EFFICACY OF WOUND INFILTRATION USING BUPIVACAINE
VERSUS ROPIVACAINE ALONG WITH FENTANYL FOR
POSTOPERATIVE ANALGESIA FOLLOWING ABDOMINAL
HYSTERECTOMY UNDER SPINAL ANESTHESIA
ABSTRACT
Background: Wound infiltration with local anesthetics and opioids is
increasingly being used as a part of multimodal postoperative analgesia.
Objectives: A prospective randomized double blind placebo controlled study
was carried out to investigate the efficacy of wound infiltration using
bupivacaine versus ropivacaine with fentanyl for postoperative analgesia.
Method: 93 female patients of ASA grade I/II posted for abdominal
hysterectomy under spinal anesthesia were randomly divided into three equal
groups destined to receive wound infiltration at the end of surgery using 14.5 ml
0.5% isobaric solution of either bupivacaine or ropivacaine along with 0.5 ml
(25 mcg) fentanyl in group BF and RF respectively, and with 15 ml normal
saline in control group (Group S). As a part of multimodal analgesia, all patients
received intramuscular injection of diclofenac 75 mg at the end of surgery and
in night (bid) and rescue analgesic butorphanol 1 mg (opioid) was given if
patient complained of pain.
Three groups were compared regarding postoperative analgesia in terms of
visual analogue score ( 0-100 mm) and rescue opioids consumption in 24 hour
period, and satisfaction score of patient, surgeon and anesthesiologist.
Results: All 31 (100%) patients of group S received rescue opioids [ 1 dose= 3
(9.67%), 2 doses = 26(83.8%), 3 doses = 2(6.45%) patients]; whereas rescue
opioid was required in 21(67.7%) patients of group BF and 26 ( 83.8%) patients
of group RF, and all of them received single dose.
Thus total rescue opioid (butorphanol) consumption was significantly higher in
group S (61 mg), as compared to group BF (21 mg) and group RF (26 mg), p=
0.000. However group BF and group RF were comparable p=0.473. (Group S >
group RF~ Group BF).
Mean VAS score at rest, cough and movement was significantly less and
satisfaction of patient, surgeon and anesthesiologist was significantly higher in
group BF than in group RF than in group S, p<0.05. No adverse effects related
to wound infiltration were observed.
Conclusion: We conclude that wound infiltration using bupivacaine or
ropivacaine with fentanyl is an easy, safe and effective technique for providing
postoperative analgesia. Among two local anesthetics bupivacaine seems to be
superior to ropivacaine in wound infiltration in terms of significantly less pain
score and better satisfaction score, however rescue analgesic consumption was
comparable.
KEY WORDS: wound infiltration, bupivacaine, ropivacaine, fentanyl,
postoperative analgesia, multimodal analgesia.
INTRODUCTION
Total abdominal hysterectomy is commonly performed via a pfannenstial
incision and causes moderate to severe pain, which is often multifactorial and
can be attributed to combination of incision pain, pain from deeper visceral
structures, and dynamic pain on movement, such as during straining, coughing
or mobilizing that may be severe1.
Injured nerve fibers innervating the site of incision/ retraction and sutures
generate pain impulses. Increased inflammatory mediators at the surgical site
also sensitize uninjured and injured nerve fibres. Transmission of pain from the
wound is reduced by local anesthetic application, and the local inflammatory
response to the injury is also suppressed. Consequently hyperalgesia due to
sensitization of nociceptors may be prevented2.
A traditional approach for post-operative pain control includes inhibition
of peripheral nerves innervating the surgical site by local wound infiltration3.
It is a method of post operative analgesia commonly used alone or alongwith
other analgesic regimens. It also reduces opioids consumption, minimizes
opioid adverse reactions, reduces nursing work, decreases resting pain, pain on
motion, and thus allows better patient mobility4.
Various clinical studies had been published which support the analgesic
properties of peripheral use of opioids and numerous mechanism have been
stated for this action through peripheral opioid receptors3,5,6.
Bupivacaine has been the long-acting local anaesthetic agent of choice
since a long time7. Ropivacaine has been introduced as a long-acting local
anesthetic agent with potential advantages over bupivacaine, particularly with
respect to reduced cardiac toxicity8.
Efficacy of both bupivacaine9,10 and ropivacaine11,12 for wound infiltration
as a component of multimodal post operative analgesia had been studied with
varying results. But the comparison of analgesic effect of these two agents in
wound infiltration has not been much investigated13.
Hence the present study was undertaken to test the hypothesis whether
wound infiltration using bupivacaine or ropivacaine along with fentanyl as a
part of multimodal analgesia could reduce the opioids consumption in first 24
hours in post operative period. The analgesic profile of two local anesthetics
was also compared.
MATERIALS AND METHODS
After institutional ethical committee clearance, this prospective, randomized,
placebo-controlled, double blind study was carried out at Department of
Anesthesia in RNT medical college attached to MB Hospital in Udaipur
(Rajasthan).
Basis of sample size:
The number of patients required for the study was calculated on the basis
of total opioid consumption during 24 hrs. We expected a reduction in opioid
consumption by 25% in the group given local anesthetic infiltration. Assuming
 = 0.05, we calculated that we would need 93 patients (31 in each group) to
achieve, a power of 90% ( = 0.9).
Patient selection:
93 female patients of age group 20-65 years, ASA physical status I and II,
undergoing elective total abdominal hysterectomy (TAH) with bilateral
salpingo-oophorectomy (BSO) using pfannestial incision were enrolled in the
study. After explaining the study procedure, written informed consent regarding
participation in the study was taken from all of the patients.
Exclusion criteria:
Patients were excluded if TAH was scheduled for malignancy or if there
was a history of chronic pain, continuous use of analgesic drugs, patients with a
history of clinically significant cardiovascular, pulmonary, hepatic, renal,
neurologic, psychiatric, or metabolic disease. Patients having severe obesity
(BMI > 35 kg/m2), coagulation disorder, on anticoagulants, severe spinal
deformity, allergy to local anesthetic, or any contraindication to spinal
anesthesia were excluded from the study.
Randomization, group allocation and blindness to the study:
93 selected patients were randomly assigned to 3 equal groups using
sequentially numbered, opaque sealed envelopes depending upon the drugs used
for wound infiltration (15ml) at the end of surgery.
 Group S (Control group): received wound infiltration using normal
saline(15 ml)
 Group BF (Bupivacaine group): received wound infiltration using 14.5 ml
(72.5 mg) of isobaric bupivacaine (0.5%) with 0.5 ml (25mcg) fentanyl.
 Group RF (Ropivacaine group): received wound infiltration with 14.5 ml
(72.5 mg) of isobaric ropivacaine (0.5%) with 0.5ml (25mcg) fentanyl.
To provide double blindness to the study, drugs for wound infiltration were
prepared by a separate anesthesiologist who was not involved further in the
study .Wound infiltration was done by surgeon who was not aware of group
allocation, and not involved in data recording. Data were recorded by an
independent anesthesiologist who was not aware of group allocation. Patients
had given consent for participation in the study but not aware of group
allocation.
Anesthesia technique:- After thorough pre-anesthetic evaluation patients were
taken in elective operation theatres after 8 hours fasting.
Standard monitoring of heart rate (HR), non invasive blood pressure
(N.I.B.P.), electrocardiography (E.C.G.) and pulse oximetry (SpO2 ) was done
with a multipara monitor.
After taking an intravenous access with 18 G cannula, infusion of 500ml
Ringer lactate was given, all patients were premedicated with 1mg midazolam
intravenously. Base line heart rate, systolic and diastolic blood pressure was
measured before spinal anesthesia. Under full aseptic precautions in all patients
lumbar puncture was performed at L3-L4 intervertebral space in lateral
decubitus position through a midline approach using 25 G quincke spinal
needle. Correct needle placement was identified by free flow of cerebrospinal
fluid and 3ml (15mg) of 0.5% hyperbaric bupivacaine was given for
subarachnoid block.
Standard monitoring was done throughout the operation. E.C.G. and
pulse-oximetry was monitored continuously while N.I.B.P. was monitored
every 3 min for first 15 min, thereafter every 5 min till completion of surgery.
Hypotension (decrease in systolic B.P. of 20% of baseline or less than 100 mm
of Hg) was treated with i.v. bolus of 6mg ephedrine hydrochloride. Bradycardia
(<60 beat/min) was treated with i.v. bolus of 0.3 – 0.5 mg of atropine sulphate.
Surgical technique: The total abdominal hysterectomy with bilateral salpingo–
oophorectomy was performed in all the patients following standard steps:
abdomen was opened in layers via pfannenstial incision, and then
infundibulopelvic ligament was clamped followed by clamping of uterine artery
and Mackenrodts ligament. Then uterus along with bilateral ovaries and cervix
was removed (TAH with BSO) vault was closed, hemostasis achieved and
abdomen closed in layers.
Wound infiltration technique:
The surgeon who was blinded to the treatment groups was asked to
infiltrate all layers of the abdominal wall during closure, including muscle and
cutaneous layers, using drugs as per group allocation.
For postoperative analgesia: Multimodal analgesic regime was followed in
which patients received intramuscular injection of diclofenac 75 mg [
nonsteroidal anti-inflammatory drug (NSAID)] immediately
after wound
infiltration and subsequently after 12hr.Thus each patient received two doses of
diclofenac during the study period of 24 hours. Rescue analgesic in form of
butorphanol 1mg (opioid) was given as slow iv injection whenever patient
complained of pain in the postoperative periods, or VAS was > 40 mm at rest.
Data recording: In the postoperative period, assessments were made at shifting
of the patient in ward (0hr) as baseline then at 1hr, 2hr, 6hr, 12hr and 24 hr, by
anesthesiologist blinded to the treatment groups. Pain at rest, cough and on
movement (induced by leg raising as bending of the knees) was assessed on
Visual Analog Scale (0-100 mm) as 0- no pain, 100- worst imaginable pain at
above time intervals. In addition, total rescue analgesic (opioid) requirement in
terms of number of doses and total dose in mg in 24 hrs was recorded. Heart
rate (HR), Systolic blood pressure (SBP), Diastolic blood pressure (DBP) was
also recorded at above time intervals. Sedation was assessed at same time
intervals as VAS using a categorical scale (1: awake and alert, 2: awake but
drowsy responding to verbal stimulus, 3: drowsy but rousable responding to
physical stimulus, 4: unrousable not responding to physical stimulus. In
addition, any episode of nausea and vomiting were recorded during the 24 hr
postoperative period and rescue antiemetic ondansetron 4mg i.v. was given for
nausea, vomiting and repeated if necessary. Any other side effect if occurred
was noted. Satisfaction score of patients, surgeon and anesthesiologist regarding
post operative analgesia was assessed at 24 hours postoperatively and graded as:
0-poor, 1-satisfactory, 2-good, 3-excellent, and the study was declared as
complete.
Statistical analysis:
Data were entered and analyzed with the help of MS Excel EPI info 6 and
SPSS. Qualitative or categorical data were presented as number (proportion)
and compared with Chi-square test. Quantitative or continuous variables were
presented as mean ± SD and compared using student‘t’ test. ANOVA was
applied as per need as test of significance. A post hoc test was used to assess
intergroup differences. p< 0.05 was considered as statistically significant.
Results
All the three groups were comparable regarding mean age (p=0.367),
mean weight (p=0.384), residence (p=0.565) and education status
(p=0.840).(Table 1)
The base line vital parameters (HR, SBP, DBP) were statistically
comparable in all the three groups (p>0.05). There was no significant
difference in HR, SBP and DBP at various time intervals during
postoperative period (0-24hr) in three groups, as compared to baseline
(p>0.05)and no significant intergroup variations were observed ,( p >
0.05).
Post-operative analgesia:
VAS score : In all the three groups, 0, 1, and 2 hours postoperatively
mean VAS was found 0 at rest, cough, and movement due to persistence
effect of spinal anesthesia .Mean VAS at rest, cough and movement at 6,
12 and 24 hours was significantly less in group BF and group RF as
compared to group S, p<0.05. Mean VAS was also significantly less in
group BF than in group RF, p<0.05. Thus mean VAS was in order of
group BF< group RF< group S. (Table 2)
Rescue analgesic consumption
During 24 hours postoperatively, rescue analgesic was required by
all 31 patients (100%) in Group S. Out of these 3(9.67%) patients
received a single dose, 26(83.8%) received 2 doses and 2(6.45%)
required 3 doses. Whereas opioids were required in 21 (67.7%) patients
in Group BF and 26 (83.8%) patients in Group RF and all received the
single dose. It was noteworthy that 10(32.2%) patients in group BF and 5
(16.1%) patients in group RF did not require any rescue opioids in 24
hours post operative period.
Requirement of rescue analgesic in postoperative period (24hr) in
terms of total number of doses and total dose in mg was significantly
more in group Group S(61mg) as compared to Group BF (21mg) and
Group RF (26mg), p= 0.000; however, group BF and group RF were
comparable, p=0.473. Thus rescue analgesic requirement was GroupS >
GroupRF ≈GroupBF.
Requirement of rescue analgesic(butorphanol) in terms of mean dose in
mg for each patient was significantly more in GroupS(1.96±0.40mg), as
compared to GroupBF (0.667±0.47mg), p=0.035 and GroupRF (0.83±0.37 mg),
p=0.028; nevertheless, GroupRF and GroupBF were comparable P=0.086 .
Wound infiltration with ropivacaine and bupivacaine along with fentanyl was
found to reduce rescue analgesic consumption by 57.3% (group RF) and 65.5%
(group BF) respectively as compared to control group (group S), which
was statistically significant, p=0.000(Table 3).
Satisfaction score
Mean satisfaction score of patient, surgeons and anesthesiologist were
significantly higher in the GroupBF (1.35±0.48, 1.71±0.46, 1.73±0.45
respectively)
and
GroupRF
(0.94±0.30,
1.51±0.25,
1.51±0.25
respectively), p=0.000; as compared to group S (0.42±0.50, 0.97±0.48,
0.97±0.49 respectively), p=0.000. Mean Satisfaction score of patients,
surgeon and anesthesiologist in GroupBF was also significantly higher
than in GroupRF, p= 0.000. Thus satisfaction score was GroupBF >
GroupRF > GroupS.
Sedation score
Mean sedation score was significantly more in group S(1.06±024) as
compared to group BF(1) and group RF(1) in which all patients remained
alert at all time intervals , p=0.000.
Postoperative adverse effects:
Emetic episode were minimal in present study. Only 1 (3.2%) patient
each in group S and group BF had vomiting and received ondansetron 4
mg. None of the patient in the study had other side effects such as
pruritis, wound infection, wound rupture, wound hematoma, delayed
wound healing etc.
Table 1: Demographic characteristics
Group S
Group BF
Group RF
(n=31)
(n=31)
(n=31)
20-40
19 (33.3%)
21 (36.8%)
17 (29.8%)
Age
>40-60
12 (35.2%)
8 (23.5%)
14 (41.1%)
(years)
>60
0 (0%)
2(6.45%)
0 (0%)
Mean ±SD
40.5±6.52
39.8±6.65
39.9±7.31
40-60
30 (35.2%)
28 (32.9%)
27(31.7%)
1(12.5%)
3(37.5%)
Mean ±SD
53.2±5.33
53.7±6.43
52.8±6.15
Rural
20 (39.2%)
16 (31.3%)
17 (33.3%)
Urban
11 (27.5%)
15 (37.5%)
14(35.0%)
Literate
18(34.61%)
18(34.61%)
16 (30.7%)
Illiterate
13 (30.9%)
13 (30.9%)
17(54.8%)
Variable
0.367
Weight(kg) >60-80
Residence
Education
P Value
4(50.0%)
0.384
0.565
Data are expressed as mean ±SD or n (%) as appropriate
0.840
TABLE 2
Postoperative analgesia in terms of VAS score (0-100 mm) at various time
intervals in three groups
Time
VAS score
P value
GrS
vs
GrBF
GrS
vs
GrRF
GrBF
vs
GrRF
24.8±2.56
0.043
0.035
0.025
24.7±3.86
32.8±4.28
0.034
0.024
0.023
51.0±8.51
27.7±4.05
37.8±5.85
0.046
0.026
0.025
R
36.8±7.02
12.3±3.61
22.6±2.21
0.030
0.023
0.028
C
45.5±6.63
21.0±3.96
30.8±3.85
0.043
0.040
0.025
M
49.2±7.76
23.9±5.58
34.5±4.43
0.046
0.032
0.022
R
35.6±6.25
11.3±5.09
21.2±2.85
0.039
0.026
0.022
C
43.9±6.29
16.8±5.09
28.0±4.15
0.034
0.043
0.035
L
46.8±7.8
20.3±6.94
31.5±3.08
0.042
0.022
0.037
Overall
R
36.8±1.30
13.4±2.92
22.8±1.81
0.030
VAS (6C
43.5±1.31
20.8±3.95
30.5±2.41
0.032
24 hours)
M
49.0±2.10
23.9±3.70
34.6±3.51
0.036
R-Rest, C-cough, M-Movement (on leg raising).
Data are expressed as mean ± SD and post-hoc test (ANOVA) used.
0.043
0.046
0.045
0.048
0.046
0.049
0 hr
1 hr
2 hr
6 hr
12 hr
24 hr
Gr (S)
Gr (BF)
Gr (RF)
R
0
0
0
C
0
0
0
L
0
0
0
R
0
0
0
C
0
0
0
M
0
0
0
R
0
0
0
C
0
0
0
M
0
0
0
R
38.2±8.02
16.8±5.09
C
46.5±8.68
M
Table 3: Comparison of rescue analgesic requirement in three groups in
first 24 hours postoperatively
Rescue analgesia
P value
Group
n=31
No. of
requiring
analgesic
Patient
distribution
according
to no. of
doses
patient
rescue
31(100%)
S
Group BF
n= 31
Group
n=31
21(67.7%)
26(83.8%)
RF
No
dose
0
10(32.3%)
5(16.2%)
Single
dose
3(9.67%)
21(67.7%)
26(83.8%)
Two
doses
26(83.8%)
0
0
Three
doses
2(6.45%)
0
0
61
21
26
Total no of doses of
rescue analgesic
Total no. dose in mg
of rescue analgesic
(butorphanol) (mg)
61
21
26
Mean dose in mg for
each patient
1.96±0.40
0.677±0.47
0.83±0.37
GrS/
GrBF
GrS/
GrpRF
GrpBF/
GrpRF
0.162
0.515
0.473
0.000
0.000
0.473
0.000
0.000
0.473
0.035
0.028
0.086
Data are expressed as mean ±SD or n(%) as appropriate
DISCUSSION
Opioids remain the primary analgesic agent for management of acute
postoperative pain after major surgery; opioid related adverse effects inhibit
rapid recovery and rehabilitation14. Currently, the American society of
Anesthesiologists task force on acute pain management advocates the use of
multimodal analgesia15. The combination of different analgesic agents in
multimodal analgesia act by different mechanisms and at different sites in the
nervous system. This provides additive or synergistic analgesia with lowered
adverse effects of sole administration of individual analgesic14.
As such, one approach for multimodal analgesia is the use of regional
anesthesia and analgesia to inhibit the neural conduction from the surgical site
to the spinal cord which decreases spinal cord sensitization14. This was also
followed in present study where all hysterectomies were conducted under spinal
anesthesia using 15 mg of 0.5% hyperbaric bupivacaine.
Guidelines for postoperative acute pain management specifies that “unless
contraindicated all patients should receive round the clock regimen of nonsteroidal anti-inflammatory drugs (NSAIDs or cyclooxygenase-2 inhibitors
(COX2) or acetaminophen”15. Mechanism of action of NSAIDs includes
inhibition of the synthesis of prostaglandins both in the spinal cord and at the
periphery. Thus it decreases the hyperalgesic state after surgical trauma and
decreases
postoperative
opioid
requirement14.
All
patients
received
intramuscular injection of diclofenac 75 mg on conclusion of the surgical
procedure and at 12 hr interval thereafter as a part of multimodal post-operative
analgesia regimen in the present study.
Wound infiltration at the time of closure had been described as a part of
multimodal analgesia and demonstrated to have an analgesic sparing effect and
has the major influence on the patients’ ability to resume their normal activities
of daily living10. Due to the local application, transmission of pain from the
wound is reduced, and the local inflammatory response to the injury is
suppressed. Consequently sensitization of nociceptors, and the ensuing
hyperalgesia may be prevented2. Various agents like local anesthetics, opioids,
NSAIDs have been used for wound infiltration, but with varying results3.16.17
Opioid receptors have been demonstrated in the peripheral nerve ending
of afferent neurons. Blockade of these receptors with peripherally administered
opioids
is
believed
to
result
in
analgesia3.
Fentanyl5,
morphine18,
bupernorphine3, tramadol6 have been used for wound infiltration and were
found to improve postoperative analgesia.
Tverskoy et al5
reported that
spontaneous and movement associated pain measured 24 hr postoperatively was
decreased with the addition of fentanyl for wound infiltration (compared with
the control) by approximately half ,and prolonged the duration of anesthesia by
approximately 50%.Therefore in present study 25mcg fentanyl was used as an
adjuvant along with local anesthetic for wound infiltration.
When wound infiltration with bupivacaine or ropivacaine alongwith fentanyl
was done as a part of multimodal analgesia in our study it resulted in significant
improvement in postoperative analgesia. It allowed a significant reduction in
pain scores and opioid consumption in first 24 hours postoperatively and this
led to a significantly better satisfaction of patient, surgeon and anesthesiologist
regarding postoperative pain. Wound infiltration by local anesthetics had been
found effective in providing post operative analgesia in previous studies11,16,18,19.
Local anesthetic application to wound can provide analgesia through
various mechanisms. Firstly, they inhibit the transmission of pain from
nociceptive afferents from the wound surface. Secondly, local inflammatory
response to injury that sensitizes nociceptive receptors and contributes to pain
and hyperalgesia, is also prevented by local anaesthetics. In addition they
decrease the release of inflammatory mediators from neutrophils and neutrophil
adhesion to the endothelium. They also decrease the formation of free radicals
and edema20. Local anesthetic infiltration could alter the perception of deeper
visceral pain by blocking the superficial component of pain16,21.
The analgesic action of local anesthetics can be enhanced by infiltration of
opioids in addition to local anesthetics3,5,18 .Opioids inhibit the neuronal firing
by increasing the potassium current and decreasing calcium current in sensory
neurons. They also block the transmitter release and calcium dependent release
of excitatory pro-inflammatory compounds e.g. substance P contributing to their
analgesic and anti –inflammatory actions. The anti-nociceptive effect of opioids
is increased by inflammation in various ways. The perineurium (normally an
impermeable membrane) is disrupted by presence of inflammation and it
enhances the entry of various mediators like corticotrophin releasing hormones,
interleukin 1B and other related cytokines. Inflammation increases the release
of peptides from immune cells leading to activation of opioid receptors 3.
Inflammation activates the previously inactive opioid receptors. In
addition it also increases the receptor up- regulation (increase in their number in
peripheral nerve terminals) thus potentiates the analgesic properties of opioids22.
Fentanyl’s pharmacokinetic variables also allows it to stay in the muscle and fat
compartments for many hours, the mean transit time for fat tissue being 1418
min23,24.After a bolus dose administration of fentanyl its action on opioid
receptors in the wound area continue beyond 24 hrs and thus reduces the wound
hyperalgesia5.
In contrast some authors found that there was no significant difference in
pain scores or rescue analgesic consumption in postoperative period in wound
infiltration groups10,25. This ineffectivity of wound infiltration was attributed to
various possibilities like inadequate dose or concentration of local anesthetic,
inter-individual differences in patients perception of pain, difference in opioid
effect or difference in pharmacokinetics. Some gave explanation that pain
arising from viscera and deeper peritoneal layers is of greater significance than
that from cutaneous, subcutaneous and muscular layer of a wound incision,
afferent from deeper structure would be unaffected by wound infiltration10,25.
The relative contribution of somatic and visceral pain after abdominal
surgery is unknown and difficult to eluciadate26. Pfannenstial incision is used to
perform total abdominal hysterectomy with bilateral salpingo-oophorectomy. It
is associated with extensive dissection and tissue damage during surgery. Thus
it contributes to both somatic and visceral pain27. Local anesthetic infiltration
near surgical wound decreases the somatic pain by altering
peripheral pain
transduction by inhibiting the transmission of noxious impulses from the site of
injury28. According to some neural pain pathway theories, sensitization of
nervous system to painful sensation occurs by stimulation of superficial pain
receptors29. Alteration of perception of deeper visceral pain can be done by
elimination of some of the superficial component of pain 30.The wound
infiltration of local anesthetics is also effective in reducing postoperative
narcotic requirements which has been observed in various studies 18,27 including
ours. But the explanation regarding the mechanism of local anesthetics in
decreasing the noxious impulses generated by visceral tissues distant to the site
of drug infiltration is difficult27. Systemic analgesic effect may also occur due to
systemic absorption of local anesthetic drugs31. This is supported by the
observation that local anesthetics decrease dorsal horn neuronal excitability
when administered systemically to decerebrated animals
32
. Certainly wound
infiltration technique involves large volumes leading to significant systemic
levels of local anesthetic or opioids. In present study 14.5 ml of 0.5%
bupivacaine or ropivacaine (72.5mg) and 25mcg of fentanyl were infiltrated in
the wound. In view of the large volumes and milligram doses of local
anesthetics it would seem sensible to use a drug with a lower toxicity. Serious
and sometime lethal cardiac toxicity has been described with bupivacaine,
particularly when large doses are used. The cardiotoxicity of ropivacaine has
been well shown to be significantly less than that of bupivacaine. In addition the
cardiotoxic manifestations are easier to manage7.
When wound infiltration with bupivacaine and ropivacaine was compared
in the present study, efficacy of postoperative analgesia in terms of pain score
(VAS score) was significantly superior in bupivacaine group as compared to
ropivacaine group however there was no significant difference in opioid
consumption in both the groups. Ropivacaine has a clinical profile similar to
that of bupivacaine, and minimal difference reported between the two
anesthetics are mainly related to the slightly different anesthetic potency, with
racemic bupivacaine > ropivacaine33. It has been reported that relative analgesic
potencies of ropivacaine: bupivacaine were 0.6 (for epidural minimum local
analgesic concentration) and 0.65 (for intrathecal minimum local analgesic
dose) and relative motor block potency of ropivacaine : bupivacaine was 0.66
after epidural administration. Ropivacaine is a levoisomer of bupivacaine and
has propyl group in place of butyl group. These structural differences make it
less lipid soluble resulting in less potency and less cardiotoxicity. Reduced
lipophilicity renders difficulty in penetration of large myelinated motor
fibers8,34.
Some authors who were unable to detect appreciable benefit from single
injection of local anesthetic35 reported that the ability to provide prolonged
application of local anesthetic to wounds through a catheter is probably
important20. Therefore continuous36 and/or intermittent infusion37 of the surgical
wound with local anesthetic solution has been introduced as a way of extending
local anesthetic induced incision pain relief in postoperative period38, with the
introduction of new portable pumps can now be used on an ambulatory basis 39
with these catheter delivery system ,the risk of infection appears to be small.
However bacterial colonization of the catheter is a common occurrence 40. Thus
in future wound infiltration using catheter technique should be planned.
Conclusion
This study establishes the effectiveness of wound infiltration using local
anesthetics(bupivacaine/ropivacaine) alongwith fentanyl as a part of multimodal
analgesia for postoperative pain relief after total abdominal hysterectomy with
bilateral salpingo-oophorectomy under spinal anesthesia. When bupivacaine or
ropivacaine are used in similar dose and concentration for wound infiltration,
bupivacaine seems to be more effective in decreasing pain scores and provided
better satisfaction scores, however it could not affect rescue analgesic
consumption.
REFERENCES
1. Leong SB, Sia ATH. Postoperative pain management after abdominal
hysterectomy. Journal of Pediatrics, Obstetrics and Gynaecology 2011;
37(1): 5-12.
2. Dahl JB, Moinich S. Relief of postoperative pain by local
anaesthetic
infiltration: Efficacy for major abdominal and orthopedic surgery. Pain
2009; 143: 7-11.
3. Mehta TR, Parikh BK, Bhosale GP, Butala BP, Shah VR. Postoperative
analgesia after incisional infiltration of bupivacaine v/s bupivacaine with
buprenorphine. J Anaesthesiol Clin Pharmacol 2011; 27(2): 211-14.
4. Mehta TR, Parikh BK, Bhosale GP, Butala BP, Shah VR. Postoperative
analgesia after incisional infiltration of bupivacaine v/s bupivacaine with
buprenorphine. J Anaesthesiol Clin Pharmacol 2011; 27(2): 211-14.
5. Tverskoy M, Braslasky A, Mazor A, Ferman R, Kissin I. The peripheral
effect of fentanyl on postoperative pain. Anesth Analg 1998; 87:1121-4.
6. Mostafa GM, Mohamad MF, Bakry RM, Farrag WSH.
Effect of
tramadol and ropivacaine infiltration on plasma catecholamine and
postoperative pain. Journal of American science 2011; 7(7):473-79.
7. Fayman M, Beeton A, Potgieter E, Becker PJ. Comparative analysis of
bupivacaine and ropivacaine for infiltration analgesia for bilateral breast
surgery. Aesth Plast Surg 2003; 27:100-103.
8. Simpson D, Curran MP, Oldfield V, Keating GM. Ropivacaine: a review
of its use in regional anaesthesia and acute pain management. Drugs
2005; 65(18): 2675-717.
9. Hannibal K, Galatius H, Hansen A, Obel E, Ellen E. Preoperative wound
infiltration with bupivacaine reduces early and late opioid requirement
after hysterectomy. Anesth Analg 1996; 83: 376-81.
10. Cobby TF, Reid MF. Wound infiltration with local anaesthetic after
abdominal hysterectomy. Br J Anaesth 1997; 78: 431-32.
11. Mulroy MF, Burgess FW, Emanuelsson BM. Ropivacaine 0.25% and
0.5%, but not 0.125% provide effective wound infiltration analgesia after
outpatient hernia repair, but with sustained plasma drug levels. Reg
Anesth Pain Med 1999; 24(2):136-41.
12. Fredman B, Shapiro A, Zohar E, Feldman E, Shorer S, Rawal N, et al.
The analgesic efficacy of patient-controlled ropivacaine instillation after
cesarean delivery. Anesth Analg 2000; 91(6):1436-40.
13. Erichsen CJ, Vibits H, Dahl JB, Kehlet H. Wound infiltration with
ropivacaine and bupivacaine for pain after inguinal herniotomy. Acta
Anaesthesiol Scand 1995; 39(1): 67-70.
14. Buvanendran A and Kroin JS. Multimodal analgesia for controlling acute
postoperative pain. Curr Opin Anaesthesiol 2009; 22: 588-93.
15. Ashburn MA, Caplan RA, Carr DB. Practice guidelines for
acute pain
management in the perioperative setting. An updated report by the
American Society of Anesthesiologists Task Force on acute pain
management. Anesthesiology 2004; 100:1573–81.
16. Zahid S. Effectiveness of wound infiltration with local anesthetic agent
after abdominal surgery. JPMI 2007; 21(4):274-77.
17. Lavand’ homme PM, Roleants F, Waterloos H, Kock D. Postoperative
analgesia effect of
continuous wound infiltration with diclofenac after
elective cesarean delivery. Anesthesiology 2007; 106 (6): 1220-5.
18. Shadangi BK, Garg R, Pandey R. A randomized, placebo-controlled,
double-blind study of the analgesic efficacy of extraperitoneal wound
instillation of bupivacaine and morphine in abdominal surgeries. Anaesth
Pain and Intensive Care 2012; 16(2):169-73.
19. Ng A, Swami A, Davidson AC, Emembolu J. The analgesic effect of
intraperitoneal and incisional bupivacaine with epinephrine after total
abdominal hysterectomy. Anesth Analg 2002; 95(1): 158-62.
20. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous
wound catheters delivering local anesthetic for postoperative analgesia: A
quantitative and qualitative systematic review of randomized controlled
trials. J Am Coll Surg 2006; 203(6): 914-32.
21. Givens VA, Lipscomb GH, Meyer NL. A randomized trial of
postoperative wound irrigation with local anesthetic for pain after
cesarean delivery. Am J Obstret Gynecol 2002; 186(6):1188-91.
22. Stein C, Schafer M, Machelska H. Attacking pain at its source: new
perspectives on opioids. Nat Med 2003; 9(8):1003-8.
23. Stein C, Millan MJ, Shippenberg TS, Herz A. Peripheral effects of
fentanyl upon nociception in inflamed tissue of the rat. Neurosci Lett
1988; 84: 225-8.
24. Boirkman S, Stanski M D, Verotta D, Harashima H. Comparative tissue
concentration profiles of fentanyl and alfentanil in humans predicted from
tissue/blood partition data obtained in rats. Anesthesiology 1990; 72: 86573.
25. Klein JR, Heaton JP, Thompson JP, Cotton BR, Davidson AC, Smith G.
Infiltration of the abdominal wall with local anaesthetic after total
abdominal hysterectomy has no opioid-sparing effect. Br J Anaesth 2000;
84(2): 248-9.
26. Cervero F. Visceral pain: mechanisms of peripheral and central
sensitization. Ann Med 1995; 27:235-9.
27. Zohar E, Fredman B, Phillipov A, Jedeikin, Shapiro A. The
analgesic
efficacy of patient-controlled bupivacaine wound instillation after total
abdominal hysterectomy with bilateral salpingo-oophorectomy. Anesth
Analg 2001; 93(2):482-87.
28. Dahl J, Moiniche S, Kehlet H. Wound infiltration with local anaesthetics
for postoperative pain. Acta Anaesthesiol Scand 1994; 38:7–14.
29. Moinich S, Kehlet H, Dahl JB. A qualitative and quantitative
systematic review of preemptive analgesia for postoperative pain
relief: The role of timing of analgesia. Anesthesiology 2002; 96:725-41.
30. Al- hakim NHH, Alidreesi ZMS. The effect of local anaesthetic wound
infiltration on postoperative pain after caesarean section. Journal of
Surgery Pakistan 2010; 15(3):131-34.
31. Wallace MS, Dyck JB, Rossi SS, Yaksh TL. Computer-controlled
lidocaine infusion for the evaluation of neuropathic pain after peripheral
nerve injury. Pain 1996; 66: 69–77.
32. Woolf CJ, Wiesenfeld-Hallin Z. The systemic administration of local
anesthetics produces a selective depression of C-afferent fibre evoked
activity in the spinal cord. Pain 1985; 23: 361–74.
33. Zink W, Graf BM. The toxicity of local anaesthetics: the place of
ropivacaine and levobupivacaine. Curr Opin Anaesthesiol 2008; 21:645–
50.
34. Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology
and clinical use. Indian J Anaesth 2011; 55(2): 104-10.
35. Moiniche S, Jorgensen H, Wetterslev J, Dahl JB. Local anesthetic
infiltration
for
postoperative
pain
relief
after
laparoscopy:
A
qualitative and quantitative systematic review of intraperitoneal, port-site
infiltration and mesosalpinx block. Anesth Analg 2000; 90:899-12.
36. Gibbs P, Purushotam A, Auld C, Cuschieri RJ. Continuous wound
perfusion with bupivacaine for postoperative wound pain. Br J Surg
1988; 75: 923-4.
37. Gupta A, Thorn SE, Axelsson K, Larsson LG, Agren G, Holmstrom B, et
al. Postoperative pain relief using intermittent injections of 0.5%
ropivacaine through a catheter after laparoscopic cholecystectomy.
Anesth Analg 2002; 95:450–6.
38. White PF. The changing role of non-opioid analgesic techniques in the
management of postoperative pain. Anesth Analg 2005; 101 (5 Suppl):
S5–S22.
39. Ilfeld BM, Morey TE, Enneking FK. New portable infusion pumps: real
advantages or just more of the same in a different package. Reg Anesth
Pain Med 2004; 29:371-6.
40. Cuvillon P, Ripart J, Lalourcey L, Veyrat E, L'Hermite J, Boisson C, et
al. The continuous femoral nerve block catheter for postoperative
analgesia: bacterial colonization, infectious rate and adverse effects.
Anesth Analg 2001; 93:1045–9.