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Local anaesthetic wound infiltration for postcaesarean analgesia - subfascial administration way to go
ESRA Academy. Van de Velde M. Mar 7, 2017; 170354
Dr. Marc Van de Velde
Dr. Marc Van de Velde
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Adesope and colleagues from Duke University Medical Center performed a systematic review and meta-analysis of trials looking at local anaesthetic wound infiltration to treat post-Caesarean section pain. In patients without intrathecal morphine, local anaesthetic wound infiltration with a catheter below the fascia seems to be associated with better pain relief. In patients with intrathecal morphine; the benefits of wound infiltration are less clear but there is a relative paucity of data. Hence, the use of infiltration together with intrathecal morphine as part of multimodal analgesia needs further study.
Wound infiltration, especially by using a catheter, is associated with an opioid-sparing effect of 23%, which I personally think is a clinically significant effect. Problems with continuous infusion wound catheters are wound problems, dislocation of the catheter and repetitive wet dressings of the wound. Although this method of pain relief is attractive and useful, more study of the optimal administration technique is required. PROSPECT (the group that provides procedure specific pain relief guidelines) also suggests that wound infiltration is a very useful method to use.

BACKGROUND:

Wound infiltration with local anaesthetics has been investigated as a potentially useful method for providing analgesia after caesarean delivery, but the literature is inconclusive.

OBJECTIVE:

The objective is to assess the efficacy of local anaesthetic wound infiltration in reducing pain scores and opioid consumption in women undergoing caesarean delivery.

DESIGN:

Systematic review of randomised controlled trials with meta-analyses.

DATA SOURCES:

MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled trials (CENTRAL) until December 2015.

ELIGIBILITY CRITERIA:

Randomised controlled trials that assessed the efficacy of local anaesthetic wound infiltration using an infusion or single injection technique for postcaesarean section analgesia.

RESULTS:

A total of 21 studies were included in the final analysis (11 studies using an infusion technique and 10 studies using single infiltration). Local anaesthetic wound infiltration significantly decreased opioid consumption at 24 h [mean difference -9.69 mg morphine equivalents, 95% confidence interval (CI), -14.85 to -4.52] and pain scores after 24 h at rest (mean difference -0.36, 95% CI, -0.58 to -0.14) and on movement (mean difference -0.61, 95% CI, -1.19 to -0.03). Subgroup analysis did not suggest a difference in primary outcomes between infusions and single infiltration. Opioid consumption was reduced in patients who did not receive intrathecal morphine but not in those who received intrathecal morphine, although there were very little data in patients receiving intrathecal morphine. Pain scores at rest and on movement at 24 h were reduced with catheter placement below the fascia but not above the fascia. There were no statistically significant reductions in nausea, vomiting or pruritus with local anaesthetic infiltration.

CONCLUSION:

Local anaesthetic wound infiltration reduces postoperative opioid consumption but had minimal effect on pain scores and did not reduce opioid-related side-effects in women who had undergone delivery by caesarean section. The review is limited by a paucity of studies using intrathecal morphine and by the indirect comparisons performed for subgroup analyses.

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