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Nebulization of Bupivicaine Intra-Abdominally Reduces Post-Operative Shoulder Pain and Opioid Use In Children Undergoing Robotic-Assisted Urologic Surgery

Saturday, October 20, 2012: 11:21 AM
Grand Ballroom A/B (Hilton Riverside)
Lorenzo F. M. Trevisani1, Constance S. Houck2, Gustavo N.C. Inoue1, Brian M. Rosman1, Petra M. Meier2, Carlos Munoz-San Julian2, Courtney K. Rowe1, Vitor C. Zanetta1, Hiep T. Nguyen1 and Carlo C. Passerotti3, (1)Urology, Children's Hospital Boston, Boston, MA, (2)Anesthesiology, Children's Hospital Boston, Boston, MA, (3)Urology, UNINOVE, São Paulo, Brazil

Purpose:

Laparoscopic surgery has been shown to decrease the severity of postoperative pain in children compared to open surgery. However, patients still complain about diffuse abdominal and shoulder pain. Our objective was to assess the effectiveness of the administration of intraperitoneal bupivacaine in reducing post-operative pain and opioid use.

Methods:

This is a prospective, randomized, controlled, double-blinded clinical trial. To date, 75 patients between 5 and 18 years of age that had robot-assisted laparoscopic surgery have been enrolled. Patients were randomized to receive either intraperitoneal bupivacaine (1.25 mg/kg) or an equivalent volume of saline after establishment of the pneumoperitoneum utilizing either a micro-pump nebulizer or an aerosolizer. Patients in the nebulizer group received undiluted 0.5% bupivacaine while patients in the aerosolizer group received the same dose of bupivacaine but diluted so that all patients received a total volume of 30 mL.  Postoperative pain scores were recorded at defined time points, along with pain characteristics and cumulative opioid dose for 24 hours postoperatively.

Results:

39 patients received bupivacaine (26 aerosolized, 13 nebulized) and 36 received saline (25 aerosolized, 11 nebulized).  There were no differences in demographic characteristics or length of surgery between the treatment and control groups. Pain scores were not different at any time point but patients in the saline group reported significanty more shoulder pain postoperatively. (Table1). Patients in the nebulizer group (both saline and bupivacaine) demonstrated a decreasing trend in the use of opioids as compared to the aerosolization group. More importantly, the nebulized bupivacaine group required significantly less opioid when compared to the saline group. (Figure 1).  There were no adverse effects from bupivacaine reported, and the systemic absorption as measured in the peripheral blood was minimal.

Conclusion:

Nebulized bupivacaine given at the beginning of the procedure can reduce shoulder pain and opioid requirements postoperatively.  This study is ongoing but these preliminary results suggest that it may be an effective and safe addition to the anesthetic protocol to reduce the diffuse abdominal and shoulder pain after laparoscopic surgery.

 

Table 1

Pain Characteristic 24 hours after surgery

Characteristic

Bupivacaine (n=39)

Saline (n=36)

p-value*

Abdominal diffuse/non specified

6 (42.8%)

8 (57.7%)

0.322

Shoulder

2 (16.7%)

10 (83.3%)

0.008

Bladder

 6 (60%)

4 (40%)

0.421

Incisional

5 (55.5%)

4 (44.5%)

0.552

Stomach

1 (50%)

1 (50%)

0.733

Catheter

3 (75%)

1 (25%)

0.338

Other

1 (50%)

1 (50%)

0.733

*Chi-square