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A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives

      ABSTRACT

      Objective

      To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring.

      Data Sources

      We searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo.

      Results

      As expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] –1.28; 95% CI –1.96 to –0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD –0.57; 95% CI –1.10 to –0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD –0.74; 95% CI –0.93 to –0.54, P < 0.01) and laparotomy (MD –2.60; 95% CI –2.93 to –2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI –0.69 to 1.09, P = 0.66) or prolapse surgery (MD –0.11; 95% CI –0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD –0.11; 95% CI –0.59 to 0.38, P = 0.67).

      Conclusion

      As expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.

      RÉSUMÉ

      Objectif

      Examiner toutes les données probantes de haute qualité disponibles concernant l'effet de la bupivacaïne 24 heures (ou 8,9 demi-vies) après son administration peropératoire pendant une intervention chirurgicale gynécologique et vérifier si un deuxième mode d'action se produit, au-delà de la prévention initiale de l'ouverture des canaux sodiques par dépolarisation et du bloc de l'impulsion.

      Sources de données

      Nous avons fait des recherches dans toutes les grandes bases de données à l'aide d'un algorithme conçu pour inclure tous les essais randomisés qui ont utilisé n'importe quelle forme de bupivacaïne locale, quelle que soit la dose ou la voie d'administration, pendant une intervention chirurgicale gynécologique et qui ont comparé son utilisation avec un placebo de solution saline.

      Résultats

      Comme attendu, nous avons constaté que la bupivacaïne permettait d'obtenir une amélioration significative pour toutes les interventions chirurgicales gynécologiques en ce qui concerne l'intensité de la douleur 6 heures après l'intervention comparativement au groupe de la solution saline (différence moyenne [DM] : -1,28; IC à 95 % : -1,96 à -0,61, p = 0,07). Nous avons également constaté une différence significative 24 heures après l'intervention, ce qui indique la possibilité d'un deuxième mode d'action (DM : -0,57; IC à 95 % : -1,10 à -0,05, p = 0,01). Une autre analyse de sous-groupe des intensités de douleur à 24 heures indique une diminution significative de la douleur pour les sous-groupes de la laparoscopie (DM : -0,74; IC à 95 % : -0,93 à -0,54, p < 0,01) et de la laparotomie (DM : -2,60; IC à 95 % : -2,93 à -2,27, p < 0,01), mais pas pour ceux de l'hystérectomie vaginale (DM : 0,20; IC à 95 % : -0,69 à 1,09, p = 0,66) et de la réparation d'un prolapsus (DM : -0,11; IC à 95 % : -0,41 à 0,19, p = 0,48). Aucune différence significative n'a été observée quant à la durée d'hospitalisation (DM : -0,11; IC à 95 % : -0,59 à 0,38, p = 0,67).

      Conclusion

      Comme attendu, la bupivacaïne a significativement réduit les scores visuels analogiques de la douleur comparativement au placebo 6 heures après l'intervention, mais elle a également montré une différence significative 24 heures après l'intervention, ce qui laisse croire à un deuxième mode d'action après le bloc des canaux sodiques.

      Keywords

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