January 03, 2017
2 min read
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Similar pain relief with liposomal bupivacaine, nerve block for shoulder arthroplasty

More research on use of various local infiltration agents in different surgeries is needed.

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Patients who received liposomal bupivacaine and underwent shoulder arthroplasty experienced similar overall pain relief, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery compared with patients who received interscalene nerve block, according to recently published study results.

“Our study found that it is possible to achieve equivalent pain control in patients undergoing shoulder arthroplasty with use of local infiltration method compared to using the traditional interscalene nerve block,” Kelechi R. Okoroha, MD, of Henry Ford Hospital, told Orthopedics Today.

Liposomal bupivacaine vs INB

Okoroha and his colleagues randomly assigned 57 patients undergoing primary shoulder arthroplasty to either intraoperative local infiltration of liposomal bupivacaine (Pacira) or preoperative interscalene nerve block (INB). Primary outcome was postoperative average daily VAS scores for 4 days, while secondary outcomes included opioid consumption, length of stay and complications.

Results showed a significant increase in pain in the first 8 hours postoperatively among patients who received liposomal bupivacaine and a significant increase in intravenous morphine equivalents at 13 hours to 16 hours in the INB group. However, on the day of surgery and 24 hours postoperatively, the overall average pain score did not significantly differ between the liposomal bupivacaine and INB groups.

“With liposomal bupivacaine, it takes about 8 hours for the drug to reach optimal plasma levels. [Therefore,] in the first 8 hours, [patients] had more pain in that group compared with interscalene nerve block,” Okoroha said. “Whereas the interscalene nerve block eliminates pain immediately until 18 hours postoperatively and patients have an acute rebound of pain at about 18 hours, which is significant.”

In the first 24 hours after surgery, patients in the liposomal bupivacaine group had a significantly decreased opioid requirement. While researchers noted no significant differences in opioid requirements on postoperative day 1 between the two groups, the liposomal bupivacaine group had a trend toward higher narcotic requirements on postoperative day 2. On postoperative day 3, both treatment groups had no differences in opioid requirements.

Local infiltration evaluation

According to Okoroha, this research identified cost differences between the use of local infiltration and interscalene nerve block, as well as differences in complications.

“There is the complication risk with the interscalene nerve blocks one has to take into account,” Okoroha said. “With the local infiltration, there is practically no complication rate, whereas the interscalene nerve blocks, there is about a 3% risk of either nerve injury or motor paralysis you have to take into account.”

He noted future research should continue to evaluate the use of local infiltration methods in different surgeries and compare the results with more traditional methods to find the best outcomes.

“The next step would be evaluating [different surgeries] with different kinds of local infiltration agents, such as lidocaine and Marcaine, as opposed to the long-acting liposomal bupivacaine,” Okoroha said. – by Casey Tingle

Disclosure: Okoroha reports no relevant financial disclosures.