Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol

Abstract

Introduction:The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture.Methods:A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05.Results:One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272).Conclusion:The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.

Liposomal Bupivacaine for Peripheral Nerve Blockade: A Randomized, Controlled, Crossover, Triple-blinded Pharmacodynamic Study in Volunteers

“…[35][36][37][38] Liposomal bupivacaine, as investigated in the current study, was initially used for surgical infiltration with the main focus on postoperative pain therapy. [11][12][13]24,25,29 Only then was the spectrum of applications expanded to interscalene brachial plexus, 15,16 femoral nerve, 18,39 intercostal nerve, [19][20][21][22][23]40 and fascial plane block 41 techniques.…”

“…9 Human studies began a decade later, 10 with initial applications of site infiltration in hip, knee, or shoulder surgery. [11][12][13] More recently, liposomal bupivacaine has even been used in blocking the brachial plexus (interscalene approach) [14][15][16] or the femoral 17,18 or intercostal [19][20][21][22][23] nerve.…”

“…However, most of the available research has dealt with infiltration and fascial plane techniques, which cannot truly be considered regional anesthesia. 12,13,24,25 Those very few studies in the literature that do report on liposomal bupivacaine for peripheral nerve blockade have recently been subjected to meta-analysis, the results of which have engendered great controversy. 26 Despite a good base of citable reports, little is known about the pharmacodynamic characteristics of liposomal bupivacaine, considering that the available clinical studies almost invariably used postoperative opioid requirements as their primary outcome measure.…”

“…However, most of the available research has dealt with infiltration and fascial plane techniques, which cannot truly be considered regional anesthesia. 12,13,24,25 Those very few studies in the literature that do report on liposomal bupivacaine for peripheral nerve blockade have recently been subjected to meta-analysis, the results of which have engendered great controversy. 26…”

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

“…Basmajian et al demonstrated a postoperative pain improvement after the administration of liposomal bupivacaine, and similarly, more recent studies have demonstrated the same. 32–34 Other cocktails like those used in arthroplasty may also be of benefit. 31,35,36 A paucity of evidence exists within the literature exploring these options, representing an area for further study as these cocktails may be used in lieu of or as part of the continuum of pain control.…”