Ropivacaine for Continuous Wound Infusion for Postoperative Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background: The use of continuous wound infusion (CWI) of local anaesthetics has been suggested as a safe and effective alternative technique to epidural anaesthesia/analgesia that allows surgeons to provide postoperative pain relief while reducing opioid consumption and associated adverse events. A previous meta-analysis by Liu et al. [Am Coll Surg 2006;203:914-932] reported results mainly from studies of bupivacaine. Subsequently, several new randomized controlled trials (RCTs) of ropivacaine have been published. This systematic review and quantitative meta-analysis evaluates the efficacy of ropivacaine for CWI. Methods: Systematic literature searches (EMBASE, MEDLINE) were performed to retrieve studies which met the following criteria: double-blind RCT of ropivacaine versus either placebo or an active comparator; use of ropivacaine solution without added active agents, and prohibition of other routine analgesics during the study period except rescue patient-controlled analgesia. For each included study, standardized effect sizes for ropivacaine versus placebo were calculated for opioid rescue use, pain score at rest, and pain score at mobilization. Meta-analyses were conducted for each endpoint. Results: Fourteen RCTs comparing ropivacaine (n = 376) versus placebo (n = 380) were identified. Effect size estimates revealed significantly less opioid rescue use for ropivacaine patients (-1.3; 95% CI -1.5 to -1.1) and significantly less pain for ropivacaine patients both at rest (-1.1; 95% CI -1.3 to -0.9) and on mobilization (-1.5; 95% CI -1.7 to -1.3). The weighted mean reduction in opioid rescue use was 22.4 mg. Conclusion: This systematic review and meta-analysis presents substantial evidence that ropivacaine provides clinically meaningful reductions in opioid use and pain outcomes. Ropivacaine CWI is effective for postoperative pain management in a wide range of surgical procedures.

Current issues in postoperative pain management

“…70 A more recent meta-analysis of 14 RCTs (756 patients) focused on ropivacaine for WCI, the authors noting consistent evidence of effective analgesia and opioid sparing in a wide range of surgical procedures such as total knee or hip replacement, and major abdominal and cardiac surgery. 71 Similarly, a meta-analysis of infiltrative techniques (WCI, TAP, intraperitoneal) versus placebo for routine analgesia for colorectal surgery concluded that the infiltrative techniques were associated with lower pain scores, reduction of opioid requirements, shorter length of stay and no increase in complications. 72 It must be emphasised that all studies with wound infiltration are not positive.…”

Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty

“…102 A more recent meta-analysis of 14 RCTs (756 patients) focused on ropivacaine for wound catheter infusion; the authors noted consistent evidence of effective analgesia and opioid sparing across a wide range of surgical procedures including TKA. 103 Plasma concentration of local anesthetic was below toxic levels, despite 8 to 20 mg/h ropivacaine infusion for 48 hours. 103 Wound catheter infusion techniques should preferably be called surgical-site catheter techniques because the catheters are not always strictly in the surgical wound.…”

“…103 Plasma concentration of local anesthetic was below toxic levels, despite 8 to 20 mg/h ropivacaine infusion for 48 hours. 103 Wound catheter infusion techniques should preferably be called surgical-site catheter techniques because the catheters are not always strictly in the surgical wound. In clinical practice, catheters have been placed through the surgical wound into deeper layers and in cavities (subcutaneous, subfascial, subacromial, intraarticular, intraperitoneal, preperitoneal, intraosseous, etc).…”

Ropivacaine Wound Infiltration for Pain Management After Breast Cancer Mastectomy: A Population Pharmacokinetic Analysis

“…Ropivacaine is a long‐acting local anesthetic increasingly used in the management of postoperative analgesia. A meta‐analysis has recently presented some evidence of the clinical efficacy of ropivacaine continuous wound infusion (CWI) in a wide range of surgical procedures . This technique is one of the multimodal pain relief strategies used to prevent acute and chronic pain and to reduce opioid consumption and side effects.…”

“…A meta-analysis has recently presented some evidence of the clinical efficacy of ropivacaine continuous wound infusion (CWI) in a wide range of surgical procedures. 1 This technique is one of the multimodal pain relief strategies used to prevent acute and chronic pain and to reduce opioid consumption and side effects. In women undergoing breast cancer surgery, CWI of ropivacaine is a promising procedure used to prolong the analgesic effect, 2 which could allow an ambulatory setting and early discharge home.…”