Effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy

The Effects of Erector Spinae Plane Block Versus Incision Site Local Anesthetic Infiltration on Stress Hormone Response in Patients Undergoing Laparoscopic Cholecystectomy: Randomized Controlled Study

BACKGROUND

After laparoscopic cholecystectomy surgery, an increase in stress hormones and moderate-to-severe pain occur in the postoperative period. The aim is to compare the effects of unilateral erector spinae plane block (ESPB) and port site local anesthetic (LA) infiltration methods on stress hormone response and postoperative pain in laparoscopic cholecystectomy operations.

METHODS

This study was a prospective, randomized controlled, single-blind trial that divided laparoscopic cholecystectomy patients into 3 groups. In group I, local anesthetic infiltration was administered at 4 trocar sites; group E underwent unilateral ESPB guided by ultrasound; and group C was the control group with no intervention. Stress hormones were measured preoperatively and postoperatively, and postoperative VAS scores were recorded. The primary outcome was to compare the effects of LA infiltration and ESPB on stress hormone response, while the secondary outcome was the efficacy of postoperative analgesia.

RESULTS

A total of 90 patients were included in the study. The duration of analgesia was significantly longer in group I compared with group C (P<0.05). Postoperative VAS scores were significantly lower in group E and group I than in group C (P<0.05). Group E significantly suppressed prolactin levels compared with the other 2 groups (P<0.05). In addition, group E significantly reduced glucose levels compared with group C (P<0.05).

CONCLUSION

Unilateral ESPB and infiltration have similar effects on pain and stress hormones after laparoscopic cholecystectomy. Infiltration may be preferred due to its easier application.

Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review

The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.

Use of local wound infiltration in open hepatectomy to reduce wound pain: A systematic review and meta-analysis

The aim of this study was to assess the effects of local wound infiltration anaesthesia on postoperative wound pain in patients undergoing open liver resection. The Cochrane Library, PubMed, EMBASE, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM) and Wanfang databases were searched. The search period spanned from database creation to December 2022. All relevant studies on local wound infiltration anaesthesia for analgesia after hepatectomy were included. Two investigators independently screened the literature, extracted data and evaluated the quality of each study. Review Manager (RevMan) 5.4 software (Cochrane Collaboration) was used for the meta-analysis, in which 12 studies with 986 patients were included. The results show that local wound infiltration anaesthesia effectively reduced surgical site wound pain at 4 h (mean difference [MD]: -1.26, 95% confidence intervals [CIs]: -2.15 to -0.37, P = .005), 12 h (MD: -0.84, 95% CIs: -1.26 to -0.42, P < .001), 24 h (MD: -0.57, 95% CIs: -1.01 to -0.14, P = .009) and 48 h (MD: -0.54, 95% CIs: -0.81 to -0.26, P < .001) postoperatively; however, there was no significant difference in analgesia at 72 h postoperatively (MD: -0.10, 95% CIs: -0.80 to 0.59, P = .77). These findings suggest that local wound infiltration anaesthesia administered to patients undergoing open liver resection provides good postoperative wound analgesia at the surgical site.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Comparison of the Analgesic Effect of Subcutaneous Bupivacaine Infiltration and Intravenous Diclofenac vs. Intravenous Diclofenac Monotherapy After Inguinal Hernioplasty: A Retrospective Study

Background

Postoperative pain is a significant problem encountered by patients after a surgical intervention, and there is a crucial need for effective postoperative pain control. The studies have shown that multimodal analgesia and wound infiltration are effective ways to reduce this pain and have a substantial role in the reduction of postoperative medications requirement. This study aimed to evaluate the effect of subcutaneous infiltration of bupivacaine hydrochloride and intravenous (IV) diclofenac as postoperative pain relief in adults undergoing inguinal hernia repair.

Methods

A single-center retrospective study included 104 patients aged 18-65 undergoing unilateral inguinal herniorrhaphy at the selected hospital. The patients were in two groups of 52 each. Group A received a 75 mg dose of IV diclofenac plus a subcutaneous injection of 10 mL of bupivacaine hydrochloride (HCl) 0.5% while Group B only received the IV diclofenac without the bupivacaine injection. The postoperative pain was assessed at one, two, three, six, and 12 hrs after the operation using the visual analog scale (VAS), which exhibited a range of pain from zero (no pain) to 10 (extreme pain).

Results

Of a total of 104 patients, 92% of patients were male. The patients' mean age was 36 ± 11 years, and the mean body mass index (BMI) was 22 ±3 kg/m². American Society of Anesthesiologists physical class I was similar in both groups (90.4% versus 84.6%). Patients in Group A had significantly lower VAS pain scores at one, two, three, six, and 12 hrs after the operation and a longer emergence time than Group B (all p-values were < 0.001). Subcutaneous bupivacaine infiltration and IV diclofenac were also found to be an effective analgesic technique in open hernia repair with mesh (p-value < 0.001 for all).

Conclusion

Subcutaneous injection of bupivacaine combined with IV diclofenac provides superior analgesia to monotherapy intravenous diclofenac after inguinal hernia repair.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence

BACKGROUND

The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery.

METHODS

The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors' agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design.

RESULTS

The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review.

CONCLUSIONS

The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a "blended approach" which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative "stress hormones", and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

Background and objectives

Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy and selection criteria

Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results

Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions

Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

Efficacy of local infiltration analgesia with ropivacaine for postoperative pain management in cervical laminoplasty: a retrospective study

Poor postoperative pain control impairs patient recovery and lengthens the duration of hospitalization after various surgeries. Local infiltration analgesia(LIA) has become an effective method for managing postoperative pain. This study aimed to investigate the efficacy of LIA with ropivacaine for postoperative pain control after cervical laminoplasty. In total, 68 patients undergoing cervical laminoplasty were included for retrospective review and divided into ropivacaine and control groups. The visual analogue scale (VAS) score, postoperative analgesic consumption, operative duration, intraoperative blood loss volume, incision length, hospitalization duration and incidence of complications were analyzed. In the ropivacaine group, the VAS score was 3.2 ± 1.4 at 4 hours postoperatively, which was lower than that of the control group(4.0 ± 1.4, P = 0.024). At 8, 12 and 24 hours after surgery, a significant difference was detected in the VAS score between the two groups(P ≤ 0.015). Sufentanil consumption was less in the ropivacaine group than in the control group in the first 4 hours postoperatively (25.6 ± 6.3 µg vs 32.2 ± 6.8 µg, P < 0.001), and similar results were observed in the first 8, 12, 24, 48 and 72 hours postoperatively(P < 0.001). Fewer patients required rescue analgesia in the ropivacaine group(8/33 vs 18/35 at 4–8 hours, P = 0.021; 9/33 vs 21/35 at 8–12 hours, P = 0.007). The hospitalization duration and time to ambulation were shorter in the ropivacaine group(8.5 ± 1.4 vs 9.6 ± 1.6 for postoperative duration, P = 0.002; 2.9 ± 0.7 vs 3.5 ± 0.8 for time to ambulation, P = 0.001). The incidence of nausea and vomiting was lower in the ropivacaine group than in the control group(30.3% vs 54.3%, P = 0.046). In conclusion, LIA with ropivacaine could effectively reduce postoperative pain, and postoperative analgesic consumption, and promote recovery after cervical laminoplasty.

The combination of transversus abdominis plane block and rectus sheath block reduced postoperative pain after splenectomy: a randomized trial

Background

Splenectomy performed with a curved incision results in severe postoperative pain. The aim of this study was to evaluate the effect of transversus abdominis plane block and rectus sheath block on postoperative pain relief and recovery.

Methods

A total of 150 patients were randomized into the control (C), levobupivacaine (L) and levobupivacaine/morphine (LM) groups. The patients in the C group received only patient-controlled analgesia. The patients in the L and LM groups received transversus abdominis plane block and rectus sheath block with levobupivacaine or levobupivacaine plus morphine. The intraoperative opioid consumption; postoperative pain score; time to first analgesic use; postoperative recovery data, including the times of first exhaust, defecation, oral intake and off-bed activity; the incidence of postoperative nausea and vomiting and antiemetics use; and the satisfaction score were recorded.

Results

Transversus abdominis plane block and rectus sheath block reduced intraoperative opioid consumption. The patients in the LM group showed lower postoperative pain scores, opioid consumption, postoperative nausea and vomiting incidence and antiemetic use and presented shorter recovery times and higher satisfaction scores.

Conclusions

The combination of transversus abdominis plane block and rectus sheath block with levobupivacaine and morphine can improve postoperative pain relief, reduce the consumption of analgesics, and partly accelerate postoperative recovery.

Trial registration

Chinese Clinical Trial Registry, ChiCTR 1,800,015,141, 10 March 2018.

Analgesic effect of parecoxib combined with ropivacaine in patients undergoing laparoscopic hepatectomy

BACKGROUND

Currently, there is no uniform standard for analgesia during laparoscopic hepatectomy. Most of the analgesia schemes adopt epidural analgesia after laparotomy. Although the analgesia is effective, it has a great impact on the recovery of patients after laparoscopic hepatectomy and is not completely suitable for analgesia after laparoscopic hepatectomy. Although multimodal perioperative analgesia can significantly relieve postoperative pain, there is no relevant study of parecoxib combined with ropivacaine for post-laparoscopic hepatectomy analgesia.

AIM

To study the analgesic effect of the preoperative intravenous injection of parecoxib combined with long-acting local anesthetic ropivacaine for incision infiltration in patients undergoing laparoscopic hepatectomy.

METHODS

Forty-eight patients undergoing laparoscopic hepatectomy were randomly divided into a combined group (parecoxib combined with ropivacaine) and a control group. The visual analogue scale (VAS) at rest and during movement was used to compare the analgesic effect of the two groups. Meanwhile, the cumulative sufentanil, the recovery time for enterokinesia, the length of postoperative hospital stay, and the adverse reactions (nausea and vomiting) were recorded and compared between the two groups.

RESULTS

The change tendency in VAS scores for both groups was similar after operation. At rest, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, 24 and 36 h, and during movement, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, and 24 h. The recovery time for enterokinesia in the combined group was 2.9 d, which was significantly shorter than that in the control group. The cumulative sufentanil in the combined group decreased significantly at 24, 36, and 48 h after operation.

CONCLUSION

Preoperative intravenous injection of parecoxib combined with ropivacaine for incision infiltration is a simple and effective method for postoperative analgesia in laparoscopic hepatectomy, which could relieve pain and promote recovery.

Overlay of a sponge soaked with ropivacaine and multisite infiltration analgesia result in faster recovery after laparoscopic hepatectomy

BACKGROUND

Compared with traditional open surgery, laparoscopic surgery is preferred due to the advantages of less trauma, less pain, and faster recovery. Nevertheless, many patients still suffer from postoperative pain resulting from the surgical incision and associated tissue injury. Many researchers have reported methods to improve postoperative pain control, but there is not a simple and effective method that can be clinically adopted in a widespread manner. We designed this study to prove the hypothesis that application of ropivacaine in the port site and operative site in patients is an effective and convenient method which can decrease postoperative pain and accelerate recovery.

AIM

To evaluate the effects of ropivacaine on pain control after laparoscopic hepatectomy and its contribution to patient recovery.

METHODS

From May 2017 to November 2018, 146 patients undergoing laparoscopic hepatectomy were randomized to receive infiltration of either 7.5 mg/mL ropivacaine around the trocar insertions, incision, and cutting surface of the liver (with a gelatin sponge soaked with ropivacaine) at the end of surgery (ropivacaine group), or normal saline (5 mL) at the same sites at the end of surgery (control group). The degree of pain, nausea, vomiting, heart rate (HR), and blood pressure were collected. The length of postoperative hospitalization, complications, and the levels of stress hormones were also compared between the two groups.

RESULTS

Compared with the control group, the ropivacaine group showed reduced postoperative pain at rest within 12 h (P < 0.05), and pain on movement was reduced within 48 h. The levels of epinephrine, norepinephrine, and cortisol at 24 and 48 h, HR, blood pressure, and cumulative sufentanil consumption in the ropivacaine group were significantly lower than those in the control group (P < 0.05). In the ropivacaine group, hospitalization after operation was shorter, but the difference was not statistically significant. There were no significant differences in postoperative nausea, vomiting, or other complications, including hydrothorax, ascites, peritonitis, flatulence, and venous thrombus (P > 0.05), although fewer patients in the ropivacaine group experienced these situations.

CONCLUSION

Infiltration with ropivacaine in the abdominal wound and covering the cutting surface of the liver with a gelatin sponge soaked with ropivacaine significantly reduce postoperative pain and the consumption of sufentanil.

Local Wound Infiltration with Ropivacaine for Postoperative Pain Control in Caesarean Section

Background

The rate of the caesarean section has been on a progressive rise ever since its association with improved fetal prognosis was established. This study was conducted to assess the effect of local wound infiltration with ropivacaine on the postoperative analgesia requirement and pain scores in caesarean section patients.

Methods

This was a prospective single-blinded randomized control trial conducted at the Department of Obstetrics and Gynecology, KRL Hospital, Islamabad, Pakistan over a duration of six months from January 2018 to June 2018. All the women aged 19 to 40 years, who underwent elective caesarean sections under spinal anesthesia, with American Society of Anesthesiologists (ASA) score II, were included in the study and randomized into two groups. The primary outcome studied was the efficacy of ropivacaine in controlling postoperative wound pain compared to no local analgesic. Pain severity was assessed using the visual analog scale (VAS) which was explained to the patient beforehand and which comprised a range of score from zero (no pain) to 10 (worst pain imaginable). Initially, paracetamol 1 g intravenous (IV) was given every six hours, over 24 hours. If pain did not settle on this, ketoprofen 3 mg/kg IV was given every eight hours, and in case of further analgesic demand by the patient, nalbuphine 10 mg was given IV, if necessary. The data was collected on a specific questionnaire and analyzed on the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 23.0. A p-value of less than 0.05 was considered significant.

Results

A total of 100 patients were randomized into two groups. Pain scores were significantly reduced in the ropivacaine group at four, six, and 12 hours after surgery. The percentage of patients who requested the multiple doses of IV paracetamol, ketoprofen, and nalbuphine, was significantly lowered in the ropivacaine group as compared to the placebo group (p<0.001).

Conclusions

Local infiltration with ropivacaine during caesarean section significantly reduces the postoperative analgesic requirement and visual analog scores, reducing the incidence of side effects.

Efficacy of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia in abdominal surgery: A meta-analysis of randomised controlled trials

To assess the efficacy and safety of dexmedetomidine (DEX) as an adjuvant to local wound infiltration anaesthesia in abdominal surgery, we conducted this meta-analysis. First, the systematic search strategy was performed on PubMed, Embase, and Cochrane Library and five randomised controlled trials (RCTs) involving 294 patients were included. Then, the outcome data were extracted from the studies and their effect sizes were calculated using Review Manager 5. As a result, the addition of DEX significantly reduced visual analogy scores at 6 hours after surgery (mean difference = -0.53[-0.82, -0.25], P < .001), 12 hours after surgery (mean difference = -0.39 [-0.73, -0.05]; P = .03), and 24 hours after surgery (mean difference = -0.20 [-0.29, -0.11], P < .001) and reduced total analgesic consumption within 24 hours after surgery (mean difference = -4.92 [-9.00, -0.84]; P = .02) compared with placebo groups. However, there was no difference in the incidence of postoperative nausea and vomiting (risk ratio = 0.68 [0.41, 1.14]; P = .14). In summary, DEX as a local anaesthetic adjuvant added for local wound infiltration anaesthesia in abdominal surgery could reduce visual analogy scores and postoperative analgesic consumption without changing incidence of postoperative nausea and vomiting.

A 96-hour continuous wound infiltration with ropivacaine reduces analgesic consumption after liver resection: A randomized, double-blind, controlled trial

BACKGROUND

Continuous wound infiltration (CWI) with local anesthetics to reduce morphine consumption in postoperative pain management after open liver resection in patients with cancer.

METHODS

This single-center randomized double-blind study allocated patients requiring resection of liver metastases to receive a 3.75 mg/mL ropivacaine (ROP) infiltration, followed by a 2 mg/mL ROP CWI, or placebo (P) for 96 hours. Postoperative analgesia included acetaminophen and patient-controlled analgesia morphine pump. The primary endpoint was to investigate the reduction of total morphine consumption (mg/kg) over the first 96 postoperative hours.

RESULTS

Eighty-five patients were recruited, and randomized (ROP: 42, P: 43) between 2009 and 2014. The median morphine consumption significantly decreased in the ROP arm in the first 96 postoperative hours (ROP: 1.0, P: 1.5 mg/kg; P = 0.026). Twenty-three (27%) patients had grade 3 adverse events (ROP: 14, P: 9) and four experienced grade 3 treatment-related adverse events (ROP: mental confusion [n = 1], hallucinations [n = 2], P: hematoma [n = 1]). Two (5%) patients showed a wound inflammation (ROP: 1, P: 1). Nine (11%) patients experienced at least one serious adverse event (ROP: 6, P: 3); none related to treatment.

CONCLUSION

Preperitoneal CWI of 2 mg/mL ROP significantly reduces intravenous morphine consumption during the 96 postoperative hours resulting in an absolute reduction of 0.5 mg/kg.