Retrospective analysis of quality improvement when using liposome bupivacaine for postoperative pain control

Journal of Pain Research Dovepress open access to scientific and medical research Original Research Journal of Pain Research downloaded from https://www.dovepress.com/ by 213.32.98.221 on 13-Jul-2018 For personal use only. Open Access Full Text Article Retrospective analysis of quality improvement when using liposome bupivacaine for postoperative pain control This article was published in the following Dove Press journal: Journal of Pain Research 21 April 2016 Number of times this article has been viewed Nicole M King Albin S Quiko James G Slotto Nicholas C Connolly Robert J Hackworth Justin W Heil Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, USA Background/objective: Liposome bupivacaine, a prolonged-release bupivacaine formulation, recently became available at the Naval Medical Center San Diego (NMCSD); before availability, postsurgical pain for large thoracic/abdominal procedures was primarily managed with opioids with/without continuous thoracic epidural (CTE) anesthesia. This retrospective chart review was part of a clinical quality initiative to determine whether postsurgical outcomes improved after liposome bupivacaine became available. Methods: Data from patients who underwent laparotomy, sternotomy, or thoracotomy at NMCSD from May 2013 to May 2014 (after liposome bupivacaine treatment became available) were compared with data from patients who underwent these same procedures from December 2011 to May 2012 (before liposome bupivacaine treatment became available). Collected data included demographics, postoperative pain control methods, opioid consumption, perioperative pain scores, and lengths of intensive care unit and overall hospital stays. Results: Data from 182 patients were collected: 88 pre-liposome bupivacaine (laparotomy, n=52; sternotomy, n=26; and thoracotomy, n=10) and 94 post-liposome bupivacaine (laparotomy, n=49; sternotomy, n=31; and thoracotomy, n=14) records. Mean hospital stay was 7.0 vs 5.8 days (P=0.009) in the pre- and post-liposome bupivacaine groups, respectively, and mean highest reported postoperative pain score was 7.1 vs 6.2 (P=0.007), respectively. No other significant between-group differences were observed for the overall population. In the laparotomy subgroup, there was a reduction in the proportion of patients who received CTE anesthesia post-liposome bupivacaine (22% [11/49] vs 35% [18/52] pre-liposome bupivacaine). Conclusion: Surgeons and anesthesiologists have changed the way they manage postoperative pain since the time point that liposome bupivacaine was introduced at NMCSD. Our findings suggest that utilization of liposome bupivacaine may be a useful alternative to epidural anesthesia. Keywords: laparotomy, thoracotomy, sternotomy, anesthesia, local Introduction Correspondence: Nicole M King Department of Anesthesiology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA Tel +1 619 804 1513 Fax +1 619 532 8945 Email 233 submit your manuscript | www.dovepress.com Journal of Pain Research 2016:9 233–240 Dovepress © 2016 King et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/JPR.S102305 Powered by TCPDF (www.tcpdf.org) Postsurgical pain is a significant concern for patients undergoing inpatient and outpatient procedures at US hospitals. In a recent survey regarding pre- and postsurgical pain experiences of patients (N=300) from randomly selected surgical practices across the US, pain after surgery was the most prominent presurgery concern expressed by patients in the sample; 80% reported having concerns about postsurgical pain, and 46% indicated that these concerns resulted in “high” or “very high” levels of anxiety.1 Such concerns are well founded, because approximately two-thirds of respondents reported experiencing postsurgical pain of moderate-to-extreme intensity.1 Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 213.32.98.221 on 13-Jul-2018 For personal use only. King et al The inadequacy of postsurgical pain control has been recognized for decades,1 and numerous government agencies and clinical societies have published recommendations with strategies intended to improve postsurgical analgesia practices.2–5 The American Pain Society, in collaboration with the Pain Care Coalition,6 has also advocated for the creation of a national pain and palliative care research and quality program that would ensure that military personnel, veterans, and Medicare beneficiaries receive appropriate pain management.7 However, despite these efforts, there appears to have been little or no improvement in patients’ reported levels of postsurgical pain control over the past 20 years.1 Opioid analgesics are a cornerstone of postsurgical pain management7,8 because these agents are widely recognized as the most effective option for controlling moderate-tosevere pain.7,8 However, commonly reported opioid-related adverse events (ORAEs), including constipation, nausea, and vomiting, can be burdensome,7–10 especially in the setting of abdominal surgery.11,12 In addition, health care costs have been reported to be higher for patients who experience ORAEs because of increased pharmacy and nursing requirements and increased length of hospital stay.7–9 To minimize the risk of ORAEs while still providing adequate postsurgical pain control, the American Society of Anesthesiologists (ASA) recommends the use of multimodal approaches to pain management that incorporate perioperative infiltration of local anesthetics into surgical incision sites whenever possible.3 Historically, postsurgical analgesia regimens used at the Naval Medical Center San Diego (NMCSD) for patients undergoing chest or abdominal surgery consisted of opioid analgesia with adjunctive use of a continuous thoracic epidural (CTE) anesthesia in some of the laparotomy cases. In May 2013, liposome bupivacaine became available, on a restricted basis, for use at NMCSD. This prolonged-release liposomal formulation of bupivacaine is indicated for single-dose administration into the surgical site to produce postsurgical analgesia.13 The safety and efficacy of liposome bupivacaine-based multimodal analgesic regimens compared with bupivacaine HCl and intravenous opioidbased patient-controlled analgesia have been investigated in several surgical models across multiple Phase II, III, an (...truncated)