Liposomal Bupivacaine Infiltration Research Articles

Use of liposomal bupivacaine in cats undergoing gastrointestinal surgery is associated with lower doses of full µ-opioid agonists postoperatively

Objectives The aim of the study was to analyze the association of the administration of liposomal bupivacaine (Nocita) with postoperative opioid use in cats undergoing gastrointestinal surgery, as well as to analyze the administration of antiemetics postoperatively in this study population to qualify the degree of nausea related to opioid administration. Methods Records of 187 cats undergoing gastrointestinal surgery across two institutions, the Matthew J Ryan Veterinary Hospital at the University of Pennsylvania and the University of Florida Small Animal Hospital, were analyzed for multilayer liposomal bupivacaine infiltration at the time of abdominal closure, postoperative injectable opioid use and postoperative injectable antiemetic use. Results Cats that were administered liposomal bupivacaine at the time of abdominal closure received significantly lower doses of full µ-opioid agonists postoperatively. Significantly more cats that received liposomal bupivacaine were managed with full µ + partial µ-opioid agonists postoperatively than any other opioid profile. Cats that received liposomal bupivacaine received lower doses of ondansetron in hospital compared with cats that did not receive liposomal bupivacaine. Conclusions and relevance This study suggests that in cats requiring analgesia postoperatively, the use of liposomal bupivacaine at closure reduces the use of full µ-opioid agonists postoperatively. In addition, more patients that received liposomal bupivacaine were de-escalated from full µ-opioid agonists to partial µ-opioid agonists during their hospital stay, suggesting that less analgesia was required throughout their hospitalization. Lastly, lower doses of ondansetron, a typical second-line antinausea medication after gastrointestinal surgery, were used in cats that received liposomal bupivacaine, which may suggest less postoperative nausea.

Efficacy of Liposomal Bupivacaine in Managing Postoperative Pain in Foot and Ankle Surgeries: A Prospective Randomized Blinded Controlled Study

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Surgeons’ response to the nationwide opioid epidemic has included using alternatives to narcotic pain medications. Regional anesthesia has provided options to reduce narcotic consumption after surgery. Liposomal Bupivacaine (LB) is not FDA approved for use in nerve blocks in the lower extremity, though it is approved for more dangerous blocks (interscalene for example) in the upper extremity. The literature on LB in foot and ankle surgery has been limited to local infiltration and no major study has explored its efficacy when used in lower extremity peripheral nerve blocks. In this study, we compare local LB infiltration with LB used in peripheral nerve blocks in the lower extremity and compare both of these techniques with the current standard of care, a non-LB peripheral nerve block. Methods: All patients undergoing surgery in a single surgeon foot and ankle practice were enrolled in this IRB approved, prospective, randomized controlled study. Patients having surgery between January 2022 – January 2023 were randomized to one of three study arms: Group 1 Anesthesia administered ultrasound guided nerve block with local anesthetic only, Group 2 Anesthesia administered ultrasound guided nerve block with LB/local only mix, or Group 3 Surgeon administered infiltrative field block with LB/local mix. The primary outcomes collected included the amount of narcotic pain medication required in the PACU, oral morphine equivalents (OME) up to postoperative day 4 and after postoperative day 4, subjective duration of nerve block, and patient reported outcomes (PROMIS Pain Interference/Depression/Physical Function). Collection was obtained via chart review from hospital EMR, and phone calls made to patients during specific time intervals after surgery. Analysis was performed utilizing GraphPad Prism (Ver 9.0, GraphPad Software, San Diego CA USA). Results: After exclusion of 110 patients, 248 patients met inclusion criteria. Ninety-eight underwent perineural popliteal or popliteal adductor block with LB/local mix, 70 underwent popliteal or popliteal adductor block with local only (Group 2), 80 underwent surgeon administered local field block with LB/local mix (Group 3). Median PACU morphine equivalents required for pain control were significantly lower in Groups 1 and 2 (0 OME) compared to local field block (7.5 OME) (p < 0.05). Median OME utilized up to POD 4 and median OME utilized after POD 4 were both significantly lower in the LB/local mix perineural block group (p < 0.05) compared to Groups 2 and 3. Duration of block effect was significantly higher in the LB/local mix group compared to Groups 2 and 3 (p < 0.05). Conclusion: Preoperative perineural blocks containing a mix of LB and local anesthetic significantly reduce PACU, early postoperative, and mid postoperative narcotic use of patients undergoing outpatient foot and ankle surgery. The duration of effect of perineural block is significantly extended with addition of LB to the block mixture. Consideration should be given to the use of LB blocks in foot and ankle surgical procedures to reduce patient postoperative narcotic requirements.

Risk factors of liposomal bupivacaine failure in managing postoperative pain following shoulder surgery

BackgroundAmidst a national opioid crisis, increased focus has been placed on reducing opioid consumption. Novel multimodal pain protocols including the use of liposomal bupivacaine (LB) have shown success in minimizing opioid usage after orthopedic surgery. There is disputing evidence of the effectiveness of LB use in shoulder surgery and the purpose of our study was to analyze the risk factors and determinants of LB failure for postoperative pain control after orthopedic shoulder surgeries. MethodsA retrospective review of 121 patients undergoing shoulder surgery treated by 2 fellowship-trained shoulder surgeons at a single institution was performed from 2018-2020. All patients received a standardized multimodal pain management protocol that included an LB interscalene block. Local infiltration of LB was also administered at closure. Visual analog scales (VASs) were administered at 24, 48, 72 hours, and 7 days postoperatively. LB failure was defined as visual analog scale score >7 any time within the 7-day postoperative period. Twenty-one patients were included in the liposomal bupivacaine failure (LBF) group and 100 in the liposomal bupivacaine success (LBS) group. Patient demographics, pain scores, and opioid consumption were compared between groups. ResultsBaseline characteristics were comparable, except the LBF cohort had a greater proportion of females (P = .03). The LBF group had 20% of patients with a history of chronic opioid use compared to none in the LBS group (P = .003). Logistic regression showed strong and independent associations between failure of LB and performing surgeon, chronic opioid use, gender, and history of prior surgery. Patients in the LBF group had an average of 20 total morphine equivalents 7-14 days following surgery compared to 0 total morphine equivalents (P = .002) in the LBS group, and an average of 2.9 opioid prescriptions within the first 6 months compared to 1.7 in the LBS group (P = .028). ConclusionPerforming surgeon, gender, history of opioid use, and prior surgeries were all identified as strong, independent predictor variables of LB failure. In this study, performing surgeon is likely indicative of the impact of differences in patient education on postoperative pain expectations and alternate treatments. We recommend that surgeons incorporate further preoperative patient education, and to take into account, the specific risk factors when deciding to incorporate LB into their multimodal postoperative pain management plan for patients undergoing shoulder surgery.

Incisional infiltration versus transversus abdominis plane block of liposomal bupivacaine after midline vertical laparotomy for suspected gynecologic malignancy: a pilot study

BackgroundTo evaluate whether incisional infiltration of liposomal bupivacaine would decrease opioid requirement and pain scores after midline vertical laparotomy for suspected or known gynecologic malignancy compared with transversus abdominis plane (TAP) block with liposomal bupivacaine. MethodsA prospective, single blind randomized controlled trial compared incisional infiltration of liposomal bupivacaine plus 0.5% bupivacaine versus TAP block with liposomal bupivacaine plus 0.5% bupivacaine. In the incisional infiltration group, patients received 266 mg free base liposomal bupivacaine with 150 mg bupivacaine hydrochloride. In the TAP block group, 266 mg free base bupivacaine with 150 mg bupivacaine hydrochloride was administered bilaterally. The primary outcome was total opioid use during the first 48-hour postoperative period. Secondary outcomes included pain scores at rest and with exertion at 2, 6, 12, 24 and 48 h after surgery. ResultsForty three patients were evaluated. After interim analysis, a three-fold higher sample size than originally calculated was required to detect a statistically significant difference. There was no clinical difference between the two arms in mean opioid requirement (morphine milligram equivalents) for the first 48 h after surgery (59.9 vs. 80.8, p = 0.13). There were no differences in pain scores at rest or with exertion between the two groups at pre-specified time intervals. ConclusionIn this pilot study, incisional infiltration of liposomal bupivacaine and TAP block with liposomal bupivacaine demonstrated clinically similar opioid requirement after gynecologic laparotomy for suspected or known gynecologic cancer. Given the underpowered study, these findings cannot support the superiority of either modality after open gynecologic surgery.

The Role of Liposomal Bupivacaine in Multimodal Pain Management following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther with Less Opioids.

Retrospective controlled cohort. To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on post-surgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. Group A experienced significantly lower total opioid consumption compared to Group B (44.5mg vs. 70.2mg). Morphine use was lower in Group A on post operative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. III Retrospective controlled cohort.

Abdominal and robotic sacrocolpopexy costs following implementation of enhanced recovery after surgery.

To compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway. The present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost-to-charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30. For the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331-$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P=0.754), 30-day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P=0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P=0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001). Decreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

Comparison of Femoral Nerve Catheter, Adductor Canal Catheter, and Periarticular Liposomal Bupivacaine Infiltration for Postoperative Analgesia After Primary Total Knee Arthroplasty

BackgroundPeripheral nerve catheters are used to provide analgesia after total knee arthroplasty (TKA) and have been shown to decrease pain and opioid use, to facilitate participation with physical therapy (PT), and to hasten discharge. More recently, pericapsular infiltration using liposomal bupivacaine (LB) has been employed as an alternative analgesic approach. MethodsThis retrospective study compared outcomes for three analgesic approaches: femoral nerve catheter (FNC), adductor canal catheter (ACC), and intraoperative LB infiltration. The primary outcome was numeric rating scale (NRS) pain scores at 24 hours. Secondary outcomes included pain scores at 12, 36, and 48 hours, time-to-first opioid, cumulative opioid use, distance walked, and time-to-discharge. ResultsPain scores at 24 hours were significantly lower in both the ACC and FNC cohorts when compared to the LB cohort (3.1 versus 4.6 [P = .017] and 2.4 versus 4.6 [P < .0001]). The ACC and FNC groups did not differ significantly at that timepoint (P = .27). Similar comparisons were found at 12 and 36 hours, while at 48 hours the FNC group was superior. Time to first opioid and opioid consumption favored the ACC and FNC groups. Walking distance favored the ACC group. Both the ACC and LB groups had a faster time-to-discharge than the FNC group. ConclusionBoth ACCs and FNCs provided superior analgesia at 24 hours compared to LB, while being equivalent to each other. Pain scores at 12 hours and 36 hours as well as opioid consumption through 48 hours mirrored this finding. Although various differences were found between groups in terms of time-to-first analgesic, walking distance and time-to-discharge, the ACC approach appeared to optimally balance analgesia, ambulation, and time-to-discharge.

Optimizing the use of liposomal bupivacaine in shoulder arthroplasty

BackgroundShoulder arthroplasty (SA) is the fastest growing joint replacement surgery in the United States, and it has been estimated that postoperative pain management is not adequately controlled in up to 80% of patients. Liposomal bupivacaine (LB) has been included as part of the multimodal pain management that has shown promise in reducing pain, narcotic consumption, and hospital length of stay in SAs, but there has been some controversy regarding its efficacy in the literature. This may be due to lack of standardization across studies in the utilization of LB or the lack of efficacy of local LB infiltration. The purpose of this study was to identify whether there is an optimal dilution of LB required for maximal analgesia after SA in order to direct future literature and increase the strength of evidence for recommendations in clinical practice. MethodsA retrospective review of prospectively collected data was conducted with patients undergoing primary SA categorized into 40 mL, 60 mL, or 80 mL dilutions of 20 mg of LB with 0.9% normal saline. Patient-reported pain scores and opioid consumption were collected at days 1, 3, 7, and 30 postoperatively. Dependence rates were reported and defined as three months of continuous opioid use. Opioid consumption was calculated using total morphine equivalents (TME), and an analysis of variance was performed to compare outcomes between groups. ResultsSeventy-four patients were identified and divided into one of three groups based on the dilution of LB received intraoperatively. There were significant differences in pain scores between the groups on day 7 postoperatively with the 80 mL group having significantly lowest pain scores (P = .012). No significant difference in opioid consumption was found between the groups during any time point. There was a trend toward fewer opioids over the study period in the 80 mL group relative to other groups. Overall, all dilution groups resulted in low TME and postoperative pain after the 30-day study period. ConclusionAll three dilution groups achieved excellent pain control and minimal opioid usage following SA. The 80 mL dilution group showed lower pain scores at day 7 postoperatively and trended toward less opioid consumption in the first 30 days. Our study suggests that, overall, orthopedic surgeons can consider using all three LB dilutions as an effective and safe option for pain management after an SA.

The Use of Liposomal Bupivacaine Intraoperatively Through a Superficial Cervical Plexus Blockade for Postoperative Pain Management for Carotid Endarterectomy: a Case Report

Abstract Currently, bupivacaine liposome injectable suspension (Exparel™, PACIRA BIOSCIENCES, INC., Tampa, Florida, USA) has approval by the Food and Drug Administration for the management of postoperative pain in various surgical patients. In this case report, we suggest the addition of introducing its use in surgical procedures involving the neck, specifically, patients undergoing carotid endarterectomy. The infiltration of liposomal bupivacaine into the superficial cervical plexus has proved to provide adequate pain relief for approximately 72 hours postoperatively discarding the use of other analgesics. Despite the findings, this calls for a larger study comparing the efficacy of different postoperative pain management protocols. Keywords: Liposomal Bupivacaine, Regional Anesthesia, Endarterectomy, Pain Management.

Local Infiltration of Liposomal Bupivacaine in Isolated Traumatic Rib Fractures

Local Infiltration of Liposomal Bupivacaine in Isolated Traumatic Rib Fractures

Sternotomy Wound Infiltration With Liposomal Versus Plain Bupivacaine for Postoperative Analgesia After Elective Cardiac Surgery

Poor pain control after cardiac surgery can be associated with postoperative complications, longer recovery, and development of chronic pain. The authors hypothesized that adding liposomal bupivacaine (LB) to plain bupivacaine (PB) will provide better and long-lasting analgesia when used for wound infiltration in median sternotomy. Prospective, randomized, and double-blinded clinical trial. Single institution, tertiary care university hospital. Adult patients who underwent elective cardiac surgery through median sternotomy. A single surgeon performed wound infiltration of LB plus PB or PB into the sternotomy wound, chest, and mediastinal tube sites. Patients were followed up for 72 hours for pain scores, opioid consumption, and adverse events. Sixty patients completed the study for analysis (LB group [n=29], PB group [n=31]). Patient characteristics, procedural variables, and pain scores measured at specific intervals from 4 hours until 72 hours postoperatively did not reveal any significant differences between the groups. Mixed-model regression showed that the trend of mean pain scores at movement in the LB group was significantly (p=0.01) lower compared with the PB group. Opioid consumption over 72 hours was not significantly different between the 2 groups (oral morphine equivalents; median [interquartile range], 139 [73, 212] mg in LB v 105 [54, 188] mg in PB, p=0.29). Recovery characteristics and adverse events were comparable. LB added to PB for sternotomy wound infiltration during elective cardiac surgery did not significantly improve the quality of postoperative analgesia.

Pain Levels Did Not Differ Following Uncomplicated Third Molar Extractions Utilizing Liposomal Bupivacaine Versus Standard Bupivacaine

Operations in the oral cavity are often characterized by an acute period of postoperative pain historically mitigated via opioids and other analgesics. The purpose of the study was to determine if liposomal bupivacaine infiltration (LBI) following uncomplicated extraction of bilateral, mandibular third molars will significantly reduce postoperative pain when compared to standard bupivacaine. The study was designed as a parallel-arm randomized clinical trial. The sample size was calculated for the primary outcome variable: postoperative pain levels measured at 48-hours. Using a power analysis, a sample size of n=13 for each group was required. Patients meeting the inclusion/exclusion criteria requiring exodontia from November 4, 2018, to June 16, 2022, were recruited out of the oral and maxillofacial surgery clinic. The patients were randomized and divided into 2 groups. Group A was administered 0.50% bupivacaine (with 1:200,000 epinephrine) via infiltration while group B underwent LBI. The primary outcome of interest was postoperative pain levels followed by the secondary outcomes of postoperative narcotic analgesic use, return to oral function, and satisfaction. Patient demographics and characteristics were analyzed as potential covariates utilizing the Fisher exact test and t test for continuous outcomes, respectively. Thirty patients were recruited for the study. The average age of patients receiving the third molar operation was 24.1 ± 5.8 years. Of the 30, 62.5% were female, and 37.5% were male. Seventy-five percent of the patients were Caucasian, 20.8% were African American, and 4.2% were Asian. Forty-eight-hour postoperative interviews revealed mean pain levels of 2.5±2.8 in the control group and 2.9±2.3 in the LBI group (P=.730) as measured on a visual analog scale. The 48-hour postoperative interview identified a mean of 1.9±2.1 narcotic pills used in the control group and 2.5±5.0 pills used in the LBI group (P=.693). Mandibular LBIs following bilateral mandibular third molar extractions showed no statistically significant advantage over the standard bupivacaine at either time point analyzed. Furthermore, no statistically significant difference was found regarding narcotic use between the 2 groups.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation

Study objectiveThe efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DesignA pre- and post-implementation quality improvement evaluation. SettingOperating room and post-anesthesia care unit. PatientsNinety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. InterventionsA preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MeasurementsThe primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. Main resultsPACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0–6] vs. 0 [IQR 0–4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10–23] vs. 15 [IQR 15–25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). ConclusionsLiposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.

Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy

BackgroundThe objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer. MethodsAdult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared. ResultsThe study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001). ConclusionsIn narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.

Multimodal Opioid-sparing Analgesia for Total Knee Arthroplasty: Results from a Retrospective Case Series of 40 Patients

Objective The high burden of opioids has prompted orthopedic surgeons to identify effective nonopioid pain management modalities. In this pilot retrospective case series, we describe opioid use and pain during the first 3 months after total knee arthroplasty (TKA) for consecutive patients treated with opioid-free multimodal analgesia. Methods During May and October 2020, 40 consecutive patients who underwent primary unilateral TKA performed by a single surgeon at an academic community hospital received a multimodal analgesia regimen consisting of preoperative cryoneurolysis; perioperative oral and intravenous analgesics, a neuraxial (spinal) and regional adductor canal block, and local infiltration of liposomal bupivacaine (Exparel); intraoperative periarticular infiltration of bupivacaine hydrochloride (Marcaine); and postoperative oral non-opioid analgesics. A Prescription Monitoring Program database was examined to capture opioid prescriptions filled during the 3 months before and after TKA. Self-reported pain was assessed before surgery and at 2 weeks and 3 months after surgery. Results Two thirds (67.5%; 27/40) of patients recovered from TKA without using opioids. Whereas 100% of the experienced opioid users required opioids after TKA, only 15.6% of opioid-naïve patients required postoperative opioids. Opioid-experienced patients had a higher mean number of post-TKA opioid prescriptions (3.1 vs. 1.6) and total morphine milligram equivalent (985 vs. 265) than opioid-naïve patients. Patients who used opioids after TKA reported higher levels of pain at each time point than those who had opioid-free TKA. Conclusions Multimodal analgesia allows for opioid-free TKA for the majority of patients, particularly those without a history of recent opioid use.

Incidence and severity of short-term incisional complications after intraoperative local infiltration of liposomal bupivacaine in dogs.

To report the incidence of short-term incisional complications in dogs receiving intraoperative local infiltration of liposomal bupivacaine. Retrospective study. Client-owned dogs (n=218). Medical records were searched for dogs whose surgical site was infiltrated with liposomal bupivacaine. Records were reviewed for complications within 20 days postoperatively. Cases were categorized by: (1) surgical wound classification (clean, clean-contaminated, contaminated); (2) labeled versus off-label use in orthopedic surgery - stifle surgery to address cranial cruciate ligament (CCL) disease versus other orthopedic procedures; and (3) orthopedic versus soft-tissue surgery. Complications were documented in 43/218 (19.7%) records, including 27/218 (12.4%) complications that resolved spontaneously or with topical treatment. The incidence of short-term incisional complications did not differ between surgical wound classifications (P=0.55) or between labeled versus off-label use in orthopedic surgery (P=0.21). Complications seemed more common after soft-tissue procedures (32/123; 26.0%) than orthopedic procedures (11/95; 11.6%) (P < 0.01). Surgical wound classification or type of orthopedic procedure did not seem to influence incisional complications of infiltrated surgical sites. Complications were more common after soft-tissue procedures than orthopedic procedures. Infiltration of surgical sites with liposomal bupivacaine seems safe in a broader range of orthopedic procedures than currently labeled. The results also justify further investigation in soft-tissue surgery.

Interscalene Block for Analgesia in Orthopedic Treatment of Shoulder Trauma: Single-Dose Liposomal Bupivacaine versus Perineural Catheter

BackgroundInterscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery.MethodsWe performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique.ResultsAfter statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters.ConclusionInterscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

Evaluation of liposomal bupivacaine infiltration at reconstructive skin graft donor sites in adolescent and young adult burn patients: A retrospective analysis

BackgroundPostoperative pain at skin graft donor sites is frequently undertreated in burn patients, which can impair reconstructive outcomes and result in harmful psychological consequences. We find a critical need to explore and promote non-opioid, multimodal analgesics. Donor site infiltration of the local anesthetic liposomal bupivacaine in adolescent and young adult burn patients has not been previously investigated. Therefore, the goal of this study was to evaluate intraoperative liposomal bupivacaine infiltration for postoperative donor site pain control in adolescent and young adult burn patients undergoing reconstructive skin graft procedures. MethodsThis retrospective analysis included patients aged 14–25 years, who underwent at least two reconstructive skin graft procedures, one that received donor site infiltration of the standard treatment (bupivacaine hydrochloride) and one that received donor site infiltration of liposomal bupivacaine. The final sample included 30 patients with a total of 44 liposomal bupivacaine cases and 53 standard treatment cases analyzed. ResultsIn the authors’ five-year experience, the use of liposomal bupivacaine compared to standard treatment was associated with statistically significant decreases in 0–4 h postoperative pain scores (mean 1.4/10 versus 2.3/10, p = 0.04) and 0–24 h postoperative pain scores (mean 1.7/10 versus 2.4/10, p = 0.02). Neither analgesic was associated with adverse events. Differences in length of stay and inpatient postoperative opioid usage were not regarded as significant. ConclusionIn this retrospective analysis, the authors report the first results that suggest intraoperative liposomal bupivacaine donor site infiltration may be associated with statistically improved patient outcomes in adolescent and young adult burn patients. However, the reported differences are most likely not clinically significant, establishing the necessity for further evaluation of using liposomal bupivacaine in this unique patient population.

P131. Liposomal Bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing anterior and posterior lumbar discectomy and fusion

<h3>BACKGROUND CONTEXT</h3> Patients undergoing lumbar spinal surgery often report significant postoperative pain, necessitating increased postoperative analgesia and prolonging hospital stay. Liposomal bupivacaine (LB) is a novel local anesthetic encapsulated in a lipid bilayer, resulting in sustained-release analgesia, that is believed to decrease postoperative pain. While the efficacy of perioperative LB infiltration has been demonstrated in various orthopedic procedures, there has been little evidence for its use in patients undergoing lumbar spinal surgery. <h3>PURPOSE</h3> The aim of this paper was to evaluate the efficacy of liposomal bupivacaine for lowering postoperative opiate usage and length of hospital stay in the management of anterior and posterior lumbar decompression and fusion. <h3>STUDY DESIGN/SETTING</h3> A retrospective study consisting of 107 patients who underwent lumbar spinal surgery performed by a single surgeon (R.V.) from 2016 to 2019. <h3>PATIENT SAMPLE</h3> A total of 107 patients included in analysis were those who underwent anterior or posterior decompression and fusion for lumbar spondylolisthesis and stenosis. <h3>OUTCOME MEASURES</h3> Postoperative opiate use in morphine equivalents (mEq) and hospital length of stay (LOS). <h3>METHODS</h3> Demographic information, postoperative opiate use and length of hospital stay were obtained through in-depth review of electronic medical records (EMR). Data were analyzed using independent t-tests and multiple linear regression. <h3>RESULTS</h3> There were 51 (47.6%) patients who received LB, while 56 patients did not receive any perioperative local anesthetic. Patients who received LB did not have significantly lower postoperative opiate usage on postoperative day (POD) 0, POD1, POD2, or total per LOS (p=0.861, 0.602, 0.721, 0.974 respectively). Multivariate analysis showed age significantly predicted postoperative opiate usage on POD 0 (p=0.044) and total per LOS (p=0.035), while LB did not. Patients that received LB had a longer LOS with a mean of 5.45 days compared to 4.7 days for patients that did not receive LB, although significance was not reached (p=0.235). <h3>CONCLUSIONS</h3> Local anesthetics are often employed by surgeons to improve postoperative pain control. LB did not significantly decrease postoperative opiate use or shorten LOS. At this time LB was not shown to be clinically effective in patients undergoing anterior or posterior discectomy and fusion, though further evaluation is required. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Evaluation of Liposomal Bupivacaine at Split-Thickness Skin Graft Donor Sites Through a Randomized, Controlled Trial.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with <20% TBSA burns was conducted to evaluate the efficacy of liposomal bupivacaine at STSG donor sites. The control group received standard subcutaneous infiltration of dilute lidocaine solution at the STSG donor site, and the experimental group received dilute liposomal bupivacaine infiltration in a similar fashion. Donor site pain scores and opioid consumption in morphine equivalents (MEE) were evaluated. A total of 25 patients were enrolled in each group. There were no statistical differences in demographic variables, and TBSA was 4.0% in both groups (P = .94). There were no statistical differences in pain scores at any time point postoperatively (mean control range 3.1/10-4.9/10, experimental range 3.3/10-4.3/10, P = .12-.96). There were no statistical differences in opioid consumption at 24, 48, or 72 h postoperatively between the groups (mean control MEE range 49.3-71.1, experimental MEE range 63.6-75.8, P = .34-.85). The average length of stay was 7.7 days in both groups (P = .88). No adverse events occurred in either group. There is no statistical benefit to the use of liposomal bupivacaine for infiltration at STSG donor sites compared to standard of care with respect to pain control, opioid use, or length of stay when evaluated in a randomized, controlled fashion.