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ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 18-23

A prospective study on efficacy of topical bupivacaine in split skin grafting donor site in immediate postoperative pain relief


Department of Plastic and Cosmetic Surgery, Manipal Hospital, Bengaluru, Karnataka, India

Date of Submission23-Jan-2020
Date of Decision01-Nov-2020
Date of Acceptance22-Jan-2021
Date of Web Publication21-May-2021

Correspondence Address:
Dr. Srikanth Vasudevan
Department of Plastic and Cosmetic Surgery, Manipal Hospital, Old Airport Road, Bengaluru - 560 017, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_2_20

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  Abstract 


Objective: The objective of this study was to compare the effectiveness of bupivacaine-soaked gauze dressing and conventional dressing for pain relief in patients requiring split-thickness skin graft for reconstruction of various defects.
Methodology: Fifty patients requiring split-thickness skin grafting for various soft-tissue defects were divided into two groups with 25 patients in each group. In Group A, skin graft donor site dressing was kept moist with 10 mL/100 cm2 of 0.25% bupivacaine solution-soaked gauze, and in Group B, dressing was moistened with the same amount of normal saline-soaked gauze. Outcome was measured by comparing pain scores and calculating rescue analgesia requirements in the two groups in the first 24 h. Significance was determined by comparing analgesia-sparing effect of each dressing using Chi-square test.
Results: In Group A, 1 out of 25 (4%) patients required rescue analgesia. In Group B, 23 out of 25 (92%) patients required rescue analgesia (P < 0.0001). There was 96% effectiveness of bupivacaine-soaked dressing while only 8% effectiveness of conventional dressing.
Conclusion: Bupivacaine-soaked dressing should be considered as a potent alternative to traditional saline dressings for the skin graft donor site.

Keywords: Bupivacaine, donor site, postoperative pain, rescue analgesia, split-thickness skin graft


How to cite this article:
Vasudevan S, Nagireddy SR, Chandrappa AB, Anantheshwar Y N, Batth R, Kablian HK, Sreekumar D. A prospective study on efficacy of topical bupivacaine in split skin grafting donor site in immediate postoperative pain relief. Indian J Burns 2020;28:18-23

How to cite this URL:
Vasudevan S, Nagireddy SR, Chandrappa AB, Anantheshwar Y N, Batth R, Kablian HK, Sreekumar D. A prospective study on efficacy of topical bupivacaine in split skin grafting donor site in immediate postoperative pain relief. Indian J Burns [serial online] 2020 [cited 2021 Jun 19];28:18-23. Available from: https://www.ijburns.com/text.asp?2020/28/1/18/316571




  Introduction Top


Skin grafting is the most commonly performed surgical procedure in the plastic surgery department. Split-thickness skin grafts are used to cover burn wounds, to resurface large wounds, line cavities, resurface mucosal deficits, close donor sites of flaps, and resurface muscle flaps. Donor site pain, especially burning type of pain, is the most common compliant by the most of the patients in the first 2 days. Thigh is the most commonly used donor site for skin grafting. Alleviation of this pain can achieve considerable reduction in postoperative morbidity. There are multiple methods to reduce donor site pain, which include ice application at the donor site,[1] fascia iliaca compartment block, and a number of dressings.[2] Bupivacaine is an anesthetic agent which is easily available and long acting than other commonly used local anesthetic agents. Bupivacaine acts by blocks the nerve impulses that transmit pain sensation to brain. Hence, bupivacaine-soaked dressing is an applicable option for split-thickness skin graft donor site for early postoperative analgesia. In this study, we compared the effectiveness of bupivacaine-soaked gauze dressings and conventional dressings to alleviate skin graft donor site pain using with pain scores.


  Methodology Top


This study was conducted at the Department of Plastic Surgery and Cosmetic Surgery, Manipal Hospital, Bangalore, from November 2017 to November 2018. This study was carried out on cases requiring skin grafting, which were divided into two groups. The first patient was taken as case and the second one taken as control with 25 cases in each group. The two groups were named as Group A and Group B. Study design: A comparative two-group study. Inclusion criteria were adult patients of both genders aged 16–60 years who required split-thickness skin grafting for reconstruction of various defects in whom only one thigh was used as split-thickness skin graft donor site and graft size should be equal or more than 10 cm × 10 cm. Exclusion criteria were unwillingness to participate in trial, split-thickness skin graft done under spinal anesthesia, regional block, patients medically unfit for surgery, and patients with previous history of allergy to local anesthetics. This study was a double-blinded study in which the patient and staff nurse involved were unaware of the treatment administered. Staff nurses who collected data from the patient in wards were not associated with plastic surgery.

In both the groups, split-thickness skin grafts were harvested with Watson's modified Humby's knife. Once the desired amount of the graft was harvested, in Group A, the donor site dressing was kept moist by placing the sterile gauze soaked in an aqueous solution of bupivacaine hydrochloride in a concentration of 0.25%. The amount used depended on the size of the graft taken. For every 100 cm2 of the donor site wound, 10 mL of bupivacaine solution was used immediately after the surgery [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]. Titration of blood levels of bupivacaine is a recommended way to derive the safe limit of topical dose, but in this study, the dose of anesthesia was calculated by keeping the maximum dose of bupivacaine to the systemic limit of 3 mg/kg as the topical absorption is known to be less than systemic absorption. In this way, the possibility of systemic toxicity was eliminated. The 0.25% drug composition was diluted with normal saline at a ratio of 1:2 or 1:3 to maintain the efficacy but increase the volume of solution depending on the size of the donor defect and hence solution required. Another point to be noticed is that the maximum surface area of the donor defect did not exceed 15 cm × 15 cm as the subjects did not include acute burn patients with large body surface areas rather a combination of chronic diabetic or vascular insufficiency wounds, posttraumatic wounds, and small localized burns. In Group B, the donor site dressing was kept moist by placing the sterile gauze soaked in normal saline. Just like Group A, in Group B for every 100 cm2 of the donor site wound, 10 mL of the normal saline was used immediately after the surgery, which was in turn covered with abundant amount of sterilized pads, cotton roll, and roller gauze and finally secured with adhesive plaster in both conditions.
Figure 1: Skin graft donor area

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Figure 2: 0.25% bupivacaine

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Figure 3: Skin graft donor area covered with sterile gauze

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Figure 4: Sterile gauze soaked in an aqueous solution of bupivacaine hydrochloride in a concentration of 0.25%

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Figure 5: Final dressing using with sterile dry pads, soft roller bandage, and roller bandage

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Each subject in the study, both control and case, received 1000 mg of paracetamol intravenous (IV) infusion peroperatively. Paracetamol was given to all the patients to manage the postoperative pain associated with the recipient wounds which were debrided in the same sitting before applying graft as there was no topical anesthetic applied to the recipient site. Hence, the systemic Paracetamol could not be avoided and the criteria of effectiveness of the topical donor site analgesia were not set as presence or absence of systemic analgesia rather the additional requirement of systemic analgesia was compared in both the groups. For the assessment of pain, patients were interviewed for pain using the Visual Analog Scale [Figure 6] every hourly in the first 6 h, 2nd hourly for the next 6 h, and 4th hourly for the next 12 h. Patients in whom pain score was more than 6 (i.e., need for analgesia) were given IV analgesia in the form of an additional 1000 mg paracetamol injection. Final conclusion of analgesia-sparing effect of dressings was made at 24 h postoperatively. Most of medium-sized (10 cm × 10 cm) graft patients were discharged the next day of surgery if social conditions permitted. All the information was collected through a common self-designed pro forma. The Statistical Package for the Social Sciences version 11.0 (IBM, SPSS Inc.) was used for analysis. Variables of interest such as rescue analgesic requirement in the two groups were compared using Chi-square test taking P < 0.05 as statistically significant. Qualitative variables like age were presented by calculating mean and standard deviations. Quantitative variables such as gender and rescue analgesic requirement were presented by calculating frequency and percentages.
Figure 6: Visual Analog Scale

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  Results Top


In total, 50 patients were chosen who were to undergo split-thickness skin grafting for various soft-tissue defects. The two groups were similar demographically with respect to age and gender. In Group A, the mean age of patients was 34.64 ± 15.22 years, while in Group B, the mean age of patients was 39.76 ± 14.08 years (P = 0.223) [Table 1].
Table 1: Age distribution of patients studied

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In Group A, there were 16 males and 9 females, while in Group B, there were 16 males and 9 females [Table 2].
Table 2: Gender distribution of patients studied

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In Group A, the mean surface area of the skin graft donor area was 208.00 ± 144.63,and in Group B was 158.76 ± 84.32 (P = 0.148) [Table 3]. In Group A, the mean VAS was 16.44 ± 8.61, while in Group B, the mean VAS was 53.76 ± 8.88 (P < 0.001) [Table 4].[3]
Table 3: Size (cm2) in two groups of patients studied

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Table 4: Visual Analog Scale score distribution in two groups of patients studied

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In Group A , the amount of bupivacaine used was 21.00 ± 14.34. In Group B, the amount of bupivacaine used was 15.96 ± 8.49 (P = 0.137) [Table 5]. There was a remarkable difference in the requirement of rescue analgesia between the two groups. In Group A, only 1 out of 25 patients required rescue analgesia (4%). In Group B, 23 out of 25 (92%) patients required rescue analgesia (P < 0.001) [Table 6].[4]
Table 5: Amount of 0.25% Sensorcaine used in two groups of patients studied

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Table 6: Requirement of additional analgesia in two groups of patients studied

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Since reduction in the need for analgesia was equivalent to effectiveness, and 24 out of 25 patients in Group A did not require rescue analgesia, bupivacaine-soaked gauze dressing was 96% effective in reduction of postoperative pain at split-thickness skin graft donor site. In Group B, only 2 out of 25 patients did not require rescue analgesia, hence conventional dressing was only 8% effective in reduction of postoperative pain at split-thickness skin graft donor site. Hence, bupivacaine-soaked dressing was found to be far more effective in postoperative pain reduction at split-thickness skin graft donor site than conventional dressing with P < 0.001.

Theoretically, after local infiltration, the onset of action of bupivacaine is 5–10 min and the duration of effect is up to 6 h.[5] Hence, when the patients recovered from general or spinal anesthesia, the patients did not complaint of donor site discomfort in the bupivacaine group. The exact time interval of onset of local effect could not be commented on as the duration and wearing off of anesthesia effect on the patient and surgical site varied with the type of anesthesia administered (general or regional anesthesia).


  Discussion Top


Pain at the split-thickness skin graft donor site is a significant cause of early postoperative morbidity. Donor site pain is probably the most disturbing complication in the early postoperative period that too within 24 h. This study compared the use of bupivacaine-soaked dressing with conventional dressing for pain relief in split-thickness skin graft donor site.

The basis of this study was that the use of a local anesthetic agent locally at the split-thickness skin graft donor site should provide considerable pain relief in early postoperative period due to blockage of nerve endings.

Bupivacaine is an amide anesthetic that is more potent and has a longer duration of action than lidocaine, mepivacaine, or procaine.[6] The increases in potency and duration of action are related to prolonged binding of sodium channels. Bupivacaine is a good choice for instances in which prolonged postprocedure pain control is preferred.s

  • Preparation – Bupivacaine is commercially available in concentrations of 0.25% (2.5 mg/mL) and 0.5% (5 mg/mL)
  • Dose – The dose of bupivacaine should not exceed the following:


    • Bupivacaine without epinephrine – 2 mg/kg (0.8 mL/kg of bupivacaine 0.25%, maximum total dose: 175 mg [70 mL of bupivacaine 0.25%])
    • Bupivacaine with epinephrine – 3 mg/kg (1.2 mL/kg of bupivacaine 0.25%, maximum total dose: 225 mg [90 mL of bupivacaine 0.25% with epinephrine]).


  • Onset of action and duration of anesthesia – The onset of action of bupivacaine is 5–10 min and the duration of effect is up to 6 h. Time to peak plasma concentration: 30–45 min. Protein binding: about 95%. Metabolism: hepatic excretion: renal (6% unchanged).


Split-thickness skin graft donor area contains numerous open capillaries and cutaneous nerve endings. Bupivacaine binds to the intracellular portion of voltage-gated sodium channels and blocks sodium influx into nerve cells, which prevents depolarization. Without depolarization, no initiation or conduction of a pain signal can occur. The rate of systemic absorption of bupivacaine is dependent on the dose and concentration of drug administered, the route of administration, and the vascularity of the administration site. Systemically absorbed bupivacaine has a higher risk of major toxicity (e.g., seizures and intractable cardiac arrhythmias) than lidocaine and most other local anesthetics.[7] Bupivacaine is contraindicated for local infiltration in pregnant women[5],[8] and should be infiltrated with caution in acutely ill, debilitated, or elderly patients. Clinically significant adverse events result from systemic absorption of bupivacaine and primarily involve the central nervous system (CNS) and cardiovascular system. CNS effects typically occur at lower blood plasma concentrations. Initially, cortical inhibitory pathways are selectively inhibited, causing symptoms of neuronal excitation. At higher plasma concentrations, both inhibitory and excitatory pathways are inhibited, causing CNS depression and potentially coma. Higher plasma concentrations also lead to cardiovascular effects, though cardiovascular collapse may also occur with low concentrations. Adverse CNS effects may indicate impending cardiotoxicity and should be carefully monitored.

  • CNS: Circumoral numbness, facial tingling, vertigo, tinnitus, restlessness, anxiety, dizziness, seizure, and coma
  • Cardiovascular: Hypotension, arrhythmia, bradycardia, heart block, and cardiac arrest.[9]


The purpose of choosing bupivacaine over lignocaine in this study is the longer duration of action in bupivacaine. To overcome the late onset of action of bupivacaine, dressing was done while the patient was still under the effect of general anesthesia, so local anesthetic took effect before the patient was awake postoperatively.

This study demonstrated that when the split-thickness skin graft donor site dressing is done with a 0.25% aqueous solution of bupivacaine hydrochloride-soaked gauze, it produced significantly reduced postoperative pain. This considerably reduced the need for rescue analgesia compared to conventional dressing. It has been almost universally accepted that moist dressing at split-thickness skin graft donor site has an advantage over dry dressing both in terms of healing and pain management.[10] In this study, 0.25% solution of bupivacaine was used rather than 0.5%. The reason for using 0.25% bupivacaine was that a larger amount of this solution could be used with little fear of toxicity even if absorption occurs. Hence, this method can be safely used for larger donor site areas.

A number of methods and different types of dressings have been employed in the past to address this postoperative split-thickness skin graft donor site pain, especially in early postoperative period. In our study, there were no major complications related to bupivacaine. Because of less postoperative morbidity, all our patients were discharged immediately after the first recipient site dressing, i.e., 48 h.

There have been a number of studies about the effect of local bupivacaine on the graft donor site, but most of these involve local infiltration or field block of the area with bupivacaine unlike our study which studies the effect of topical application of bupivacaine.[11],[12] There also have been studies which study topical bupivacaine effect on the Split Thickness Skin Graft sites but with repeated top-ups using a locally placed catheter in the dressing, whereas in this study, we study the effect of a one-time intraoperative topical bupivacaine dressing in the early postoperative period. This prevents the possibility of bupivacaine overdose and eliminates the need of multiple titration tests as the dose is well within the safe limit.[13] A similar study proving the superiority of bupivacaine-moistened gauze over SSG donor site was done in 1993, but it involved using a fixed amount of 20 ml of 0.5% bupivacaine in all patients irrespective of the size of the donor wound.[14]


  Conclusion Top


Bupivacaine-soaked dressing should be considered as a potent alternative to traditional saline dressings for the skin graft donor site. Low-cost topical local anesthetics enable a smooth postoperative recovery and early rehabilitation of a patient undergoing skin grafting. Early discharge also decreases the economic burden on patients, especially in developing countries, and the risk of nosocomial infections due to prolonged hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bartfield JM, Homer PJ, Ford DT, Sternklar P. Buffered lidocaine as a local anesthetic: An investigation of shelf life. Ann Emerg Med 1992;21:16-9.  Back to cited text no. 1
    
2.
Cuignet O, Pirson J, Boughrouph J, Duville D. The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures. Anesth Analg 2004;98:1077-81.  Back to cited text no. 2
    
3.
Fenn Buderer NM. Basic Statistical Concepts for Evaluating Pharmaceutical Compounding Literature: 4. Student's t-test and One-Way Analysis of Variance. Int J Pharm Compd. 1998;2:42-3.  Back to cited text no. 3
    
4.
Fisher RA. Statistical Methods for Research Workers. Oliver and Boyd. 1954. ISBN 0-05-002170-2.  Back to cited text no. 4
    
5.
McGee DL. Local and topical anesthesia. In: Clinical Procedures in Emergency Medicine. 5th ed. Roberts JR, Hedges JR, editors. Philadelphia: Saunders Elsevier; 2010. p. 481.  Back to cited text no. 5
    
6.
Tetzlaff JE. The pharmacology of local anesthetics .Anesthesiol Clin North America 2000:18:217.  Back to cited text no. 6
    
7.
Yaster, M, Tobin, JR, Kost-Byerly, S. Local anesthetics. In: Pain in Infants, Children, and Adolescents. 2nd ed. Schechter NL, Berde CB, Yaster M, editors. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003. p. 241.  Back to cited text no. 7
    
8.
Ahlstrom KK, Frodel JL. Local anesthetics for facial plastic procedures. Otolaryngol Clin North Am 2002;35:29-53, v-vi.  Back to cited text no. 8
    
9.
Tetzlaff JE. The pharmacology of local anesthetics. Anesthesiol Clin North Am 2000;18:217-33, v.  Back to cited text no. 9
    
10.
Kılınc H, Sensoz O, Ozdemir P, UnlU RE, Baran C. Which dressing for splitthickness skin graft donor sites? Ann Plast Surg 2001;46:409-14.  Back to cited text no. 10
    
11.
Dissanaike S, McCauley J, Alphonso C. Liposomal bupivacaine for the management of postsurgical donor site pain in patients with burn injuries: A case series from two institutions. Clin Case Rep 2017;6:129-35.  Back to cited text no. 11
    
12.
Artz CE, Ward MA Jr., Miles MP, Alexander K, Blanche AL, Lintner A, et al. Intraoperative liposomal bupivacaine for skin graft donor site analgesia. J Burn Care Res 2019;40(Suppl 1):S99-100.  Back to cited text no. 12
    
13.
Raza MS, Nazim T, Khan FA. Comparison of bupivacaine moistened dressing and conventional dressing for pain relief on skin graft donor sites. J Coll Physicians Surg Pak 2014;24:416-9.  Back to cited text no. 13
    
14.
Butler PE, Eadie PA, Lawlor D, Edwards G, McHugh M. Bupivacaine and Kaltostat reduces post-operative donor site pain. Br J Plast Surg 1993;46:523-4.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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