Liposomal bupivacaine may help control pain after shoulder surgery
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Use of liposomal bupivacaine in an interscalene nerve block effectively controlled pain after outpatient shoulder surgery, according to results presented at the American Shoulder and Elbow Surgeons Annual Meeting.
Brian L. Badman, MD, and colleagues randomly assigned 78 patients who were undergoing shoulder surgery for symptomatic rotator cuff tears to receive interscalene nerve block with bupivacaine and steroid (group 1), liposomal bupivacaine (group 2) or liposomal bupivacaine and steroid (group 3).
“Over the next 96 hours or 4 days, patients were sent a text three times a day asking them to self-report their pain from 0 to 10 and answer how many pain pills they took in the previous 8 to 12 hours,” Badman said in his presentation.
Researchers compared VAS pain scores and narcotic consumption converted to morphine milligram equivalents for the three groups.
Badman noted no statistically significant differences in VAS pain scores among the groups for the 4 days.
“However, when we looked at liposomal bupivacaine with and without steroid, the patients reported less pain on postop day 3 if they were given the additional steroid,” Badman said. “We saw no rebound pain in either of the liposomal bupivacaine groups beyond day 3.”
Patients in both the liposomal bupivacaine groups reported taking fewer pain pills on both day 2 and day 3 compared with patients who received bupivacaine and steroid, according to Badman. He added patients who received liposomal bupivacaine with steroid had a slight, but not statistically significant, trend toward less narcotic use.
“In no patients did we report any pulmonary issues in either of the liposomal bupivacaine groups in this series,” Badman said.
Perspective
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The opioid epidemic has led to increased efforts to minimize the use of narcotics after orthopedic surgeries such as rotator cuff repair. Decreased use of narcotics is important not only as the transition to outpatient surgery continues, but also to reduce side effects of narcotics (eg, nausea and constipation) and limit narcotic abuse and addiction.
An interscalene nerve block has been a common approach for obtaining postoperative pain control after arthroscopic rotator cuff repair. Liposomal bupivacaine has been purported to have the advantage of an extended half-life for extended pain relief. In a well-designed, double-blind randomized controlled trial, Badman and colleagues evaluated postoperative pain and narcotic use in patients undergoing arthroscopic rotator cuff repair. Twenty-six patients received a standard interscalene nerve block, 24 received a liposomal bupivacaine interscalene nerve block and 26 received a liposomal bupivacaine interscalene nerve block with dexamethasone. While pain scores were similar between groups, narcotic use was significantly lower on postoperative days 2 and 3 in both liposomal bupivacaine groups compared with the standard interscalene nerve block group. On postoperative day 2, patients in the liposomal bupivacaine group consumed 21.9 morphine mg equivalents and patients in the liposomal bupivacaine group with dexamethasone consumed 22.8 morphine mg equivalents, whereas those with the standard block consumed 36.1 morphine mg equivalents. This difference is equal to about two 5-mg oxycodone tablets (7.5 morphine mg equivalents per tablet). The findings are similar to Sethi and colleagues who previously reported a 64% reduction in narcotic use with a liposomal bupivacaine interscalene nerve block compared with a standard interscalene nerve block in the first 5 postoperative days following arthroscopic rotator cuff repair.
As we continue to seek reduction in the use of narcotics following shoulder surgery, and particularly arthroscopic rotator cuff repair, liposomal bupivacaine is one aspect of a multimodal approach to pain that can be considered. While it is associated with increased cost, it does appear to provide a modest improvement in postoperative narcotic usage.
Reference:
Sethi PM, et al. J Shoulder Elbow Surg. 2019;doi:10.1016/j.jse.2019.01.008.
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Badman BL, et al. Effectiveness of single shot liposomal bupivacaine for reducing postoperative pain and narcotic use following outpatient rotator cuff surgery: A prospective double-blind randomized controlled trial. Presented at: American Shoulder and Elbow Surgeons Annual Meeting; Oct. 2-3, 2020 (virtual meeting).
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