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Brachial plexus block with liposome bupivacaine for shoulder surgery linked with decreased opioid use
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After shoulder surgery, a single-injection of ultrasound-guided brachial plexus block with liposome bupivacaine offered analgesia through 48 hours postoperatively and decreased opioid use compared with placebo, according to recently published results.
Researchers identified 155 patients who underwent total shoulder arthroplasty or rotator cuff repair and randomly assigned 69 patients to receive an ultrasound-guided brachial plexus block with bupivacaine liposome injectable suspension (Exparel 133 mg; Pacira BioSciences Inc.), 15 patients to liposome bupivacaine 266 mg and 71 patients to placebo added to a standard analgesia protocol. The area under the curve of the VAS pain intensity score through 48 hours postoperatively was the primary endpoint. Other outcomes included total opioid consumption, percentage of opioid-free patients and time to first opioid rescue through 48 hours. Investigators collected pharmacokinetic samples through 120 hours and on days 7 and 10. Adverse events were recorded.
Results showed brachial plexus block with liposomal bupivacaine correlated with significantly decreased pain scores through 48 hours compared with placebo (136.4 vs. 254.1). Investigators noted opioid consumption and median time to opioid rescue were significantly decreased with liposomal bupivacaine through 48 hours compared with placebo (4.2 hours vs. 0.6 hours). The percentage of opioid-free patients was also significantly improved with liposomal bupivacaine through 48 hours compared with placebo. Patients who were treated with liposomal bupivacaine were nine-times more likely to be opioid free through 48 hours compared with patients treated with placebo. – by Monica Jaramillo
Disclosures: Patel reports he received research funding from Pacira BioSciences Inc. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Surena Namdari , MD, MSc
Pain management and reduction of opioid consumption after shoulder surgery remains a concern. The association between postoperative exposure to opioids and long-term dependence has been described. Liposomal bupivacaine (LB) has been utilized as a soft tissue infiltration during shoulder surgery with mixed results and unclear efficacy compared to interscalene brachial plexus blockade. Recently, LB has become FDA approved for use in an interscalene brachial plexus block.
Patel and colleagues performed a randomized, double-blinded controlled trial comparing an interscalene brachial plexus block using LB to saline (placebo) for shoulder surgery. In this industry-funded phase 3 trial, the authors found that the LB group demonstrated substantially improved pain scores and decreased narcotic consumption during the first 48 hours after surgery without an increase in adverse events. Additionally, it appeared that a smaller dosage of LB (133 mg) was sufficient to generate a sustained pain-relieving effect and rebound pain was minimal.
Based on this study, LB is clearly superior to placebo. Given that saline blocks are not used clinically, the lack of a clinically relevant control group represents the study’s most striking weakness. Further research will be necessary to compare the efficacy, safety and cost-analysis of LB to bupivacaine HCl blocks with and without catheters.
Associate professor of orthopedic surgery
Rothman Institute - Thomas Jefferson University
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