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doi: 10.1097/01.anes.0000278901.96504.49
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Continuous Local Anesthetic Wound Infusion to Improve Postoperative Outcome: Back to the Periphery?

Kehlet, Henrik M.D.†; Liu, Spencer S. M.D.‡

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EFFECTIVE postoperative analgesia is a prerequisite to enhance the recovery process and reduce morbidity. The use of local anesthetic techniques is well documented to be effective, but single-dose techniques (infiltration, peripheral blocks, neuraxial blocks) have been of limited value in major operations because of their short duration of analgesia. Continuous administration of local anesthetics at various segments in the nociceptive pathway has therefore been introduced and where the relatively demanding continuous peripheral nerve blocks and epidural techniques have proven effective, although with a small risk of complications and relatively high costs. From a theoretical point of view, administration of local anesthetics at the wound site is the most rational approach to reduce the afferent nociceptive barrage and thereby pain and stress responses with their secondary risks of organ dysfunction and morbidity. Therefore, an improved understanding of the analgesic efficacy of continuous wound infusion of local anesthetics and its consequences on outcome is important as reported by Beaussier et al.1 In their double-blind randomized setup, patients undergoing colonic surgery received continuous ropivacaine at 0.2%/10 ml/h for 48 h or saline through a multiholed wound catheter placed in the preperitoneal space. The study has important clinical implications because they assessed in detail relevant outcomes such as patient-controlled analgesia–quantified opioid sparing, level of dynamic analgesia, sleep quality, and recovery of gastrointestinal function, all of which were significantly improved, and duration of hospitalization was reduced (115 vs. 147 h) as well. No wound morbidity or ropivacaine toxicity was observed.
Hitherto, no analgesic technique has fulfilled all requirements of optimal efficacy—no side effects, low costs, high patient compliance, and improvement in outcome—and consequently, multimodal analgesic techniques have been introduced with a focus on opioid sparing to improve analgesia and recovery.2 As documented by Beaussier et al.1 as well as in randomized studies with different continuous local anesthetic wound infusion techniques,3 the available data have almost consistently shown improved analgesia across a range of procedures and with a very low (approximately 1%) technical failure rate and zero reported toxicity. Most importantly, wound infection rates have not increased,3 and patient compliance is acceptable. Unfortunately, the studies previously reported in the literature3 have not allowed sufficient analyses on postoperative recovery of different organ functions (pulmonary, ileus, mobilization, etc.), or a potential reduction in morbidity as well as duration of hospitalization will require further studies because of a lack of well-defined discharge criteria and standardized care and rehabilitation programs according to the concept of fast-track surgery.4 The report by Beaussier et al.1 therefore represents an important example of how to optimize design for an improved assessment of local anesthetic wound infusion to enhance the postoperative recovery process.
The important question is whether we have enough evidence to more widely recommend continuous local anesthetic wound infusion techniques in our perioperative care programs. The primary risk from peripheral infusions of local anesthetics is direct tissue toxicity such as myotoxicity. Although there are supportive laboratory data, the clinical experience is that such injuries are rare.5 So far, the benefits clearly outweigh the risks, and the only drawback of the technique is catheter equipment costs, which amount to approximately US $250 per patient. However, this may be acceptable in certain major procedures such as abdominal surgery, provided that the significant improvements in outcome as demonstrated by Beaussier et al.1 can be confirmed by others. The cost of this technique may be further offset by its simplicity. Because the equipment is basic and risk of serious complications is minimal, it is likely that these patients can be treated on the floor without involvement and subsequent cost of an acute pain service. This would not only save charges to the patient, but also allow the acute pain service to focus on patients with more complicated pain management techniques. On the other hand, continuous local anesthetic wound infusion in minor procedures such as inguinal herniorrhaphy may not be cost effective despite proven efficacy.3 Instead, in such minor procedures we should strive to implement effective oral multimodal nonopioid analgesia,2 which is more simple to manage and can be continued for a longer period where necessary than the usual wound infusion regimens with 2–3 days' duration.1,3
However, as is so often the case, introduction of new analgesic techniques also raises several important questions: What is the optimal concentration and volume of the local anesthetic? (no conclusive procedure-specific dose response studies available); what is the optimal site of placement of the wound catheter? Beaussier et al.1 used preperitoneal placement, which may be rational, and probably the placement should be close to the muscle-facial layer and not in the subcutaneous layer, as demonstrated in one of the few comparative studies.6 Furthermore, we should not be overoptimistic that these newer techniques alone will provide sufficient dynamic analgesia, and therefore the opioid-sparing effects should be assessed in more detail in different procedures (postoperative nausea and vomiting, sedation, sleep disturbances, etc.1,2) and combined with other nonopioid analgesics. In addition to these patient-reported outcomes, it will be interesting to examine impact on patient safety from opioid sparing. The Anesthesia Patient Safety Foundation has recently released a position statement highlighting potential risks of respiratory depression with systemic and central neuraxial opioid analgesia.* Use of continuous local anesthetic wound infusion techniques, especially with concomitant use of several nonopioid analgesics,2 may thus directly improve patient safety. Importantly, the optimal duration of wound local anesthetic infusion must be evaluated together with the effect on relevant outcomes. So far, the literature on the effect of different types of perioperative analgesia on outcome is controversial,7 most probably because the analgesic techniques have not been sufficiently incorporated into multimodal rehabilitation programs to take advantage of the provided analgesia.4 Finally, there is a need for comparative studies with other local anesthetic techniques such as epidural analgesia,7,8 predominantly to assess potential differences in technical failures, costs, and side effects. Comparison with continuous paravertebral blocks and epidural analgesia in thoracic procedures is a good example,3,9 as well as comparison with peripheral nerve blocks in major orthopedic procedures.10,11 Therefore, recent data from high-volume incisional multimodal local anesthetic infiltration/infusion12 is of major interest because of its simplicity, efficacy, and safety, but additional studies are required to assess the relative role of incisional versus intraarticular administration in major joint replacement.12 Other areas of interest could be comparison with systemic administration of local anesthetics.13
So far, the promising data on continuous wound infusion of local anesthetics call for a balanced assessment of practicality versus other benefits versus side effects with other analgesic techniques and agents. This balanced approach to evaluation may become especially valuable because multiple new peripheral analgesics are being developed for postoperative analgesia. Sustained duration local anesthetics may provide up to 96 h of analgesia after a single injection and would further improve on simplicity by removing the requirement for any infusion pump equipment.14 Additional peripheral pharmacologic agents are also being examined, such as a TRPV1 (capsaicin) agonist for sustained postoperative analgesia after total knee replacement15 and possible application of peripheral tricyclic antidepressants.16 All of these represent new, exciting, and potentially valuable means to provide nonopioid analgesia directly to the periphery. However, all must be comprehensively evaluated.
In summary, the peripheral use of continuous wound infusion of local anesthetics represents an effective analgesic technique that, because of its simplicity, may find its way to be an important instrument in our analgesic armamentarium across several major surgical procedures. It is hoped that future research will document in more detail other extra-analgesic benefits on outcomes, such as reduction of postoperative organ dysfunctions and enhanced recovery when integrated into multimodal rehabilitation programs,4 patient safety, and quality of life and health economics.
Henrik Kehlet, M.D.,†
Spencer S Liu, M.D.‡
† Section for Surgical Pathophysiology, Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark. henrik.kehlet@rh.dk ‡ Hospital for Special Surgery and Weil Medical College of Cornell University, Department of Anesthesiology, New York, New York.
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References

1. Beaussier M, El'Ayoubi H, Schiffer E, Rollin M, Parc Y, Mazoit J-X, Azizi L, Gervaz P, Rohr S, Biermann C, Lienhart A, Eledjam J-J: Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: A randomized, double-blind, placebo-controlled study. Anesthesiology 2007; 107:461–8

2. Kehlet H: Postoperative opioid sparing to hasten recovery: What are the issues? Anesthesiology 2005; 102:1083–5

3. Liu SS, Richman JM, Thirlby RC, Wu CL: Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: A quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg 2006; 203:914–32

4. Kehlet H, Dahl JB: Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362:1921–8

5. Zink W, Graf BM: Local anesthetic myotoxicity. Reg Anesth Pain Med 2004; 29:333–40

6. Yndgaard S, Holst P, Bjerre-Jepsen K, Thomsen CB, Struckmann J, Mogensen T: Subcutaneously versus subfascially administered lidocaine in pain treatment after inguinal herniotomy. Anesth Analg 1994; 79:324–7

7. Liu SS, Wu CL: Effect of postoperative analgesia on major postoperative complications: A systematic update of the evidence. Anesth Analg 2007; 104:689–702

8. Carli F, Kehlet H: Continuous epidural analgesia for colonic surgery—but what about the future? Reg Anesth Pain Med 2005; 30:140–2

9. Davies RG, Myles PS, Graham JM: A comparison of the analgesic efficacy and side-effects of paravertebral versus epidural blockade for thoracotomy: A systematic review and meta-analysis of randomized trials. Br J Anaesth 2006; 96:418–26

10. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL: Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006; 102:248–57

11. Boezaart AP: Perineural infusion of local anesthetics. Anesthesiology 2006; 104:872–80

12. Rostlund T, Kehlet H: High-dose local infiltration analgesia after hip and knee replacement: What is it, why does it work, and what are the future challenges? Acta Orthop 2007; 78:159–61

13. Kaba A, Laurent SR, Detroz BJ, Sessler DI, Durieux ME, Lamy ML, Joris JL: Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology 2007; 106:11–8

14. Pedersen JL, Lilleso J, Hammer NA, Werner MU, Holte K, Lacouture PG, Kehlet H: Bupivacaine in microcapsules prolongs analgesia after subcutaneous infiltration in humans: A dose-finding study. Anesth Analg 2004; 99:912–8

15. Davis J, Williams H, Bramlett K, Powell T, Schuster A, Richards P, Yu K, Gennevois D: Enduring and well-tolerated analgesia for total knee arthroplasty postsurgical pain produced by a single, rapidly-eliminated, intraoperative instillation of capsaicin (abstract). J Pain 2007;8(suppl 1):781

16. de Leon-Casasola OA: Multimodal approaches to the management of neuropathic pain: The role of topical analgesia. J Pain Symptom Manage 2007; 33:356–64

* Available at: http://www.apsf.org/assets/Documents/winter2007.pdf. Accessed May 30, 2007. Cited Here...

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