Bupivacaine to Reduce Pain and Narcotic Use After Mohs Micrographic Surgery

Abstract

BACKGROUND Limited data exists for bupivacaine injection after Mohs micrographic surgery (MMS). OBJECTIVE Evaluate how bupivacaine affects postoperative pain and narcotic use. MATERIALS AND METHODS In this multicenter, single-blinded, prospective randomized controlled trial, patients received bupivacaine or saline (placebo) immediately after MMS with flap reconstructions identified by American Academy of Dermatology expert consensus as high-risk for pain and narcotic use. For 48 hours postoperatively, patients logged analgesic use, pain scores (0–10), and whether pain was controlled. RESULTS One hundred seventy-four patients were included. Narcotic analgesic use was higher in the placebo group during the first 24 hours (odds ratio 2.18; confidence interval [CI]: 1.08–4.41; p = .03), second 24 hours (odds ratio 2.18; CI: 0.91–5.29; p = .08), and 48 hours combined (odds ratio 2.58; CI: 1.28–5.24; p < .01). Pain scores were lower in the bupivacaine group during the first 8 hours (mean difference 1.6; CI: 0.73–2.38; p < .001). Overall analgesic use (narcotic and non-narcotic) and percentage of patients reporting pain under control were similar between groups. There were no significant differences in demographics or surgical characteristics. No adverse events occurred. CONCLUSION Single-dose bupivacaine decreased postoperative pain and narcotic analgesic use after MMS with reconstructions likely to cause significant pain. Bupivacaine may have a role in postoperative pain management and reducing narcotic use in this population.

Liposomal and Nonliposomal Bupivacaine for Mohs Surgery: A Systematic Review

“…In a 2022 multiacademic site clinical trial, Voss and colleagues 14 assessed postoperative pain and opioid use after MMS flap reconstructions, considered high-risk for postoperative pain and opioid consumption. Patients received 0.5% bupivacaine or saline (placebo) administered in a 1-cm grid around the flap immediately after reconstruction.…”

“…2,9 In particular, expert consensus has identified certain types of reconstructions (e.g., rotation, transposition, interpolation, or advancement flaps performed on the scalp, ear, nose, and lip) as high-risk for postoperative pain and opioid use. 22 Voss and colleagues 14 intentionally included only these high-risk cases in their randomized trial, whereas Chen and colleagues 13 and Chang and colleagues 7 likely captured a high number of such cases in their studies by limiting participants to those undergoing MMS on the nose and head and neck, rendering the patient selection in all 3 studies reflective of real-world populations likely to receive postoperative opioid prescriptions.…”

“…Although the aforementioned study examined nonliposomal bupivacaine for intraoperative anesthesia in MMS, Voss and colleagues 14 investigated its potential as a postoperative adjuvant given as a one-time infiltration immediately after reconstruction. Lower pain levels were reported during the first 8 postoperative hours in the bupivacaine group (consistent with the medication's known duration of up to 8 hours), but no significant differences were observed thereafter.…”

“…5,11,12 Bupivacaine has been explored as an alternative or adjunct to lidocaine during several surgical procedures, including MMS. [13][14][15][16] In comparison to lidocaine, bupivacaine has a lower pH (which hinders effective buffering with sodium bicarbonate) and a slower onset (5 minutes vs ,2 minutes), leading to increased sensations of pain and/or burning during infiltration. 5,17 However, bupivacaine's duration of action (4-8 hours) is longer than that of lidocaine (1-2 hours without epinephrine and 2-4 hours with epinephrine).…”

Acetaminophen and warfarin: A recipe for supratherapeutic international normalized ratio with postoperative bleeding risk

“…Bupivacaine use immediately following MMS has been shown to reduce postoperative pain and narcotic analgesic use. 5 …”