TY - JOUR
AU - Wyman, Marcia, J.
AB - Abstract Purpose The duration of analgesia and comparative efficacy of liposomal bupivacaine and an elastomeric bupivacaine pump in a diverse surgical population were determined. Methods A retrospective cohort study was conducted to evaluate patient outcomes following liposomal bupivacaine and elastomeric bupivacaine pump use from January through June 2013. The primary objective of the study was to evaluate 24-hour postoperative opioid use (in morphine equivalents). Results Sixty-seven liposomal bupivacaine and 262 elastomeric bupivacaine pump patients were included. Significant between-group differences were seen in American Society of Anesthesiologists physical status, patient-controlled analgesia use, postoperative nonopioid use, and surgical procedure. On univariate analysis, liposomal bupivacaine—in comparison with elastomeric bupivacaine pump —was associated with reduced median (interquartile range, IQR) 24-hour postoperative opioid use (33.0 mg morphine equivalents [IQR, 19.0–80.4 mg morphine equivalents] versus 70.4 mg morphine equivalents [IQR, 37.1–115.4 mg morphine equivalents], p < 0.001) and median 72-hour postoperative opioid use (61.3 mg morphine equivalents [IQR, 28.7–142.8 mg morphine equivalents] versus 115.9 mg morphine equivalents [IQR, 69.9–175.4 mg morphine equivalents], p < 0.001). However, after adjustment for potential confounders with linear regression analysis, study medication was not associated with a decrease in 24-hour (β coefficient for elastomeric bupivacaine pump: 10.26; 95% confidence interval [CI]: −8.42 to 28.95; p = 0.281) or 72-hour postoperative opioid use (β coefficient for elastomeric bupivacaine pump: 2.23; 95% CI: −29.88 to 34.34; p = 0.891). Conclusion No difference was found between patients who received liposomal bupivacaine compared with elastomeric continuous infusion bupivacaine from a traditional pump in 24- or 72-hour postoperative opioid utilization after adjustment for baseline differences. Multimodal analgesia is the use of two or more drugs that act by different mechanisms and is recommended for the treatment of postoperative pain or the period up to seven days after surgery.1,2 This approach to treatment employs agents with different pharmacologic actions to allow for smaller individual doses of different drugs to reduce overall opioid-related adverse effects while still providing patients with adequate analgesia. In a recent national survey, 79% of postoperative patients experienced at least one adverse effect from their analgesic medications.3 Additionally, the occurrence of opioidrelated adverse effects has been shown to increase both total cost and length of stay (LOS) in the hospital.4 Local anesthetics are often used as part of a multimodal regimen; however, this drug class is limited by its short duration of action. Although bupivacaine is one of the longest-acting local anesthetics, with a duration of action of up to seven hours, a longer duration of analgesia is usually needed for postoperative patients.5 An option to extend the duration of action of local anesthetics and maximize the benefit of a multimodal treatment approach is through the use of continuous infusion wound catheters; however, the need for a traditional stationary bedside infusion pump may present logistical challenges for postoperative patients. An elastomeric continuous infusion bupivacaine pump (ON-Q Pain Relief System, I-Flow Corporation, Lake Forest, CA) has been utilized in this setting to allow for extended local infiltration of medication while preserving patient mobility.6,7 Although this approach is an effective way of ensuring therapeutic concentrations at the surgical site, several problems such as the inappropriate removal of catheters, an increase in infections, and catheter migration are possible; however, these problems are not currently demonstrated to an appreciable extent in the literature.8 A recent alternative to extend the duration of bupivacaine action is through encapsulation of the drug in liposomes. Liposomal bupivacaine is approved by the Food and Drug Administration for infiltration of wound margins and has been reported to have a measurable plasma concentration of up to 72 hours.9,10 It is currently indicated for use in hemorrhoidectomy and bunionectomy procedures but has been studied for other indications with mixed results.11–15 These studies have demonstrated an effective duration of analgesia at 24 hours, with minimal analgesic effects seen up to 72 hours postoperatively.9,10 This study seeks to determine the clinical duration of analgesia provided by liposomal bupivacaine compared with bupivacaine administered by an elastomeric continuous infusion pump in patients undergoing various surgical procedures by assessing postoperative opioid use. Methods This retrospective cohort study was conducted at a large academic medical center and approved by the institutional review board with a waiver of informed consent. A pharmacy database query was conducted to identify all medication orders for liposomal bupivacaine and continuous infusion bupivacaine pump between January and June 2013. Patients were included if they were 18 years or older with documented administration of liposomal bupivacaine 266 mg or elastomeric continuous infusion bupivacaine hydrochloride 0.5% in 400 mL (undiluted bupivacaine) at a rate of 4 mL/hr. This is the most commonly utilized dosage and rate at the study institution, representing the maximum dose in the product labeling. Study medications were administered only via wound infiltration. Outpatients defined as patients remaining in the hospital (less than 24 hours postoperatively), were excluded from the study because their opioid utilization could not be assessed. The primary objective for the study was to evaluate total opioid use in the first 24 hours after surgery. Secondary objectives included total opioid use in the first 72 hours after surgery, time to first rescue or other additional opioid use, and hospital LOS between the two cohorts. All opioid use was converted to milligrams of oral morphine equivalents. Data collection from each patient’s medical record included factors to determine study eligibility, demographics, and analgesic medication utilization. Demographic criteria included the surgical procedure and indication, attending surgeon, and expected postoperative pain risk classification, which was determined based on the expected rate of severe acute postoperative pain (defined as ≥6 on a numeric rating scale of 1 to 102). Additional data collected included the American Society of Anesthesiologists (ASA) Physical Status Classification for stratification of patient’s systemic illness,16 intensive care unit (ICU) admission, pain service consultation, hospital LOS, age, and sex. Analgesic medication utilization that was assessed included study medication, opioid use pre- and postoperatively, nonopioid analgesic use pre- and postoperatively, time to first unscheduled supplemental opioid dose, and patient-controlled analgesia (PCA) utilization. Documented medication-related adverse events and complications of therapy were also assessed. Descriptive data are expressed as number and percentage, median and interquartile range (IQR), or coefficient and 95% confidence interval (CI), as appropriate. Categorical data were analyzed using Pearson chi-square or Fisher’s exact test, as appropriate. Continuous variables were analyzed with the Mann–Whitney U test, which was chosen for continuous data as a conservative measure due to the challenges of determining true normality with the data set. Kaplan–Meier curves were constructed to estimate the time to the first as needed opioid use and were compared with the log-rank test. Patients who did not receive supplemental opioids at 72 hours were censored. An a priori power analysis was conducted, which demonstrated that 41 patients in each cohort would need to be included to show at least a 50% decrease in 24-hour opioid use with liposomal bupivacaine (40-mg versus 20-mg morphine equivalents; what was determined to be clinically notable), with the standard deviation equal to the mean for each cohort and a two-sided α value of 0.05 with 80% power. Multivariable linear regression analyses using the forced-entry method were constructed for 24- and 72-hour postoperative opioid use to account for differences between groups in baseline characteristics. Variables entered into the models included patient group and baseline factors with biological plausibility for affecting the primary outcome and met the a priori-determined statistical criterion of p < 0.20 on baseline univariate comparisons. These variables included age, sex, preoperative opioid use (based on morphine equivalents), ASA class, expected pain class, ICU admission, PCA use, pain service consultation, and postoperative nonopioid use (in milligrams of each individual agent). All statistical analyses were performed with SPSS, version 15.0 for Windows (SPSS Inc., Chicago, IL). Results There were 465 patients with orders for the two study medications during the study period. Of the 156 patients with liposomal bupivacaine orders who were initially identified, 89 were excluded for either lack of medication administration documentation (n = 48) or outpatient status (n = 41). Of the 309 patients with elastomeric bupivacaine pump orders who were initially identified, 47 were excluded for either lack of medication administration documentation (n = 36) or outpatient status (n = 11). A total of 329 patients were included in the study: 67 in the liposomal bupivacaine cohort and 262 in the elastomeric bupivacaine pump cohort. Baseline characteristics and demographics of the two cohorts are presented in Table 1. No significant differences existed between the groups for sex, age, preoperative opioid use, rate of preoperative nonopioid use, pain service consult, and ICU postoperative admission. Patients in the elastomeric bupivacaine cohort utilized a PCA pump postoperatively more frequently (p < 0.001). Significant differences also existed between groups for ASA physical status classification and surgical procedure (analyzed descriptively by anatomical location and by expected pain risk classification; p < 0.001 for both), indicating patients who received elastomeric bupivacaine were at higher operative risk, including postoperative pain. Table 1 Baseline Characteristics of Study Population, by Cohorta Characteristic Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p Male, no. (%) 20 (29.9) 59 (22.5) 0.261 Age with median (IQR), yr 51 (38–66) 48 (40–58) 0.190 Preoperative opioid use (mg morphine equivalents), median (IQR) 0 (0–0) 0 (0–0) 0.064 Rate of preoperative nonopioid use, no. (%) 18 (26.9) 65 (24.8) 0.753 ASA physical status class, no. (%) <0.001  1 3 (4.5) 0  2 33 (49.3) 48 (18.3)  3 28 (41.8) 199 (76.0)  4 3 (4.5) 15 (5.7) Rate of PCA use postoperatively, no. (%) 35 (52.2) 250 (95.4) <0.001 Pain service consultation, no. (%) 2 (3.0) 4 (1.5) 0.606 ICU admission postoperatively, no. (%) 0 14 (5.3) 0.082 Surgery type, no. (%) <0.001  Breast 16 (23.9) 35 (13.4)  Colorectal 8 (11.9) 0  Gastrointestinal 27 (40.3) 211 (80.5)  Genitourinary 2 (3) 5 (1.9)  Hemorrhoid 2 (3) 0  Hernia 6 (9.0) 6 (2.3)  Manipulation 5 (7.5) 4 (1.5)  Orthopedic 1 (1.5) 1 (0.4) Expected pain classification and rate of severe acute postoperative pain from surgery, no. (%) <0.001  Low risk (40–56%) 7 (10.4) 0  Moderate risk (58–63%) 0 2 (0.8)  High risk (67–69%) 22 (32.8) 42 (16)  Highest risk (76–100%) 38 (56.7) 218 (83.2) Characteristic Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p Male, no. (%) 20 (29.9) 59 (22.5) 0.261 Age with median (IQR), yr 51 (38–66) 48 (40–58) 0.190 Preoperative opioid use (mg morphine equivalents), median (IQR) 0 (0–0) 0 (0–0) 0.064 Rate of preoperative nonopioid use, no. (%) 18 (26.9) 65 (24.8) 0.753 ASA physical status class, no. (%) <0.001  1 3 (4.5) 0  2 33 (49.3) 48 (18.3)  3 28 (41.8) 199 (76.0)  4 3 (4.5) 15 (5.7) Rate of PCA use postoperatively, no. (%) 35 (52.2) 250 (95.4) <0.001 Pain service consultation, no. (%) 2 (3.0) 4 (1.5) 0.606 ICU admission postoperatively, no. (%) 0 14 (5.3) 0.082 Surgery type, no. (%) <0.001  Breast 16 (23.9) 35 (13.4)  Colorectal 8 (11.9) 0  Gastrointestinal 27 (40.3) 211 (80.5)  Genitourinary 2 (3) 5 (1.9)  Hemorrhoid 2 (3) 0  Hernia 6 (9.0) 6 (2.3)  Manipulation 5 (7.5) 4 (1.5)  Orthopedic 1 (1.5) 1 (0.4) Expected pain classification and rate of severe acute postoperative pain from surgery, no. (%) <0.001  Low risk (40–56%) 7 (10.4) 0  Moderate risk (58–63%) 0 2 (0.8)  High risk (67–69%) 22 (32.8) 42 (16)  Highest risk (76–100%) 38 (56.7) 218 (83.2) a IQR = interquartile range, ASA = American Society of Anesthesiologists, PCA = patient-controlled analgesia, ICU = intensive care unit. Open in new tab Table 1 Baseline Characteristics of Study Population, by Cohorta Characteristic Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p Male, no. (%) 20 (29.9) 59 (22.5) 0.261 Age with median (IQR), yr 51 (38–66) 48 (40–58) 0.190 Preoperative opioid use (mg morphine equivalents), median (IQR) 0 (0–0) 0 (0–0) 0.064 Rate of preoperative nonopioid use, no. (%) 18 (26.9) 65 (24.8) 0.753 ASA physical status class, no. (%) <0.001  1 3 (4.5) 0  2 33 (49.3) 48 (18.3)  3 28 (41.8) 199 (76.0)  4 3 (4.5) 15 (5.7) Rate of PCA use postoperatively, no. (%) 35 (52.2) 250 (95.4) <0.001 Pain service consultation, no. (%) 2 (3.0) 4 (1.5) 0.606 ICU admission postoperatively, no. (%) 0 14 (5.3) 0.082 Surgery type, no. (%) <0.001  Breast 16 (23.9) 35 (13.4)  Colorectal 8 (11.9) 0  Gastrointestinal 27 (40.3) 211 (80.5)  Genitourinary 2 (3) 5 (1.9)  Hemorrhoid 2 (3) 0  Hernia 6 (9.0) 6 (2.3)  Manipulation 5 (7.5) 4 (1.5)  Orthopedic 1 (1.5) 1 (0.4) Expected pain classification and rate of severe acute postoperative pain from surgery, no. (%) <0.001  Low risk (40–56%) 7 (10.4) 0  Moderate risk (58–63%) 0 2 (0.8)  High risk (67–69%) 22 (32.8) 42 (16)  Highest risk (76–100%) 38 (56.7) 218 (83.2) Characteristic Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p Male, no. (%) 20 (29.9) 59 (22.5) 0.261 Age with median (IQR), yr 51 (38–66) 48 (40–58) 0.190 Preoperative opioid use (mg morphine equivalents), median (IQR) 0 (0–0) 0 (0–0) 0.064 Rate of preoperative nonopioid use, no. (%) 18 (26.9) 65 (24.8) 0.753 ASA physical status class, no. (%) <0.001  1 3 (4.5) 0  2 33 (49.3) 48 (18.3)  3 28 (41.8) 199 (76.0)  4 3 (4.5) 15 (5.7) Rate of PCA use postoperatively, no. (%) 35 (52.2) 250 (95.4) <0.001 Pain service consultation, no. (%) 2 (3.0) 4 (1.5) 0.606 ICU admission postoperatively, no. (%) 0 14 (5.3) 0.082 Surgery type, no. (%) <0.001  Breast 16 (23.9) 35 (13.4)  Colorectal 8 (11.9) 0  Gastrointestinal 27 (40.3) 211 (80.5)  Genitourinary 2 (3) 5 (1.9)  Hemorrhoid 2 (3) 0  Hernia 6 (9.0) 6 (2.3)  Manipulation 5 (7.5) 4 (1.5)  Orthopedic 1 (1.5) 1 (0.4) Expected pain classification and rate of severe acute postoperative pain from surgery, no. (%) <0.001  Low risk (40–56%) 7 (10.4) 0  Moderate risk (58–63%) 0 2 (0.8)  High risk (67–69%) 22 (32.8) 42 (16)  Highest risk (76–100%) 38 (56.7) 218 (83.2) a IQR = interquartile range, ASA = American Society of Anesthesiologists, PCA = patient-controlled analgesia, ICU = intensive care unit. Open in new tab Liposomal bupivacaine was associated with reduced median 24-hour postoperative opioid use (33.0 mg morphine equivalents [IQR, 19.0–80.4 mg morphine equivalents] versus 70.4 mg morphine equivalents [IQR, 37.1–115.4 mg morphine equivalents], p < 0.001) and median 72-hour postoperative opioid use (61.3 mg morphine equivalents [IQR, 28.7–142.8 mg morphine equivalents] versus 115.9 mg morphine equivalents [IQR, 69.9–175.4 mg morphine equivalents], p < 0.001) (Table 2). Table 2 Results of Univariate Analysis of Opiod Use and Other Outcomes in Study Population, by Cohorta Outcome Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p 24-hr postoperative morphine equivalents (mg) with median (IQR) 33.0 (19.0–80.4) 70.4 (37.1–115.4) <0.001 72-hr postoperative morphine equivalents (mg) with median (IQR) 61.3 (28.7–142.8) 115.9 (69.9–175.4) <0.001 Hospital length of stay (days) with median (IQR) 3.2 (2.0–5.5) 3.0 (2.1–4.0) 0.371 24-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 31.3 (14.5–72.0) 66.6 (36.0–111.3) <0.001 72-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 47.5 (15.8–122.4) 104.5 (55.4–167.7) <0.001 Postoperative nonopioid orders, no. (%) 63 (94.0) 116 (44.3) <0.001 Acetaminophen orders, no. (%) 55 (82.1) 86 (32.8) <0.001 Outcome Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p 24-hr postoperative morphine equivalents (mg) with median (IQR) 33.0 (19.0–80.4) 70.4 (37.1–115.4) <0.001 72-hr postoperative morphine equivalents (mg) with median (IQR) 61.3 (28.7–142.8) 115.9 (69.9–175.4) <0.001 Hospital length of stay (days) with median (IQR) 3.2 (2.0–5.5) 3.0 (2.1–4.0) 0.371 24-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 31.3 (14.5–72.0) 66.6 (36.0–111.3) <0.001 72-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 47.5 (15.8–122.4) 104.5 (55.4–167.7) <0.001 Postoperative nonopioid orders, no. (%) 63 (94.0) 116 (44.3) <0.001 Acetaminophen orders, no. (%) 55 (82.1) 86 (32.8) <0.001 a IQR = interquartile range Open in new tab Table 2 Results of Univariate Analysis of Opiod Use and Other Outcomes in Study Population, by Cohorta Outcome Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p 24-hr postoperative morphine equivalents (mg) with median (IQR) 33.0 (19.0–80.4) 70.4 (37.1–115.4) <0.001 72-hr postoperative morphine equivalents (mg) with median (IQR) 61.3 (28.7–142.8) 115.9 (69.9–175.4) <0.001 Hospital length of stay (days) with median (IQR) 3.2 (2.0–5.5) 3.0 (2.1–4.0) 0.371 24-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 31.3 (14.5–72.0) 66.6 (36.0–111.3) <0.001 72-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 47.5 (15.8–122.4) 104.5 (55.4–167.7) <0.001 Postoperative nonopioid orders, no. (%) 63 (94.0) 116 (44.3) <0.001 Acetaminophen orders, no. (%) 55 (82.1) 86 (32.8) <0.001 Outcome Liposomal Bupivacaine (n = 67) Elastomeric Continuous Infusion Bupivacaine Pump (n = 262) p 24-hr postoperative morphine equivalents (mg) with median (IQR) 33.0 (19.0–80.4) 70.4 (37.1–115.4) <0.001 72-hr postoperative morphine equivalents (mg) with median (IQR) 61.3 (28.7–142.8) 115.9 (69.9–175.4) <0.001 Hospital length of stay (days) with median (IQR) 3.2 (2.0–5.5) 3.0 (2.1–4.0) 0.371 24-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 31.3 (14.5–72.0) 66.6 (36.0–111.3) <0.001 72-hr postoperative morphine equivalents above baseline (mg) with median (IQR) 47.5 (15.8–122.4) 104.5 (55.4–167.7) <0.001 Postoperative nonopioid orders, no. (%) 63 (94.0) 116 (44.3) <0.001 Acetaminophen orders, no. (%) 55 (82.1) 86 (32.8) <0.001 a IQR = interquartile range Open in new tab After adjusting for baseline differences in patient characteristics, comorbidities, surgical procedure, and analgesic medications received pre-and postoperatively, study medication was not associated with a change in 24-hour postoperative opioid use (β coefficient for elastomeric bupivacaine pump: 10.26; 95% CI, −8.42 to 28.95; p = 0.281) or 72-hour postoperative opioid use (β coefficient for elastomeric bupivacaine pump: 2.23; 95% CI, −29.88 to 34.34; p = 0.891). For the other secondary outcomes, there was no between-group difference in median hospital LOS (3.2 days [IQR, 2.0–5.5 days] versus 3.0 days [IQR, 2.1–4.0 days], p = 0.371), but elastomeric bupivacaine pump use was associated with a slightly longer median time to first as-needed opioid use (1.72 hours [95% CI, 1.38–2.06 hours] versus 1.63 hours [95% CI, 1.31–1.95 hours], p = 0.047). Adverse events or complications of therapy were not reported in the liposomal bupivacaine cohort, whereas 13 events were reported for patients receiving bupivacaine via elastomeric pump, including 9 (3.4%) catheter malfunctions, 2 (0.8%) instances of inappropriate self-removal of the catheter, and 2 (0.8%) opioid-related adverse events. Discussion This large retrospective cohort study characterized the benefits of liposomal bupivacaine compared with elastomeric bupivacaine pump for wound infiltration in a heterogeneous surgical population. Although the use of liposomal versus elastomeric bupivacaine was demonstrated via univariate analysis to significantly reduce opioid utilization at 24 and 72 hours (p < 0.001 for both comparisons), significant differences in baseline characteristics existed between the two cohorts, suggesting the elastomeric bupivacaine pump cohort was at higher risk for experiencing postoperative pain. Therefore, a multivariable linear regression analysis for opioid utilization was conducted to adjust for these significant differences, as well as other potential confounding variables. After these adjustments, no difference in 24- and 72-hour postoperative opioid use between the two cohorts was observed (p = 0.281 and p = 0.891, respectively). Additionally, no difference in hospital LOS was seen (p = 0.371). The time to first supplemental opioid dose was shown to be significantly different between groups; however, the difference seen (103 minutes versus 98 minutes, p = 0.047) is likely not clinically notable. Liposomal bupivacaine has been previously evaluated in a small open-label study as part of a multimodal treatment as an alternative to i.v. opioid administered via PCA in patients undergoing open colectomy. The multimodal treatment group demonstrated a 50% reduction in total postoperative opioid utilization (57 mg versus 115 mg, p = 0.025), as well as a reduction in median LOS (2.0 days versus 4.9 days, p = 0.004) and hospital costs ($8,766 versus $11,850, p = 0.027).13 Previous efficacy trials have compared liposomal bupivacaine against placebo and have demonstrated similar results11,12; our study compared the effectiveness of the extended-release formulation against a continuous infusion of the same medication to understand the true clinical duration of analgesia. The results of our study, which demonstrated a continued therapeutic benefit at 72 hours postoperatively, are in contrast to the findings of previously reported trials in which the analgesic effect of liposomal bupivacaine had been questioned after 24 hours.10–12 Although no difference in opioid utilization on multivariable analysis may be seen as a negative outcome, the present study illustrated that liposomal bupivacaine, an extended-release dosage form, was not inferior to a continuous infusion of the medication when used in a diverse surgical population. The strengths of our study included a relatively large number of patients in each cohort and a heterogeneous surgical population. We conducted a thorough review and analysis of risk factors that could influence opioid utilization, including the grouping of surgical procedures into pain-risk classifications.2 Limitations of our study included its retrospective nature and dependency on documentation for data such as medication administration and adverse events. Only patients remaining in the hospital after their surgery were included in our study; therefore, the results are not applicable to outpatient procedures. Differences between groups were observed in surgical procedure, ASA class, and PCA use, suggesting potential bias. Although selection bias cannot be ruled out, baseline characteristics and other factors were accounted for with linear regression analysis. Nevertheless, there exists the potential that patients who received the elastomeric bupivacaine had a risk of experiencing more postoperative pain, which could be expected to result in a larger separation of opioid utilization between cohorts. There were several medication-related adverse events or complications of therapy reported with the elastomeric bupivacaine pump, including inappropriate catheter removal and pump malfunction. The retrospective nature of our study and dependency on reporting in the medical record limit the applicability of these results, but the results highlight the practical differences between these two drug delivery forms. The elastomeric bupivacaine pump offers more freedom for the patient in comparison with traditional i.v. pumps, but it can result in problems such as those seen in our study, including inappropriate catheter removal, malfunction or damage to the pump itself, movement of the catheter at the wound site, and the potential for the introduction of bacteria through the insertion site. It has been demonstrated that when used at home, these catheters are retained in 95–100% of patients for up to 60 hours after discharge without an increase in infections.7 Liposomal bupivacaine largely avoids these concerns but can theoretically interaction with other local anesthetics.17 The package insert states that other forms of bupivacaine should not be administered within 96 hours of liposomal bupivacaine utilization to avoid a rapid release of intraliposomal bupivacaine, leading to potentially toxic concentrations.10 To the best of our knowledge, this was the first study to compare liposomal bupivacaine versus elastomeric bupivacaine delivered via traditional continuous infusion pump in such a large and heterogeneous population. We did not detect a difference in the duration of clinical effectiveness and analgesia between the two medications, specifically 24- or 72-hour postoperative opioid utilization. Conclusion No difference was found between patients who received liposomal bupivacaine compared with elastomeric continuous infusion bupivacaine from a traditional pump in 24- or 72-hour postoperative opioid utilization after adjustment for baseline differences. Footnotes This study was performed at the Cleveland Clinic, Cleveland, OH. Supported by institutional departmental funds from the Cleveland Clinic Department of Pharmacy. Data presented, in part, at the American Society of Anesthesiologist’s Anesthesiology 2014 Annual Meeting, New Orleans, LA, October 11–15, 2014. Encore presentation given, in part, at the American College of Clinical Pharmacy 2014 Annual Meeting, Austin, TX, October 12–15, 2014. The authors have declared no potential conflicts of interest. Michael T. Kenes, Pharm.D., BCPS, is a critical care clinical specialist in the medical intensive care unit at Wake Forest Baptist Medical Center. He received his doctor of pharmacy degree from the University of Illinois at Chicago in 2013 and went on to complete an ASHP-accredited postgraduate year (PGY) 1 pharmacy practice residency at the Cleveland Clinic and an ASHP-accredited PGY2 critical care pharmacy residency at Vanderbilt University Medical Center. His current research interests are in the areas of pain, agitation, and delirium, as well as hemodynamics and infectious diseases. References 1 American Society of Anesthesiologists Task Force on Acute Pain Management . Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management . Anesthesiology . 2012 ; 116 : 248 – 73 . Crossref Search ADS PubMed WorldCat 2 Janssen KJ , Kalkman CJ , Grobbee DE et al. . The risk of severe postoperative pain: modification and validation of a clinical prediction rule . Anesth Analg . 2008 ; 107 : 1330 – 9 . 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TI - Liposomal bupivacaine versus continuous infusion bupivacaine via an elastomeric pump for the treatment of postoperative pain
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp150168
DA - 2015-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/liposomal-bupivacaine-versus-continuous-infusion-bupivacaine-via-an-osjW6Yk8p2
SP - S127
VL - 72
IS - 23_Supplement_3
DP - DeepDyve
ER -