Intraoperative Liposomal Bupivacaine Research Articles

Erector Spinae Plane Block with Liposomal Bupivacaine for Adolescent Idiopathic Scoliosis Surgery: No Patient Controlled Analgesia Needed.

Retrospective Controlled Cohort. To evaluate the effect of intraoperative liposomal bupivacaine (LB) via Erector Spinae Plane Block (ESPB) on postoperative adolescent idiopathic scoliosis (AIS) patients with and without patient-controlled analgesia (PCA). Pain control after posterior spinal fusion (PSF) for AIS includes opioids and other modalities. The goal of these modalities is to reduce pain and opioid consumption. Two new modalities for pain control include LB and ESPB. There are scant studies on these modalities tested in concert on patients undergoing PSF for AIS. 72 consecutive patients with AIS who underwent PSF separated into patients who had a PCA (Group A) as part of their postoperative pain management and those who did not (Group B). Opioid consumption was measured via Morphine Milligram Equivalents (MME). Pain scores were measured via the Visual Acuity Score (VAS). Patient mobility was measured by steps taken. These were measured by function of postoperative day from surgery (POD). Group B had significant lower MME at every point after surgery, most notably throughout the entire hospital stay (99.8 vs. 200.7). Postoperative pain scores in Group B were the same if not better than Group A. There was no difference in mobility between the cohorts. The Group B had lower LOS (3.7 s 4.1). In postoperative PSF for AIS patients receiving LB via ESPB, those who did not receive a PCA had lower opioid consumption without worse pain scores or mobility and had a lower LOS. Adding LB via ESPB to postoperative pain regimens effectively replaces a PCA by providing the same pain control and reducing overall opioid consumption and LOS.

Liposomal Bupivacaine Does Not Decrease Postoperative Pain in Patients with Intracapsular Femoral Neck Fracture Treated with Hemiarthroplasty: HEAT-A Randomized, Controlled Trial.

Liposomal bupivacaine (LB) is a long-lasting local anesthetic agent that was developed for use in the surgical setting to help manage postoperative pain. The objective of this study was to evaluate the effect of LB on postoperative pain, function, and overall hospital course in patients with intracapsular hip fractures who were treated with hip hemiarthroplasty. This was a single-center, randomized prospective double-blinded study of 50 patients with an isolated intracapsular femoral neck fracture who were treated with hip hemiarthroplasty from 2018 to 2022. The study group consisted of 25 patients who were treated with intraoperative LB and bupivacaine hydrochloride injections, while the control group consisted of 25 patients who were treated with intraoperative bupivacaine hydrochloride injections only. Primary outcomes were a visual analog scale (VAS) score for pain, total morphine milligram equivalents (MME), delirium, and time to ambulation with physical therapy. No significant differences between the study and control groups were found in any of the outcomes measured. Most notably, there were no differences in the average postoperative pain score (VAS, 2.26 versus 2.7; p = 0.34), total MME used postoperatively (11.73 versus 9.98 MME; p = 0.71), and postoperative day of discharge (4.00 versus 3.88 days; p = 0.82). The results of our study suggest that use of LB is not associated with substantially improved postoperative pain or function or with a shorter hospital course following hip hemiarthroplasty for a femoral neck fracture. Given the higher cost of LB compared with standard postoperative pain modalities, it is worth questioning its use in the setting of geriatric hip fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of enhanced recovery protocols and tranexamic acid on double-incision versus periareolar gender-affirming mastectomy: A retrospective study of postoperative outcomes

IntroductionThe effects of enhanced recovery protocols and use of tranexamic acid (TXA) to reduce postoperative complications after periareolar and double-incision (DIM) gender-affirming mastectomies have not been previously described. We sought to evaluate the efficacy of our ERP including use of liposomal bupivacaine [Exparel] in these cases, assess the efficacy of TXA in reducing postoperative complications, and compare need for revisionary surgery between periareolar and DI mastectomy techniques. Materials and MethodsA retrospective review from November 2017 to June 2022 was performed. Data were collected on patient demographics, operative data, and postoperative outcomes including complications and revisions. Morphine milligram equivalent was used to assess opioid use after surgery. ResultsOverall, 260 patients were included: 240 (92.3%) patients in the DI and 20 (7.7%) patients in the periareolar group. Thirty-five (7.3%) breasts in the DIM group and five (12.5%) breasts in the periareolar cohort developed complications (p = 0.220). Significantly more breasts in the periareolar cohort developed hematomas (12.5% vs. 2.9%, p = 0.011). Sixteen (3.3%) breasts in the DIM group developed seromas. Significantly more breasts in the periareolar group required revisionary surgery (15.0% vs. 5.2%, p = 0.025). Patients who received intraoperative liposomal bupivacaine [Exparel] had fewer opioids intraoperatively (p = 0.019) and at discharge (p < 0.001). Use of TXA did not affect rates of complications including hematoma or seroma. ConclusionsOverall, complication rates for periareolar and DIM are similar. However, the periareolar technique results in a significantly higher rate of hematomas and revisionary surgery. Use of intraoperative liposomal bupivacaine [Exparel] resulted in significantly lower opioid use. Lastly, use of topical TXA did not lower the risk of postoperative hematoma or seroma.

Effects of intraoperative liposomal bupivacaine on postoperative opioid usage in kidney transplant recipients.

This study retrospectively evaluated the use of intraoperative locally infiltrated peri-incisional liposomal bupivacaine in kidney transplant recipients with the primary outcome of oral morphine equivalent reduction during the transplant admission. Secondary outcomes included pain scores, time to first bowel movement and length of stay. Postoperative morphine equivalents were significantly lower in the liposomal bupivacaine group <24 hours (50% reduction, p < 0.05) and 24-48 hours (56.5% reduction, p < 0.05). When accounting for analgesic medication choices, liposomal bupivacaine did not result in a significant reduction in opioid use within 48 hours postoperatively with the exception of a 51% (p = 0.02) median reduction in fentanyl patient-controlled analgesia morphine equivalents <24 hours postoperatively. Morphine equivalence reductions >48 hours, differences in pain scores, time to first bowel movement or length of stay did not reach significance. Intraoperative liposomal bupivacaine reduced kidney transplant recipient's postoperative opioid requirements, but this benefit did not reliably extend past 24 hours postoperatively.

Incidence of postoperative administration of opioids in dogs undergoing a tibial plateau leveling osteotomy after intra-operative liposomal bupivacaine administration with or without morphine epidural

ObjectiveTo determine the influence of two intraoperative pain management protocols on the need for additional opioids in patients receiving an epidural and periarticular liposomal bupivacaine (PLB) vs. PLB alone in the 12–24 h period after undergoing a TPLO.Study designRetrospective study.AnimalsOne hundred seventy-four dogs with cranial cruciate ligament tears presenting for TPLO.MethodsMedical records of dogs presenting for a unilateral or bilateral cranial cruciate ligament tear who had a TPLO performed were reviewed for signalment, weight, body condition score, and peri-operative pain management protocol. Dogs were divided into two groups: those who received an epidural and PLB, and those who received only PLB. Post-operative opioid administration was recorded for each group.ResultsPatients who received an epidural and PLB received fewer postoperative opioids. There were 36% fewer opioid injections administered to dogs who received epidurals compared to dogs who did not receive epidurals (IRR) (95% CI) = 0.64 (0.45–0.92), P = 0.02). BCS was not a significant predictor of the post-operative opioid requirement (IRR (95% CI) = 1.3 (0.75–2.4), P = 0.38). When adjusting for BCS as a possible confounder, there were 39% fewer opioid injections in dogs who received epidurals than dogs without (IRR (95% CI) = 0.61 (0.42–0.88), P = 0.009).ConclusionsThe incidence of postoperative opioid administration was significantly diminished in patients receiving both an epidural and PLB.Clinical significanceAdministration of an epidural in addition to infiltration of PLB significantly decreased the incidence of postoperative opioid administration in dogs undergoing a TPLO.

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.

Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol.

The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture. A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05. One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272). The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.

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.

Liposomal bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing anterior cervical discectomy and fusion.

BackgroundDespite its widespread use, definitive data demonstrating the efficacy of liposomal bupivacaine (LB) is limited especially in patients undergoing anterior cervical discectomy and fusion (ACDF). Therefore, this investigation examined whether ACDF patients who received intra-operative LB (LB cohort) exhibited decreased post-operative opioid use and lengths of hospital stay (LOS) compared to ACDF patients who did not receive intra-operative LB (controls).MethodsEighty-two patients who underwent primary ACDF by a single surgeon from 2016 to 2019 were identified from an institutional database. Fifty-nine patients received intra-operative LB while twenty-three did not. Patient characteristics, medical comorbidities, complications, post-operative opioid consumption, and LOS data were collected.ResultsThe LB cohort did not require fewer opioids on post-operative day (POD) 0, POD1, POD2, or throughout the hospital course after normalizing by LOS (total per LOS). The number of cervical vertebrae involved in surgery, but not LB use, predicted opioid consumption on POD0, POD1, and total per LOS. For every vertebral level involved, 242 additional morphine milligram equivalents (MME) were consumed on POD0, 266 additional MME were utilized on POD1, and 130 additional MME were consumed in total per LOS.ConclusionsACDF patients who received intra-operative LB did not require fewer post-operative opioids or exhibit a decreased LOS compared to controls. Patients whose procedures involved a greater number of cervical vertebrae were associated with greater opioid consumption on POD0, POD1, and total per LOS. ACDF patients, especially those who had a high number of vertebrae involved, may require alternative analgesia to LB.

Will the Use of Intraoperative Liposomal Bupivacaine During Thumb Carpometacarpal Arthroplasty Decrease Postoperative Use of Opioids? A Prospective Randomized Study

This study evaluated the use of intraoperative local injection of liposomal bupivacaine to decrease opioid use in the early postoperative period for patients undergoing outpatient thumb carpometacarpal joint arthroplasty. A prospective, randomized, controlled, single-blinded study was designed to compare 2 groups of patients for opioid use, pain scores, and nonopioid pill consumption within 5 days after surgery. The investigational group received an intraoperative injection of 10 ml (133 mg) liposomal bupivacaine. The control group received no local anesthetic. All patients were anesthetized with a standardized supraclavicular nerve block and were prescribed equal amounts of oral narcotic analgesic. Outcomes were assessed by collecting the data from postoperative patient-reported diaries. The experimental group reported a significantly lower total opioid consumption for the 5 days after surgery. Daily opioid use, as measured by both opioid pill equivalent count and morphine milligram equivalent in addition to postoperative pain scores and nonopioid pill consumption, was not different between groups. Intraoperative injection of liposomal bupivacaine was shown to decrease total opioid intake during the 5 days after thumb carpometacarpal arthroplasty. Therapeutic II.

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures.

BackgroundIntertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine.MethodsThis is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05.ResultsAlthough the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine.ConclusionsDespite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

Multimodal opioid-sparing pain management after lung transplantation and the impact of liposomal bupivacaine intercostal nerve block.

Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pre-transplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228mg vs. 517mg, P=.032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.

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.

Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty : no effect on pain scores, opioid consumption, or functional status.

Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J2021;103-B(6 Supple A):102-107.

Discontinuation of Intraoperative Liposomal Bupivacaine in Primary THA Does Not Clinically Change Postoperative Subjective Pain, Opioid Consumption, or Objective Functional Status

BackgroundThere is debate regarding the benefit of liposomal bupivacaine (LB) as part of a periarticular injection (PAI) in total hip arthroplasty (THA). Here, we evaluate the effect of discontinuing intraoperative LB PAI on immediate postoperative subjective pain, opioid consumption, and objective functional outcomes. MethodsOn July 1, 2019, an institutional policy discontinued the use of intraoperative LB PAI. A consecutive cohort that received LB PAI and a subsequent cohort that did not were compared. All patients received the same opioid-sparing protocol. Nursing documented verbal rating scale pain scores were averaged per patient per 12-hour interval. Opiate administration events were converted into morphine milligram equivalences per patient per 24-hour interval. The validated Activity Measure for Postacute Care (AM-PAC) tool was used to evaluate functional outcomes. ResultsSix hundred thirty eight primary THAs received LB followed by 939 that did not. In the non-LB THAs, BMI was higher (30.06 vs 29.43; P < .05). Besides marital status, the remaining baseline demographics were similar between the two cohorts (P > .05). The non-LB THA cohort demonstrated a marginal increase in verbal rating scale pain scores between 12 to 24 hours (4.42 ± 1.70 vs 4.20 ± 1.87; P < .05) and 36 to 48 hours (4.49 ± 1.72 vs 4.21 ± 1.83; P < .05). There was no difference in inpatient opioid administration up to 96 hours postoperatively (P > .05) or AM-PAC functional scores within the first 24 hours (P > .05). ConclusionA small statistical, but not clinically meaningful, difference was observed in subjective pain scores with LB PAI discontinuation. Opioid consumption and postoperative AM-PAC functional scores were unchanged after LB PAI discontinuation.

Opioid-Sparing Effect of Liposomal Bupivacaine and Intravenous Acetaminophen in Colorectal Surgery

BackgroundThis study evaluated the opioid-sparing effect of liposomal bupivacaine and intravenous acetaminophen in colorectal surgery. Materials and methodsThis study was a retrospective, 2 × 2 factorial cohort conducted at an academic medical center from May 2016 to February 2018. Patients undergoing open or minimally invasive colorectal resection were included. Exclusion criteria were age <18 y, surgery after second hospital day, ostomy, and allergy to acetaminophen, opioids, or bupivacaine. Intraoperative liposomal bupivacaine and intravenous acetaminophen administration within 18 h after surgery were evaluated. The primary outcome was intravenous morphine milligram equivalents administered within 24 h after surgery. A linear regression model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, and height was used for the primary analysis. ResultsAmong 486 included patients, 193 received both liposomal bupivacaine and intravenous acetaminophen, 93 received liposomal bupivacaine only, 104 received intravenous acetaminophen only, and 96 did not receive either. On average, patients received 21 (SD = 31) morphine equivalents over 24 h. Intraoperative liposomal bupivacaine was associated with a reduction of morphine equivalents (adjusted change −11, 95% CI −17 to −6), but intravenous acetaminophen was not (2, 95% CI −3 to 7). Intraoperative liposomal bupivacaine was associated with a reduction of length of stay (adjusted change = −1.2 d, 95% CI −2.1 to −0.3), but intravenous acetaminophen was not (adjusted change = 1.5 d, 95% CI 0.7 to 2.2). ConclusionsLiposomal bupivacaine was associated with a significant reduction of opioid use within 24 h after colorectal surgery, but intravenous acetaminophen was not.

Liposomial Bupivacaine for Postoperative Pain Control in Fragility Intertrochanteric Hip Fractures.

To determine whether intraoperative liposomal bupivacaine reduces postoperative opioid requirements, pain scores, and length of stay (LOS) in patients with fragility intertrochanteric femur fractures in comparison with a group of patients who did not receive liposomal bupivacaine. Retrospective observational study. Two academic medical centers. One hundred two patients with intertrochanteric hip fracture treated with a cephalomedullary nail implant. Nonrandomized administration of liposomal bupivacaine in 2 cohorts of patients with similar injuries and treatment. Postoperative oral average morphine equivalents (MME) and average numerical pain rating score (NRS). Secondary endpoints included postoperative LOS, operative time, and home discharge. Forty-six patients received intraoperative liposomal bupivacaine and 56 patients did not. There was no significant difference between age, sex, and American Society of Anesthesiologist level between groups (P > 0.05). The liposomal bupivacaine group received significantly less MME (0.34 vs. 0.92 mg/h/kg, P = 0.04) and had significantly lower NRS (2.89 vs. 5.13, P = 0.04) in the first 24 hours after surgery. MME (1.18 vs. 1.37 mg/h/kg, P = 0.27) and NRS (3.61 vs. 5.51, P = 0.34) were similar at the 36-hour mark. The liposomal bupivacaine group had similar LOS (3.2 days vs. 3.8, P = 0.08), more home discharges (7 vs. 2, P = 0.001), and longer operative time (73.4 vs. 67.2 minutes, P = 0.004). Intraoperative liposomal bupivacaine use reduced opioid use and postoperative pain for the first 24 hours after fixation of intertrochanteric femur fractures. Significant increases in likelihood of discharge to home may present an opportunity for cost savings. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Liposomal bupivacaine reduces opiate consumption after rotator cuff repair in a randomized controlled trial

Arthroscopic rotator cuff repair (ARCR) provides excellent clinical outcomes but is often associated with significant postoperative pain. The use of intraoperative anesthesia in conjunction with multimodal pharmacologicstrategies is a widely accepted approach for managing surgical pain and reducing opiate use. The purpose of this study was to determine whether using a combined field and suprascapular nerve block with liposomal bupivacaine (LB) in addition to an interscalene blockwould provide greater pain relief and a reduction in opiate consumption compared with an interscalene block alone. The study enrolled 50 patients with full-thickness rotator cuff tears undergoing primary ARCR surgery. Patients were randomized to receive intraoperative LB (n = 25) or not (n = 25) and given postoperative "pain journals" to document visual analog scale pain scores and to track their daily opioid consumption during the first 5 postoperative days. Patients in the LB group reported statistically and clinically lower pain scores during postoperative days 1 and 2 (P < .0001 and P = .03, respectively). In addition, patients in the LB group consumed significantly fewer narcotics than the control group during the 5-day period, demonstrating a 64% reduction in total narcotic consumption (P = .002). The findings of this study suggest that the addition of LB to multimodal anesthetic protocols significantly reduces the acute perioperative pain experienced following rotator cuff repair and the number of narcotic pills consumed in the first 5 days after ARCR. Furthermore, the findings provide guidelines for postoperative narcotic prescribing to reduce the quantity of opiates prescribed.

Comparison of cost and outcomes in patients receiving thoracic epidural versus liposomal bupivacaine for video-assisted thoracoscopic pulmonary resection

BackgroundThoracic Epidural has long been the most recommended treatment for postoperative pain management in general thoracic surgery. This study compares liposomal bupivacaine (LB) as an alternative method for pain control and compares it to the standard. MethodsLB was compared to thoracic epidural bupivacaine hydrochloride (TE BH) in 387 patients who underwent video-assisted thoracoscopic pulmonary resection (VATS-R) at our institution. Patients received either continuous TE BH or intraoperative LB at a predetermined dose. A total of 237 patients received TE BH from April 2010 to March 2014 and 143 patients received LB from April 2014 to March 2016. After propensity matching, 95 patients in each group had similar demographics and clinical characteristics including gender, age, race, American Society of Anesthesia (ASA) classification, Zubrod scores, and FEV1 and DLCO percent predicted measurements. Outcome measures included hospital costs, length of stay (LOS), adverse events, postoperative opioid medication use, and pain scores. ResultsCompared to the TE BH group, the LB group had significantly lower pain scores (average visual analogue scale the day of surgery: 3.9 versus 4.5, p < 0.05), decreased postoperative opioid medication (morphine equivalent dose during the first 3 days: 344.5 versus 269.5, p < 0.05), and lower total and direct hospital costs ($2906 and $1865 respectively, p < 0.05). Although a shorter LOS in the LB group was not statistically significant (4.3 versus 5.1 days, p = 0.156), more patients in the LB group were discharged directly home than the control group (44.2% versus 28.4%, p < 0.05). There was no difference noted in overall adverse events including 30-day readmissions between the two groups. ConclusionLB is a viable alternative for pain management in patients undergoing VATS-R. With recent scrutiny on healthcare costs and the opioid epidemic, these results are encouraging and should be further investigated.

Efficacy of liposomal bupivacaine in pediatric patients undergoing spine surgery.

Liposomal bupivacaine may be an option for reducing opioid utilization in pediatric scoliosis surgery. The use of liposomal bupivacaine in this patient population has not been previously described. Patients who underwent posterior spinal fusion surgery at our institution from 2011-2016 were identified. We performed a retrospective matched cohort study, matching patients who received intraoperative liposomal bupivacaine by age, gender, and extent of surgery to patients who did not. The primary endpoint was the use of morphine equivalents in the first 72hours after surgery. Data collection included demographic and surgical data, pain medication utilization, and pain scores. Area under the curve (AUC) for pain scores was calculated. Descriptive statistical methods and univariable analysis were used to compare patients who received liposomal bupivacaine to patients who did not. One hundred and forty-one patients met study criteria; 47 patients who received liposomal bupivacaine were matched to 94 control patients who did not receive liposomal bupivacaine. No significant differences were noted in the patient population with the patients requiring a median of 11 segments (range 10-13 segments) fused. Patients received a mean of 56.6±37.4mg/kg of intravenous acetaminophen, a mean of 3.4±2.1mg/kg of intravenous ketorolac, and 1.9±0.93mg/kg of morphine equivalents in the first 72hours after surgery. On univariable analysis, no differences were noted in intravenous acetaminophen use, pain score AUC, intravenous ketorolac use, or morphine equivalents (2.0±98 vs 1.8±0.82) in patients who did not receive liposomal bupivacaine as compared to those patient who did received liposomal bupivacaine. Liposomal bupivacaine was not associated with reductions in postoperative opioid use in pediatric spinal surgery.