Intraperitoneal Instillation of Lidocaine Cuts Post-Cesarean Pain

By Marilynn Larkin

NEW YORK (Reuters Health) - Intraperitoneal instillation of lidocaine improves the management of early postoperative pain after a cesarean delivery and reduces the number of women requesting opioids in the immediate postpartum period, according to researchers in Canada.

Because intraperitoneal instillation of lidocaine reduces pain after abdominal surgery, Ruchira Patel of the University of Toronto in Ontario and colleagues investigated its effect on post-cesarean delivery pain when given as part of a multimodal analgesia intervention.

As reported in Anesthesia and Analgesia, online December 15, the team recruited 204 women (mean age, 35) scheduled for elective cesarean delivery under spinal anesthesia, 193 of whom were included in the final analysis.

Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine, fentanyl, and morphine. At the end of the cesarean delivery, right before parietal peritoneum or fascia closure, 99 women received 20 mL 2% lidocaine with epinephrine and 94 received 20 mL normal saline instilled into the peritoneal cavity.

Pain scores on movement at 24 hours postcesarean delivery were similar in both groups, as were scores for pain at rest at 24 hours, pain at rest at 48 hours, and pain on movement at 48 hours.

However, scores for pain at 2 hours postcesarean delivery on movement (P=0.001) and at rest (P=0.001) were lower in the lidocaine group. Further, a subgroup analysis of women who underwent peritoneum closure showed significantly lower pain scores at 24 hours on movement in the lidocaine group (P=0.032).

In addition, the number of women requesting opioids for breakthrough pain was significantly lower in the lidocaine group (40; 40%) than in the placebo group (61; 65%; relative risk 0.59).

Dr. Anita Gupta, vice-chair, Department of Anesthesiology and Pain Medicine at Drexel University College of Medicine in Philadelphia, called the approach "innovative" but added, "It is not always practical to do an invasive procedure on a pregnant patient. The risk of injury always exists and complications can ensue."

"Opioids carry just as much risk," she noted by email. "The decision to do such a procedure is always based on the particular clinical situation and if there is a clinical need to consider adjuvants that will reduce need for high dose opioids. Opioids are often only used minimally during delivery, given epidural injections are very effective in minimizing pain and discomfort during c-section."

She concluded, "What is helpful with this paper is another novel way to provide analgesia in an urgent or critical situation when there may not be adequate time to provide an epidural quickly enough."

Dr. Octavia Cannon, co-owner of Arboretum Obstetrics and Gynecology, LLC, in Charlotte, North Carolina, told Reuters Health, "I have used the lidocaine approach during my laparoscopic tubal sterilization cases for over 16 years. It's very difficult to determine whether it decreased the pain for the patients, but I usually do not get callbacks on the outpatient procedures."

"I am a big proponent of using 2% lidocaine with epinephrine in many procedures, particularly office procedures, and injecting it into the incisions at closure for laparoscopic procedures," she said by email.

"This cesarean technique has some promise; however, I was disappointed to learn that the 24-hour post-operative pain rating was the same in both the lidocaine and control groups," she noted. "It seems that it is only helpful with patients one to two hours postoperatively."

Dr. Cannon concluded, "I'm hopeful additional case studies will perfect the technique and provide longer analgesia for the patients. As an osteopathic physician, I remain concerned about the overuse and over-prescription of opioids. This is definitely an important option to continue to explore."

The authors did not reply to requests for a comment.

SOURCE: https://bit.ly/2hYuxA7

Anesth Analg 2016.

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