Efficacy of a continuous wound infiltration system for postoperative pain management in gynecologic patients who underwent single-port access laparoscopy for adnexal disease.

Introduction: Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease. Methods: A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed (combined group [CWI + IV PCA, n = 159] vs. PCA group [IV PCA only, n = 212]). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected. Results: The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, p < 0.001) and 24 h (1.82 ± 0.82 vs. 2.11 ± 1.44, p = 0.026) after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05). Conclusion: Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease.

Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia?

BACKGROUND: Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA). METHODS: Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method. RESULTS: 92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%. CONCLUSIONS: TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.

Continuous wound infusion combined with intrathecal morphine for analgesia after Cesarean delivery compared with intrathecal morphine or continuous wound infusion alone.

STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT02279628); registered 31 October 2014.

Continuous Wound Infiltration with Local Anesthetic Is an Effective and Safe Postoperative Analgesic Strategy: A Meta-Analysis.

INTRODUCTION: Postoperative pain management is an essential module for perioperative care, especially for enhanced recovery after surgery programs. Continuous wound infiltration (CWI) with local anesthetic may be a promising postoperative analgesic strategy. However, its analgesic efficacy and safety remain debatable. METHODS: Embase and PubMed databases were systematically searched for relevant randomized controlled trials (RCTs). RCTs assessing the analgesic efficacy and safety of CWI with local anesthetic for postoperative analgesia were selected. The outcomes contained pain scores during rest and mobilization, total opioid consumption, time to the first request of rescue analgesia, length of hospital stay, satisfaction with analgesia, time to return of bowel function, postoperative nausea and vomiting, total complication, wound infection, hypotension, and pruritus. The weighted mean difference and risk ratio were used to pool continuous and dichotomous variables, respectively. RESULTS: A total of 121 RCTs were included. CWI with local anesthetic reduced postoperative pain during rest and mobilization at different time points, increased satisfaction with analgesia, shortened recovery of bowel function, and reduced postoperative nausea and vomiting compared with the placebo group, especially for laparotomy surgery. There were no significant differences in these clinical outcomes compared to epidural and intravenous analgesia. CWI with local anesthetic reduced the total opioid consumption and hypotension risk and did not increase total complications, wound infection, or pruritus. CWI with local anesthetic had a better analgesic efficacy without increased side effects for sternotomy surgery. However, CWI with local anesthetic did not translate into favorable analgesic benefits in laparoscopic surgery. CONCLUSION: CWI with local anesthetic is an effective postoperative analgesic strategy with good safety profiles in laparotomy and sternotomy surgery, and thus CWI with local anesthetic may be a promising analgesic option enhancing recovery after surgery programs for these surgeries.

Continuous wound infiltration (CWI) with local anesthetic may be a promising postoperative analgesic strategy, but its effect remains debatable. We performed this meta-analysis based on 121 high-quality articles (RCTs) to evaluate the analgesic efficacy and safety of CWI with local anesthetic. We found that CWI with local anesthetic could reduce postoperative pain, increase satisfaction with analgesia, shorten recovery of bowel function, and reduce postoperative nausea and vomiting, especially for laparotomy surgery. However, CWI with local anesthetic did not show favorable analgesic benefits in laparoscopic surgery.

Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives.

Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.

A 96-hour continuous wound infiltration with ropivacaine reduces analgesic consumption after liver resection: A randomized, double-blind, controlled trial.

BACKGROUND: Continuous wound infiltration (CWI) with local anesthetics to reduce morphine consumption in postoperative pain management after open liver resection in patients with cancer. METHODS: This single-center randomized double-blind study allocated patients requiring resection of liver metastases to receive a 3.75 mg/mL ropivacaine (ROP) infiltration, followed by a 2 mg/mL ROP CWI, or placebo (P) for 96 hours. Postoperative analgesia included acetaminophen and patient-controlled analgesia morphine pump. The primary endpoint was to investigate the reduction of total morphine consumption (mg/kg) over the first 96 postoperative hours. RESULTS: Eighty-five patients were recruited, and randomized (ROP: 42, P: 43) between 2009 and 2014. The median morphine consumption significantly decreased in the ROP arm in the first 96 postoperative hours (ROP: 1.0, P: 1.5 mg/kg; P = 0.026). Twenty-three (27%) patients had grade 3 adverse events (ROP: 14, P: 9) and four experienced grade 3 treatment-related adverse events (ROP: mental confusion [n = 1], hallucinations [n = 2], P: hematoma [n = 1]). Two (5%) patients showed a wound inflammation (ROP: 1, P: 1). Nine (11%) patients experienced at least one serious adverse event (ROP: 6, P: 3); none related to treatment. CONCLUSION: Preperitoneal CWI of 2 mg/mL ROP significantly reduces intravenous morphine consumption during the 96 postoperative hours resulting in an absolute reduction of 0.5 mg/kg.

Comparison of the postoperative effect between epidural anesthesia and continuous wound infiltration on patients with open surgeries: A meta-analysis.

PURPOSE: The study aimed to compare the effect of epidural anesthesia (EA) and continuous wound infiltration (CWI) on surgical patients. METHODS: The literature retrieval was conducted in relevant databases from their inception to June 2018 with the predefined searching strategy and selection criteria. Then, the Cochrane Collaboration's tool was used to assess the quality of included studies. In addition, odds ratio (OR) and standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) were used as a measure of effect size for evaluating outcomes indicators. RESULTS: Totally, sixteen RCTs were included. The incidence of hypotension in EA group was significantly higher than CWI group (OR = 3.7398; 95% CI: 1.0632 to 13.1555). In addition, EA provided better pain relief than CWI on rest at 72 h (SMD = -0.6037; 95% CI: -1.0767 to -0.1308) after surgery. Additionally, there were no significant differences in pain score on rest and mobilization at 2 h, 12 h, 24 h and 48 h. Moreover, the subgroup analysis showed that pain scores in EA group was significantly reduced at 2 h on rest and 12 h on mobilization than CWI group after liver resection surgery, as well as at 72 h on rest after colorectal surgery. CONCLUSION: CWI is superior to EA with a lower incidence of complications for use in surgery, and EA may provide better pain control than CWI on pain relief after surgery.

Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study. / Utilidad de los catéteres percutáneos para perfusión continua de anestésico local en el manejo del dolor postoperatorio en pacientes sometidos a artrodesis lumbar instrumentada. Estudio de cohortes prospectivas.

OBJECTIVE: To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia. MATERIAL AND METHODS: An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded. RESULTS: Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences. CONCLUSIONS: A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant.

Continuous Wound Infiltration After Hallux Valgus Surgery.

BACKGROUND: Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery. METHODS: In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction. RESULTS: No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed. CONCLUSION: CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Post-operative effectiveness of continuous wound infiltration, continuous epidural infusion and intravenous patient-controlled analgesia on post-operative pain management in patients undergoing spinal surgery.

BACKGROUND AND AIMS: Very few studies have compared continuous wound infiltration (CWI), continuous epidural infusion (CEI) and intravenous Patient Controlled Analgesia (PCA) with morphine in spine surgery. This study compared these modalities in patients undergoing microdissectomy. METHODS: This prospective, randomized control trial was conducted on 75 patients of American Society of Anesthesiologists' physical status I or II undergoing microdiscectomy. Patients in all the three groups received morphine 1 mg IV, with a lockout period of 10 min after each bolus, and the maximum allowed dose was 15 mg/5 h postoperatively. Patients in Group A received CWI with 0.25% levobupivacaine 20 mL as bolus after extubation followed by infusion at 5 mL/h. Group B received CEI with 0.25% levobupivacaine at 5 mL/h. Patients in Group C received intravenous (IV) morphine by PCA pump only. The primary end points were static and dynamic visual analogue scores (VAS) and postoperative pain scores. Secondary observations were postoperative morphine consumption at 8 h, 24 h and 48 h, and patient satisfaction. RESULTS: Group A showed greater analgesic effects at 12 h (P < 0.02), 24 h (P < 0.03), 36 h (P < 0.008) and 48 h (P < 0.007) when compared to the other two techniques, as pain scores were less in group A as compared to group B and C. The requirement of postoperative intravenous morphine (mg) was 18 ± 12.82, 22.92 ± 9.88, 41.56 ± 8.83 for groups A, B and C after 48 h (P < 0.001). CONCLUSION: Continuous wound infiltration is an effective postoperative pain control technique with minimal side effects, after spinal surgery.

Analysis on efficacy of local incision continuous local ropivacine infiltration anesthetic analgesia after total knee arthroplasty / 重庆医学

Objective To investigate and evaluate the effectiveness and safety of continuous local incision infiltration anesthetic analgesia after total knee arthroplasty(TKA).Methods Forty-eight patients with initial unilateral TKA in the Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University from August 2015 to May 2016 were allocated to three groups according to systematic random sampling methods:16 cases in the control group received continuous local incision infiltration anesthesia and femoral nerve block analgesia,16 cases received continuous femoral nerve block analgesia after TKA(CFNB) and other 16 cases received local ropivacaine continuous local incision infiltration anesthesia analgesia(CWI).The preoperative general situation,visual analogue scale (VAS) score of operative site in movement and rest on postoperative 1-3 d,postoperative early function recovery and postoperative complication were compared among 3 groups.Results All cases were followed up.There was no statistically significant difference in the general situation postoperative complications among 3 groups(P＞0.05).the VAS score under movement status on postoperative 1-3 d and rest status in the CWI group and CFNB group were similar,which were lower than those in the control group,the difference was statistically significant(P＜0.05);the postoperative early function recovery in the CWI group was superior to that in the control group and CFNB group.Conclusion local incision infiltration anesthetic analgesia after TKA can relief postoperative pain,facilitate patient's early function exercise and rehabilitation,and improves patient's satisfaction.

Continuous wound infiltration with 0.2% ropivacaine versus a single intercostal nerve block with 0.75% ropivacaine for postoperative pain management after reconstructive surgery for microtia.

BACKGROUND AND AIM: In reconstructive surgery for microtia during childhood, costal cartilage is used for pinna formation. Postoperative pain in the region from which the costal cartilage is taken is severe, which delays recovery after surgery. We evaluated prospectively whether continuous wound infiltration (CWI) of a local anesthetic (LA) reduces pain and enables rapid recovery compared with a single intercostal nerve block (ICNB). METHOD: Forty-eight patients were randomly divided into two groups. In Group I, a single ICNB with 10 ml of 0.75% ropivacaine was performed at the end of surgery. In Group C, a catheter was inserted into the space between the abdominal external oblique muscle and the rectus abdominis muscle. Then, a 0.4-ml/kg bolus of 0.2% ropivacaine was administered, followed by continuous infusion at 2-4 ml/h for 48 h. Postoperative pain intensity evaluated using the Face Scale, dose of supplemental analgesics, and time until mobilization were evaluated. In Group C, the plasma concentrations of ropivacaine were analyzed. RESULTS: The pain intensity at rest was significantly lower in Group C than in Group I, but the values during coughing were comparable. The number of patients receiving a supplemental analgesic and the median number of doses were significantly larger in Group I than in Group C (P = 0.029, P = 0.0007, respectively). The plasma concentrations of ropivacaine were within the safe range over 48 h. The times until mobilization were comparable. CONCLUSION: CWI of 0.2% ropivacaine is a better and safe technique for postoperative pain management after costal cartilage graft harvest in children.

Influence of different positioning of a local pain catheter on postoperative pain after paramedian laparotomy-a blinded, randomized trial.

BACKGROUND: Continuous application of local anaesthetics reduces postoperative pain after different approaches for laparotomy. In this randomized, blinded trial, we investigated the effect of continuous application of local anaesthetics after paramedian laparotomy either with subfascial or subcutaneous catheter in addition to a standardized systemic analgesia. MATERIALS AND METHODS: Patients with stage III/IV melanoma and indication for radical iliac lymph node dissection (RILND) were randomized to a continuous application of a local anaesthetic through either a subfascial or subcutaneous catheter. Participants and those assessing the outcomes were blinded. The main outcome criterion was the pain level on the first postoperative morning while exercising measured with a visual analogue scale. Minor criteria were the pain measured by the area-under-curve until the third postoperative day, the patient's satisfaction with analgesic treatment, the analgesic requirement, the overall complications and the day of discharge. RESULTS: Fifty-two patients were evaluated. Pain therapy was sufficient in both groups during the postoperative course while resting and during mobilization. There were no significant differences regarding the main and minor outcome criteria. Doses of additional analgesics did not differ between groups. No adverse events or side effects were observed. CONCLUSION: For patients who undergo paramedian laparotomy, none of the investigated techniques is superior to the other at a median pain level under visual analogue scale (VAS) 30 mm on the first postoperative morning. TRIAL REGISTRATION NUMBER: DRKS00003632 (German Register of Clinical Trials).

Comparison of the analgesic effect between continuous wound infiltration and single-injection transversus abdominis plane block after gynecologic laparotomy.

PURPOSE: Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy. METHODS: We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2. RESULTS: Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups. CONCLUSION: CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

Custo-efetividade da infiltração contínua da ferida cirúrgica com ropivacaína versus morfina para controle de dor aguda / Cost-effectiveness of ropivacaine continuous wound infiltration versus morphine for acute pain control

OBJETIVOS: Avaliar a custo-efetividade da infiltração contínua da ferida cirúrgica (ICFC) com ropivacaína versus infusão de morfina, sob a perspectiva da Saúde Suplementar Brasileira, em horizonte de 48 horas após cirurgias de grande porte. MÉTODOS: Análise de custo-efetividade por modelo analítico de decisão, empregando dados clínicos de sucesso de analgesia e redução de efeitos colaterais, como náuseas e vômitos pós-operatórios ligados à analgesia com opioides (PONV), obtidos por revisão de literatura. Foram considerados no modelo custos médicos diretos e custos relacionados à internação (receita líquida por leito). RESULTADOS: A eficácia clínica da tecnologia de ICFC mostrou-se superior em todos os cenários apresentados, quando comparada à morfina endovenosa, com menor incidência de PONV, maior taxa de sucesso da analgesia e menor necessidade de opioides de resgate. Ainda, a ICFC mostrou-se menos dispendiosa do que o comparador selecionado, seja administrado por infusão em bolus ou por dispositivo de infusão de fármacos. O resultadose deve, majoritariamente, à redução do tempo de permanência hospitalar. CONCLUSÃO: A ICFC é uma alternativa extremamente efetiva, do ponto de vista clínico, para controle de dor aguda. A tecnologia pode trazer ainda economia de recursos financeiros em curto prazo, já que a dor aguda ea incidência de PONV, além de aumentar o consumo de medicamentos, como opioides e antieméticos, pode prolongar a recuperação do paciente e a sua permanência hospitalar.

OBJECTIVES: To assess cost-effectiveness of continuous wound infiltration (CWI) with ropivacaine versus intravenous morphine, under the perspective of the Brazilian Supplementary Health System, in a time horizon of 48 hours after major surgeries. METHODS: Cost-effectiveness analysis through an analytic decision model, applying clinical data of success rate of analgesia and reduction of side effects, such as opioid related postoperative nausea and vomiting (PONV), obtained through literature review. The model accomplishes direct medical costs and costs related to hospital stay (incomeper hospital bed). RESULTS: Clinical efficacy of CWI has shown superior results in all scenarios presented, when compared to intravenous morphine, with lower incidence of PONV, higher success rates in analgesia and less need of rescue with opioids. CWI has also shown less expensive than the selected comparator administered either in bolus or drug infusion devices. This result is specially derived from the reduction on the hospital length of stay. CONCLUSION: CWI is an extremely effective alternative for acute pain control, in the clinical point of view. It can also generate cost-savings in the short term, as acute pain and PONV incidence, besides increasing consumption of opioids and antiemetic drugs, can jeopardize patient recovery and prolong unnecessarily his hospital stay.