A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures

Abstract

Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF. METHODS:Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality. RESULTS:Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB. CONCLUSION:In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF.

Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial

“…By contrast, in our study, both patient and physician were blinded to treatment regimen further minimizing bias in the results. Further, a recent study by Leasia et al 32 provided more evidence that single injection of liposomal bupivacaine provides comparable analgesia to a continuous peripheral nerve plane analgesia catheter in patients undergoing rib fracture surgical stabilization with no significant reductions in opiate use.…”

Expanding clinicians’ armamentarium for regional pain control after thoracic surgery

“…Sheets et al found that traumatic rib fracture patients receiving ICNB with liposomal bupivacaine were intubated less frequently and had shorter intensive care unit and overall hospital stays than patients with TEA ( 10 ). Similarly, a randomized controlled trial demonstrated that a single liposomal bupivacaine block provided comparable pain control to an indwelling peripheral analgesic catheter placed in a similar space for patients undergoing surgical stabilization of rib fractures ( 11 ). Another large retrospective analysis of patients undergoing abdominal surgery discovered that patients who received liposomal bupivacaine blocks had shorter lengths of stay, lower rates of readmission and lower rates of post-surgical hypotension and vasopressor use than those who received epidural analgesia ( 12 ).…”