Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia

Abstract

Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection.

Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents.

Results Two-tailed t-test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort.

Conclusion The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients.

Level of Evidence Therapeutic level III.

Keywords

preemptive - analgesia - BJA - pre-incision - anesthetic - bupivacaine - Marcaine

• References

• 1 Chelly JE, Ben-David B, Williams BA, Kentor ML. Anesthesia and postoperative analgesia: outcomes following orthopedic surgery. Orthopedics 2003; 26 (8, Suppl): s865-s871
• 2 Berend KR, Lombardi Jr AV, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int 2004; 13: 239-247
• 3 Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005; 23 (01) 21-36
• 4 Anastassopoulos KP, Chow W, Ackerman SJ, Tapia C, Benson C, Kim MS. Oxycodone-related side effects: impact on degree of bother, adherence, pain relief, satisfaction, and quality of life. J Opioid Manag 2011; 7 (03) 203-215
• 5 Kelley BP, Shauver MJ, Chung KC. Management of acute postoperative pain in hand surgery: a systematic review. J Hand Surg Am 2015; 40 (08) 1610-1619 , 1619.e1
• 6 Dahl JB, Møiniche S. Pre-emptive analgesia. Br Med Bull 2004; 71: 13-27
• 7 Sai S, Fujii K, Hiranuma K, Sato T, Nemoto T. Preoperative ampiroxicam reduces postoperative pain after hand surgery. J Hand Surg [Br] 2001; 26 (04) 377-379
• 8 Denti M, Randelli P, Bigoni M, Vitale G, Marino MR, Fraschini N. Pre- and postoperative intra-articular analgesia for arthroscopic surgery of the knee and arthroscopy-assisted anterior cruciate ligament reconstruction. A double-blind randomized, prospective study. Knee Surg Sports Traumatol Arthrosc 1997; 5 (04) 206-212
• 9 Mardani-Kivi M, Karimi Mobarakeh M, Haghighi M. , et al. Celecoxib as a pre-emptive analgesia after arthroscopic knee surgery; a triple-blinded randomized controlled trial. Arch Orthop Trauma Surg 2013; 133 (11) 1561-1566
• 10 Sekar C, Rajasekaran S, Kannan R, Reddy S, Shetty TA, Pithwa YK. Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial. Spine J 2004; 4 (03) 261-264
• 11 Yang C, Chang H, Zhang T, Liang C, Li E. Pre-emptive epidural analgesia improves post-operative pain and immune function in patients undergoing thoracotomy. ANZ J Surg 2015; 85 (06) 472-477
• 12 Ahiskalioglu A, İnce İ, Aksoy M, Yalcin E, Ahiskalioglu EO, Kilinc A. Effects of a single dose of pre-emptive pregabalin on postoperative pain and opioid consumption after double jaw surgery: a randomized controlled trial. J Oral Maxillofac Surg 2016; 74 (01) 53.e1-53.e7
• 13 Vallejo MC, Phelps AL, Sah N. , et al. Preemptive analgesia with bupivacaine for segmental mastectomy. Reg Anesth Pain Med 2006; 31 (03) 227-232
• 14 Newcomb W, Lincourt A, Hope W. , et al. Prospective, double-blinded, randomized, placebo-controlled comparison of local anesthetic and nonsteroidal anti-inflammatory drugs for postoperative pain management after laparoscopic surgery. Am Surg 2007; 73 (06) 618-624 , discussion 624–625
• 15 Kim N, Matzon JL, Abboudi J. , et al. A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines. J Bone Joint Surg Am 2016; 98 (20) e89
• 16 Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am 2012; 37 (04) 645-650
• 17 Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res 2014; 472 (08) 2542-2549
• 18 Coluzzi F, Bragazzi L, Di Bussolo E, Pizza G, Mattia C. Determinants of patient satisfaction in postoperative pain management following hand ambulatory day-surgery. Minerva Med 2011; 102 (03) 177-186
• 19 Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol 1975; 8 (06) 415-420
• 20 Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011; 63 (Suppl. 11) S240-S252