ORIGINAL ARTICLE
EFFICACY OF WOUND INFILTRATION USING BUPIVACAINE VERSUS
ROPIVACAINE ALONG WITH FENTANYL FOR POSTOPERATIVE ANALGESIA
FOLLOWING ABDOMINAL HYSTERECTOMY UNDER SPINAL ANESTHESIA
Udita Naithani1, Indira Kumari2, Rekha Roat3, Vinita Agarwal4, Chayenika Gokula5, Harsha6, Vimla
Doshi7
HOW TO CITE THIS ARTICLE:
Udita Naithani, Indira Kumari, Rekha Roat, Vinita Agarwal, Chayenika Gokula, Harsha, Vimla Doshi . “Efficacy of
wound infiltration using bupivacaine versus ropivacaine along with fentanyl for postoperative analgesia
following abdominal hysterectomy under spinal anesthesia”. Journal of Evolution of Medical and Dental
Sciences 2013; Vol2, Issue 34, August 26; Page: 6478-6489.
ABSTRACT: BACKGROUND: Wound infiltration with local anesthetics and opioids is increasingly
being used as a part of multimodal postoperative analgesia. OBJECTIVES: A prospective randomized
double blind placebo controlled study was conducted to investigate the efficacy of wound infiltration
using bupivacaine versus ropivacaine with fentanyl for postoperative analgesia. METHOD: 93
female patients of ASA grade I/II posted for abdominal hysterectomy under spinal anesthesia were
randomly divided into three groups destined to receive wound infiltration at the end of surgery
using 14.5 ml 0.5% isobaric solution of either bupivacaine or ropivacaine along with 0.5 ml (25 mcg)
fentanyl in group BF and RF respectively, and with 15 ml normal saline in control group (Group S).
All patients received diclofenac 75 mg I.M. (B.D.) and rescue analgesic butorphanol 1 mg was given if
pain occurs. Postoperative analgesia in terms of visual analogue score rescue opioids consumption
in 24 hour period, and satisfaction score of patient, surgeon and anesthesiologist was compared.
Rescue opioid (butorphanol) consumption in 24 hours was significantly higher in group S (61 mg),
as compared to group BF (21 mg) and group RF (26 mg), p= 0.000. However group BF and group RF
were comparable p=0.473. (Group S > group RF~ Group BF). Mean VAS score at rest, cough and
movement was significantly less and satisfaction of patient, surgeon and anesthesiologist was
significantly higher in group BF than in group RF than in group S, p<0.05. CONCLUSION: We
conclude that wound infiltration using bupivacaine or ropivacaine with fentanyl is an easy, safe and
effective technique for providing postoperative analgesia. Moreover, bupivacaine seems to be
superior to ropivacaine in wound infiltration in terms of significantly less pain score and better
satisfaction score.
KEY WORDS: wound infiltration, bupivacaine, ropivacaine, fentanyl, postoperative analgesia,
multimodal analgesia.
INTRODUCTION: Total abdominal hysterectomy is commonly performed via a Pfannenstiel incision
and causes moderate to severe pain, which is often multifactorial and can be attributed to
combination of incision pain, pain from deeper visceral structures, and dynamic pain on movement,
such as during straining, coughing or mobilizing that may be severe1.
Injured nerve fibers innervating the site of incision/ retraction and sutures generate pain
impulses. Increased inflammatory mediators at the surgical site also sensitize uninjured and injured
nerve fibres. Transmission of pain from the wound is reduced by local anesthetic application, and
the local inflammatory response to the injury is also suppressed. Consequently hyperalgesia due to
sensitization of nociceptors may be prevented2.
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ORIGINAL ARTICLE
A traditional approach for post-operative pain control includes inhibition of peripheral
nerves innervating the surgical site by local wound infiltration.
It is a method of post operative analgesia commonly used alone or along with other analgesic
regimens. It also reduces opioids consumption, minimizes opioid adverse reactions, reduces nursing
work, decreases resting pain, pain on motion, and thus allows better patient mobility3.
Various clinical studies had been published which support the analgesic properties of
peripheral use of opioids and numerous mechanism have been stated for this action through
peripheral opioid receptors3,4,5.
Bupivacaine has been the long-acting local anaesthetic agent of choice since a long time6.
Ropivacaine has been introduced as a long-acting local anesthetic agent with potential advantages
over bupivacaine, particularly with respect to reduced cardiac toxicity7.
Efficacy of both bupivacaine3 and ropivacaine5, 8 for wound infiltration as a component of
multimodal post operative analgesia had been studied with varying results. But the comparison of
analgesic effect of these two agents in wound infiltration has not been much investigated6.
Hence the present study was undertaken to test the hypothesis whether wound infiltration
using bupivacaine or ropivacaine along with fentanyl as a part of multimodal analgesia could reduce
the opioids consumption in first 24 hours in post operative period. The analgesic profile of two local
anesthetics was also compared.
MATERIALS AND METHODS: After institutional ethical committee clearance, this prospective,
randomized, placebo-controlled, double blind study was carried out at Department of Anesthesia in
RNT medical college attached to MB Hospital in Udaipur (Rajasthan).
Basis of sample size: The number of patients required for the study was calculated on the basis of
total opioid consumption during 24 hrs. We expected a reduction in opioid consumption by 25% in
the group given local anesthetic infiltration. Assuming  = 0.05, we calculated that we would need 93
patients (31 in each group) to achieve, a power of 90% ( = 0.9).
Patient selection: After taking informed written consent 93 female patients of age group 20-65
years, ASA physical status I and II, undergoing elective total abdominal hysterectomy (TAH) with
bilateral salpingo-oophorectomy (BSO) using Pfannenstiel incision under spinal anesthesia were
enrolled in the study.
Exclusion criteria: Patients were excluded if TAH was scheduled for malignancy or if there was a
history of chronic pain, continuous use of analgesic drugs, patients with a history of clinically
significant cardiovascular, pulmonary, hepatic, renal, neurologic, psychiatric, or metabolic disease.
Patients having severe obesity (BMI > 35 kg/m2), coagulation disorder, on anticoagulants, severe
spinal deformity, allergy to local anesthetic, or any contraindication to spinal anesthesia were
excluded from the study.
Randomization, group allocation and blindness to the study: 93 selected patients were
randomly assigned to 3 equal groups using sequentially numbered, opaque sealed envelopes
depending upon the drugs used for wound infiltration (15ml) at the end of surgery.
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ORIGINAL ARTICLE


Using normal saline(15 ml) in Group S(control);
14.5 ml (72.5 mg) of isobaric bupivacaine (0.5%) with 0.5 ml (25mcg) fentanyl in Group BF
and.
 14.5 ml (72.5 mg) of isobaric ropivacaine (0.5%) with 0.5ml (25mcg) fentanyl in Group RF.
To provide double blindness to the study, drugs were prepared by a separate
anesthesiologist who was not further involved in the study. Patient, surgeon who did wound
infiltration and anesthesiologist who recorded data were not aware of group allocation.
Anesthesia technique: - After thorough pre-anesthetic evaluation patients were taken in elective
operation theatres after 8 hours fasting.
After taking an intravenous access with 18 G cannula, infusion of 500ml Ringer lactate was
given. Base line heart rate, systolic and diastolic blood pressure was measured before spinal
anesthesia. Under full aseptic precautions in all patients lumbar puncture was performed at L3-L4
intervertebral space in lateral decubitus position through a midline approach using 25 G quincke
spinal needle. Correct needle placement was identified by free flow of cerebrospinal fluid and 3ml
(15mg) of 0.5% hyperbaric bupivacaine was given for subarachnoid block.
Standard monitoring was done throughout the operation. Electrocardiography (E.C.G.) and
pulse-oximetry (SpO2) was monitored continuously while noninvasive blood pressure (NIBP) was
monitored every 3 min for first 15 min, thereafter every 5 min till completion of surgery.
Hypotension (decrease in systolic BP of 20% of baseline or less than 100 mm of Hg) was treated
with i.v. bolus of 6mg ephedrine hydrochloride. Bradycardia (<60 beat/min) was treated with i.v.
bolus of 0.3 – 0.5 mg of atropine sulphate.
Surgical technique: The total abdominal hysterectomy with bilateral salpingo–oophorectomy was
performed in all the patients following standard steps: abdomen was opened in layers via
Pfannenstiel incision, and then infundibulopelvic ligament was clamped followed by clamping of
uterine artery and Mackenrodt’s ligament. Then uterus along with bilateral ovaries and cervix was
removed and vault was closed, hemostasis achieved and abdomen closed in layers.
Wound infiltration technique: The surgeon who was blinded to the treatment groups was asked to
infiltrate all layers of the abdominal wall during closure, including muscle and cutaneous layers,
using drugs as per group allocation.
For postoperative analgesia: Multimodal analgesic regime was followed in which patients received
intramuscular injection of diclofenac 75 mg [ nonsteroidal anti-inflammatory drug (NSAID)]
immediately after wound infiltration and subsequently after 12hr.Thus each patient received two
doses of diclofenac during the study period of 24 hours. Rescue analgesic in form of butorphanol
1mg (opioid) was given as slow IV injection whenever patient complained of pain in the
postoperative periods, or VAS was > 40 mm at rest.
Data recording: In the postoperative period, assessments were made at shifting of the patient in
ward (0hr) as baseline then at 1hr, 2hr, 6hr, 12hr and 24 hr, by anesthesiologist blinded to the
treatment groups. Pain at rest, cough and on movement (induced by leg raising as bending of the
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ORIGINAL ARTICLE
knees) was assessed on Visual Analog Scale (0-100 mm) as 0- no pain, 100- worst imaginable pain at
above time intervals. In addition, total rescue analgesic (opioid) requirement in terms of number of
doses and total dose in mg in 24 hrs was recorded. Heart rate (HR), Systolic blood pressure (SBP),
Diastolic blood pressure (DBP) was also recorded at above time intervals. Sedation was assessed at
same time intervals as VAS using a categorical scale (1: awake and alert, 2: awake but drowsy
responding to verbal stimulus, 3: drowsy but arousable responding to physical stimulus, 4:
unarousable not responding to physical stimulus. In addition, any episode of nausea and vomiting
were recorded during the 24 hr postoperative period and rescue antiemetic ondansetron 4mg i.v.
was given for nausea, vomiting and repeated if necessary. Any other side effect if occurred was
noted. Satisfaction score of patients, surgeon and anesthesiologist regarding post operative
analgesia was assessed at 24 hours postoperatively and graded as: 0-poor, 1-satisfactory, 2-good, 3excellent, and the study were declared as complete.
Statistical analysis: Data were entered and analyzed with the help of MS Excel EPI info 6 and SPSS.
Qualitative or categorical data were presented as number (proportion) and compared with Chisquare test. Quantitative or continuous variables were presented as mean ± SD and compared using
student ‘t’ test. ANOVA was applied as per need as test of significance. A post hoc test was used to
assess intergroup differences. p < 0.05 was considered as statistically significant.
RESULTS: All the three groups were comparable regarding mean age, mean weight, residence and
education status P>0.05. (Table 1)
There was no significant difference in HR, SBP and DBP at various time intervals during
postoperative period (0-24hr) in three groups, as compared to baseline (p>0.05) and no significant
intergroup variations were observed, (p > 0.05).
Post-operative analgesia: VAS score: In all the three groups, 0, 1, and 2 hours postoperatively
mean VAS was found 0 at rest, cough, and movement due to persistence effect of spinal anesthesia.
Mean VAS at rest, cough and movement at 6, 12 and 24 hours was significantly less in group BF and
group RF as compared to group S, p<0.05. Mean VAS was also significantly less in group BF than in
group RF, p<0.05. Thus mean VAS was in order of group BF< group RF< group S. (Table 2)
Rescue analgesic consumption: During 24 hours postoperatively, rescue analgesic was required
by all 31 patients (100%) in Group S. Out of these 3(9.67%) patients received a single dose,
26(83.8%) received 2 doses and 2(6.45%) required 3 doses. Whereas opioids were required in 21
(67.7%) patients in Group BF and 26 (83.8%) patients in Group RF and all received the single dose.
It was noteworthy that 10(32.2%) patients in group BF and 5 (16.1%) patients in group RF did not
require any rescue opioids in 24 hours post operative period.
Requirement of rescue analgesic in postoperative period (24hr) in terms of total number of
doses and total dose in mg was significantly more in Group S (61mg) as compared to Group BF
(21mg) and Group RF (26mg), p= 0.000; however, group BF and group RF were comparable,
p=0.473. Thus rescue analgesic requirement was Group S > Group RF ≈ Group BF.
Requirement of rescue analgesic(butorphanol) in terms of mean dose in mg for each patient
was significantly more in Group S (1.96±0.40mg), as compared to Group BF (0.667±0.47mg),
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ORIGINAL ARTICLE
p=0.035 and Group RF (0.83±0.37 mg), p=0.028; nevertheless, Group RF and Group BF were
comparable P=0.086 . Wound infiltration with ropivacaine and bupivacaine along with fentanyl was
found to reduce rescue analgesic consumption by 57.3% (group RF) and 65.5% (group BF)
respectively as compared to control group (group S), which was statistically significant,
p=0.000(Table 3).
Satisfaction score: Mean satisfaction score of patient, surgeons and anesthesiologist were
significantly higher in the Group BF (1.35±0.48, 1.71±0.46, 1.73±0.45 respectively) and Group RF
(0.94±0.30, 1.51±0.25, 1.51±0.25 respectively), p=0.000; as compared to group S (0.42±0.50,
0.97±0.48, 0.97±0.49 respectively), p=0.000. Mean Satisfaction score of patients, surgeon and
anesthesiologist in Group BF was also significantly higher than in Group RF, p= 0.000. Thus
satisfaction score was Group BF > Group RF > Group S.
Sedation score: Mean sedation score was significantly more in group S(1.06±024) as compared to
group BF(1) and group RF(1) in which all patients remained alert at all time intervals , p=0.000.
Postoperative adverse effects:
Emetic episode were minimal in present study. Only 1 (3.2%) patient each in group S and
group BF had vomiting and received ondansetron 4 mg. None of the patient in the study had other
side effects such as pruritis, wound infection, wound rupture, wound hematoma, delayed wound
healing etc.
Table 1: Demographic characteristics
Group S
Variable
(n=31)
Age
(years)
Group BF
(n=31)
Group RF
(n=31)
20-40
19 (33.3%)
21 (36.8%)
17 (29.8%)
>40-60
12 (35.2%)
8 (23.5%)
14 (41.1%)
>60
0 (0%)
2(6.45%)
0 (0%)
Mean ±SD 40.5±6.52
39.8±6.65
39.9±7.31
40-60
30 (35.2%) 28 (32.9%) 27(31.7%)
Weight(kg)
>60-80
1(12.5%)
3(37.5%)
4(50.0%)
Mean ±SD 53.2±5.33
53.7±6.43
52.8±6.15
Rural
20 (39.2%) 16 (31.3%) 17 (33.3%)
Residence
Urban
11 (27.5%) 15 (37.5%) 14(35.0%)
Literate 18(34.61%) 18(34.61%) 16 (30.7%)
Education
Illiterate 13 (30.9%) 13 (30.9%) 17(54.8%)
P Value
0.367
0.384
0.565
0.840
Data are expressed as mean ±SD or n (%) as appropriate
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TABLE 2: Postoperative analgesia in terms of VAS score (0-100 mm) at various time intervals
in three groups
VAS score
P value
Gr S
Gr S Gr BF
Time
Gr (S)
Gr (BF)
Gr (RF)
vs.
vs.
vs.
Gr BF Gr RF Gr RF
R
0
0
0
0 hr
C
0
0
0
L
0
0
0
R
0
0
0
1 hr
C
0
0
0
M
0
0
0
R
0
0
0
2 hr
C
0
0
0
M
0
0
0
R 38.2±8.02 16.8±5.09 24.8±2.56 0.043 0.035 0.025
6 hr
C 46.5±8.68 24.7±3.86 32.8±4.28 0.034 0.024 0.023
M 51.0±8.51 27.7±4.05 37.8±5.85 0.046 0.026 0.025
R 36.8±7.02 12.3±3.61 22.6±2.21 0.030 0.023 0.028
12 hr
C 45.5±6.63 21.0±3.96 30.8±3.85 0.043 0.040 0.025
M 49.2±7.76 23.9±5.58 34.5±4.43 0.046 0.032 0.022
R 35.6±6.25 11.3±5.09 21.2±2.85 0.039 0.026 0.022
24 hr
C 43.9±6.29 16.8±5.09 28.0±4.15 0.034 0.043 0.035
L 46.8±7.8 20.3±6.94 31.5±3.08 0.042 0.022 0.037
R 36.8±1.30 13.4±2.92 22.8±1.81 0.030 0.043 0.046
Overall VAS (6-24 hours) C 43.5±1.31 20.8±3.95 30.5±2.41 0.032 0.045 0.048
M 49.0±2.10 23.9±3.70 34.6±3.51 0.036 0.046 0.049
R-Rest, C-cough, M-Movement (on leg rising).
Data are expressed as mean ± SD and post-hoc test (ANOVA) used.
Table 3: Comparison of rescue analgesic requirement in three groups in first 24 hours
postoperatively
Rescue analgesia
P value
No. of patient requiring
rescue analgesic
No
dose
Patient
Single
distribution
dose
Group S
n=31
Group BF
n= 31
Group RF
n=31
Gr S/
Gr BF
Gr S/
Gr RF
Gr BF/
Gr RF
31(100%)
21(67.7%)
26(83.8%)
0.162
0.515
0.473
0
10(32.3%)
5(16.2%)
3(9.67%)
21(67.7%)
26(83.8%)
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ORIGINAL ARTICLE
according to no.
of doses
Two
doses
Three
doses
Total no of doses of rescue
analgesic
Total no. dose in mg of
rescue analgesic
(butorphanol) (mg)
Mean dose in mg for each
patient
26(83.8%)
0
0
2(6.45%)
0
0
61
21
26
61
21
26
1.96±0.40
0.677±0.47
0.83±0.37
0.000
0.000
0.473
0.000
0.000
0.473
0.035
0.028
0.086
Data are expressed as mean ±SD or n (%) as appropriate
DISCUSSION: Opioids remain the primary analgesic agent for management of acute postoperative
pain after major surgery; opioid related adverse effects inhibit rapid recovery and rehabilitation9.
Currently, the American society of Anesthesiologists task force on acute pain management advocates
the use of multimodal analgesia10. The combination of different analgesic agents in multimodal
analgesia act by different mechanisms and at different sites in the nervous system. This provides
additive or synergistic analgesia with lowered adverse effects of sole administration of individual
analgesic9.
As such, one approach for multimodal analgesia is the use of regional anesthesia and
analgesia to inhibit the neural conduction from the surgical site to the spinal cord which decreases
spinal cord sensitization9. This was also followed in present study where all hysterectomies were
conducted under spinal anesthesia using 15 mg of 0.5% hyperbaric bupivacaine.
Guidelines for postoperative acute pain management specifies that “unless contraindicated
all patients should receive round the clock regimen of non-steroidal anti-inflammatory drugs
(NSAIDs or cyclooxygenase-2 inhibitors (COX2) or acetaminophen”10. Mechanism of action of
NSAIDs includes inhibition of the synthesis of prostaglandins both in the spinal cord and at the
periphery. Thus it decreases the hyperalgesic state after surgical trauma and decreases
postoperative opioid requirement9. All patients received intramuscular injection of diclofenac 75 mg
on conclusion of the surgical procedure and at 12 hr interval thereafter as a part of multimodal postoperative analgesia regimen in the present study.
Wound infiltration at the time of closure had been described as a part of multimodal
analgesia and demonstrated to have an analgesic sparing effect and has the major influence on the
patients’ ability to resume their normal activities of daily living2. Due to the local application,
transmission of pain from the wound is reduced, and the local inflammatory response to the injury is
suppressed. Consequently sensitization of nociceptors and the ensuing hyperalgesia may be
prevented2. Various agents like local anesthetics, opioids, NSAIDs have been used for wound
infiltration, but with varying results3, 11, 12
Opioid receptors have been demonstrated in the peripheral nerve ending of afferent
neurons. Blockade of these receptors with peripherally administered opioids is believed to result in
analgesia3. Fentanyl4, morphine13, bupernorphine3, tramadol5 have been used for wound infiltration
and were found to improve postoperative analgesia. Tverskoy et al4 reported that spontaneous and
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ORIGINAL ARTICLE
movement associated pain measured 24 hr postoperatively was decreased with the addition of
fentanyl for wound infiltration (compared with the control) by approximately half ,and prolonged
the duration of anesthesia by approximately 50%.Therefore in present study 25mcg fentanyl was
used as an adjuvant along with local anesthetic for wound infiltration.
When wound infiltration with bupivacaine or ropivacaine along with fentanyl was done as a
part of multimodal analgesia in our study it resulted in significant improvement in postoperative
analgesia. It allowed a significant reduction in pain scores and opioid consumption in first 24 hours
postoperatively and this led to a significantly better satisfaction of patient, surgeon and
anesthesiologist regarding postoperative pain. Wound infiltration by local anesthetics had been
found effective in providing post operative analgesia in previous studies11, 13, 14.
Local anesthetic application to wound can provide analgesia through various mechanisms.
Firstly, they inhibit the transmission of pain from nociceptive afferents from the wound surface.
Secondly, local inflammatory response to injury that sensitizes nociceptive receptors and
contributes to pain and hyperalgesia is also prevented by local anaesthetics. In addition they
decrease the release of inflammatory mediators from neutrophils and neutrophil adhesion to the
endothelium. They also decrease the formation of free radicals and edema20. Local anesthetic
infiltration could alter the perception of deeper visceral pain by blocking the superficial component
of pain11.
The analgesic action of local anaesthetics can be enhanced by infiltration of opioids in
addition to local anesthetics3,4,13 .Opioids inhibit the neuronal firing by increasing the potassium
current and decreasing calcium current in sensory neurons. They also block the transmitter release
and calcium dependent release of excitatory pro-inflammatory compounds e.g. substance P
contributing to their analgesic and anti –inflammatory actions. The anti-nociceptive effect of opioids
is increased by inflammation in various ways. The perineurium (normally an impermeable
membrane) is disrupted by presence of inflammation and it enhances the entry of various mediators
like corticotrophin releasing hormones, interleukin 1B and other related cytokines. Inflammation
increases the release of peptides from immune cells leading to activation of opioid receptors 3.
Inflammation activates the previously inactive opioid receptors. In addition it also increases
the receptor up- regulation (increase in their number in peripheral nerve terminals) thus
potentiates the analgesic properties of opioids16. Fentanyl’s pharmacokinetic variables also allows
it to stay in the muscle and fat compartments for many hours, the mean transit time for fat tissue
being 1418 min17.After a bolus dose administration of fentanyl its action on opioid receptors in the
wound area continue beyond 24 hrs and thus reduces the wound hyperalgesia4.
In contrast some authors found that there was no significant difference in pain scores or
rescue analgesic consumption in postoperative period in wound infiltration groups18. This
ineffectivity of wound infiltration was attributed to various possibilities like inadequate dose or
concentration of local anesthetic, inter-individual differences in patient’s perception of pain,
difference in opioid effect or difference in pharmacokinetics. Some gave explanation that pain arising
from viscera and deeper peritoneal layers is of greater significance than that from cutaneous,
subcutaneous and muscular layer of a wound incision, afferent from deeper structure would be
unaffected by wound infiltration18.
The relative contribution of somatic and visceral pain after abdominal surgery is unknown
and difficult to eluciadate19. Pfannenstiel incision is used to perform total abdominal hysterectomy
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ORIGINAL ARTICLE
with bilateral salpingo-oophorectomy. It is associated with extensive dissection and tissue damage
during surgery. Thus it contributes to both somatic and visceral pain20. Local anesthetic infiltration
near surgical wound decreases the somatic pain by altering peripheral pain transduction by
inhibiting the transmission of noxious impulses from the site of injury. According to some neural
pain pathway theories, sensitization of nervous system to painful sensation occurs by stimulation of
superficial pain receptors. Alteration of perception of deeper visceral pain can be done by
elimination of some of the superficial component of pain21.The wound infiltration of local
anesthetics is also effective in reducing postoperative narcotic requirements which has been
observed in various studies13,20 including ours. But the explanation regarding the mechanism of local
anesthetics in decreasing the noxious impulses generated by visceral tissues distant to the site of
drug infiltration is difficult20. Systemic analgesic effect may also occur due to systemic absorption of
local anesthetic drugs20. This is supported by the observation that local anesthetics decrease dorsal
horn neuronal excitability when administered systemically to decerebrated animals 23. Certainly
wound infiltration technique involves large volumes leading to significant systemic levels of local
anesthetic or opioids. In present study 14.5 ml of 0.5% bupivacaine or ropivacaine (72.5mg) and
25mcg of fentanyl were infiltrated in the wound. In view of the large volumes and milligram doses of
local anesthetics it would seem sensible to use a drug with a lower toxicity. Serious and sometime
lethal cardiac toxicity has been described with bupivacaine, particularly when large doses are used.
The cardiotoxicity of ropivacaine has been well shown to be significantly less than that of
bupivacaine. In addition the cardiotoxic manifestations are easier to manage6.
When wound infiltration with bupivacaine and ropivacaine was compared in the present
study, efficacy of postoperative analgesia in terms of pain score (VAS score) was significantly
superior in bupivacaine group as compared to ropivacaine group however there was no significant
difference in opioid consumption in both the groups. Ropivacaine has a clinical profile similar to that
of bupivacaine, and minimal difference reported between the two anesthetics are mainly related to
the slightly different anesthetic potency, with racemic bupivacaine > ropivacaine24. It has been
reported that relative analgesic potency of ropivacaine: bupivacaine were 0.6 (for epidural minimum
local analgesic concentration) and 0.65 (for intrathecal minimum local analgesic dose) and relative
motor block potency of ropivacaine: bupivacaine was 0.66 after epidural administration.
Ropivacaine is a levo isomer of bupivacaine and has propyl group in place of butyl group. These
structural differences make it less lipid soluble resulting in less potency and less cardiotoxicity.
Reduced lipophilicity renders difficulty in penetration of large myelinated motor fibers7, 25.
Some authors who were unable to detect appreciable benefit from single injection of local
anesthetic26 reported that the ability to provide prolonged application of local anesthetic to wounds
through a catheter is probably important15. Therefore continuous27 and/or intermittent infusion28 of
the surgical wound with local anesthetic solution has been introduced as a way of extending local
anesthetic induced incision pain relief in postoperative period, with the introduction of new
portable pumps can now be used on an ambulatory basis29 with these catheter delivery system ,the
risk of infection appears to be small. However bacterial colonization of the catheter is a common
occurrence30. Thus in future wound infiltration using catheter technique should be planned.
CONCLUSION: This study establishes the effectiveness of wound infiltration using local anesthetics
(bupivacaine/ropivacaine) along with fentanyl as a part of multimodal analgesia for postoperative
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pain relief after total abdominal hysterectomy with bilateral salpingo-oophorectomy under spinal
anesthesia. When bupivacaine or ropivacaine are used in similar dose and concentration for wound
infiltration, bupivacaine seems to be more effective in decreasing pain scores and provided better
satisfaction scores, however it could not affect rescue analgesic consumption.
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2. Dahl JB, Moinich S. Relief of postoperative pain by local anaesthetic infiltration: Efficacy for
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AUTHORS:
1. Udita Naithani
2. Indira Kumari
3. Rekha Roat
4. Vinita Agarwal
5. Chayenika Gokula
6. Harsha
7. Vimla Doshi
PARTICULARS OF CONTRIBUTORS:
1. Associate
Professor,
Department
of
Anaesthesia, RNT Medical College attached to
MB hospital, Udaipur (Rajasthan), India.
2. Senior Professor, Department of Anaesthesia,
RNT Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
3. Senior Resident, Department of Anaesthesia,
RNT Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
4. Senior Resistrar, Department of Anaesthesia,
RNT Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
5.
6.
7.
Senior Resistrar, Department of Anaesthesia,
RNT Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
Senior Resistrar, Department of Anaesthesia,
RNT Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
Professor, Department of Anaesthesia, RNT
Medical College attached to MB hospital,
Udaipur (Rajasthan), India.
NAME ADRRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Rekha Roat,
331, Moti Nagar West,
Queens Road,
Jaipur, (Rajasthan)
Email – drnamyaroat@gmail.com
Date of Submission: 16/08/2013.
Date of Peer Review: 17/08/2013.
Date of Acceptance: 20/08/2013.
Date of Publishing: 22/08/2013
Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 34/ August 26, 2013
Page 6489