In this study, BH was replaced with LB for local infiltration of the wound in patients undergoing complex cytoreductive (121 patients) or staging laparotomy (72 patients) surgeries for gynecologic cancer.  Their cumulative pain scores, opioid needs, and medical costs were compared to historical controls treated with BH.1

For patients undergoing complex cytoreductive surgery, no differences were found for cumulative pain scores at 24 (P = .48) and 48 (P = .97) hours. However, there was significant reduction in cumulative opioid needs as measured by oral morphine equivalents in the LB group compared to the historical controls (30 mg vs 54 mg, P = .002 at 24 hours; 38 mg vs 83 mg, P = .005 at 48 hours; 62 mg vs 101 mg P = .006 at the remaining length of stay).1 


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Further, there was a significantly higher percentage of patients in the LB group free of tramadol and opioids at 24 hours (P = .01), 48 hours (P = .04), and at the remaining length of stay (P < .001).

The need for patient-controlled analgesia decreased from 33.3% to 4.1% (P < .001) and the need or rescue intravenous opioids decreased from 55.6% to 28.9% (P < .001). Patients in the LB group also experienced lower rate of ileus (12% vs 22%, P = .04) and postoperative nausea (25% vs 61%, P < .001 at 24 hours; 30% vs 56%, P < .001 at 48 hours).

Although no data were provided, the LB group undergoing staging laparotomy demonstrated similar results for opioid needs, rescue intravenous narcotics or PCA needs, and nausea, according to the study.

However, they found no significant differences in length of stay, 30-day complications, 30-day adjusted total costs, or pharmacy costs.1

Dr Dowdy continued, “If you look at some of the prior literature, the use of liposomal bupivacaine reduced length of stay after surgery. I think the reason we didn’t see that is because we had already optimized the perioperative care.” He called the reduction in the use of PCA “astounding.”

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“So now we use 90% less narcotics than we did before enhanced recovery. We had a further reduction in the total narcotic use in the first 48 hours. And then there was also a reduction in the use of intravenous rescue narcotics. Some of the other improvements that we also saw was a reduction in nausea, I think because patients were using even less opioids. And then lastly, we saw a 50% reduction in postoperative ileus. So that went from 22% to 12%,” Dr Dowdy said.

References

  1. Kalogera E, Bakkum-Gamez JN, Weaver AL, et al. Liposomal bupivacaine reduces total opioid requirements and the need for IV opioids after laparotomy for gynecologic malignancies. Abstract presented at: Gynecologic Oncology’s 2016 Annual Meeting on Women’s Cancer; March 19-22, 2016, San Diego, California. 
  2. Chandrakantan A, Gan TJ. Demonstrating value: a case study of enhanced recovery. Anesthesiol Clin. 2015;33(4):629-650.
  3. Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014;135(3):586-594.
  4. Chahar P, Cummings KC. Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012;5:257-64.