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Liposome bupivacaine for postsurgical pain in an obese woman with chronic pain undergoing laparoscopic gastrectomy: a case report.

Bertin PM - J Med Case Rep (2014)

Bottom Line: To reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended.At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction.Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

View Article: PubMed Central - HTML - PubMed

Affiliation: Excela Health Westmoreland Hospital, 532 West Pittsburgh Street, Greensburg, PA 15601, USA. pbertin@ExcelaHealth.org.

ABSTRACT

Introduction: To reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended. In this report, we discuss the use of liposome bupivacaine, a novel multivesicular formulation of bupivacaine indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia, as part of a multimodal analgesic regimen in a patient with a history of chronic pain scheduled to undergo laparoscopic sleeve gastrectomy. To the best of our knowledge, this is the first published report of liposome bupivacaine in the setting of laparoscopic sleeve gastrectomy.

Case presentation: A 35-year-old white woman with morbid obesity was admitted for laparoscopic sleeve gastrectomy to lose weight prior to hip replacement surgery. Because of a complicated medical history that included rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and chronic pain, for which she was receiving high doses of opioid analgesics, postsurgical pain management was a concern and she was considered a candidate for multimodal analgesia. At initiation of surgery, 50mL of lidocaine and epinephrine was infiltrated around the port sites. At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction. Laparoscopic sleeve gastrectomy was successfully completed. Our patient was discharged to the postanesthesia care unit for approximately four hours before discharge to the surgical floor with a pain score of 5 (11-point scale; 0 = no pain, 10 = worst possible pain). Her postoperative course was uneventful; no adverse events were recorded during surgery or during the remainder of her hospital stay. Our patient was discharged on the same opioid regimen used previously for control of her preexisting chronic pain.

Conclusions: Liposome bupivacaine use in this morbidly obese patient undergoing laparoscopic sleeve gastrectomy provided analgesic efficacy and limited postsurgical opioids to a level comparable with her baseline opioid regimen for chronic pain. Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

No MeSH data available.


Related in: MedlinePlus

Laparoscopic view of infiltration of liposome bupivacaine at 12-mm port site. (a) Insertion of needle into deep tissue layers. Advancement of needle is stopped just prior to penetration of the parietal peritoneum. (b) Infiltration of liposome bupivacaine and dispersion of fluid to form a wheal (outlined by white oval). This process was repeated in four quadrants around the site of the trocar to form a field block. Photographs courtesy of Peter M. Bertin, DO.
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Figure 1: Laparoscopic view of infiltration of liposome bupivacaine at 12-mm port site. (a) Insertion of needle into deep tissue layers. Advancement of needle is stopped just prior to penetration of the parietal peritoneum. (b) Infiltration of liposome bupivacaine and dispersion of fluid to form a wheal (outlined by white oval). This process was repeated in four quadrants around the site of the trocar to form a field block. Photographs courtesy of Peter M. Bertin, DO.

Mentions: A 35-year-old white woman with morbid obesity (height, 5 feet 1.5 inches; weight, 305 pounds; body mass index, 56kg/m2) and normal renal function (baseline creatinine, 0.6mg/dL) was admitted to our institution for LSG. She required weight loss in order to qualify for hip replacement surgery. Her past medical history was significant for rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and obstructive sleep apnea. Our patient also had a history of chronic pain, for which she was receiving high doses of opioid analgesics (including transmucosal fentanyl, controlled-release oral morphine, and oral tramadol; see Table 1). The source of our patient’s pain was mostly in her joints, as a result of rheumatoid arthritis. In addition, our patient reported previously experiencing severe pain necessitating a prolonged hospital stay (>2 days) following a standard laparoscopic cholecystectomy. Given our patient’s history of both acute postsurgical and chronic pain and high baseline opioid usage, she was a desirable candidate for an opioid-reducing, multimodal pain management strategy.At the initiation of surgery prior to trocar insertion, 50mL of 1% lidocaine and epinephrine (1:100,000) was infiltrated around the port sites. At the conclusion of the procedure (which was more than 20 minutes after administration of the lidocaine), 25mL of 0.9% preservative-free normal sterile saline was added to a 20-mL vial of liposome bupivacaine (266mg) for a total volume of 45mL. It was injected using a spinal needle around the port sites (Figure 1): the flanking 5-mm port sites received 5mL each; the central 12-mm ports, 15mL each; and 5mL was infused at the site of liver retraction. The dose of liposome bupivacaine was based on the surgical site and the volume required to cover the area. Aided by visualization provided by the laparoscope, liposome bupivacaine was infiltrated directly into the deep tissue with the needle. The needle was slowly withdrawn so that infiltration of liposome bupivacaine was targeted primarily to the myofascial level. Our patient was administered a total of 925μg of IV fentanyl during surgery.


Liposome bupivacaine for postsurgical pain in an obese woman with chronic pain undergoing laparoscopic gastrectomy: a case report.

Bertin PM - J Med Case Rep (2014)

Laparoscopic view of infiltration of liposome bupivacaine at 12-mm port site. (a) Insertion of needle into deep tissue layers. Advancement of needle is stopped just prior to penetration of the parietal peritoneum. (b) Infiltration of liposome bupivacaine and dispersion of fluid to form a wheal (outlined by white oval). This process was repeated in four quadrants around the site of the trocar to form a field block. Photographs courtesy of Peter M. Bertin, DO.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3974146&req=5

Figure 1: Laparoscopic view of infiltration of liposome bupivacaine at 12-mm port site. (a) Insertion of needle into deep tissue layers. Advancement of needle is stopped just prior to penetration of the parietal peritoneum. (b) Infiltration of liposome bupivacaine and dispersion of fluid to form a wheal (outlined by white oval). This process was repeated in four quadrants around the site of the trocar to form a field block. Photographs courtesy of Peter M. Bertin, DO.
Mentions: A 35-year-old white woman with morbid obesity (height, 5 feet 1.5 inches; weight, 305 pounds; body mass index, 56kg/m2) and normal renal function (baseline creatinine, 0.6mg/dL) was admitted to our institution for LSG. She required weight loss in order to qualify for hip replacement surgery. Her past medical history was significant for rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and obstructive sleep apnea. Our patient also had a history of chronic pain, for which she was receiving high doses of opioid analgesics (including transmucosal fentanyl, controlled-release oral morphine, and oral tramadol; see Table 1). The source of our patient’s pain was mostly in her joints, as a result of rheumatoid arthritis. In addition, our patient reported previously experiencing severe pain necessitating a prolonged hospital stay (>2 days) following a standard laparoscopic cholecystectomy. Given our patient’s history of both acute postsurgical and chronic pain and high baseline opioid usage, she was a desirable candidate for an opioid-reducing, multimodal pain management strategy.At the initiation of surgery prior to trocar insertion, 50mL of 1% lidocaine and epinephrine (1:100,000) was infiltrated around the port sites. At the conclusion of the procedure (which was more than 20 minutes after administration of the lidocaine), 25mL of 0.9% preservative-free normal sterile saline was added to a 20-mL vial of liposome bupivacaine (266mg) for a total volume of 45mL. It was injected using a spinal needle around the port sites (Figure 1): the flanking 5-mm port sites received 5mL each; the central 12-mm ports, 15mL each; and 5mL was infused at the site of liver retraction. The dose of liposome bupivacaine was based on the surgical site and the volume required to cover the area. Aided by visualization provided by the laparoscope, liposome bupivacaine was infiltrated directly into the deep tissue with the needle. The needle was slowly withdrawn so that infiltration of liposome bupivacaine was targeted primarily to the myofascial level. Our patient was administered a total of 925μg of IV fentanyl during surgery.

Bottom Line: To reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended.At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction.Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

View Article: PubMed Central - HTML - PubMed

Affiliation: Excela Health Westmoreland Hospital, 532 West Pittsburgh Street, Greensburg, PA 15601, USA. pbertin@ExcelaHealth.org.

ABSTRACT

Introduction: To reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended. In this report, we discuss the use of liposome bupivacaine, a novel multivesicular formulation of bupivacaine indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia, as part of a multimodal analgesic regimen in a patient with a history of chronic pain scheduled to undergo laparoscopic sleeve gastrectomy. To the best of our knowledge, this is the first published report of liposome bupivacaine in the setting of laparoscopic sleeve gastrectomy.

Case presentation: A 35-year-old white woman with morbid obesity was admitted for laparoscopic sleeve gastrectomy to lose weight prior to hip replacement surgery. Because of a complicated medical history that included rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and chronic pain, for which she was receiving high doses of opioid analgesics, postsurgical pain management was a concern and she was considered a candidate for multimodal analgesia. At initiation of surgery, 50mL of lidocaine and epinephrine was infiltrated around the port sites. At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction. Laparoscopic sleeve gastrectomy was successfully completed. Our patient was discharged to the postanesthesia care unit for approximately four hours before discharge to the surgical floor with a pain score of 5 (11-point scale; 0 = no pain, 10 = worst possible pain). Her postoperative course was uneventful; no adverse events were recorded during surgery or during the remainder of her hospital stay. Our patient was discharged on the same opioid regimen used previously for control of her preexisting chronic pain.

Conclusions: Liposome bupivacaine use in this morbidly obese patient undergoing laparoscopic sleeve gastrectomy provided analgesic efficacy and limited postsurgical opioids to a level comparable with her baseline opioid regimen for chronic pain. Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

No MeSH data available.


Related in: MedlinePlus