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Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

ABSTRACT: Several reports have confirmed the ability of intraoperative periarticular injections to control pain after THA. However, these studies used differing combinations of analgesic agents and the contribution of each, including the local anesthetic agent, is uncertain. Understanding the independent effects of the various agents could assist in improved pain management after surgery.We therefore determined the ability of intraoperative periarticular infiltration of levobupivacaine to (1) reduce postoperative pain, (2) reduce postoperative morphine requirements, and (3) reduce the incidence of nausea and urinary retention.A double-blinded, randomized, placebo-controlled trial of patients undergoing primary THAs was performed. Patients were randomized to receive a periarticular infiltration of 150 mg levobupivacaine in 60 mL 0.9% saline (n = 45) or a placebo consisting of 60 mL 0.9% saline (n = 46). We obtained a short-form McGill pain score, visual analog scale (VAS), and morphine requirements via patient-controlled analgesia (PCA) as primary measures. Postoperative antiemetic requirements and need for catheterization for urinary retention were determined as secondary measures.Subjectively reported pain scores and the overall intensity scores were similar for both groups in the postoperative period. At the same time the mean morphine consumption was less in the levobupivacaine group, most notable in the first 12 hours after surgery: treatment group 11.5 mg vs control group 21.2 mg. We observed no differences in the frequency of postoperative nausea and vomiting or urinary retention.Our observations suggest periarticular injection of levobupivacaine can supplement available postoperative analgesic techniques and reduce postoperative morphine requirements after THA.Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

SUBMITTER: Murphy TP

PROVIDER: S-EPMC3293978 | biostudies-literature | 2012 Apr

REPOSITORIES: biostudies-literature

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Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

Murphy Terence P TP Byrne Damien P DP Curtin Paul P Baker Joseph F JF Mulhall Kevin J KJ

Clinical orthopaedics and related research 20110930 4

<h4>Background</h4>Several reports have confirmed the ability of intraoperative periarticular injections to control pain after THA. However, these studies used differing combinations of analgesic agents and the contribution of each, including the local anesthetic agent, is uncertain. Understanding the independent effects of the various agents could assist in improved pain management after surgery.<h4>Questions/purposes</h4>We therefore determined the ability of intraoperative periarticular infil ...[more]

PMID: 21960156

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Project description:The optimal postoperative analgesia after primary total hip arthroplasty remains in question. This randomized, double-blind, placebo-controlled study compared the use of patient-controlled epidural analgesia (PCEA) with use of a multimodal pain regimen including periarticular injection (PAI). We hypothesized that PAI would lead to earlier readiness for discharge, decreased opioid consumption, and lower pain scores.Forty-one patients received PAI, and forty-three patients received PCEA. Preoperatively, both groups were administered dexamethasone (6 mg, orally). The PAI group received a clonidine patch and sustained-release oxycodone (10 mg), while the PCEA group had placebo. Both groups received combined spinal-epidural anesthesia and used an epidural pain pump postoperatively; the PAI group had normal saline solution, while the PCEA group had bupivacaine and hydromorphone. The primary outcome, readiness for discharge, required the discontinuation of the epidural, a pain score of <4 (numeric rating scale) without parenteral narcotics, normal eating, minimal nausea, urination without a catheter, a dry surgical wound, no acute medical problems, and the ability to independently transfer and walk 12.2 m (40 ft).The mean time to readiness for discharge (and standard deviation) was 2.4 ± 0.7 days (PAI) compared with 2.3 ± 0.8 days (PCEA) (p = 0.86). The mean length of stay was 3.0 ± 0.8 days (PAI) compared with 3.1 ± 0.7 days (PCEA) (p = 0.46). A significant mean difference in pain score of 0.74 with ambulation (p = 0.01; 95% confidence interval [CI], 0.18 to 1.31) and 0.80 during physical therapy (p = 0.03; 95% CI, 0.09 to 1.51) favored the PCEA group. The mean opioid consumption (oral morphine equivalents in milligrams) was significantly higher in the PAI group on postoperative day 0 (43 ± 21 compared with 28 ± 23; p = 0.002) and postoperative days 0 through 2 (136 ± 59 compared with 90 ± 79; p = 0.004). Opioid-Related Symptom Distress Scale (ORSDS) composite scores for severity and bothersomeness as well as scores for nausea, vomiting, and itchiness were significantly higher in the PCEA group (p < 0.05). Quality of Recovery-40 scores and patient satisfaction were similar.PAI did not decrease the time to discharge and was associated with higher pain scores and greater opioid consumption but lower ORSDS scores compared with PCEA. The choice for analgesic regimen may depend on a particular patient's threshold for pain and the potential side effects.

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Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

Publications

Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

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