SLR - November 2014 - Russell H. Bates
Reference: Haddock, N., Weinstein, A., Sinno, S., & Chiu, D. (2014). Thrombin and Topical Local Anesthetic for Postoperative Pain Management. Annals of Plastic Surgery, 73(1), 30-33.Scientific Literature Review
Reviewed By: Russell H. Bates, DPM
Residency Program: Albert Einstein Medical Center
Podiatric Relevance: The management of a patient’s postoperative pain should be high on the priority list of a good surgeon. It would also seem efficacious to do so without the need to prescribe large amounts of opioids or other pain medications, in order to reduce short and possible long term complications. Narcotics can cause nausea, altered mental status and constipation, which subsequently result in the need for further use of medications such as antiemetics and laxitives/stool softeners. The use of intraoperative local anesthetics (LA) have been shown to reduce post-op pain and reduce post-anesthetic care unit (PACU) times, which has shown a decrease in the need for immediate post-op use of narcotics. This study gathers statistics to show that, rather than using LA combinations alone, using LA and thrombin together reduces PACU time and the number of opioid pills required in the week following surgical procedures. Thrombin and fibrin glue are already used as mediums to deliver medications in the body such as antibiotics, so it would be intriguing to see if a LA combination would be beneficial in managing post-op pain.
Methods: The study was done as a prospective single-blinded clinical study. It included 49 patients undergoing elective hand surgery. Preoperatively, all patients received 5mL of 1 percent xylocaine injected into the arm for local analgesia. Arm tourniquets were also used in all cases. The patients were placed into seven groups of seven patients using an envelope system for patient selection: (1) No postoperative anesthetic (Control), (2) 5 mL of 2 percent xylocaine (X), (3) 5 mL of 0.5 percent bupivacaine (B), (4) 2.5 mL of 2 percent xylocaine and 2.5 mL of 0.5 percent bupivacaine (XB), (5) thrombin mixed with 5 mL of 2 percent xylocaine (XT), (6) thrombin mixed with 5 mL of 0.5 percent bupivacaine (BT), (7) thrombin mixed with 2.5 mL of 2 percent xylocaine and 0.5 percent bupivacaine (XBT). Follow up was done hourly in the PACU by nurses who were unaware of the patient’s post-op anesthetic combinations, using the visual analog scale for pain. Secondary follow-ups were done with the patients completing the survey asking the number of pain medications (325mg acetaminophen and 5mg hydrocodone) used during the first five days postoperatively.
Results: Of the 83 patients asked to do the study, 55 agreed. None of these patients took pre-operative pain medications. Six of the patient’s documentation post-op was incomplete, and of the remaining 49 patients 22 were male and 27 were female. The mean time of all patient’s PACU time was 96.6 minutes with significant differences (P=0.001) between medications used. The control group mean PACU time was 132.1 minutes, xylocaine 110.7 minutes, and bupivacaine 101.4 minutes did not reduce PACU time, but their combination XB did at 92.14 minutes (P=0.007). With the thrombin combinations, PACU times continued to decrease with XT at 72.4 minutes, and XBT at 74.3 minutes. The BT combination was not significantly different from bupivacaine alone. It also showed significantly improved pain scores as reported by the patients with thrombin combinations, as well as significantly less pain pills required by the patient in the five days following the surgery with the XB and XBT combinations. There were no reports of side-effects regarding the thrombin combinations
Conclusions: The study found that the use of XBT was the most effective method of delivery for LA for post-operative pain management. The positive results of this study merit further investigation into this delivery system. If we can find a way to improve patient pain management and, in turn, reduce reliance on narcotic medications, physicians will be able to offer their patients superior methods of pain control while reducing their risk for postoperative complications secondary to the medications we prescribe. Physicians who care about their patients’ well being, and finding improved methods of treating those we work for/with, will be encouraged to learn of these other methods of pain control.