BACKGROUND AND OVERVIEW

Title/Citation  Fascia iliaca blockade with the addition of liposomal bupivacaine vs. plain bupivacaine for perioperative pain management
following hip arthroscopy.
 Peer reviewed journal (Knee Surgery, Sports Traumatology, Arthoscopy)
Background  America’s opioid crisis has prompted physicians and other members of the healthcare team to look for alternative ways to
treat pain.
 The use of multimodal pain control is on the rise as an adjunct to pain relief following hip arthroscopy. Plain bupivacaine has
a short elimination half-life (2.7 hours)
 Liposomal bupivacaine was developed to prolong the half-life and the analgesic effects of bupivacaine (24 – 34 hours)
Funding  No source of funding
Research Hypothesis  Decreases in post-operative pain scores will not be statistically significant with the addition of liposomal bupivacaine at any
post-operative time period
Purpose/ Objectives  The purpose of this study is to determine if liposomal bupivacaine is effective in decreasing pain scores and reducing
narcotic requirements following hip arthroscopy when used in addition to a suprainguinal fascia iliaca blockade with
traditional bupivacaine alone.
METHODS
Study Design  Retrospective cohort study of consecutive patients undergoing hip arthroscopy between the dates of August 2015 through
February 2016.
 Control group received 40 cc of 0.25% plain bupivacaine (100mg)
 Treatment group received 20 cc (266 mg) of liposomal bupivacaine mixed with 20 cc of 0.5% plain bupivacaine (100 mg)
 Pre-op medication for patients included in study
o Celebrex 200 mg
o Acetaminophen 975 mg
o Gabapentin 300 mg
o Oxycontin 10 mg
Inclusion/Exclusion  Any patient undergoing hip arthroscopy over this time period who consented to having an ultrasound-guided suprainguinal
Criteria fascia iliaca blockade performed was included.
Outcome measures/  The primary outcome was the defense veteran pain rating scale (DVPRS) at 1 day, 2 days, 3 days, and 2 weeks post-op.
Endpoints o Obtained via phone surveys by anesthesia nurses.
 Secondary outcomes included duration of hospital admission, PACU opioid use, PACU pain scores, and duration of nerve
blockade at 48 hours, and any complications.
o The nerve blockade duration was measured by subjective lack of anterior thigh sensation

Statistical analyses  Statistical analysis was performed using SPSS software.

 Means between study and control group: ANOVA
 Categorical differences between the two groups: chi –squared
 Standard deviation in pain scores assumed to be 2.5
 Alpha= 0.0125 (using Bonferroni correction)
o 4 comparison points on pain scale
o alpha 0.05/4=0.0125
 To achieve a power of 80%: 37 patients would need to be in each group
 Alpha= 0.05 for secondary scores
RESULTS
Baseline characteristics
Efficacy

AUTHORS’ DISCUSSION & CONCLUSIONS

Author’s main discussion  The DVPRS scale considers the impact on patient function and other psychosocial measures.
points  Post-op and PACU pain scores between plain bupivacaine and the addition of liposomal bupivacaine were similar for
patients undergoing a fascia iliaca blockade during hip arthroscopy surgery.
 Liposomal bupivacaine is used in peripheral nerve blocks, bunionectomies, and at the surgical site of hemorrhoidectomies.
o Lower pain scores, increased time to first narcotic use, less narcotics used and overall higher patient satisfaction
with post-surgical analgesia.
 Its use in total knee arthrosplasties displayed a statistical difference at higher does.
 Liposomal bupivacaine has an increased duration of action, but it had no significant impact on post-op pain scores and it
costs nearly 6 times that of plain bupivacaine, therefore its use in hip arthroscopy surgeries is not justified.
 Liposomal bupivacaine -up to 72 hours of pain relief,
o Hip arthroscopy likely does not require that length of analgesia.
o May only need 18 -24 hours of pain relief, which is achievable by the plain bupivacaine.
Authors’ Conclusions  It is not beneficial in decreasing post-operative pain scores or decreasing PACU narcotic requirement and may not warrant
the six fold higher cost of liposomal bupivacaine compared to plain bupivacaine.

STUDENT CRITIQUE, DISCUSSION, & CONCLUSIONS

Critique & Study  Strengths:
Limitations o Baseline characteristics were similar amongst treatment groups
 Limitations/weaknesses:
o Selection bias (retrospective study)
 Age of patients (average 32.4 (Treatment) and 34.7 (Control))
o The reported data is misleading because it does not include p values for data points that were not statistically significant
 To protect from a Type 1 error (False positive) they used the bonferroni correction
 Alpha= 0.05/ 4 data points (POD1, POD2, POD3, and POD14)
 Alpha = 0.0125
o Makes it more difficult to show statistical significance
o To meet power of 80%, 37 people should be in each treatment group
 They only had 34
 Did not meet power
 Likelihood of type 2 error (false negative) increases
o 79.4% of the patients in both groups were smokers
 External validity can be challenged
o Would have been helpful to know comorbidities
o Lumbar disease was one of the patient demographics but they did not report the results
o 48 hour nerve blockade was measured by a subjective lack of anterior thigh sensation measured by the patient over the
phone
Student Conclusions and  The use of liposomal bupivacaine can be useful in many procedures such as TAP blocks and should further be studied and used at
recommendations for this institution for that indication
others  The use of this article alone to justify the return of liposomal bupivacaine in hip arthoscopies would not be appropriate

Reviewed By: Deja Finley Pharm. D Candidate