Abstract
Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries
performed under general anesthesia to minimize postoperative pain. To better understand
the role of timing of the injection of local anesthesia in hand surgery performed
under general anesthesia, we evaluated the effect of pre- versus postincisional local
analgesic injection on immediate postoperative pain experience. We hypothesize that
the preincisional (preemptive) injection will result in decreased immediate postoperative
pain experience and analgesic use when compared with postincisional injection.
Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period
were retrospectively reviewed. During the first half of the study period, the surgical
site was infiltrated with 0.5% bupivacaine at the completion of surgery following
closure. During the second half of the study period, the surgical site was infiltrated
with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics,
immediate postoperative recovery room (PACU) pain scores, and postoperative opioid
consumption in morphine equivalents.
Results Two-tailed t-test identified no significant difference between the pre- and postincision cohorts
relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores
were significantly lower in the preincision cohort. The mean PACU pain score was also
significantly lower in the preincision cohort. PACU opioid consumption, converted
into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg
in the postincision cohort.
Conclusion The preincisional (preemptive) injection of local anesthesia was found to result
in lower pain scores during and upon exit of the PACU as compared with the postclosure
group. In addition, the preincision cohort also trended toward lower opioid consumption
while in the PACU. Consideration should be given to the routine use of preincision
injection of local anesthesia to maximize pain relief in a multimodal pain strategy
in hand surgical patients.
Level of Evidence Therapeutic level III.
Keywords
preemptive - analgesia - BJA - pre-incision - anesthetic - bupivacaine - Marcaine
