Connect the Dots—January 2018
Obstet Gynecol 2018;131:39–46
On a national scale, the public health community is dealing with the ravages of the narcotic abuse epidemic. In our specialty, there are many efforts underway to reduce overprescribing narcotics while maintaining adequate pain control for our patients. These efforts include enhanced recovery after surgery (ERAS) protocols, using alternatives to postoperative narcotics such as intravenous acetaminophen or ketorolac, and limiting the number of prescribed doses of narcotics.
Intraoperative use of liposomal bupivacaine has been shown in some surgical procedures to improve patient comfort while limiting narcotic requirements. Dr. Yeung and her co-investigators (see page 39) performed a randomized, single blind study of liposomal bupivacaine injected locally at the time of posterior colporrhaphy and robotic sacrocolpopexy compared with injection of saline alone.1 The intraoperative pain relief approaches were standardized and similar in the two groups. There was no difference in pain relief at 18 hours for either abdominal or vaginal incisions, nor at any later time. Their conclusion is that, for this procedure, liposomal bupivacaine given at this dose does not provide any benefit over standard pain management.
The study design and randomization methods resulted in both study groups being similar, as expected. The authors tried to control as much as possible to limit any differences in the treatment of the two groups and to protect against the risk of bias. They suggest that a higher dose of the drug may result in better pain control (a study to be considered at a later time).
Studies such as this are important to help define the value of our interventions. Drugs that work in nonpregnant women may have a lower therapeutic threshold in pregnant women and these profiles may differ for men compared with women. This study has helped to promote patient comfort without added costs.
Nancy C. Chescheir, MD
University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
1. Yeung J, Crisp C, Mazloomdoost D, Kleeman SD, Pauls RN. Liposomal bupivacaine during robotic colpopexy and posterior repair: a randomized controlled trial. Obstet Gynecol 2018;131:39–46.