Surgical site anesthetic infusion may enhance analgesia after mastectomy

1. Continuous postoperative levobupivacaine infusion into the surgical site was associated with less pain and decreased consumption of analgesics following modified radical mastectomy.

2. Patients in the levobupivacaine group reported high levels of satisfaction with no change in rates of nausea and vomiting.

Evidence Rating Level: 1 (Excellent)

Study Rundown: The use of local anesthetics has become increasingly common in mastectomies and other types of surgery. However, the efficacy of continuously infused postoperative local anesthetic in patients undergoing modified radical mastectomy is unknown. In this study, the authors evaluated whether a catheter placed in the surgical wound to deliver levobupivicaine could effectively control postoperative pain in women undergoing modified radical mastectomy. Secondary objectives were to determine whether this therapy was associated with a decreased consumption of analgesics, greater patient satisfaction, and less nausea and vomiting. They found that patients in the levobupivacaine group reported significantly less pain compared to the control group in the PACU and on the ward. In addition, the levobupivacaine group required fewer analgesics to manage postoperative pain. Finally, levobupivacaine was associated with high patient satisfaction with no change in rates of nausea and vomiting. An important strength of this study is its robust RCT study design. However, its limitations include a small sample size from a single institution. Although several studies have previously investigated the role of local anesthetic infusion in breast surgery, this is the first study to evaluate the efficacy of this therapy in patients undergoing modified radical mastectomy.

Click to read the study in Plastic and Reconstructive Surgery

Relevant Reading: The efficacy of continuous local anesthetic infiltration in breast surgery: reduction mammaplasty and reconstruction.

In-Depth [randomized controlled trial]: This is a randomized, double-blind, placebo-controlled, parallel-groups clinical trial involving 80 patients (73 analyzed) from a single institution. All included patients were diagnosed with operable breast cancer and underwent modified radical mastectomy from October 2008 to January 2011. Patients who agreed to participate in the study were assigned either to the levobupivacaine or control group using a computer-generated random sequence. One hundred ml of 0.5% levobupivacaine or saline was infused at 2ml/h for 48 hours through a wound catheter. In this study, the authors found that continuous postoperative infusion of levobupivacaine was associated with less pain compared to controls (p<0.001) in the PACU (1.6 ± 1.3 versus 6.7 ± 1.8) and on the ward at 24h (0.8 ± 0.9 versus 4.2 ± 1.9) and 48h (0.4 ± 0.7 versus 3.3 ± 2.3). In addition, they found that the levobupivacaine group required fewer analgesic medications during their hospital stay (p<0.001). Finally, patients in the levobupivacaine group reported high levels of satisfaction and there was no change in rates of nausea and vomiting between the groups in the PACU (0.2 ± 0.4 versus 0.4 ± 0.5; p=0.081) or on the ward (0.3 ± 0.5 versus 0.4 ± 0.5; p=0.563).

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