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Liposomal Bupivacaine Injection as an Adjuvant Therapy for Pain Control After Scheduled Cesarean Deliveries
Purpose: The purpose of our study is to quantify benefits of liposomal Bupivacaine injection as an infiltrate in the three layers of the abdominal wall during closure of cesarean delivery as compared to no injection regarding pain control, narcotic use, and length of stay.
Background: Cesarean delivery is the most common US operating room procedure in 2014, accounting for 9% of operations and 32% of births. Post cesarean section pain control is imperative for maternal -infant bonding, recovery, postpartum depression, persistent pain after recovery, and reduced stress and success with breastfeeding. Multimodal pain control is an important component of enhanced recovery after surgery, ERAS. There have been several studies involving the use of liposomal Bupivacaine, (LB) for pain control as a part of cesarean delivery. Specifically, this has been studied as both a transversus abdominis plane block and local injection at closure. Our goal is to attempt to quantify improvements of using LB injection as an infiltrate through all the layers of the abdominal wall during closure and compare it to no injection regarding pain control, narcotics used, and length of stay.
Methods: IRB was approved for this study. Initially our goal was to include 100 patients in the study group. We choose to study only scheduled cesarean delivery cases to avoid any variance of pain control during failed vaginal delivery attempts, preterm labor, or premature rupture of membranes. Approval was obtained from Pharmacy and Therapy meetings for 100 doses of Liposomal bupivacaine (LB) for purposes of the study. A standardized method of dilution, infiltration, and patient education was prepared and taught to all surgeons, OR personal, and postop nursing. Surgeons were trained in a formal didactic which included demonstration and video of technique used. We based our solution off smaller case-controlled studies using; 20 cc of liposomal bupivacaine, 30 cc of bupivacaine HCl 0.5%, and 50 cc Normal Saline for a solution of 100 cc total. Infiltration was taught and subsequently performed in a standardized fashion in 3 layers at time of abdominal closure. A total of 30 cc of solution was injected below the fascia after fascial closure. Then, an additional 30 cc of solution was injected above the fascia. Lastly, a final layer of 40 cc of solution was injected into the subcutaneous layer prior to subcutaneous closure. Patient subjective pain scores, narcotic use (Morphine Milligram equivalent MME), length of stay, and narcotic prescription at discharge post operatively were measured.
Results: A total of 38 patients received liposomal bupivacaine injection as a part of ERAS pathway in a standard fashion at time of closure of scheduled cesarean section deliveries as compared to 39 patients with standard ERAS protocol and no LB injection. Patients in the LB injection group had a mean length of stay of 2.45 days, compared with those without LB injection stayed 2.56 days. This was not a statistically significant decrease (P= 0.4403) in length of stay however, it is demonstrating a trend to faster recovery with LB injection.
At time of discharge, 60.3% of patients who received LB bupivacaine required any oral narcotics during their postoperative stay (30 of 38 patients), whereas 97% of those who did not receive LB (38 of 39 patients) required oral narcotics. Of the patients using oral narcotics post operatively, the average morphine milligram equivalents (MME) of those in the study group was 33.91 mg whereas for those in the standard group it was 47.86 mg. The average pain score was slightly lower in the study group 3.27 (1-10 pain scale) compared to the control group 3.73, suggesting improved pain scores with less oral narcotics however this did not reach statistical significance (P=0.1954). The prescribed MMEs (morphine milligram equivalents) of those obtaining LB at closure was 26 mg as compared to 43.85 in those who did not obtain LB. Of the patients in the intervention group who received a discharge prescription for opioids, 77% (23/30) received less than the standard dose from the control group.
Discussion: This study showed infiltrating LB at abdominal wall closure decreased the number of oral narcotics required post scheduled cesarean delivery. The study population who obtained LB injection was significantly less likely to receive any oral narcotics postoperatively. Patients requiring oral narcotics in the LB injection group used a significantly less amount than those who did not receive the LB injection. Average pain scores were slightly improved in those patients who received the LB injection, even though they received less narcotics. There was also a tend toward a shorter length of stay in the LB injection group. Our study shows the potential of LB injection to improve pain control and thus decrease the number of narcotics given post operatively and upon discharge for scheduled cesarean deliveries.
Topics:
SES, 2023,
