Liposomal bupivacaine infiltration at the surgical site for the management of post-operative pain

The management of post-operative pain has become increasingly interesting to surgeons as it has improved patient experiences, as well as facilitated earlier mobilisation and reduced length of stay. In the days of ‘payment by results’ and national dashboards, patient expectations and experiences now have a direct impact on hospital funding. Local anaesthetic infiltration plays a key role in the now-common enhanced recovery programmes we see in lower limb arthroplasty surgery. This study reviews the novel liposomal bupivacaine which, although more expensive, is thought to produce a sustained release of local anaesthetic at the surgical site.²

Of the nine studies that the authors reviewed, two studies (total 383 participants) were in knee arthroplasty and one study (193 participants) reported outcomes in first ray surgery. One of the arthroplasty studies reported a better analgesic effect in the liposomal bupivacaine group when compared with bupivacaine hydrochloride at rest,³ while the other study reported generally less post-operative supplementary opioid analgesic use with liposomal bupivacaine, though this finding did not achieve statistical significance.⁴ The study looking at bunionectomies only compared the liposomal bupivacaine with placebo, finding that the drug provided extended pain relief and decreased post-operative opioid use when compared with placebo.⁵

These studies reflect the general conclusions that were drawn by the Cochrane authors, however, they suggest that the limited evidence was not sufficient to establish a clear superiority of liposomal bupivacaine over bupivacaine hydrochloride.² With trends towards improvement it would not seem unreasonable to use the agent, however, given the increased cost and limited evidence of efficacy, one wonders if that healthcare dollar might be better spent elsewhere.