Meeting NewsPerspective

Standard plus liposomal bupivacaine associated with decreased opioid use in lower extremity amputation

Results presented at the Regional Anesthesiology and Acute Pain Medicine Meeting showed that patients who underwent major lower extremity amputation and received peripheral nerve blockade with combined standard and liposomal bupivacaine had lower oral morphine-equivalent use than patients who did not receive regional anesthesia.

Catalina I. Dumitrascu, MD, and colleagues categorized 631 patients undergoing major lower extremity amputation to three categories: no regional anesthesia (n=416), peripheral nerve blockade with standard bupivacaine alone (n=84) or peripheral nerve blockade with a mixture of standard and liposomal bupivacaine (n=131).

“Our primary outcome was total postoperative oral morphine-equivalent use at 72 hours,” Dumitrascu said in a press release. “Secondary outcomes included pain scores at 24, 48 and 72 hours and any pain scores greater than seven out of 10 in the first 72 hours, as well as postoperative opioid-related respiratory depression.”

In a multivariable analysis adjusted for history of chronic pain, preoperative opioid use, patient comorbidities, surgical features and baseline pain scores, results showed patients in the no regional anesthesia group had 1.5- times greater opioid requirements compared with patients who received peripheral nerve block with combined standard and liposomal bupivacaine. Dumitrascu noted that there was also signal for benefit in the group of patients receiving peripheral nerve block with standard bupivacaine alone, such that opioid consumption was 30% higher in the no regional group; though these results did not meet statistical significance.

“Importantly, there was no difference in opioid utilization between patients using regional anesthesia with or without liposomal bupivacaine,” Dumitrascu said. – by Casey Tingle

 

References:

Dumitrascu CI, et al. Abstract 6562. Presented at: Regional Anesthesiology and Acute Pain Medicine Meeting; April 11-13, 2019; Las Vegas.

 

www.newswise.com/articles/view/710512/?sc=dwhr&xy=10007438

 

Disclosure: Dumitrascu reports no relevant financial disclosures.

Results presented at the Regional Anesthesiology and Acute Pain Medicine Meeting showed that patients who underwent major lower extremity amputation and received peripheral nerve blockade with combined standard and liposomal bupivacaine had lower oral morphine-equivalent use than patients who did not receive regional anesthesia.

Catalina I. Dumitrascu, MD, and colleagues categorized 631 patients undergoing major lower extremity amputation to three categories: no regional anesthesia (n=416), peripheral nerve blockade with standard bupivacaine alone (n=84) or peripheral nerve blockade with a mixture of standard and liposomal bupivacaine (n=131).

“Our primary outcome was total postoperative oral morphine-equivalent use at 72 hours,” Dumitrascu said in a press release. “Secondary outcomes included pain scores at 24, 48 and 72 hours and any pain scores greater than seven out of 10 in the first 72 hours, as well as postoperative opioid-related respiratory depression.”

In a multivariable analysis adjusted for history of chronic pain, preoperative opioid use, patient comorbidities, surgical features and baseline pain scores, results showed patients in the no regional anesthesia group had 1.5- times greater opioid requirements compared with patients who received peripheral nerve block with combined standard and liposomal bupivacaine. Dumitrascu noted that there was also signal for benefit in the group of patients receiving peripheral nerve block with standard bupivacaine alone, such that opioid consumption was 30% higher in the no regional group; though these results did not meet statistical significance.

“Importantly, there was no difference in opioid utilization between patients using regional anesthesia with or without liposomal bupivacaine,” Dumitrascu said. – by Casey Tingle

 

References:

Dumitrascu CI, et al. Abstract 6562. Presented at: Regional Anesthesiology and Acute Pain Medicine Meeting; April 11-13, 2019; Las Vegas.

 

www.newswise.com/articles/view/710512/?sc=dwhr&xy=10007438

 

Disclosure: Dumitrascu reports no relevant financial disclosures.

    Perspective
    Babar Shafiq

    Babar Shafiq

    Pain following major lower extremity amputation is multifactorial and involves variation in genetics, preoperative pain, intraoperative strategies, psychological factors and patient indication (vascular, diabetic, acute trauma and failed limb salvage). Current strategies for immediate perioperative pain management post-major lower extremity amputation clearly support the use of neuraxial and peripheral nerve blockade with nerve catheters and the use of continuous anesthetic, as well as local anesthetic infiltration.

    Evidence on optimal drug and dosing combinations is sparse. Liposomal bupivacaine has shown to provide superior postoperative pain relief for multiple procedures, including hip and knee arthroplasty, and may provide improved analgesia post major lower extremity amputation. While liposomal bupivacaine may provide lasting pain relief up to 72 hours when used alone, it may not offer sufficient immediate pain control as when combined with faster-acting local anesthetic infiltration.

    This study addresses this important question in an effort to reduce pain throughout the immediate and early postoperative periods. It would be interesting to know if immediate pain relief in the period before 24 hours was different among the three groups and if there was lasting pain relief beyond 72 hours. Given the heterogeneity of patients in a retrospective study such as this, a well-designed randomized controlled trial may allow for better assessment of the benefits of liposomal bupivacaine vs. liposomal bupivacaine plus local anesthetic infiltration in specific subsets of patients undergoing major lower extremity amputation.

    • Babar Shafiq, MD, MS
    • Assistant professor of orthopedic surgery
      Johns Hopkins Medicine
      Baltimore

    Disclosures: Shafiq reports no relevant financial disclosures.