SLR - May 2021 - Ashmi Shah

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

Reference: Hussain N, Brull R, Sheehy B, Essandoh MK, Stahl DL, Weaver TE, Abdallah FW. Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia. Anesthesiology. 2021 Feb 1;134(2):147-164.

Level of Evidence: Level II

Scientific Literature Review

Reviewed By: Ashmi Shah, DPM
Residency Program: Roxborough Memorial Hospital – Philadelphia, PA

Podiatric Relevance: Postoperative pain control is important in surgery because it leads to higher patient satisfaction and decreased opioid use. Liposomal bupivacaine is advertised as extending postoperative pain relief for 72 hours. However, it is generally more expensive than nonliposomal bupivacaine and other local anesthetics. This study demonstrates that there is no significant clinical difference between the two, which makes them both acceptable for use in postoperative pain control and that there may be no need to incur the additional cost of liposomal bupivacaine for a similar outcome with a cheaper option. 

Methods: The authors extracted data from randomized trials comparing nonliposomal local anesthetic versus liposomal bupivacaine. A total of nine citations with 619 total patients were included in this study. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-hour rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. The types of surgeries performed included major shoulder surgery, rotator cuff surgery,  arthroscopic shoulder surgery, hip arthroscopy, total knee arthroplasty, video-assisted thoracoscopic surgery, minimally invasive lung resection,  inflatable penile prosthesis placement, and total mastectomy. A meta-analysis was performed to determine the final results from the nine studies. 

Results: Across 24- to 72-hours, the mean difference in AUC of rest pain was found to be 1.0 centimeter · h in favor of liposomal bupivacaine, but the difference was not statistically significant. There were no statistically significant differences in any of the secondary outcomes. 

Conclusions: The authors believe that they have provided high quality evidence demonstrating that although rest pain was found to be better controlled with liposomal bupivacaine, there was no clinical difference between liposomal bupivaciane and nonliposomal anesthetics. There were no foot or ankle surgeries included in the randomized trials, however the basic principles still apply. If podiatrists are going to use liposomal bupivacaine, they should still expect the same results as when they use other local anesthetics and plan postoperative pain medications accordingly. Podiatrists can also choose not to use the more expensive liposomal anesthetic when the cheaper local anesthetics will achieve the same results.  

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