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Preoperative lidocaine infiltration for reduction mammoplasty: Worth the effort?
Regional Anesthesia and Pain Medicine 24(6): 581-586, 1999
Letters to the Editor
Reply to Dr. Vercauteren
Preoperative Lidocaine Infiltration for Reduction Mammoplasty: Worth the Effort?
To the Editor: I am pleased to have the opportunity to respond to Dr. Vercauteren's comments regarding the study design and results of our study (i). First, the plastic surgeons at our institution were routinely using a 10 mL/kg preoperative injection of saline and adrenaline before the start of our study. This practice markedly reduces blood loss associated with reduction mammoplasty (2). The only additional "effort" involved opening a few bottles of 2% lidocaine and injecting this into a bag of saline and adrenaline. Although this is hardly time consuming, it is n o w conveniently pre-mixed by our pharmacy department. The cost of the ]idocaine (approx. $13 Canada) cannot be described as excessive. We believe that our results are clinically significant. The patients who received preoperative infiltration with lidocaine experienced a reduction in pain score by approximately 40% on awakening from surgery and a similar reduction of i.v. morphine consumption after surgery. In our opinion, these results are important, regardless of the fact that time to discharge from hospital was the same as patients receiving infiltration with saline and adrenaline. Time to discharge from hospital should not be viewed as the only important criterion in postoperative pain studies. Following Dr. Vercauteren's apparent logic, should we then, withold analgesics (e.g., local anesthetic infiltration) perioperatively unless these drugs enable us to discharge patients from hospital earlier? We believe that this is too narrow a definition of outcome criteria in clinical trials of postoperative pain and also is ethically questionable. Dr. Vercauteren's suggestion that we should have designed the study to determine preincision versus postoperative (preemptive) effect does not make sense. A large a m o u n t of breast tissue is excised during surgery, and injection of the same a m o u n t of local anesthetic after surgery would not be reasonable or scientifically valid. Obviously, after surgery one would be injecting the same volume (mass) of drug into a much smaller breast. Also, in practical terms, injecting such a large volume of lidocaine into a remodeled breast after surgery would likely disrupt the extensive surgical suturing. The results of our study add to the literature supporting the value of preincisional analgesia (3).
To the Editor: I have been reading with much interest the article by Rosaeg et al. ( 1). Before bilateral reduction mammoplasty, they infiltrated lidocaine 0.35% (10 mL/kg), divided over the two breasts. I would like to comment on the study design and the interpretation of the results. Reduced morphine dose requirements and better pain scores during the first two postoperative hours will not be a real surprise to most readers. The lower morphine requirements during the first 9 hours only refer to the difference made during these first hours. The authors have missed the opportunity to make the study more valuable by measuring the effect of preincision infiltration during operation and awakening and by selecting a study design that might have demonstrated a preemptive effect. The latter is only possible by comparing an infiltration with placebo or a local anesthetic made before or after surgery. I can understand that this would have complicated the interpretation of their results because of the significant a m o u n t of resected tissue, thereby influencing systemic resorption of the local anesthetic. Taking into account the similar home readiness and the energy, time and costs (i.e., + six 20-mL vials of 2% lidocaine) required to inject up to 700 mL of fluid, I do not feel encouraged to follow a similar protocol in the near future. In addition, if peak plasma levels of ]idocaine have been shown to occur up to 8 hours after completion of surgery, earlier discharge and day case surgery may be problematic. Marcel Vercauteren, M.D., Ph.D.
University Hospital Antwerp Antwerp, Belgium
Reference 1. Rosaeg OP, Bell M, Cicutti NJ, Dennehy KC, Lui ACP, Krpeski B. £re-incisioninfiltrationwith lidocaine reduces pain and opioid consumption after reduction mammoplasty. Reg Anesth Pain Med 1998: 23: 575-579.
Ola P. Rosaeg, M.B., F.R.C.P.C.
Ottawa Hospital University of Ottawa Ottawa, Ontario, Canada
Accepted for publication February 17, 1999.
581
Letters to the Editor
Reply to Dr. Vercauteren
Preoperative Lidocaine Infiltration for Reduction Mammoplasty: Worth the Effort?
To the Editor: I am pleased to have the opportunity to respond to Dr. Vercauteren's comments regarding the study design and results of our study (i). First, the plastic surgeons at our institution were routinely using a 10 mL/kg preoperative injection of saline and adrenaline before the start of our study. This practice markedly reduces blood loss associated with reduction mammoplasty (2). The only additional "effort" involved opening a few bottles of 2% lidocaine and injecting this into a bag of saline and adrenaline. Although this is hardly time consuming, it is n o w conveniently pre-mixed by our pharmacy department. The cost of the ]idocaine (approx. $13 Canada) cannot be described as excessive. We believe that our results are clinically significant. The patients who received preoperative infiltration with lidocaine experienced a reduction in pain score by approximately 40% on awakening from surgery and a similar reduction of i.v. morphine consumption after surgery. In our opinion, these results are important, regardless of the fact that time to discharge from hospital was the same as patients receiving infiltration with saline and adrenaline. Time to discharge from hospital should not be viewed as the only important criterion in postoperative pain studies. Following Dr. Vercauteren's apparent logic, should we then, withold analgesics (e.g., local anesthetic infiltration) perioperatively unless these drugs enable us to discharge patients from hospital earlier? We believe that this is too narrow a definition of outcome criteria in clinical trials of postoperative pain and also is ethically questionable. Dr. Vercauteren's suggestion that we should have designed the study to determine preincision versus postoperative (preemptive) effect does not make sense. A large a m o u n t of breast tissue is excised during surgery, and injection of the same a m o u n t of local anesthetic after surgery would not be reasonable or scientifically valid. Obviously, after surgery one would be injecting the same volume (mass) of drug into a much smaller breast. Also, in practical terms, injecting such a large volume of lidocaine into a remodeled breast after surgery would likely disrupt the extensive surgical suturing. The results of our study add to the literature supporting the value of preincisional analgesia (3).
To the Editor: I have been reading with much interest the article by Rosaeg et al. ( 1). Before bilateral reduction mammoplasty, they infiltrated lidocaine 0.35% (10 mL/kg), divided over the two breasts. I would like to comment on the study design and the interpretation of the results. Reduced morphine dose requirements and better pain scores during the first two postoperative hours will not be a real surprise to most readers. The lower morphine requirements during the first 9 hours only refer to the difference made during these first hours. The authors have missed the opportunity to make the study more valuable by measuring the effect of preincision infiltration during operation and awakening and by selecting a study design that might have demonstrated a preemptive effect. The latter is only possible by comparing an infiltration with placebo or a local anesthetic made before or after surgery. I can understand that this would have complicated the interpretation of their results because of the significant a m o u n t of resected tissue, thereby influencing systemic resorption of the local anesthetic. Taking into account the similar home readiness and the energy, time and costs (i.e., + six 20-mL vials of 2% lidocaine) required to inject up to 700 mL of fluid, I do not feel encouraged to follow a similar protocol in the near future. In addition, if peak plasma levels of ]idocaine have been shown to occur up to 8 hours after completion of surgery, earlier discharge and day case surgery may be problematic. Marcel Vercauteren, M.D., Ph.D.
University Hospital Antwerp Antwerp, Belgium
Reference 1. Rosaeg OP, Bell M, Cicutti NJ, Dennehy KC, Lui ACP, Krpeski B. £re-incisioninfiltrationwith lidocaine reduces pain and opioid consumption after reduction mammoplasty. Reg Anesth Pain Med 1998: 23: 575-579.
Ola P. Rosaeg, M.B., F.R.C.P.C.
Ottawa Hospital University of Ottawa Ottawa, Ontario, Canada
Accepted for publication February 17, 1999.
581