Continuous wound infiltration with ropivacaine for analgesia after caesarean section: a randomised, placebo-controlled trial

To assess the analgesic efficacy of adjuvant magnesium sulfate added with ropivacaine over ropivacaine alone as a continuous infiltration in total abdominal hysterectomy wound: A randomized controlled trial

Background and Aims

Magnesium sulfate (MgSO4) has been demonstrated to have analgesic property in various clinical settings. This study explores if addition of MgSO4 to ropivacaine increases its analgesic efficacy when infiltrated continuously in the postsurgical wound following total abdominal hysterectomy.

Material and Methods

This randomized controlled trial was conducted at a tertiary care referral hospital in New Delhi, India. Fifty-two patients were randomized into two groups to receive the intervention of which 48 were able to complete the study. The first group (n = 26) received 0.25% ropivacaine infiltration and the second group (n = 26) received 0.25% ropivacaine with 5% MgSO4 at the incision site for 48 h postoperatively. Primary objective was to compare the total postoperative opioid (morphine) consumption by the study participants in both the groups and the secondary objectives were pain scores at rest and at movement, patient satisfaction score, and wound quality of life on the 7th postoperative day among the two groups.

Results

Both the groups were comparable in their demographic characteristics. The median morphine consumed at 48 h postoperatively was 16.5 [0-77] mg in the ropivacaine group and 13[1-45] mg in the ropivacaine with MgSO4 group and the difference was statistically insignificant (P = 0.788). There was no statistical difference between the groups with respect to the pain scores, patient satisfaction, or wound quality of life at 7 days.

Conclusion

The addition of MgSO4 to ropivacaine does not confer any additional postoperative analgesic benefits over ropivacaine alone in continuous wound infiltration following total abdominal hysterectomy.

Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

Preperitoneal ropivacaine infusion versus epidural ropivacaine-morphine for postoperative analgesia in dogs undergoing ovariohysterectomy: a randomized clinical trial

OBJECTIVE

To assess the effect of continuous wound infusion (CWI) with preperitoneal ropivacaine on postoperative analgesia and compare it with the epidural administration of ropivacaine and morphine in bitches undergoing ovariohysterectomy.

STUDY DESIGN

A parallel, randomized, clinical, prospective and nonblinded study.

ANIMALS

A group of 38 Greyhound bitches.

METHODS

In the catheter group (CathG), CWI with ropivacaine 1% (1 mg kg^-1 + 0.8 mg kg^-1 hour^-1) was applied to the preperitoneal space over the surgical incision. In the epidural group (EpiG), ropivacaine 0.5% (1.3 mg kg^-1) and morphine (0.1 mg kg^-1) were epidurally administered. Occipital-coccygeal length was used to calculate the volume for the epidural. Pain was scored using a dynamic interactive visual analogue scale (DIVAS) and Glasgow composite measure pain scale-short form (CMPS-SF) before anaesthesia and at 2, 4, 6, 18, 21 and 24 hours after extubation. Incisional sensitivity using a dynamometer (MWTs-incision) was evaluated simultaneously. Plasma ropivacaine and cortisol concentrations, degree of sedation, motor blockade and response to interdigital clamping were measured or assessed. A two-way mixed analysis of variance and a Mann-Whitney U test were used to analyse data; p < 0.05.

RESULTS

No differences were detected in the DIVAS (p = 0.301), CMPS-SF (p = 0.600) scores, MWTs-incision measurements (p = 0.257) and cortisol values (p = 0.878) between the groups. Rescue analgesia was required in two dogs, one in each group, at 2 hours. Sedation, motor blockade and negative response to interdigital clamping were detected in EpiG at 2, 4 and 6 hours. Mean plasma ropivacaine values were higher in CathG (0.475 ± 0.164 ng mL^-1) than in EpiG (0.184 ± 0.213 ng mL^-1; p = 0.001).

CONCLUSION AND CLINICAL RELEVANCE

Compared with epidural ropivacaine and morphine, CWI with preperitoneal ropivacaine is an effective analgesic technique for postoperative pain management in bitches undergoing ovariohysterectomy without motor blockade.

Continuous wound infiltration of ropivacaine for reducing of postoperative pain after anterior lumbar fusion surgery: a clinical retrospective comparative study

Background

Local anesthetic infiltration at the site of a surgical wound is commonly used to control postoperative pain. In this study, we examined the effectiveness of continuous local infiltration at an abdominal surgical site in patients undergoing anterior lumbar interbody fusion (ALIF) surgery.

Methods

Sixty-one patients who underwent ALIF surgery were enrolled. For thirty-one of them, a continuous local anesthetics infiltration system was used at the abdominal site. We collected data regarding the patients’ sleep quality; satisfaction with pain control after surgery; abilities to perform physical tasks and the additional application of opioids in the postoperative 48 hours.

Results

The On-Q system group showed reduced visual analogue scale scores for pain at the surgical site during rest and movement at 0, 12, 24, and 48 hours; and more was satisfied with pain control management at the first postoperative day (7.0 ± 1.2 vs. 6.0 ± 1.4; P = 0.003) and week (8.1 ± 1.6 vs. 7.0 ± 1.8; P = 0.010) than the control group. The number of additional patient-controlled analgesia (PCA) bolus and pethidine injections was lower in the On-Q group (PCA 3.67 ± 1.35 vs. 4.60 ± 1.88; P = 0.049 and pethidine 2.09 ± 1.07 vs. 2.73 ± 1.38; P = 0.032). Patients who used the On-Q system performed more diverse activity and achieved earlier ambulation than those in the control group.

Conclusions

Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery.

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence

PURPOSE OF REVIEW

In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD).

RECENT FINDINGS

Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.

Continuous ropivacaine subfascial wound infusion after cesarean delivery in pain management: A prospective randomized controlled double-blind study

OBJECTIVE

The aim of this study is to analyze post-cesarean morphine consumption using continuous ropivacaine subfascial wound infusion.

METHODS

After standardized spinal anesthesia (0.5% hyperbaric bupivacaine 8-10 mg combined with sufentanil 2-2.5 μg), women undergoing cesarean section (n = 69) were randomly allocated to receive either ropivacaine 0.2% (n = 35) or NaCl 0.9% (n = 34) infused through a subfascial wound catheter during 48 h in a multimodal analgesic approach. As primary outcome, opioid use by intravenous patient-controlled analgesia was analyzed. Secondary outcomes were intensity of pain on visual analog scale at rest and at mobilization, postoperative nausea/vomiting, pruritus and time of first ambulation. Independent t test or Mann-Whitney U test, and Pearson's χ² test or Fisher's exact test were used as appropriate.

RESULTS

Morphine consumption was significantly lower in the ropivacaine group (21.52 ± 21.56 mg) compared with the placebo group (29.57 ± 22.38 mg; 95% confidence interval -18.8 to 2.76; p = 0.047). No significant differences were observed in pain evaluated by visual analog scale, except for pain at mobilization 6 h after surgery (ropivacaine versus placebo: 3.90 ± 2.66 versus 5.36 ± 2.55; p = 0.030). No significant differences were observed in the incidence of postoperative nausea/vomiting, pruritus, and time of first ambulation.

CONCLUSION

Continuous ropivacaine subfascial wound infusion results in less post-cesarean morphine consumption. EudraCT trail registration number: 2017-004797-33. EudraCT link: https://www.clinicaltrialsregister.eu/ctr-search/trial/2017-004797-33/BE#A.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Ropivacaine and Ketorolac Wound Infusion for Post-Cesarean Delivery Analgesia: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of wound infusion with ropivacaine plus ketorolac compared with placebo for post-cesarean delivery analgesia in women who received a multimodal analgesic regimen including intrathecal morphine.

METHODS

In a randomized double-blind study, women undergoing scheduled cesarean delivery under spinal or combined spinal epidural anesthesia were randomized to wound infusion with ropivacaine 0.2% plus ketorolac, or saline placebo using an elastometric pump for 48 hours. The primary outcome was pain score with movement at 24 hours after surgery (0-10 scale, 0=no pain and 10=worst possible pain). Secondary outcomes included pain scores at rest at 24 hours, pain scores at rest and with movement at 2 and 48 hours, opioid consumption, and time to first rescue analgesic. A sample size of 35 per group (n=70) was planned.

RESULTS

From November 8, 2016, to May 17, 2019, 247 women were screened, and 71 completed the study per protocol: 38 in the placebo group and 33 in the ropivacaine plus ketorolac group. Patient demographics and intraoperative characteristics were comparable between the groups. There was no significant difference between the groups in the primary outcome of pain score with movement at 24 hours (difference in median score 0, 95% CI -1 to 2, P=.94). There were also no significant differences between the placebo and ropivacaine plus ketorolac groups in pain scores at other time points, in total opioid consumption (difference in median consumption -12.5 mg, 95% CI -30 to 5, P=.11), or in time to rescue analgesics (median [interquartile range] 660 [9-1,496] vs 954 [244-1,710] minutes, hazard ratio 0.69, 95% CI 0.41 to 1.17, P=.16).

CONCLUSION

There was no benefit of wound infusion with ropivacaine and ketorolac in women who received intrathecal morphine and a multimodal analgesic regimen.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02829944.

FUNDING SOURCE

The study was supported in part by Avanos Medical Inc.

Occlusion of multi-holed catheters used in continuous wound infusion in open gynecologic surgery: A pathological study

Background:

Continuous wound infusion (CWI) with local anesthetics is useful as a method of pain management after abdominal surgery. However, there have been no studies regarding the obstruction of multi-holed catheters in this application.

Methods:

We conducted from July to November 2015. In the first portion of the study, we obtained 34 catheters used postoperatively with open gynecologic surgery, and evaluated the status of each hole in vitro. Each catheter had eight holes, and we investigated the number of open holes after the removal of the catheter. In the second portion of the study, we reviewed pathological specimens from four occluded catheters. Statistical analysis was performed using the statistical software MedCalc™ (MedCalc, Ostend, Belgium), and intergroup comparisons were made with independent sample t-test. Data are expressed by mean and standard deviation.

Results:

In each catheter, the number of remaining open holes was 0–7, and there were no catheters with all eight holes still open. Although the occlusion may be occurred after the end of infusion, 38.2% (n = 12) did not have any open holes remaining in our investigation. The composition of the emboli in the catheters was clotted blood and plasma, with a mass of fibrin and possibly some inflammation around the embolus.

Conclusions:

Occlusion of these catheters occurs at a very high rate, and the catheter embolus might be composed of clotted blood, plasma, and/or fibrin.

Postoperative analgesic efficacy of continuous wound infusion with local anesthetics after laparoscopy (PAIN): a randomized, double-blind, placebo-controlled trial

BACKGROUND

To investigate the efficacy of continuous wound infusion (CWI) with local anesthetics for reducing postoperative pain compared with placebo in patients undergoing benign gynecologic laparoscopy.

METHODS

In this double-blind trial, 66 patients were randomly assigned to receive either ropivacaine or normal saline though a multi-orifice catheter placed into the umbilical surgical wound for 50 h postoperatively. The primary outcome measure was the severity of postoperative pain 1, 6, 12, 24, and 48 h after surgery. The secondary outcome measure was the number of rescue analgesics requested.

RESULTS

Baseline characteristics did not statistically differ between the ropivacaine and placebo groups. The intensity of postoperative pain was significantly lower in the ropivacaine group than in the placebo group 1, 6, 12, 24, and 48 h after surgery (all P < 0.05). The number of rescue analgesics requested was also significantly lower in the ropivacaine group than in the placebo group. There were no significant differences between the two groups regarding other surgical outcomes.

CONCLUSION

CWI with local anesthetics after laparoscopic surgery provides good analgesia and reduces rescue analgesics consumption.

A review of peripheral nerve blocks for cesarean delivery analgesia

Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.

A Review of Enhanced Recovery After Surgery Principles Used for Scheduled Caesarean Delivery

There is an increasing body of evidence to support the success of Enhanced Recovery After Surgery (ERAS) for a wide range of surgical procedures. There has been little formalized application, however, of ERAS principles in obstetrical surgery. The aim of this review was to examine the evidence base of perioperative care for patients undergoing Caesarean delivery (CD) and to determine the feasibility of developing an ERAS Society guideline for this obstetrical care plan. The literature on enhanced recovery programs was reviewed, including fast-track surgery and perioperative care components in the preoperative, intraoperative, and postoperative phases of CD. These studies included randomized controlled trials (RCTs), prospective cohort studies, non-RCT studies, meta-analyses, systematic reviews, reviews, and case studies. This is not a systematic review because each ERAS topic area would require a new question. Certain ERAS elements have the potential to benefit patients undergoing CD. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postoperative nausea and vomiting prevention, hypothermia prevention, perioperative fluid management, postoperative analgesia, ileus prevention, breastfeeding promotion, and early mobilization. ERAS has the potential to be successfully implemented in CD on the basis of the evidence obtained from this review. Knowledge transfer and implementation will require multidisciplinary coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS guideline.

Local anaesthetic wound infiltration for postcaesarean section analgesia: A systematic review and meta-analysis

BACKGROUND

Wound infiltration with local anaesthetics has been investigated as a potentially useful method for providing analgesia after caesarean delivery, but the literature is inconclusive.

OBJECTIVE

The objective is to assess the efficacy of local anaesthetic wound infiltration in reducing pain scores and opioid consumption in women undergoing caesarean delivery.

DESIGN

Systematic review of randomised controlled trials with meta-analyses.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled trials (CENTRAL) until December 2015.

ELIGIBILITY CRITERIA

Randomised controlled trials that assessed the efficacy of local anaesthetic wound infiltration using an infusion or single injection technique for postcaesarean section analgesia.

RESULTS

A total of 21 studies were included in the final analysis (11 studies using an infusion technique and 10 studies using single infiltration). Local anaesthetic wound infiltration significantly decreased opioid consumption at 24 h [mean difference -9.69 mg morphine equivalents, 95% confidence interval (CI), -14.85 to -4.52] and pain scores after 24 h at rest (mean difference -0.36, 95% CI, -0.58 to -0.14) and on movement (mean difference -0.61, 95% CI, -1.19 to -0.03). Subgroup analysis did not suggest a difference in primary outcomes between infusions and single infiltration. Opioid consumption was reduced in patients who did not receive intrathecal morphine but not in those who received intrathecal morphine, although there were very little data in patients receiving intrathecal morphine. Pain scores at rest and on movement at 24 h were reduced with catheter placement below the fascia but not above the fascia. There were no statistically significant reductions in nausea, vomiting or pruritus with local anaesthetic infiltration.

CONCLUSION

Local anaesthetic wound infiltration reduces postoperative opioid consumption but had minimal effect on pain scores and did not reduce opioid-related side-effects in women who had undergone delivery by caesarean section. The review is limited by a paucity of studies using intrathecal morphine and by the indirect comparisons performed for subgroup analyses.

The effect of local/topical analgesics on incisional pain in a pig model

Interest in the development of new topical/local drug administration for blocking pain at peripheral sites, with maximum drug activity and minimal systemic effects, is on the rise. In the review article by Kopsky and Stahl, four critical barriers in the process of research and development of topical analgesics were indicated. The active pharmaceutical ingredient (API) and the formulation are among the major challenges. The road to the development of such drugs passes through preclinical studies. These studies, if planned correctly, should serve as guidance for choosing the right API and formulation. Although rodent models for pain continue to provide valuable data on the mechanisms driving pain, their use in developing topical and localized treatment approaches is limited for technical (intraplate injection area is small) as well as mechanical reasons (non-similarity to human skin and innervation). It has been previously shown that pigs are comparable to humans in ways that make them a better choice for evaluating topical and local analgesics. The aim of this study was to summarize several experiments that used pigs for testing postoperative pain in an incisional pain model (skin incision [SI] and skin and muscle incision [SMI]). At the end of the surgery, the animals were treated with different doses of bupivacaine solution (Marcaine^®), bupivacaine liposomal formulation (Exparel^®) or ropivacaine solution (Naropin). Von Frey testing demonstrated a decrease in the animals’ sensitivity to mechanical stimulation expressed as an increase in the withdrawal force following local treatment. These changes reflect the clinical condition in the level as well as in the duration of the response. These data indicate a good resemblance between pig and human skin and suggest that use of these animals in the preclinical phase of developing topical analgesics can, to some extent, release the bottleneck.

Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial

BACKGROUND

Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours.

METHODS

Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, the incidence of side effects (nausea and vomiting and pruritis), and patient satisfaction.

RESULTS

Data from 78 patients (39 patients in each group) were analyzed. The mean ± SD of cumulative fentanyl consumption at 24 hours was 157.4 ± 63.4 μg in the infiltration group and 153.3 ± 68.3 μg in the TAP group (difference in means [95% confidence interval] is 4.1 [-25.6 to 33.8] μg; P = .8). There were no significant differences between the 2 groups in the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, and patient satisfaction. The incidence of side effects (nausea and vomiting and pruritis) was low in the 2 groups.

CONCLUSIONS

TAP block and wound infiltration did not significantly differ regarding postoperative fentanyl consumption, pain scores, and patient satisfaction in parturients undergoing cesarean delivery under spinal anesthesia.

Effects of Ropivacaine on Postoperative Pain and Peak Expiratory Flow Rate in Patients Undergoing Percutaneous Nephrolithotomy

BACKGROUND

Postoperative analgesic effects of ropivacaine have been demonstrated in various surgical procedures; however, its beneficial effect on postoperative pain relief and ability to breathe out air in urological surgeries, particularly in local interventions such as percutaneous nephrolithotomy (PCNL), has remained uncertain.

OBJECTIVES

The aim of this study was to assess the efficacy of ropivacaine on postoperative pain severity and peak expiratory flow (PEF) in patients undergoing PCNL procedure.

PATIENTS AND METHODS

This randomized double-blinded clinical trial was performed on 55 consecutive adult patients aged 15 to 60 years who underwent Tubeless PCNL surgery. The patients were randomly assigned to instill 30 mL of ropivacaine 0.2% or 30 mL of isotonic saline with the same protocol. The parameters of visual analogue scale (VAS) (for assessment of pain severity) and PEF (for assessment of ability to breathe out air) were measured 4 and 6 hours after completing the procedure. Moreover, the amounts of opioids or analgesics administered within 6 hours after the operation were recorded.

RESULTS

We found no difference in the mean pain severity score between the case and control groups 4 hours (P = 0.332) and 6 hours (P = 0.830) after the operation. The mean PEF at baseline was similar in case and control groups (P = 0.738). Moreover, no difference was revealed in PEF index 4 hours (P = 0.398) and 6 hours (P = 0.335) after PCNL between the groups. The mean VAS scores 4 hours after the operation slightly decreased 2 hours later (P < 0.001) in the both groups. Moreover, in the both groups, a sudden decrease in PEF index was observed within 4 hours after the operation and increased with a mild gradient for the next 2 hours. No difference was found in the amount of postoperative analgesic used in the both groups.

CONCLUSIONS

Instillation of ropivacaine 0.2% (30 mL) within tubeless PCNL surgery does not have a significant effect on postoperative pain relief and improvement of PEF within 6 hours after the operation.

Cesarean analgesia using levobupivacaine continuous wound infiltration: a randomized trial

OBJECTIVE

Neuraxial morphine is considered as a "gold standard" for pain relief after cesarean section, however it causes bothersome side effects. Alternative analgesia including nonsteroidal antiinflammatory drugs (NSAID) has been proposed. We aimed to assess the morphine sparing effect of continuous wound infiltration with a local anesthetic, when added to multimodal systemic analgesia including NSAID without subarachnoid morphine.

STUDY DESIGN

Sixty-eight women scheduled for elective cesarean section under spinal anesthesia were included in a randomized controlled open-label trial. Patients received bupivacaine spinal anesthesia without intrathecal morphine. Postoperative analgesia consisted for all patients in multimodal systemic analgesia with acetaminophen, nefopam, celecoxib, and patient-controlled intravenous morphine for 24h. The intervention group also received subfascial levobupivacaine infiltration through a multi-holed catheter, at 6.25mg/h for 48h. The primary endpoint was total morphine consumption at 24h postoperatively; and secondary endpoints were pain scores, side effects, breastfeeding comfort, maternal satisfaction, and nurse workload. Student t test, Mann-Whitney test or χ(2) test were used when appropriate.

RESULTS

The intervention group had 6.7mg less morphine consumption (95%CI -1.3mg; -12mg, P=0.02), and 0.8 pain point less at rest on the numerical rating scale 0-10 (95%CI -0.3; -1.3, P=0.002). The intervention was associated with significantly better breastfeeding comfort (+1.7 at numerical rating scale score 0-10, 95%CI +0; +3.3, P=0.0498). Wound dressing changes were required in a significantly higher proportion of intervention-group women (12/34 vs. 1/34, P=0.002).

CONCLUSION

Adding continuous levobupivacaine infiltration to multimodal analgesia after cesarean section without subarachnoid morphine decreased postoperative morphine consumption and pain, facilitated breastfeeding initial comfort, and slightly increased nurse workload.