Author: Brian Hoyle
Local anesthetics reduce opioid requirement and pain scores after lumpectomy and sentinel node biopsy with multimodal analgesia, according to a study presented at the 2021 Virtual Meeting of the Society of Surgical Oncology (SSO).
“Multimodal analgesia during ambulatory breast surgery is associated with reduced postoperative opioid use and pain scores, but the relative effect of intraoperative local anaesthetics on these outcomes is unclear, as is dosing for optimal pain control,” said Kate Pawloski, MD, Memorial Sloan Kettering Cancer Center, New York, New York.
To further clarify, the researchers analysed data from 1,603 patients who underwent sentinel node biopsy between January 2019 and April 2020 under a routine multimodal analgesia protocol, including intravenous ketorolac, acetaminophen, limited opioids, plus local injection of 1% lidocaine and 0.5% bupivacaine. Median tumour size was 14 mm.
Of the patients, 594 (37%) reported no pain, 331 (20%) had mild pain, and 678 (42%) had moderate to severe pain.
The researchers found that increasing the use of 1% lidocaine and 0.5% bupivacaine were independently associated with the decreased need for pain relief in the form of opioids once post-operative analgesia ended following ambulatory breast surgery.
After adjusting for intraoperative opioids, ketorolac, acetaminophen, anaesthesia type, and body mass index, increasing doses of lidocaine and bupivacaine were associated with lower postoperative anesthesia care unit (PACU) opioid requirement (P = .014 and P = .008, respectively) and, for bupivacaine, the odds of no pain increased with higher doses (odds ratio = 1.03; 95% confidence interval, 1.01-1.05; P = .001).
Of the 1,199 patients with T1 tumours, infiltration of >10 ml, vs <10 mL, was associated with lower mean opioid morphine milligram equivalents (lidocaine, P = .018; bupivacaine, P = .007) and, for bupivacaine, a lower frequency of moderate to severe pain (39% vs 46%; P = .01).
“Infiltration of higher doses of lidocaine and bupivacaine were significantly associated with lower PACU opioid requirement and pain scores,” the authors concluded. “Local dosing should be standardised and maximised within weight-based limits, as this represents a low-risk, cost-effective pain control strategy that can be used in diverse practice settings.”