Continuous Local Infusion Research Articles

A Prospective, Randomized, Double-Blind, Controlled Trial of Continuous Local Anesthetic Infusion in Cosmetic Breast Augmentation

A Prospective, Randomized, Double-Blind, Controlled Trial of Continuous Local Anesthetic Infusion in Cosmetic Breast Augmentation

A Prospective, Randomized, Double-Blind, Controlled Trial of Continuous Local Anesthetic Infusion in Cosmetic Breast Augmentation

A Prospective, Randomized, Double-Blind, Controlled Trial of Continuous Local Anesthetic Infusion in Cosmetic Breast Augmentation

Chondrolysis of the Glenohumeral Joint (SS-23)

Chondrolysis has become a recognized complication of arthroscopic procedures. We present 18 patients who developed chondrolysis of the glenohumeral joint following arthroscopic shoulder surgery. All 18 patients had a labral stabilization procedure and received an intra-articular pain pump catheter (IAPPC) for post-operative pain control. The IAPPC's were loaded with 0.5% bupivacaine with epinephrine to provide a continuous infusion of local anaesthetic into the joint. We suspect the continuous infusion of bupivacaine may have contributed to the development of chondrolysis. We caution against the use of IAPPC's until their safety has been proven. Two orthopaedic surgeons identified 18 patients who developed glenohumeral chondrolysis following arthroscopic shoulder surgery. The index surgery for all 18 patients occurred over an 18 month period. We sought to find any common factors among the 18 cases. A retrospective chart review of all 18 patients was performed. We gathered information on patient demographics, type of surgical procedure, nature of shoulder instability, post-operative complications such as infection, the use of radiofrequency energy, the type/number of suture anchors, the use of an IAPPC and the type of local anaesthetic used. We compared pre-operative radiographs and MRI scans to the intra-operative findings from the operative report to confirm that no chondrolysis was present pre-operatively. We examined post-operative radiographs and MRI scans to document the extent of chondrolysis. Of the 18 patients who developed chondrolysis, we had 15 males and 3 females with an average age of 23 years (range 16-39). 17 patients had shoulder instability due to a definitive traumatic event while 1 patient had an atraumatic etiology. No radiofrequency energy was used in any of the cases. No post-operative infections were diagnosed and many had work-ups for infection which included ESR, CRP, bone & gallium/WBC scans. All patients had labral stabilization procedures, 15 anterior (Bankart), 1 posterior, and 2 combinations. All patients received suture anchors, 13 patients had 2 anchors and 5 had 3 anchors. 2 different manufacturer's suture anchors were used, 10 patients received Smith & Nephew anchors while 8 patients received Linvatec anchors. 10 patients received bioabsorbable anchors and 8 patients received metal anchors. All patients received an IAPPC loaded with 0.5% bupivacaine with epinephrine for post-operative pain control. 15 of the IAPPC's were considered large with an infusion rate of 5 mL/hr and a fill volume of 275 mL. 3 IAPPC's were considered small with an infusion rate of 2 mL/hr and a fill volume of 100 mL. We suspect a continuous intra-articular infusion of bupivacaine with epinephrine may have contributed to the development of glenohumeral chondrolysis. We caution against the use of IAPPC's until their safety has been proven.

Preemptive Antihyperalgesia to Improve Preemptive Analgesia

Preemptive Antihyperalgesia to Improve Preemptive Analgesia

A Prospective, Randomized, Double-Blind, Controlled Trial of Continuous Local Anesthetic Infusion in Cosmetic Breast Augmentation

Narcotic pain medications are a significant component of most postoperative pain control regimens. Although they are usually effective, they produce several untoward side effects and sometimes provide inadequate analgesia. The continuous infusion of local anesthetic agents (via pain pump) has been used to supplement narcotic analgesics after various surgical procedures. The purpose of this study was to examine the effectiveness of the pain pump after cosmetic breast augmentation. Twenty-five women were enrolled in the study; five were eliminated from analysis because of data inadequacy or device problems. After bilateral augmentation, the remaining 20 patients received a 4-day continuous infusion of bupivacaine in one breast pocket and saline in the other. Laterality of bupivacaine infusion was randomized and blinded to both the patient and the surgeon. Patients completed a questionnaire on postoperative days 1, 2, 3, 4, and 7, rating their pain on a scale of 0 to 10, with 10 being worst. On postoperative day 1, the mean pain score was 4.7 on the bupivacaine side versus 5.4 on the saline side (p = 0.36). On postoperative days 2, 3, 4, and 7, the mean scores were 4.3 versus 4.6 (p = 0.63), 3.3 versus 3.8 (p = 0.50), 3.4 versus 3.6 (p = 0.78), and 3.4 versus 3.1 (p = 0.63) for the bupivacaine and saline sides, respectively. The pain pump appears to provide breast augmentation patients marginal improvement in pain control, although this advantage did not reach statistical significance in this study. The benefit, if real, also appears to wane over the first postoperative week.

Postoperative Continuous Paravertebral Anesthetic Infusion for Pain Control in Lumbar Spinal Fusion Surgery

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. 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. 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. 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. 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. 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.

Regional Anesthesia for Postoperative Pain Control in Children

Regional anesthesia is widely employed for postoperative pain control in both adults and children. Central or perineural approaches can be performed as a bolus injection or as a continuous infusion of local anesthetics. However, bolus injections, even with the addition of adjuvants, are inadequate for prolonged surgery and long-term pain control. Continuous infusion remains the technique of choice when there is a prolonged operation or intense postoperative pain. This article reviews the safety and efficacy of central and perineural continuous infusions for postoperative pain control in children. The literature confirms the very low rate of complications and adverse effects of regional anesthesia in children. However, clinicians need to be aware of the key points for performing a block and placing a catheter in children: good knowledge of anatomic and physiologic differences between adults and children is necessary; the use of newer local anesthetics, such as ropivacaine and levobupivacaine, increases the therapeutic window; and that it is mandatory to work with dedicated pediatric equipment. Through the use of new techniques such as nerve mapping and/or ultrasound the success of blocks can be improved and the risks reduced.

Safe, Cost-Effective Pain Control Using a Continuous Local Anesthetic Infusion Pump after an Abdominoplasty

Safe, Cost-Effective Pain Control Using a Continuous Local Anesthetic Infusion Pump after an Abdominoplasty

A Prospective, Randomized, Double-Blind Study of the Efficacy of Postoperative Continuous Local Anesthetic Infusion at the Iliac Crest Bone Graft Site After Posterior Spinal Arthrodesis

Parallel design, prospective, double-blinded, randomized, controlled trial composed of 2 independent groups treated with a continuous infusion catheter (saline vs. Marcain) placed into the iliac crest bone graft site (ICBG). To determine the long-term effects of postoperative continuous local anesthetic agent infusion at the ICBG harvest site in reducing chronic pain, narcotic usage and improving long-term, postoperative function and satisfaction with the surgical procedure. Harvesting iliac crest bone has been shown to be a source of pain and morbidity. In our initial study, we reported that patients who received local anesthetic at the graft site noted a reduction in acute postoperative pain (VAS) and narcotic usage. METHODS.: Twenty-six patients underwent posterior iliac crest bone graft harvesting. Patients were randomly assigned to receive 96 mL (2 mL/h x 48 hours) of either 0.5% Marcain or normal saline delivered via a continuous infusion catheter placed at the ICBG harvest site. Postoperative pain scores, narcotic use/frequency, activity level, and length of stay (LOS) were recorded and reported previously. At a minimum of 4 years after surgery (mean, 4.7 years; range, 4.5-5.4 years), all patients completed a questionnaire documenting their current VAS pain score (iliac crest), frequency of pain (days per month), level of activity, chronic pain at the ICBG site, and overall satisfaction with the procedure. Nine of 11 patients (82%) in the treatment group and 10 of 14 patients (71%) in the control group were available at final follow-up (1 death occurred in the control group unrelated to the study). The treatment group had a statistically significant decrease in the graft site pain VAS score (1.4 vs. 4.8) and increased satisfaction with the procedure at a minimum of 4 years postprocedure (P < 0.05). Additionally, no patient in the treatment group developed chronic iliac crest dysesthesias (0 of 9) versus 7 of 10 patients (70%) in the control group (P < 0.05). Continuous infusion of 0.5% Marcain at the ICBG harvest site significantly reduced chronic dysesthesias. Overall satisfaction with the procedure, number of painful days per month, and VAS scores were significantly better in the treatment group at 4 years. No long-term complications were attributed to either the ICBG site or the catheter-infusion system. The use of continuous local anesthetic infusion at the iliac crest may help in alleviating graft-related pain beyond the perioperative phase.

Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Under Epidural Anesthesia: A Detailed Evaluation

After reading the article, Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Under Epidural Anesthesia: A Detailed Evaluation, by Lal et al. [3], we have a few comments and suggestions about the techniques they practice. At our institution, we perform surgical procedures such as off-pump coronary artery bypass surgery, upper abdominal surgeries, and laparoscopic surgeries with the patient under thoracic epidural anesthesia (TEA). We have performed more than 2,000 cardiac surgeries with concomitant use of TEA [2]. We also have performed cardiac surgeries using TEA as the sole anesthetic [1]. In recent months, we have performed a few laparoscopic procedures including cholecystectomy and diagnostic laparoscopy (without endotracheal intubation). We share our experience performing laparoscopic procedures with the patient under TEA. As mentioned rightly by the authors, a block from T6 to L5 is necessary. To achieve a large block via a lumbar epidural procedure, large doses of a local anesthetic agent are required, exposing the patient to the possible hazard of its toxicity. The authors do not mention the quantity of the local anesthetic used to achieve this block. We usually insert a catheter at the thoracic 8 or 9 level. We achieve the required block initially by administering approximately 6 to 8 ml of the said local anesthetic and set up an infusion of the same local anesthetic at a rate of 5 ml/h. Because of the epidural catheter’s proximity to the zone of analgesia, the total amount of local anesthetic we use for a 2-h surgery is about 12 to 15 ml of 0.5% bupivacaine. We are of the opinion that a continuous infusion of local anesthetic is necessary to prevent inadvertent muscle recovery, which makes working conditions suboptimal for the operating surgeon and sometimes may be a cause for conversion to general anesthesia. In our experience, shoulder tip pain seems to be one of the unmanageable hassles during awake laparoscopic surgeries. Unfortunately, the authors do not suggest management of this issue. We have a few suggestions, which include spraying 0.06% bupivacaine on the peritoneum over the diaphragm via one of the ports and ‘‘painting’’ the diaphragm with a gauze piece soaked in the same concentration of bupivacaine. By these maneuvers, the pain can be alleviated to some extent. In our view, shoulder tip pain becomes a cause for conversion to general anesthesia. From our experience of awake cardiac surgical practice, we have learned that a transparent mask can be strapped onto the patient’s face by a harness. This allows us to assess and assist the patient’s ventilation. At times, after insufflation of the peritoneum with carbon dioxide, a few patients experience dyspnea. Administration of continuous positive pressure ventilation may optimize ventilatory parameters (tidal volume and end-tidal carbon dioxide). Application of this mask helps us measure end-tidal carbon dioxide. Some laparoscopic surgeons wish to use a nasogastric tube in situ. It may be prudent to pass it well in advance of surgery rather than to insert it on the operating table. Ultimately, it is needless to mention that the operating surgeon should be able to adapt himor herself to the consequences of spontaneous respiratory movements. We are of the opinion that this technique is not for novices (Fig. 1). M. C. M. Bhat (&) Department of Minimal Access Surgery, Wockhardt Hospitals, Bangalore, India e-mail: chakravarthy@gmail.com

Continuous local infusion of fibroblast growth factor-2 enhances consolidation of the bone segment lengthened by distraction osteogenesis in rabbit experiment

Experimental tibial lengthening was achieved in 61 rabbits to examine the effect of continuous local infusion of recombinant human fibroblast growth factor-2 (rhFGF-2) on bone healing of the lengthened segment. The tibial diaphysis was separated by osteotomy and was subjected to slow progressive distraction (rate: 0.35 mm/12 h) using a monolateral external fixator. There were a lag phase for 1 week, a distraction phase for 2 weeks, and a consolidation phase for 5 weeks in this experiment. At various stages of distraction, rhFGF-2 was infused continuously for 2 weeks into the lengthened segment (rate: 14.28 μg/60 μl/day) using an osmotic pump implanted under the skin. Bone healing was significantly accelerated when rhFGF-2 was infused in the beginning of consolidation phase, but not in the distraction phase or in the lag phase. Infusion of normal saline (N/S) using the same osmotic pump had no effect. Dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computerized tomography (pQCT) studies demonstrated that rhFGF-2-treated tibia had increased bone mineral density (BMD), bone mineral content (BMC) and cortical bone thickness (CBT) when compared with N/S-treated tibia. Three-point bending test demonstrated that rhFGF-2-treated bone had significantly stronger mechanical properties than N/S-treated bone. Finally, distribution of the infused materials was checked by using Indian ink or radio-opaque. The dyes distributed widely but exclusively in the lengthened segment. Based on these results, we conclude that direct delivery of rhFGF-2 into the lengthened segment can shorten the consolidation phase of limb lengthening and the method is applicable to the clinical treatment.

Continuous Local Anesthetic Wound Infusion to Improve Postoperative Outcome

Continuous Local Anesthetic Wound Infusion to Improve Postoperative Outcome

126. Prospective, Randomized, Double Blind Study of the Efficacy of Post-operative Continuous Local Anesthetic Infusion at the Iliac Crest Bone Graft Site after Posterior Spinal Fusion: Four-year Follow-up

BACKGROUND CONTEXT: Harvesting iliac crest bone has been shown to be a source of pain and morbidity. In our initial study, we reported that patients who received local anesthetic at the graft site noted a reduction in acute postoperative pain (VAS) and narcotic usage (Singh et al., Spine 2005).

Anesthetic management of labor in a patient with congenitally corrected transposition of the great arteries

Laboring patients with congenitally corrected transposition of the great arteries present an interesting challenge to anesthesiologists because of the physiological changes that take place during pregnancy and the stress induced by labor. This paper describes the detailed management of a symptomatic parturient with congenitally corrected transposition of the great arteries. The patient was managed with epidural analgesia instituted early in labor with a continuous low-concentration infusion of local anesthetic and opioid but without an initial bolus. She underwent uneventful forceps-assisted vaginal delivery.

Anaesthesia for Hemipelvectomy—A Series of 49 Cases

We undertook an audit of 49 consecutive hemipelvectomies performed for primary or secondary malignancy. Combined epidural and general anaesthesia was used in 41 patients. The operations were long (range 90 to 600 minutes). The median crystalloid requirement was 8500 ml (range 1000 to 42000 ml) and a median of seven units of packed red blood cells were transfused (range 0 to 44 units). All measures of coagulation were normalised by the first postoperative day using fresh frozen plasma, platelets and cryoprecipitate. Warmed blood was administered at high flow rates using a custom designed system consisting of a roller pump and high capacity fluid warmer Thirty-five patients were managed postoperatively in the intensive care unit, of whom 31 remained intubated for postoperative ventilation. In 41 patients, postoperative pain management was by a continuous epidural infusion of local anaesthetic and opioid. The average duration of infusion was 4.25 days (range 3 to 6 days). One patient died during surgery from complications relating to massive blood loss, 14 had wound infections and one had an acute brain syndrome. There was significant utilisation of resources involving anaesthesia, surgery, intensive care and blood transfusion services. Anaesthesia for hemipelvectomy is challenging because of the extensive tissue trauma involved, the potential for massive blood loss and the potential for severe postoperative pain. The perioperative management necessitates care from a well coordinated, directed and focused healthcare team.

Continuous Perineural Block of the Palmar Nerves: A New Technique for Pain Relief in the Distal Equine Forelimb

Pain therapy is an important aspect of equine orthopedic and trauma surgery. Although long-term epidural analgesia has become an almost routine method of treatment for painful conditions in the horse’s hind limb, a similarly effective technique for management of pain originating in the horse’s front limb has not yet been developed. Continuous perineural nerve block (CPNB) is a method that entails continuous low-volume infusion of local anesthetics via catheters placed along peripheral nerves. This technique has gained much popularity in human medicine and is currently applied with great success for treatment of perioperative pain in upper and lower extremities. Recently, both in vitro and in vivo experiments were conducted to adopt this treatment method to the horse by developing a simple and reproducible technique for placing in standing, sedated horses CPNB catheters along peripheral nerves in the forelimb. Simultaneously, the analgesic efficacy of CPNB with low-volume local anesthetic infusion without significantly affecting systemic health was evaluated. The present report outlines a continuous palmar nerve block technique suitable for pain therapy in the horse. Anatomic landmarks and a technique for safe placement of catheters along the lateral and medial palmar nerves including sedation and local anesthetic protocols are described in detail, as are local anesthetic drug regimens for effective CPNB. Furthermore, special precautions and potential complications are addressed, followed by a brief clinical case report that demonstrates the potential of the described CPNB technique to provide sustained pain relief in the lower forelimb of horses suffering from severely painful conditions.

Postoperative pain management for shoulder arthroscopy in ambulatory surgery: comparation between single injection or continuous perineural infusion of local anesthetic

Postoperative pain management for shoulder arthroscopy in ambulatory surgery: comparation between single injection or continuous perineural infusion of local anesthetic

Pediatric regional anesthesia – update

New topics in pediatric regional anesthesia are discussed. Continuous peripheral nerve blocks, new local anesthetics and the performance of regional blocks with ultrasonography guidance are summarized. Prolonged analgesia with continuous peripheral nerve blocks in the treatment of pediatric postoperative limb pain, sometimes with patient-controlled regional analgesia, should be preferred instead of continuous epidural analgesia. Levobupivacaine and ropivacaine display the same pharmacokinetic profile as racemic bupivacaine with less cardiac toxicity. Conversely, continuous infusion of these new local anesthetics offers the safest therapeutic index, especially in infants. Many adjuvants have been used, but clonidine offers clear advantages. Ultrasonography guidance blocks will probably become the reference technique for local anesthetics injection and regional anesthesia catheter placement; new training in this field should be available.

Innovations in Postoperative Pain Management: Continuous Infusion of Local Anesthetics

Patients and health care providers alike struggle with alleviating postoperative pain. Patients with unrelieved pain are less likely to cough, breathe deeply, or move easily after surgery, which adversely affects their recovery. Innovations in technology, such as continuous infusion of local anesthetics, have revolutionized postoperative pain management. Technological improvements in needles, catheter insertion techniques, and effortless drug delivery systems are facilitating prolonged analgesia with few adverse effects, increasing patient satisfaction, and expediting postoperative recovery.

Thoracic Epidural Used In The Emergency Department To Reduce Pain In A Patient With Multiple Rib Fractures: A Case Report

Multiple rib fractures cause considerable pain that can seriously compromise respiratory mechanics and exacerbate underlying lung injury, predisposing to respiratory failure. Management of the patient with chest wall injury is directed allowing adequate oxygenation and ventilation. Multiple rib fractures due to blunt trauma to the chest wall as the result of assault, falls or motor vehicle accidents is a common presentation to the Emergency Department. Analgesia remains the mainstay of therapy for rib fractures. Opioid analgesics are useful but may cause respiratory depression if used in high doses. Continuous epidural infusion of local anaesthetic is a good option for treating patients with multiple rib fractures allowing improved inspiration and coughing without the risk of respiratory depression. We report such a case and discuss the subsequent clinical course and management.