Addition of Liposomal Bupivacaine to Standard Bupivacaine versus Standard Bupivacaine Alone in the Supraclavicular Brachial Plexus Block: A Randomized Controlled Trial

Abstract

Background: The analgesic effect of adding liposomal bupivacaine to standard bupivacaine in supraclavicular brachial plexus block is not known. The authors hypothesized that addition of liposomal bupivacaine would reduce acute postoperative pain compared to standard bupivacaine alone.

Methods: A randomized controlled trial was conducted. Patients and outcome assessors were blinded. Eighty patients undergoing distal radial fracture fixation during regional anesthesia with supraclavicular brachial plexus block were randomized into two groups. The liposomal bupivacaine group received 10 ml 0.5% plain bupivacaine immediately followed by 10 ml 1.33% liposomal bupivacaine (n = 40). The standard bupivacaine group received 20 ml 0.5% plain bupivacaine (n = 40). The primary outcome was weighted area under curve (AUC) numerical rating scale pain score at rest during the first 48 h after surgery. Secondary outcomes included weighted AUC scores for pain with movement, overall benefit with analgesia score, and other functional scores.

Results: For the primary outcome, the liposomal bupivacaine group was associated with statistically significantly lower weighted AUC pain score at rest (0.6 vs. 1.4; P < 0.001) in the first 48 h. Of the secondary outcomes, no difference between treatment groups reached statistical significance with the exception of weighted AUC score for pain with movement (2.3 vs. 3.7; adjusted P < 0.001) and overall benefit with analgesia score (1.1 vs. 1.7; adjusted P = 0.020) in the first 48 h, as well as numerical rating scale pain score at rest (0.5 vs. 1.9; adjusted P < 0.001) and with movement (2.7 vs. 4.9; adjusted P < 0.001) on postoperative day 1. Differences in numerical rating scale pain scores on postoperative days 2, 3, and 4 did not reach the level of statistical significance. There were no statistically significant differences in sensory function.

Conclusions: Liposomal bupivacaine given via supraclavicular brachial plexus block reduced pain at rest in the early postoperative period.

Fig. 1.

Flow diagram of patients involved in this study. ITT, intention-to-treat; LB-BPB. liposomal bupivacaine group; S-BPB. standard bupivacaine group.

Fig. 2.

Weighted area under the curve (AUC) values for overall benefit with analgesia score (OBAS) in the first 48 h after surgery. Values are expressed as mean (95% CI). The liposomal bupivacaine (LB-BPB) group was associated with lower weighted AUC OBAS with statistical significance. S-BPB, standard bupivacaine group*P < 0.05 after Hochberg correction.

Fig. 3.

Numerical rating scale (NRS) pain scores from before surgery to postoperative day 7. (A) Pain score at rest. (B) Pain score with movement. Values were expressed as median (interquartile range). Liposomal bupivacaine was associated with statistically significant lower numerical rating scale pain scores at rest and with movement on postoperative day 1 compared to the standard bupivacaine group. *P < 0.05 after Hochberg correction. Pre, the same day before surgery; PACU, postanesthesia care unit (30 min after surgery)

Fig. 4.

Oxycodone consumption (in tablet, 5 mg per tablet), overall benefit with analgesia score (OBAS), Quality of Recovery (QoR), and sleep disturbance scores from postoperative days 1 to 7. Values are expressed as median (interquartile range). No comparison between the two treatment groups reached statistical significance. Oxycodone consumption: oral oxycodone consumption. LB-BPB. liposomal bupivacaine group; S-BPB. standard bupivacaine group.