Liposomal Bupivacaine Research Articles

Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization.

Migration of total knee arthroplasty (TKA) procedures from the inpatient setting to outpatient venues, especially freestanding ambulatory surgery centers (ASCs), requires the use of reliable patient selection algorithms and standardized perioperative pathways to facilitate favorable outcomes for patients. This retrospective chart review included consecutive TKA procedures performed over a 5-year period between January 2014 and January 2019 at 2 freestanding ASCs. The patient selection algorithm was developed on the basis of patient comorbidities to minimize the potential for adverse events. All procedures were performed by one of eight orthopedic surgeons who were identified a priori as adhering to similar multimodal pain management regimens, including the use of spinal anesthesia, general or monitored-care anesthesia, adductor canal blocks, pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen, and oxycodone on an as-needed basis. Outcomes, including surgical complications, healthcare resource utilization (HCRU), and patient satisfaction, were measured before discharge and at a 90-day follow-up visit. Four hundred thirty-nine TKA procedures in 386 patients were identified for inclusion. Of these patients, 115 (29.8%) were performed in patients with the American Society of Anesthesiologists physical status IIIa. Mean (standard deviation) length of stay at the ASC was 500 (107) minutes, including 136 (47) minutes of surgery and 201 (78) minutes to ambulation. The overall rates of surgical complications and 90-day hospital admissions were low (1.4% and 0.7%, respectively), as was the need for additional HCRU, including additional surgical procedures related to index surgery, emergency department visits, and unplanned clinic visits or calls. At the 90-day follow-up visit, 96% of patients reported being pleased with their outcomes. With careful patient selection, standardized perioperative pathways, and multimodal analgesia protocols, TKA procedures can be performed in the ASC setting with low complication rates, minimal postdischarge HCRU, and high rates of patient satisfaction. III.

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia.

Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h. Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported. Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.

This Month in Anesthesiology

This Month in Anesthesiology

Anesthesiology

Liposomal bupivacaine is purported to extend analgesia associated with wound infiltration and peripheral nerve blocks. However, evidence of the clinical effectiveness of liposomal bupivacaine is mixed. In this issue of Anesthesiology, Hussain et al. present a meta-analysis to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared to nonliposomal local anesthetics. In the same issue, Ilfeld et al. provide a comprehensive summary of all currently published randomized controlled trials involving the clinical administration of liposomal bupivacaine to control postoperative pain. In an accompanying editorial, McCann reviews the history of clinical trial data and approval of liposomal bupivacaine by the U. S. Food and Drug Administration. Cover Illustration: A. Johnson, Vivo Visuals.

A randomized-controlled trial comparing liposomal bupivacaine, plain bupivacaine, and the mixture of liposomal bupivacaine and plain bupivacaine in transversus abdominus plane block for postoperative analgesia for open abdominal hysterectomies.

Transversus abdominus plane (TAP) blocks are widely used for postoperative analgesia for abdominal surgical procedures. The purpose of this study was to compare the analgesic efficacy of plain bupivacaine, liposomal bupivacaine, and the mixture of plain bupivacaine with liposomal bupivacaine when used in a TAP block. This study was a single centre, prospective, patient-, observer-, and surgeon-blinded, randomized-controlled trial in which 90 patients undergoing an open abdominal hysterectomy with a midline incision were randomized to receive a TAP block with plain bupivacaine (group bupivacaine), liposomal bupivacaine (group liposomal), or a mixture of liposomal bupivacaine and plain bupivacaine (group mixture). Primary outcomes included time to the first rescue opioid analgesic and total opioid consumption during the first 72 postoperative hours. Secondary outcomes included pain scores, patient satisfaction, incidence of hemodynamic instability, presence of local anesthetic systemic toxicity, and length of hospital stay. The median [interquartile range] time to first opioid was 51 [28-66] min in group bupivacaine, 63 [44-102] min in group liposomal, and 51 [24-84] min in group mixture (P = 0.20). The median [interquartile range] total opioid consumption in the first 72 postoperative hours was 208 [155-270] mg in group bupivacaine, 203 [153-283] mg in group liposomal, and 202 [116-325] mg in group mixture (P = 0.92). There were no significant differences in secondary outcomes between groups. In this small study at risk of being under-powered, the mixture of liposomal bupivacaine with plain bupivacaine for TAP block did not improve analgesia compared with either liposomal bupivacaine or plain bupivacaine on their own. www.clinicaltrials.gov (NCT03250507); registered 5 April 2017.

A Multimodal Analgesic Regimen Including Liposomal Bupivacaine Moderated Acute Pain Levels After Third Molar Surgery

This prospective, observational study was designed to moderate post-surgerical acute pain with a multimodal analgesic regimen including liposomal bupivacaine implemented for patients having third molar surgery. We hypothesized that acute pain would be reported no higher than 50% of the maximum possible. Patients and methods: Inclusion criteria: ASA risk classification I or II, age 18-35 years, and at least two mandibular third molars below the occlusal plane. All subject-patients were enrolled after consent for surgery and treated with the multimodal analgesic regimen. Data at surgery were completed by patient and surgeon. Acute pain data were derived from a 14-day diary completed by subject-patients each Post-Surgical Day (PSD) for the past 24 hours. The primary outcome variable was subjects experiencing “worst pain” which was defined as the three highest values on a 7 point Likert scale. Secondary outcome variables were the time in number of days until “little or no pain” were recorded. This was defined as the two lowest values on the same Likert scale. We used descriptive statistics to report outcomes. Results: Data were from 50 subjects. Thirty-two (64%) were female, median age was 22 years (IQR 19y, 26y), 48% were Caucasian, 25% Latino, 17% African-American, 10% other ethnicity. Surgeons’ median estimate of degree of difficulty was 9 out of 28 (IQR 5,15). Median surgery time was 32min (IQR 20,40). Thirty-nine patients had maxillary third molars removed; 86%, were vertical or distoangular. Bone was removed from 35%. All had both mandibular third molars removed; 54% were mesioangular or horizontal. Bone was removed from 95%. Eleven (23%) patients reported worst pain on PSD1, 17 (35%) on PSD2, 18 (37.5%) on PSD3, and 12 (25%) on PSD4. By PSD6, half of the subject-patients reported little or no pain. Conclusions: Outcomes for pain after third molar surgery were moderated by the multimodal analgesic regimen including liposomal bupivacaine, but the goal of all reporting pain 50% of the maximum possible was not achieved.

Reduced Opioid Use Among Patients Who Received Liposomal Bupivacaine for ACL Reconstruction.

Standard multimodal pain management for anterior cruciate ligament reconstruction typically includes a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and opioids. Opioids present a substantial risk, and there is a rising number of prescription opioid-related overdoses in the United States. The goal of this study was to evaluate the quantity of opioids prescribed to patients who received liposomal bupivacaine as a component of their multi-modal pain regimen. The electronic medical records of patients who underwent anterior cruciate ligament reconstruction by a single surgeon at an urban hospital during a 2-year period were evaluated. Patients in the case group received liposomal bupivacaine and those in the control group did not. Statistical analysis of the number of pills prescribed and numeric pain rating scale scores was performed with a 2-tailed unequal variance t test. Statistical analysis of opioid prescription refills was performed with a chi-square test. A total of 67 patients were included. The mean number of 5-mg oxycodone tablets prescribed to the case group (9.29±10.29 tablets) was significantly lower (P<.01) compared with the number prescribed to the control group (66.26±37.13 tablets). Patients in the case group also were less likely to require an opioid prescription refill at the first follow-up appointment (P<.01; absolute risk reduction, 50%; number needed to treat, 2). Mean numeric pain rating scale score at 2 weeks was 2.8±2.1 in the case group and 3.8±2.4 in the control group (P=.09). Patients who received liposomal bupivacaine as part of multimodal pain management had significantly fewer opioid prescriptions. Despite the reduction in opioids prescribed, patients in the case group only showed a trend toward a reduction in pain at 2-week follow-up. [Orthopedics. 2021;44(2):e229-e235.].

A Retrospective Comparison of Interscalene Continuous Catheter Verse Single-Injection with Liposomal Bupivacaine in Total Shoulder Arthroplasty

Background: One common method of pain control for total shoulder arthroplasty is long-duration delivery of local anesthetic via interscalene brachial plexus block (ISB) with a continuous catheter. Alternatively, liposomal bupivacaine has also been administered as an ISB as a means to prolong the analgesic effect. This study was completed to measure the non-inferiority of single-injection ISB with liposomal bupivacaine compared with ISB continuous catheter for total shoulder arthroplasty. Methods: We performed a retrospective chart review of patients who underwent total shoulder arthroplasty using either an ISB continuous catheter or a single injection ISB with liposomal bupivacaine for post operative analgesia. The primary goal of this study was to determine if single-injection with liposomal bupivacaine conferred non-inferior pain scores compared to the continuous catheter. Secondary outcomes evaluated oxygen saturation as a measure of hemidiaphragmatic paresis, post operative opioid requirements, and difference in cost. Results: We identified 333 patients for the study: 126 received continuous catheter and 207 received single-injection with liposomal bupivacaine. The median length of stay was 1 day. Pain scores for those treated with single-injection with liposomal bupivacaine were non-inferior to pain scores of those treated with the continuous catheter on post-op days 0, 1 and 2. Pain scores were lower for single-injection with liposomal bupivacaine patients on days 3 and 4, however they did not reach statistical significance. There was no significant difference in oxygen saturation between the two groups. Both groups had similar daily morphine milligram equivalent requirements. Liposomal bupivacaine ISB was also found to be less expensive. Conclusion: Single-injection ISB with liposomal bupivacaine provides non-inferior analgesia at a reduced cost compared with continuous catheter ISB for total shoulder arthroplasty.

Impact of liposomal bupivacaine and provider choice on opioid use and service outcomes in Medicare outpatient surgical patients

Aims There is wide variation in opioid prescribing patterns after common surgical procedures. This study examines outcomes for beneficiaries undergoing hospital outpatient department (HOPD) procedures using liposomal bupivacaine (LB) for control of post-surgical pain. As a non-opioid surgical analgesic, LB may afford beneficial outcomes for reducing subsequent opioid use and improving post-surgical service use outcomes. Methods This retrospective cohort comparison study analyzed 100% Medicare claims data from 2014–2019. HOPD claims were matched to approximately 100 of the most common surgical procedures where LB was utilized. Within these procedures, a one-to-many, with replacement propensity score matching model was used to control for possible selection bias. By procedure, those claims which were identified as using LB for control of post-surgical pain were matched to those not receiving LB. Outcomes were the probability of a subsequent Part D opioid prescription fill, emergency department (ED) visit, and short-term acute care hospital admission. Results Higher provider use rates of LB are significantly correlated with a decrease in post-HOPD opioid use and a reduction in post-operative ED visits. For each 10% increase in LB use rate by a given provider, Part D opioid events by Day 30 decreased by 2.6 percentage points and by 2.1 percentage points by day 90 (p < .01). Similarly, for each 10% increase in provider LB use rate, there is a 0.4 percentage point reduction in post-operative ED use by day 30 (p < .01) and a 0.3 percentage point reduction by day 90 (p < .05). Limitations Part D data only indicate that a prescription was filled, not whether the drug was taken. Conclusions Increased provider use of LB is correlated with improved patient outcomes in real-world provider experience with the Medicare population for many outpatient procedures. Policies that support increased provider use of LB should reduce reliance on opioid drugs for post-surgical pain management.

The use of bilateral transversus abdominis plane blocks with liposomal bupivacaine on postoperative cesarean delivery patients during COVID-19 pandemic is associated with reduced narcotics use and reduced length of stay.

Background:The use of transversus abdominis plane blocks has been previously shown in both large-scale studies and our own institution to significantly reduce postoperative pain and opioid use. In addition, the use of bilateral transversus abdominis plane blocks using liposomal bupivacaine in combination with neuraxial morphine significantly reduced post-cesarean-delivery pain and opioid use. During the COVID-19 crisis, our anesthesia department in a collaborative effort with our obstetric colleagues thought that the use of bilateral transversus abdominis plane blocks with liposomal bupivacaine could reduce the use of opioids to treat postoperative pain and might result in decreased length of stay.Methods:After institutional review board approval, a retrospective study of 288 patients who underwent cesarean delivery under spinal or epidural (neuraxial) anesthesia at Maimonides Medical Center in Brooklyn, NY was conducted. Historical controls were from 142 consecutive patients from 1 January 2012 through 12 May 2012. An additional set of controls consisted of 30 consecutive patients from 10 March 2020 through 13 April 2020. The primary outcome data analyzed were the use of opioids and length of stay.Results:Post cesarean delivery, patients who received both bilateral transversus abdominis plane blocks with liposomal bupivacaine and neuraxial morphine was associated with a significant decrease in the number of patients using post operative opioids, 54%–60% decreased to 18% (p < 0.001), and a decreased length of stay; 3.1 days was reduced to 2.39 (p < 0.001).Conclusion:Neuraxial opioids combined with liposomal bupivacaine transversus abdominis plane blocks provided significant pain relief for patients post cesarean delivery, required less post operative opioids, and facilitated earlier discharge that may aid in reducing patient exposure and hospital burden secondary to COVID-19.

Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie's disease surgery: a pilot study.

BackgroundNovel strategies have been proposed to minimize postoperative opioid use, yet many patients experience significant pain after penile surgery. Our objective was to evaluate postoperative opioid use in patients undergoing penile ring block with long-acting liposomal bupivacaine (LB; Exparel) during surgery for Peyronie’s disease (PD).MethodsWe identified patients who underwent tunica albuginea plication (TAP) and plaque excision/grafting (PEG) for PD between July 2019 and September 2020. Intraoperatively, a ring block was administered at the penile base penis with 20 cc of LB. Patients were instructed to use over the counter pain medications as first line treatment for postoperative pain, and opioids were available for severe breakthrough pain as needed [7.5 oral morphine equivalents (OME) =5 mg oxycodone]. Opioid use was assessed during the first five days postoperatively.ResultsIn total, 28 patients met inclusion criteria including 18/28 (64%) who underwent TAP and 10/28 (36%) who underwent PEG. Median patient age was 56 years (IGR 51;61). Median postoperative 10-point visual analogue pain score was 0 (range 0–3). Duration of penile anesthesia ranged from 1.5–4 days. In total, 9/28 patients (32%) utilized opioids during the first five days postoperatively (range 7.5–75 OME). Two patients (7%) required opioids during the first two days after surgery. 27/28 (96%) were satisfied or highly satisfied with postoperative pain control.ConclusionsIntraoperative penile ring block with LB resulted in excellent pain control with local anesthetic duration of 1.5–4 days. The majority of patients did not require any opioids during the early postoperative period. Further study comparing outcomes with shorter-acting local anesthetics is necessary to balance pain control benefits with additional cost.

Breast Cancer Extirpation, Reconstruction, and COVID-19: Paradigm Shifting Management during a Global Pandemic.

COVID-19 has changed societal norms and continues to impact our health care system and economy in ways that have never been documented before. The realm of plastic surgery is no exception to this threat and uncertainty. In addition to complete cessation of cosmetic and most elective surgeries, we have also noticed an interesting trend in patients undergoing breast cancer care at our own institution during the COVID-19 pandemic. Many patients previously scheduled for mastectomy with breast reconstruction were converted to breast conservation therapy (BCT) during the pandemic. At our institution during the months of August, September, and October of 2019, 112 (41%) patients underwent mastectomies, whereas 163 (59%) patients were elected to undergo BCT. During the same period, 93 patients had breast reconstruction surgery. In contrast, during the months of March, April, and May of 2020, when COVID-19 was at its peak, of the 123 breast cancer patients who underwent surgical intervention, the majority opted for BCT over mastectomy [90 patients (73%) versus 33 (27%) patients]. During the same period, only 13 patients had breast reconstruction. In March of 2020, Centers for Medicare and Medicaid Services released recommendations to postpone elective and nonessential surgeries and procedures during the COVID-19 pandemic.1 Additionally, the American College of Surgeons and the American Society of Breast Surgeons released guidelines regarding the care of breast cancer patients during the COVID-19 pandemic. Recommendations included opting for breast conservation wherever radiation oncology services were available and delaying breast reconstruction unless it was deemed medically necessary.2 This led to a nation-wide decrease in breast reconstruction. Although this situation is unprecedented, some similarities can be seen in oncological care of breast cancer patients in rural settings.3 With limited access to plastic surgeons, BCT with radiation therapy is accepted as an appropriate treatment and locally established standard of care for early stage breast cancer in rural areas. As a result of this, fewer patients in the rural communities undergo mastectomy with breast reconstruction.4 Despite evidence showing immense quality-of-life benefits of breast reconstruction after mastectomy, many continue to argue that there is not a direct positive impact on mortality and morbidity, and as such, these reconstructive surgeries are often categorized as elective and, therefore, nonurgent.5 Perhaps in an attempt to alleviate potential bed crunches, and the need to preserve resources, there is an important role of enhanced recovery after surgery protocols, including the use of liposomal bupivacaine, and a shift to outpatient management in specific patient populations (eg, tissue expander patients). Drastic societal changes are often observed during times of hardship, and COVID-19 has proved this, with the changes we have seen in society and the healthcare system as we continue to battle this pandemic. Although some of the changes are fleeting, others are evolving to become new established norms. With that in mind, is the future care of oncologic breast patients changing? And if so, where does the plastic surgeon fall within that care team?

Liposomal Bupivacaine.

Liposomal Bupivacaine.

Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain.

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.

Bupivacaine local anesthetic to decrease opioid requirements after radical cystectomy: Does formulation matter?

IntroductionReduction of opioids is an important goal in the care of patients undergoing radical cystectomy (RC). Liposomal bupivacaine (LB) has been shown to be a safe and effective pain reliever in the immediate postoperative period and has been reported to reduce postoperative opioid requirements. Since the liposomal formulation is predicated on slow systemic absorption, the amount of bupivacaine administered is notably higher than that typically used with standard bupivacaine (SB) formulations. In addition, LB is costly, not universally available, and studies comparing this formulation to SB are lacking. We sought to determine if there is a difference in postoperative opioid requirements in patients who receive LB vs. high dose SB at the time of RC. MethodsIn May 2019 we transitioned to administration of high-volume SB injected intraoperatively at the time of RC. This prospective cohort was compared to a historical cohort of patients who received injection of LB at the time of surgery. Primary endpoints included postsurgical opioid use measured in morphine equivalent dose (MED) and patient-reported Numeric Rating Scale (NRS) pain scores and length of stay. All patients were managed using principles of enhanced recovery after surgery (ERAS). ResultsFrom May 2019 through August 2019, 28 patients underwent RC and met eligibility criteria to receive SB at the time of surgery. They were compared to a historical cohort of 34 patients who received LB between November 2017 and July 2018. There was no difference in MED exposure either in the postanesthesia care unit (SB 9.0 ± 8.9 MED vs. LB 6.5 ± 9.4 MED, P= 0.29) or during the remainder of the hospital stay (SB 36.8 ± 56.9 MED vs. LB 42.1 ± 102.5 MED, P= 0.81), no difference in NRS pain scores on postoperative day 1 (SB 2.6 ± 1.6 vs. LB 2.1 ± 1.7, P= 0.23), day 2 (SB 2.4 ± 1.8 vs. LB 1.9 ± 1.6, P= 0.19), or day 3 (SB 1.9 ± 1.8 vs. LB 1.7 ± 1.7, P= 0.69) and no difference in length of stay (SB 5.0 ± 1.7 days, LB 4.9 ± 3.3 days, P= 0.93). Subgroup analysis of open RC and robotic-assisted RC showed no significant difference in MED or pain scores between LB and SB patients. ConclusionsAmong patients undergoing RC under ERAS protocol there was no significant difference in postoperative opioid consumption, NRS pain scores, or length of stay among patients receiving SB compared to LB.

Liposomal bupivacaine infiltration in the surgical site for analgesia after rotator cuff repair: a randomized, double-blinded, placebo-controlled trial

Arthroscopic rotator cuff repair is among the most painful of orthopedic surgeries. Liposomal bupivacaine is Food and Drug Administration approved for administration into surgical sites to provide postsurgical analgesia and has been used to address postoperative pain after many types of surgery, including total shoulder arthroplasty. However, its efficacy for pain control after rotator cuff repair is unclear. In this randomized, double-blind, placebo-controlled trial, we compared liposomal bupivacaine with an equivalent volume of saline injected into the subacromial space and arthroscopy portal sites in patients undergoing rotator cuff repair under the interscalene block with sedation. The primary outcome measure was numeric rating pain score at the time of block resolution, as reported during the follow-up phone call on postoperative day 1. Secondary outcomes included mean pain scores at rest as well as oral morphine equivalent requirements on postoperative days 1, 2, and 3. This study provides Level 1 evidence. There were no statistically significant differences in the primary outcome of numeric rating pain scores on resolution of the interscalene nerve block, nor in those reported on postoperative day 1 or 2. There was a minor but statistically significant difference in mean resting pain scores on day 3, though opioid consumption and patient satisfaction score did not differ between groups. In those instructed to perform passive range-of-motion exercises, there was no difference in reported mean pain scores among the groups. In this study of patients undergoing arthroscopic rotator cuff repair, we found no statistically significant difference in mean pain scores on interscalene block resolution, a result consistent with a number of studies investigating liposomal bupivacaine for total shoulder arthroplasty. A modest reduction in pain was evident only on day 3, and there was no impact on perioperative opioid requirements, opioid-related side effects, or pain with motion. Liposomal bupivacaine, when injected into the subacromial space and the tissues around the arthroscopy port sites, provided minimal improvement in pain control in this patient population.

Liposomal Bupivacaine Decreases Postoperative Length of Stay and Opioid Use in Patients Undergoing Radical Cystectomy

To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia. This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge. LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P<.001), less total opioid use (mean 188.3 vs 612.2 OME, P <.001), earlier diet advancement (mean 1.6 vs 2.4 days, P <.001), and decreased overall direct costs ($23,188 vs $29,628, P <.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5). Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.

The Efficacy of Liposomal Bupivacaine on Postoperative Pain Following Abdominal Wall Reconstruction: A Randomized, Double-blind, Placebo-controlled Trial.

To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction. Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared with placebo in the first 72 hours after surgery. This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 yrs of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patientreported quality of life. Of the 164 patients who were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine, and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared with simple bupivacaine and placebo (325 ± 225 vs 350 ± 284 vs 310 ± 272, respectively, P = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life. There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared with simple bupivacaine and placebo for open abdominal wall reconstruction.

Liposomal Bupivacaine Versus Bupivacaine Hydrochloride for Intercostal Nerve Blockade in Minimally Invasive Thoracic Surgery

The objective of this study was to compare the effects of liposomal bupivacaine (Lipo-B) and bupivacaine hydrochloride (B-HCl), in the presence of multimodal analgesia, on postoperative analgesia and opioid consumption in minimally invasive thoracic surgery (MITS) lobectomy. Retrospective observational cohort study. Tertiary care cancer center. A total of 60 patients who underwent MITS lobectomy and received intercostal nerve blockade (ICNB) with either 0.66% Lipo-B (n = 29) or 0.5% B-HCl (n = 31). All patients received intravenous patient-controlled analgesia for the first 12 hours postoperatively, followed by opioids and nonsteroidal anti-inflammatory drugs as needed. Perioperative opioid and nonopioid consumption and pain scores were compared between groups at 12-hour intervals for the first 72 hours. Between the two groups, there were no statistically significant differences in demographic characteristics, intraoperative (p = 0.46) and postoperative opioid consumption, Richmond Agitation-Sedation Scale scores and pain scores upon postanesthesia care unit arrival and after four hours, length of postanesthesia care unit stay (p = 0.84), or length of hospital stay (p = 0.55). Both groups received intra- and postoperative multimodal analgesia. In this cohort, no differences in opioid consumption or pain scores were observed in the immediate postoperative period following MITS lobectomy between patients given ICNB with Lipo-B and those given ICNB with B-HCl in the presence of multimodal analgesia.

Changing Practices: Pain Management in the Opioid Epidemic

Practice Pointers| December 01 2020 Changing Practices: Pain Management in the Opioid Epidemic Crit Care Nurse (2020) 40 (6): 84. https://doi.org/10.4037/ccn2020806 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Cite Icon Cite Get Permissions Citation Changing Practices: Pain Management in the Opioid Epidemic. Crit Care Nurse 1 December 2020; 40 (6): 84. doi: https://doi.org/10.4037/ccn2020806 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentCritical Care Nurse Search Advanced Search For opioid-naïve patients, generally, a 3- to 5-day supply may be sufficient. Consultation with a provider may need to be arranged if another prescription is needed. The practice of safe prescribing is not intended to deny patients pain medication, but to prescribe safely and with appropriate follow-up. Bupivacaine liposome injection is often used intraoperatively, especially with abdominal and orthopedic procedures. This injection is expected to last 96 hours, but that can vary from patient to patient. The transition to oral medications can be made easier with the use of an opioid calculator. Please exercise caution and use a verified opioid calculator from a reliable source; it should help determine initial and subsequent dosing. Also take into account the equianalgesic chart and cross-tolerance if changing medication. Setting reasonable patient and family expectations is a key component in developing the plan of care. Providing education and definitions to patients about tolerance and... You do not currently have access to this content.