared each of these patients with a case-matched control patient. Data included pain scores and opiate use during the first 5 postoperative days (PODs), length of hospital stay, and complications. Variables such as age, American Society of Anesthesiologists (ASA) physical status, and surgical procedure were similar between matched cases. One patient was excluded because of active heroine abuse.

RESULTS

Patients with the ON-Q PainBuster used 41.2% less narcotics on POD 1, 50.1% less on day 2, and 47.1% less on day 3 compared with the control patients. Differences in opiate usage were not statistically significant on POD 4 (45.5% less) and 5 (50.3% less). A lower average pain score was observed among patients with the ON-Q PainBuster on each POD: 39.1% less pain on POD 1, 34.0% on day 2, 45.1% on day 3, 29.5% on day 4, and 43.6% on day 5. No differences were observed in length of hospital stay or complication rate.

CONCLUSION

Patients who received the ON-Q PainBuster used less narcotic medications than case-matched patients during the first 3 PODs, and reported lower pain scores during the first 5 PODs. No complications attributable to the device were noted. These results suggest that continuous infusion of local anesthetic into the wound during the immediate postoperative period is a safe and effective technique that results in lower pain scores and narcotic use. Further data may reveal additional benefits such as lower incidence of nausea and vomiting and decreased times to mobility and functional independence.

The analgesic efficacy of continuous elastomeric pump ropivacaine wound instillation after appendectomy

STUDY OBJECTIVE

To evaluate the analgesic efficacy and safety of ropivacaine 0.2% when administered continuously via elastomeric pump after appendectomy.

DESIGN

Prospective, randomized, double-blinded study.

SETTING

Surgical ward of a university hospital.

PATIENTS

96 ASA physical status I and II patients of at least 14 years of age, undergoing appendectomy through a McBurney incision.

INTERVENTIONS

Patients were randomly assigned into two groups: 500 mg of ropivacaine in 48 hours (10 mL of 0.2% ropivacaine 20 mg, starter dose plus 5 mL/h continuous wound infusion via elastomeric pump device; n = 48) in the experimental group and 250 mL of normal saline, as placebo, in the control group.

MEASUREMENTS

Postappendectomy pain, measured either with a simple verbal scale or with a visual analog scale, parenteral analgesic consumption, and global satisfaction were all measured.

MAIN RESULTS

A reduction in postoperative pain was observed in the ropivacaine group. Degree of pain, with a simple verbal scale measurement of severe and unbearable, was significantly lower in the ropivacaine group than in the normal saline group from time 0 to 24 hours at rest and from time 0 to 36 hours on coughing. A significant lower pain intensity (visual analog scale) was found in the ropivacaine group both at rest and on coughing, beginning at three hours and continuing to 36 hours postoperatively. The mean number of rescue analgesic doses was significantly lower in the ropivacaine group. There were no statistically significant differences in the frequency of adverse events between the two groups.

CONCLUSIONS

Wound instillation with ropivacaine 0.2% is a useful, practical, and safe method for management of postoperative pain after appendectomy.

Evaluation of a local anesthetic delivery system for the postoperative analgesic management of canine total ear canal ablation--a randomized, controlled, double-blinded study

OBJECTIVE

To determine if a constant rate local anesthetic delivery system is more effective than continuous intravenous (IV) morphine infusion for postoperative analgesia.

ANIMALS

Twenty client-owned dogs undergoing total ear canal ablation.

METHODS

Dogs were randomly assigned to the lidocaine group (LID) or the morphine group (MOR). The LID group received a constant rate infusion of lidocaine locally and a continuous IV infusion of saline, while the MOR group received a constant rate infusion of saline locally and a continuous IV infusion of morphine. The primary investigator evaluated each patient and determined a hospital behavior score, anesthesia recovery score, preoperative pain score, and serial postoperative pain and sedation scores over 38 hours. Pain and sedation observations were videotaped and scored by three additional evaluators. Evaluators were blinded to treatment assignments.

RESULTS

There were no significant differences in age, weight, hospital behavior scores or anesthesia recovery scores. The primary investigator's pain scores were not significantly different, but sedation scores were significantly lower for the LID group. Sedation and pain scores by the video evaluators were not significantly different between groups. Kappa agreement between observers was poor, but better agreement was noted between sedation scores than pain scores. Drug-related complications were significantly lower in the LID group (n = 0) compared with the MOR group (n = 5). Wound complications were not significantly different (LID = 4, MOR = 4). Intravenous delivery complications occurred in 12 (60%) patients. Local delivery complications occurred in five (25%) dogs. Delivery complications were not significantly different between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Continuous incisional lidocaine delivery was an equipotent and viable method of providing postoperative analgesia compared with IV morphine. Lidocaine delivery resulted in a trend toward lower pain scores, significantly lower sedation scores, and no dogs requiring analgesic rescue. Wound complications secondary to local infusion were minor and self-limiting. Drug-related complications occurred only in the MOR group.

Postoperative analgesia requirements at home after inguinal hernia repair: effects of wound infiltration on postoperative pain*

The aim of this study was to evaluate our postoperative pain protocol after ambulatory herniorrhaphy and to determine how infiltration with local anaesthetics would add to our management of postoperative pain. Two groups of 60 patients, scheduled for herniorrhaphy, received wound infiltration with 20 ml levobupivacaine 0.5% or saline 0.9%. Postoperatively, the patients regulated their own analgesic consumption and registered VAS scores, use of analgesics and side-effects in a diary for 5 days. The median time to first analgesic, the pain visual analogue scale scores, number of patients using no analgesic and the use of analgesic medication were significantly lower in the levobupivacaine group in the first 24 h, but not thereafter. Most patients used acetaminophen in the first 5 days after surgery and occasionally diclofenac. Only a minority used tramadol. Our multimodal pain protocol achieved reasonable results at rest, but a considerable number of patients experienced moderate to severe pain with movement.

A bioabsorbable microcatheter for the continuous and direct treatment of surgical sites

A bioabsorbable microcatheter comprising of a polyglycolideco-lactide microtube and an absorbable braid is developed for the continuous delivery of therapeutic fluids directly to a surgical site. Studies conducted with tissue staining dye and radio-opaque solution using porcine models indicate that infusion of fluids in the wound site is rapid and complete. The tissue reaction to the microtube and braid is generally characterized by minimal to mild chronic inflammation or foreign body reaction that decreases in severity as the material is absorbed. The microtube is considered to be absorbed at 56 days postimplantation while the bulk of the braid is considered to be absorbed by 70 days postimplantation.

Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study

BACKGROUND

This study evaluated efficacy, safety and patient satisfaction with incisional analgesia with a subfascial catheter compared to epidural analgesia for pain relief following caesarean section.

METHODS

Forty patients were randomised after elective caesarean section to receive either intermittent 10-mL boluses of 0.125% levobupivacaine into the epidural space and physiologic saline into the surgical wound or intermittent 10-mL boluses of 0.25% levobupivacaine into the wound and epidural saline with a repeated 10-dose regimen. Analgesic efficacy was evaluated by numerical pain scores (0-10, 0=no pain, 10=worst pain) and based on the consumption of supplemental opioid. Side effects, patient satisfaction and plasma concentrations of levobupivacaine were recorded.

RESULTS

In the epidural group average pain scores were lower (1.8 vs. 3, P=0.006) and the consumption of local anaesthetic (29 mL vs. 38 mL, P=0.01) was smaller during the first four postoperative hours, after which both groups had pain scores of 3 or less at rest. All parturients were able to walk after the 24-h study period. The total consumption of rescue opioid oxycodone (32 vs. 37 mg, P=0.6) during the whole 72-h study period was low in both study groups. Side effects were mild and rare. Satisfaction scores were equally high in the two groups. Peak plasma concentrations of levobupivacaine were below the toxic range.

CONCLUSION

Incisional local analgesia via a subfascial catheter provided satisfactory pain relief with patient satisfaction comparable to that seen with epidural analgesia. This technique may be a good alternative to the more invasive epidural technique following caesarean section as a component of multimodal pain management.

Patient Outcomes After Axillary Lymph Node Dissection for Breast Cancer: Use of Postoperative Continuous Local Anesthesia Infusion

BACKGROUND

Although considered a safe surgical procedure, axillary lymph node dissection (ALND) is associated with postoperative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique and the absence of long thoracic or thoracodorsal nerve injury, the risk of these complications are reported as great as 35% to 50%, with a subset of patients developing chronic pain syndromes.

METHODS

Female patients (n = 27) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group 1 received standard axillary lymph node dissection. Patients assigned to group 2 or 3 (double-blinded) received 120 h continuous 0.9% saline solution or 0.5% bupivacaine using a catheter placed into the axilla and delivered by an elastomeric pump device. After routine postoperative care, patients were discharged with oral opioid analgesics. Twice-daily assessment of pain, sedation, and nausea were conducted using validated visual-analog scale measures. Daily and total opioid analgesic requirements after surgery were recorded.

RESULTS

Patients treated with a continuous infusion of bupivacaine experienced significantly lower pain scores (P < 0.001) during the first 5 postoperative days. Postoperative opioid analgesic requirements also were significantly decreased in the bupivacaine group, and these effects persisted until postoperative day 14 (P < 0.001). Concomitant to the observed decreases in pain and oral opioid requirements, nausea and morning sedation also were significantly reduced. There were no pump-related complications, wound infections, or postoperative axillary fluid collections.

CONCLUSIONS

The use of continuous administration of bupivicaine after ALND significantly decreases pain and opioid analgesic requirements, with concomitant decreases in nausea and sedation. This study provides encouraging evidence of the therapeutic benefits of continuous infusion of local anesthesia and may represent a valuable adjunct for surgical patients who require ALND, including those with breast cancer and melanoma.

Perioperative Pain Control: A Strategy for Management

A thorough understanding of the anatomy and neurophysiology of the pain response is necessary for the effective treatment of perioperative pain. This article describes the mechanisms that produce pain,including those related to inflammation. Other topics include the pharmacologies of nonopioid and opioid analgesics. Nonopioid analgesics can be separated into two categories: nonsteroidal anti-inflammatory drugs, such as salicylates, and acetaminophen. Opioids include morphine, fentanyl, and meperidine. The pharmacology of local anesthesia is discussed. The six major adverse reactions to local anesthetics are cardiac arrhythmias, hypertension, direct tissue toxicity, central nervous system toxicity, methemoglobinemia and allergic reactions. Methods for measuring pain are described.

Incisional Administration of Local Anesthetic Provides Satisfactory Analgesia following Port Access Heart Surgery

AIM OF THE STUDY

To evaluate the new method of postoperative pain relief following port access (PA) heart surgery.

METHODS

Patients scheduled for PA heart surgery under cardioplegic arrest were enrolled in the study. At the end of the operation an epidural catheter was placed in the surgical wound. Analgesia was started with a bolus of 20 mL 0.75% ropivacaine through the catheter followed by 0.15% ropivacaine administered via patient control analgesia pump. Metamizol was also given to the patient every 12 hours intravenously (IV), and, in the case of inadequate analgesia, the rescue analgetic piritramid IV was used. The variables recorded were the visual analogue scale (VAS), the number of bolus applications of local anesthetic, and the number of bolus applications of rescue analgetic piritramid.

RESULTS

The pain control at the end of the operation was satisfactory with all patients who were extubated on the table. In the first 24 hours the mean VAS pain score was 2.5, the number of bolus applications of local anesthetic was 2.0, and the number of applications of rescue medication was 1.5. There were no wound infections related to the catheter and no complications related to local anesthetic.

CONCLUSION

The incisional administration of local anesthetic provides satisfactory pain control after PA heart surgery.

[Ropivacain after inguinal hernia surgery. A prospective, randomised, double-blinded, controlled study]

BACKGROUND

To optimise the satisfaction of patients after repair of primary inguinal hernias under local anaesthesia, we analysed the analgetic power of Ropivacain in the postoperative period.

MATERIAL AND METHODS

One hundred consecutive patients underwent repair under local anaesthesia with the same volume of 0.75% Ropivacain or 1% Mepivacain in a randomised and blinded manner. Postoperative pain analysis was carried out in all patients.

RESULTS

Subjective pain levels at rest and under stress as well as impairment by pain were found to be significantly lower in the Ropivacain group at the day of operation. Decrease in vital capacity and peak flow showed similar results. The postoperative amount of analgesics and time of mobilisation showed a positive influence by the use of Ropivacain.

CONCLUSION

Ropivacain reduces postoperative pain levels after hernia repair. This leads to increased comfort for patients, without elevated perioperative risk.

Evaluation of continuous infusion of 0.5% bupivacaine by elastomeric pump for postoperative pain management after open inguinal hernia repair

BACKGROUND

Postoperative pain management and narcotic usage after inguinal hernia repair is an important concern for anesthesiologists and surgeons. Regional anesthesia incisional infiltration techniques may reduce the need for systemic medications.

STUDY DESIGN

Double-blind study of 52 patients undergoing open hernia repair with the Prolene Hernia System prospectively randomized to receive either 0.5% bupivacaine or saline continuously for 48 hours at 2 mL/hour through use of an elastomeric continuous infusion pump (ONQ Pain Relief System). Outcomes measured over the 120 hours postoperatively were: narcotic use, Visual Analogue Scale pain scores, site inflammation (visual inspection), and side effects. Comparisons between the groups were made by applying the Mann-Whitney rank sum test and analysis of variance with treatment as a fixed effect in the model.

RESULTS

In the bupivacaine group, 24% (versus 4% in the placebo group) required no narcotics (p < 0.05). Daily and total narcotic usages for all 5 study days were significantly less (p < 0.05) in the bupivacaine group. There were no reports of complications at the catheter-insertion site or surgical-wound site.

CONCLUSIONS

Demonstrable benefits include reduction of narcotic usage and pain with no apparent increase in the risk of infection or complication. Continuous infusion of 0.5% bupivacaine at 2 mL/h through the ONQ pump is a safe and effective adjunct in postoperative pain management for open inguinal hernia repair. This represents a viable and possibly superior option for prolonged pain management, minimizing use of narcotics in patients undergoing this procedure.

Local Anesthetic Infusion Pumps Improve Postoperative Pain after Inguinal Hernia Repair: A Randomized Trial

Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.

Postoperative recovery and discharge

Ambulatory surgery provides quality care that is cost-effective. The use of innovative surgical and anesthetic techniques will allow larger numbers of patients to take advantage of the benefits of undergoing an elective operation on an ambulatory basis. Anesthesiologists will be faced with more complex surgery, which will require careful selection and assessment of patients to ensure continuity of the excellent safety record of ambulatory anesthesia. Minor adverse events, such as pain and PONV, are still common. The occurrence of these minor adverse advents is now the major area of quality assessment and an area where improvement could be targeted. Fast tracking facilitates earlier discharge, but we must ensure this has benefit to the patient as speedy discharge may mask the true incidence of adverse minor symptoms. This can lead to patient dissatisfaction and a poor impression of ambulatory surgery.