Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS

Abstract

Background: Our previous standardized postoperative pain management plan for AIS patients undergoing PSF included the placement of an epidural (EPI) catheter by the spine surgeon prior to fascial closure. The epidural was used for 24 hours, in conjunction with a multi-modal post-operative pain protocol. Local Problem: The 2020 COVID-19 pandemic highlighted the need for our surgical AIS patients and their families to have private rooms/bathrooms. Epidural catheters require arterial line blood pressure monitoring to ensure safety. Unfortunately, the arterial lines could not be utilized in the private rooms due to lack of appropriate monitors, therefore we transitioned away from epidurals. Liposomal bupivacaine (LB) is an encapsulated local anesthetic that has a duration of action up to 72 hours. Specific Aims: This quality initiative (QI) focused on the enhancement of the standardized postoperative care pathway for AIS patients undergoing PSF. The aims of the initiative were to 1) minimize narcotic usage, and 2) allow for earlier mobilization. Intervention: The (2020) LB cohort had a mixture of LB, bupivacaine HCL and normal saline injected into the fascial and subcutaneous layers of the incision prior to fascial closure. The (2019) control cohort had an epidural (EPI) catheter placed prior to fascial closure. The epidural infusion consisted of ropivacaine 0.1% (0.1-0.2 ml/kg/hr.) The cohorts received the same pain protocol (intravenous opioid with transition to oral opioid, as well as dexmedetomidine, acetaminophen, ketorolac, and diazepam). Measures and Analysis: Two cohorts of prospective AIS patients that underwent PSF were retrospectively reviewed. They were compared regarding age, BMI, average preoperative major Cobb angle, average preoperative kyphosis, VAS pain scores and narcotic consumption. Time to ambulation, and length of stay (LOS) were also evaluated. Results: 159 AIS patients were reviewed. There were no preoperative differences between the 2020 LB cohort (n =101) and the 2019 EPI cohort (n = 58) when comparing age (14.3 vs.15.0 years), average BMI (21.7 vs.20.8 kg/m2), preoperative major Cobb (60.7° vs.60.3°), or average preoperative kyphosis (25.7° vs. 27.1°). The LB cohort consumed similar morphine equivalents during the initial 24 hrs. (37.8mg vs.37.3mg), but less at 24-48 hrs. (37.2mg vs 41.0mg) (p=0.031), and 48-72hrs (23.3mg vs. 29.6mg) (p=0.015). The LB cohort ambulated 6.8 hrs. sooner (17.1 vs 23.9 hrs.) (p=.0001). Summary: LB associated with less consumption of post-operative morphine equivalents and earlier ambulation.

The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

“…In a quality improvement study, McIntosh et al retrospectively reviewed 159 AIS patients undergoing PSF and found that patients who received LB required significantly less morphine equivalents than patients who received an epidural catheter with continuous infusion of ropivacaine. 21 They also found the administration of LB was associated with quicker time to ambulation (6 to 7 hours). Our results had similar findings in terms of decreased opioid consumption, as well as mobility, as patients ambulated a mean of 335 feet further on POD 2 when LB was injected locally at the time of surgery.…”

“…In a quality improvement study, McIntosh et al retrospectively reviewed 159 AIS patients undergoing PSF and found that patients who received LB required significantly less morphine equivalents than patients who received an epidural catheter with continuous infusion of ropivacaine 21 . They also found the administration of LB was associated with quicker time to ambulation (6 to 7 hours).…”

Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

“…There is a growing pool of evidence supporting nonopioid medications, including intravenous acetaminophen, liposomal and nonliposomal bupivacaine, steroids, and muscle relaxers in both the intra and postoperative time periods for the reduction of postoperative opioid use 7,23 . Of these medications, liposomal bupivacaine was found to have the largest individual-associated decrease in postoperative opioid use while accounting for other intraoperative medications, echoing a growing pool of recent literature supporting liposomal bupivacaine in the pediatric spine population 6,15 . Patients in the TRC cohort, in addition, received statistically significantly greater amounts of the majority of other nonopioid intraoperative medications, with significant association with decreased postoperative MME when accounting for all other variables found in methocarbamol and dexmedetomidine, in addition to liposomal bupivacaine.…”

“…Opioid medications are commonly prescribed for pain management after surgery in pediatric populations, 8 despite known risk factors including persistent opioid use and overdose 9–12 . While previous studies have focused on various pain management regimens in the early postoperative timeframe, 13,14 more recent studies have evaluated the effects of intraoperative pain regimens on postoperative outcomes 15,16 . In efforts to manage postsurgical pain and minimize in-hospital opioid consumption and length of stay, multimodal analgesic regimens, including nonopioid regional anesthetics, have been proposed 6,17 …”

“…Liposomal bupivacaine has recently gained FDA approval for use in the pediatric population 18 . It functions as a long-acting single-dose formulation of the local anesthetic bupivacaine that can be administered subcutaneously during surgical procedures, with a duration of action of up to 72 hours, 15 and has proved efficacious in the reduction of postoperative pain after a variety of surgical procedures 6,19–21 …”