Intraperitoneal bupivacaine to reduce postoperative opioid-use following laparoscopic appendectomy
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Instilling post-operative intraperitoneal bupivacaine at the base of the caecum reduces postoperative pain scores and in-hospital opioid-use in patients undergoing laparoscopic appendectomy, as reported in the American Journal of Surgery by investigators of the Metro Health Hospital in Wyoming, MI, United States (NCT03004222).1Sevensma K, et al. Am J Surg. 2018 Oct 31. pii: S0002-9610(18)31011-0. doi: 10.1016/j.amjsurg.2018.10.045,2Metro Health, Michigan. Available from: https://clinicaltrials.gov/ct2/show/NCT03004222. NLM identifier: NCT03004222. Accessed November 22, 2018.
“Improving postoperative pain control may lead to improved outcomes including decreased opioid use, shorter hospital stays, and improved patient satisfaction.”
The prospective, randomised, double-blind, placebo-controlled study enrolled 101 subjects with acute appendicitis undergoing laparoscopic appendectomy at Metro Health, Michigan. At the close of surgery, subjects were randomised to receive bupivacaine (N=53) or saline (N=48) intraperitoneally. Exclusion critera included known or suspected malignant disease, patients with known allergies or contraindications to the local anaesthetic or ketorolac, patients using opioid pain medications for chronic conditions, those undergoing elective laparoscopic appendectomy, and those unable to consent in English. The primary outcome measure was the effectiveness of intraperitoneal bupivacaine at the conclusion of laparoscopic appendectomy for postoperative pain control. A secondary outcome measures included the time to discharge and pain level-scores postoperatively.
The authors did not report significant differences in demographics between the two groups. The procedure time, estimated blood loss, and pre-operative opioid use were similar between the two groups, though there was a difference in the number of patients with a perforated appendicitis between the bupivacaine (N=1) and saline (N=9) groups (P=0.006). The postoperative opioid-use and pain scores 1h post-surgery were significantly lower with a mean opioid-use of 7.394 mg vs 16.921 mg (P=0.007) and a mean pain-score of 2.48 versus 3.8 (P = 0.014), both for the bupivacaine vs the saline groups. Finally post-operative intraperitoneal bupivacaine at the base of the caecum was associated with a shorter hospital stay of 1372 minutes in the bupivacaine-group vs 683 minutes in the saline-group (P=0.023). However, when excluding patients with a perforation, the duration of hospital stay was numerical shorter with bupivacaine vs saline, 659 vs 795 minutes respectively, but did not meet significance anymore (P=0.229).
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