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Acta Anaesthesiol Scand 2000; 44: 1093–1098
Copyright CActa Anaesthesiol Scand 2000
Printed in Denmark. All rights reserved
ACTA ANAESTHESIOLOGICA SCANDINAVICA
ISSN 0001-5172
Preoperative ropivacaine infiltration in breast surgery
A
.
J
OHANSSON
1
,
J
.
A
XELSON
2
,
C
.
I
NGVAR
2
,
H
.-
H
.
L
UTTROPP
1
and J
.
L
UNDBERG
1
1
Department of Anaesthesiology and Intensive Care, and
2
Department of Surgery, Lund University Hospital, Lund, Sweden
Purpose: The aim of the study was to investigate whether pre-
operative infiltration with ropivacaine in conjunction with
breast surgery improves postoperative pain management and
attenuates postoperative nausea and vomiting.
Method: Prospective, randomised, double-blind study, includ-
ing 60 healthy women (ASA 1–2) allocated to one of two groups.
Thirty patients were given 0.3 ml/kg saline in the operating
field before surgery. Another 30 patients received a similar vol-
ume of ropivacaine 3.75 mg/ml. A visual analogue scale (0–100
mm) was used for evaluation of postoperative pain, nausea and
vomiting. If the score was more than 30 mm at rest, the patients
were given ketobemidone i.v. as treatment for postoperative
pain, and dixyrazine i.v. against nausea and vomiting. The intra-
and postoperative analgesic requirements and postoperative
nausea and vomiting were registered.
Results: The intraoperative fentanyl consumption was similar
in the saline group 81∫22 mgvs76∫28 mg; (ns) in the ropiva-
caine group. The postoperative 24-h ketobemidone consumption
was also similar to those treated with ropivacaine (4.2∫2.6 mg
S
INCE OPIOIDS
produce a number of dose-dependent
adverse effects such as nausea, vomiting and se-
dation (1), alternative analgesic regimes in the peri-
and postoperative periods may reduce unwanted side
effects. Administration of local anaesthetics in the sur-
gical wound is a simple and attractive technique to
improve postoperative pain relief. However, contro-
versy exists regarding the efficacy of this technique
(2–5). Preoperative wound infiltration may reduce
postoperative pain more than postoperative infil-
tration after hernia repair in children (6), while no
such effect is observed with preincisional infiltration
after cholecystectomy (7).
Previous studies regarding preoperative infiltration
with local anaesthetics have not focused on the effects
on postoperative nausea and vomiting. Ropivacaine is
a long-acting local anaesthetic that is structurally re-
lated to bupivacaine. Recent data show that ropiva-
caine produces fewer central nervous system and car-
diovascular side effects compared to bupivacaine (8).
Therefore, it seems appropriate to utilise ropivacaine
as a local anaesthetic agent for wound infiltration.
1093
vs 4.2∫4.3 mg; ns). Postoperative nausea and vomiting (PONV)
occurred with similar frequencies in both groups. The 24-h dixy-
razine consumption was the same in the two groups (2.1∫2.7
mg in the saline group compared to 2.4∫2.8 mg in the ropiva-
caine group; ns). After6hrecovery, 41% of all patients had
experienced nausea and 20% vomiting.
Conclusion: We found no differences in postoperative pain
management between 3.75 mg/ml ropivacaine and saline
wound infiltration before breast surgery. The data show similar
postoperative needs of analgesics and antiemetics with a similar
frequency of PONV.
Received 28 September 1999, accepted for publication 3 April 2000
Key words: Anesthesia, wound infiltration; local anesthetics,
ropivacaine; main measures, postoperative: pain, nausea and
vomiting; surgery, breast; nursing, pain, nausea and vomiting.
cActa Anaesthesiologica Scandinavica 44 (2000)
Our hypothesis was that infiltration with local anaes-
thetics would reduce the pain experience and need of
opioids, leading to a lower incidence of postoperative
nausea and vomiting.
The aim of this study was to evaluate whether pre-
operative wound infiltration with ropivacaine im-
proved peri- and postoperative pain management, re-
duced the amount of opioid analgesics and attenuated
nausea and vomiting following breast surgery.
Methods
Sixty healthy women (ASA 1–2), scheduled for partial
mastectomy alone or in combination with axillary dis-
section, were studied after approval by the local ethics
committee and obtaining informed consent from each
patient. Exclusion criteria were a history of pre-
existing nausea and vomiting or administration of
drugs with antiemetic properties prior to surgery. The
patients were randomly assigned in a double-blind
fashion to one of two treatments using the closed en-
velope method. The randomisation resulted in 30 pa-
A. Johansson et al.
Table 1
Demographic data and intraoperative fentanyl consumption in pa-
tients undergoing elective breast surgery with general anaesthesia
and preoperative infiltration with either ropivacaine 0.375% or NaCl
0.9%.
Ropivacaine NaCl
Group (nΩ30) (nΩ29)
Age (yr) 54∫11 55∫9
Height (cm) 165∫1 165∫1
Weight (kg) 68∫267∫2
ASA (1/2) 18/12 15/14
Duration of anaesthesia (min) 115∫7 126∫7
Duration of surgery (min) 79∫785∫6
Surgical procedure (n)
– Partial mastectomy 14 15
– Partial mastectomy with axillary 16 14
dissection
Peroperative fentanyl (mg) 76∫28 81∫22
Patients receiving extra fentanyl (n) 5 9
Values are shown as mean∫SD. There were no statistical differ-
ences between the groups.
tients assigned to each treatment. One group received
0.3 ml/kg saline in the breast and 0.3 ml/kg saline
in the axilla before surgery. The other group instead
received the same volumes of ropivacaine 3.75 mg/
ml (0.75% Narop
A
, Astra, mixed with saline).
All patients were premedicated with midazolam 5–
7.5 mg rectally 30 min before induction. Intravenous
fluid therapy consisted of 0.5 ml/kg ¡non per os hours
before anaesthesia and maintenance with 150 ml/h of
2.5% buffered glucose. Monitoring included ECG,
pulse-oximetry and non-invasive blood pressure. Gen-
eral anaesthesia was induced with intravenous glyco-
pyrrolate 0.2 mg, fentanyl 0.5 mg/kg, and propofol 2–
2.5 mg/kg before inserting the laryngeal mask airway.
Subsequently paracetamol 1g was given rectally. An-
aesthesia was maintained with fentanyl 0.5 mg/kg im-
mediately before skin incision, O
2
/N
2
O (40:60) and
sevoflurane with an end-tidal concentration of 0.7
MAC. All patients maintained spontaneous breathing
in a circle system with a carbon dioxide absorber. The
fresh gas flow was set at 1 l. An additional dose of fen-
tanyl 0.5 mg/kg was given if the systolic blood pressure
increased above the baseline level assessed at rest dur-
ing the preoperative evaluation.
Five senior surgeons were involved in the study
and thoroughly instructed by A.J. about the infil-
tration technique. When the patient was asleep and
after marking the surgical incision, the subcutaneous
tissue was infiltrated. During the procedure, the sur-
geons infiltrated the breast and axilla, with the pur-
pose to operate in pre-infiltrated tissues. Except for
the surgical scrub nurse, who prepared the study
1094
drug, no one involved in the patient care knew
whether saline or ropivacaine was used.
The visual analgue scale (VAS) scores for postopera-
tive pain and postoperative nausea and vomiting
(PONV) were recorded at 0, 1, 2, 3, 4, 5, 6, 12, 18 and
24 h in the postoperative care unit. Entering the recov-
ery room was considered as time zero. The nursing
staff in the recovery room used a 100 mm horizontal
VAS(0mmΩno pain/nausea to the left and 100 mmΩ
worst pain/nausea to the right). The patients were
asked to evaluate the degree of pain/nausea during
the assessment. If VAS for pain or PONV was more
than 30 mm at rest, the nurse administered i.v. keto-
bemidone in 1 mg doses and i.v. dixyrazine in 2 mg
doses as postoperative analgesia and PONV treat-
ment, respectively.
When arriving at the postsurgical ward patients
were given oral dextropropoxyphene 100 mg for pain
treatment, repeated every 6 h if necessary. Nausea and
vomiting were treated with metoclopramide 20 mg
rectally as required.
A power analysis revealed that a study population
of 60 patients was needed to reach the 0.05 signifi-
cance level. An average standard deviation (SD) of ap-
proximately 20 mm and an intergroup difference in
VAS scoring of 15 mm would reach a power of ap-
proximately 0.85 (9).
The results are expressed as mean∫SD. Data were
analysed using repeated measures analysis of vari-
ance followed by pairwise comparisons of contrasts
and Fisher’s exact test. P⬍0.05 was considered statisti-
cally significant.
Table 2
Emetic symptoms and need for ketobemidone and/or dixyrazine in
59 patients after breast surgery in ropivacaine and NaCl treated pa-
tients.
Ropivacaine NaCl
Group (nΩ30) (nΩ29)
PONV (%)
No symptoms 57 62
Nausea 43 38
Vomiting 13 28
Patients needing ketobemidone (%)
0–2 h 77 83
2–4 h 13 10
4–6 h 3 0
Patients needing dixyrazine (%)
0–2 h 40 41
2–4 h 7 10
4–6 h 7 3
The frequencies of symptoms and medication were not statistically
different between the two groups.
Preoperative ropivacaine infiltration
Fig. 1. Pain at rest after breast surgery measured by using a 100 mm
VAS scale (0Ωno pain to 100Ωsevere pain) at 0, 1, 2, 3, 4, 5, 6, 12,
18 and 24 h postoperatively. Mean∫SD.
Fig. 2. The postoperative ketobemidone requirements during the first,
second and third 2-h period postoperatively. Mean∫SD.
Results
One patient in the saline group was excluded from
the study due to an altered surgical procedure. Demo-
graphic data, duration of anaesthesia and surgery, and
intraoperative fentanyl administration are shown in
Table 1. The fentanyl consumption was similar in the
two groups, 81∫22 mg in the saline group versus
76∫28 mg in the ropivacaine group (ns). Fourteen pa-
tients (24%) needed extra fentanyl doses according to
the algorithm (9 vs 5 patients in the saline/ropiva-
caine group, respectively; ns).
There were no differences in postoperative anal-
gesic requirements during the first, second and third
2-h period postoperatively (Table 2 and Fig. 2; ns). The
VAS pain scores at rest in the two groups decreased
over the 24-h study period (Fig. 1). The 24-h ketobem-
idone utilisation in the saline group (4.2∫2.6 mg) was
1095
not different compared to the ropivacaine group
(4.2∫4.3 mg) (ns). There were no differences in post-
operative antiemetic requirements during the first,
second and third 2-h period postoperatively (Table 2
and Fig. 3; ns). The postoperative 24-h dixyrazine con-
sumption was also similar in both groups (2.1∫2.7 mg
vs 2.4∫2.8 mg; ns).
Postoperative nausea and vomiting occurred with a
similar frequency in both groups (Tables 2 and 3).
After 6 h, 41% of all patients had experienced nausea
and 20% vomiting. Following 6 h postoperative care,
100 mg dextropropoxyphene alone was adequate for
pain relief in all patients. No patient needed metoclo-
pramide for nausea treatment. There were no adverse
drug effects during the infiltration of ropivacaine and
the surgeons experienced no technical difficulties due
to the infiltrated volume. Besides PONV there were
no opioid related side effects in the postoperative
period and no patient needed rescue medication.
Table 3
The number of patients and distribution over time of postoperative
nausea in relation to VAS scoring (ropivacaine/saline).
VAS⬎0mm VAS⬎30 mm VAS⬎50 mm
0 h 7/4 4/2 2/1
1 h 6/7 3/2 1/2
2 h 4/4 0/1 0/1
3 h 4/1 2/1 1/1
4 h 3/2 3/1 2/1
5 h 1/3 1/2 0/1
6 h 2/3 1/1 0/0
12 h 0/0 0/0 0/0
18 h 0/0 0/0 0/0
24 h 0/0 0/0 0/0
There was no overall significant difference between treatment groups
regarding the frequency of nausea.
Fig. 3. The postoperative dixyrazine requirements during the first, sec-
ond and third 2-h period postoperatively. Mean∫SD.
A. Johansson et al.
Discussion
This study indicates no differences in postoperative
pain management between ropivacaine and saline
wound infiltration before breast surgery. We found
similar intra- and postoperative needs of analgesics,
antiemetics and frequency of PONV. Our findings are
consistent with previous studies that failed to demon-
strate an opioid sparing effect of wound infiltration
with local anaesthetics following cholecystectomy (7)
and caesarean section (10).
Breast surgery is normally associated with a high
incidence of postoperative pain and PONV. It has
been shown that 48–87% of patients undergoing mi-
nor breast surgery, mastectomy and breast reconstruc-
tion suffer from PONV (11–15). Troublesome pain and
PONV can prolong recovery and hospitalisation, and
are some of the most common causes of hospital ad-
mission following ambulatory surgery (16). Accord-
ingly, it is of great value for both patients and health
care providers to reduce pain and minimise PONV.
Many factors may influence PONV including gender,
obesity, surgical procedure, anaesthetic agents and
postoperative pain (17). Postoperative opioid con-
sumption and/or a history of motion sickness have
been identified as important factors that predict post-
operative sickness (18, 19). However, the pre- and in-
traoperative use of opiates may also induce PONV
(20).
Ropivacaine is a recently introduced local anaes-
thetic less prone to elicit adverse effects from the CNS
and the circulatory system, and with a long duration
(21). Although previous studies have failed to demon-
strate analgesic effects of wound infiltration with local
anaesthetic solutions following abdominal surgery
(22), the treatment seems to be more efficient when
used during minor surgical procedures such as ingui-
nal hernia repair (23). Whether the infiltration should
be performed before or after surgery has been a mat-
ter of debate. During abdominal hysterectomy, both
pre- and postincision infiltration with bupivacaine
0.5% failed to alter the postoperative pain response
(24). Neither did preincisional ropivacaine infiltration
reduce long-term pain following laparotomy (25).
However, experimental studies have demonstrated
that noxious stimuli in peripheral tissue without
nerve block can influence electrophysiological
changes in the dorsal horns of the medulla and inten-
sify the pain response (26).
In the present study variables influencing PONV,
such as demographic data, type of surgery, anaes-
thetics and analgesics, did not differ between the
groups. Patients with a history of motion sickness
1096
were not included in the study with the aim that
PONV was related solely to the postoperative pain
intensity and the agents administered perioperatively.
We utilised the visual analogue scale both for pain
and PONV at a given time point. This assessment
technique for pain and PONV has demonstrated simi-
lar results compared with other measurement tech-
niques (27).
We found no differences in the pain management
or incidence of PONV between the groups. Thus, both
treatments are likely to be ineffective, or theoretically
both techniques have analgesic properties. One possi-
bility could be that intracutaneous saline preinfil-
tration may attenuate pain by blocking the release of
sensory mediators at the periphery. A dilution of loc-
ally released mediators with saline may interfere with
the action of prostaglandins and thereby attenuate the
cyclooxygenase-2 isoenzyme that is activated after
trauma and inflammation (28, 29).
Our results must be interpreted with caution since
the difference in infiltration technique, general anaes-
thesia, surgical technique and postoperative care
make it difficult to determine what role the infiltration
agents might have had in comparison to other studies.
It can be argued that we included patients with two
different surgical procedures and that the study de-
sign did not differ between postoperative pain from
the breast wound and the axillary dissection. The vol-
ume administration in the axilla was similar to the
breast, and the number of patients in each category
was similar. We believe that this minimised the influ-
ence on pain and pain treatment due to the two types
of surgery. The intraoperative administration of fen-
tanyl and paracetamol may have influenced the re-
sponse to pain, but in our opinion the total amount of
fentanyl was low in combination with 1.3 MAC vol-
atile agents. Only 24% of the patients needed extra
fentanyl during the procedure, and the total intra-
operative fentanyl consumption, pain scores, PONV
scores, and postoperative antiemetics and analgesics
were identical in both groups.
We were unable to detect a benefical analgesic or
antiemetic effect of ropivacaine compared to saline.
However, in contrast to Oddy-Muhrbeck et al., who
found that a majority of emetic symptoms occurred
after leaving the postoperative unit (11), we observed
the highest frequency of nausea during the first two
postoperative hours. The low pain scores and the low
fentanyl and ketobemidone utilisation may also reflect
the rapidly decreasing PONV over time. Since the over-
all frequency of PONV was lower than previously re-
ported, a larger sample of patients may have shown a
difference in PONV between the groups.
Preoperative ropivacaine infiltration
Another explanation for the lack of analgesic differ-
ence between the groups may have been that the in-
filtration with ropivacaine did not adequately block
the afferent neuronal input. Mulroy et al. concluded
that both ropivacaine 0.25% and 0.5% are adequate for
pain relief after outpatient hernia repair (30). We
chose 3.75 mg/ml ropivacaine for breast surgery, but
it is possible that a higher concentration of ropiva-
caine might have improved analgesia. The infiltration
technique used in this study may have influenced the
results, since we used preoperative infiltration. Per-
haps it is better to inject the local anaesthetic at the
end of the operation, since the tissue removal during
surgery will reduce the amount of local anaesthetic
available for postoperative pain relief. Apart from the
study design, five different surgeons performed the
surgical procedure. However, the individual sur-
geon’s experience of local infiltration was developed
during surgical procedures preceding the study. No
data show any difficulty during the surgical pro-
cedures, and based on our demographic data and re-
sults, the surgeon’s influence on the results seems to
be of minor importance.
The results of our study show that recovery from
uncomplicated breast surgery is rapid regarding post-
operative pain. The pain scoring shows the highest
ratings immediately upon arrival at the recovery
room, and with similar rates of early-onset nausea
and vomiting. The use of local anaesthetics may have
an impact on PONV. To further clarify this effect, we
have instituted a study with a placebo group without
utilising saline for wound infiltration.
In conclusion, we found no effect of ropivacaine
compared with saline infiltration. Our data indicate
that ropivacaine and saline wound infiltration re-
sulted in similar intra- and postoperative needs for
analgesics and antiemetics, and similar frequency of
PONV.
Acknowledgements
The authors wish to thank Professor Dag Lundberg for valuable
discussions, and Lena Nordin Linderqvist, CRNA, and Lena
Svensson, RN, for invaluable help during the study.
References
1. Raeder J, Breivik H. Premedication with midazolam in out-
patient general anaesthesia. A comparison with morphine-
scopolamine and placebo. Acta Anaesthesiol Scand 1987: 31:
1–6.
2. Willard PT, Blair NP. Is wound infiltration with anaesthetic
effective as pre-emptive analgesia? A clinical trial in appen-
dectomy patients. Can J Surg 1997: 40: 213–217.
1097
3. Johansson B, Hallerback B, Stubberod A, Janbu T, Edwin B,
Glise H et al. Preoperative local infiltration with ropivacaine
for postoperative pain relief after inguinal hernia repair. A
randomised controlled trail. Eur J Surg 1997: 163: 371–378.
4. Hannibal K, Galatius H, Hansen A, Obel E, Ejlersen E. Pre-
operative wound infiltration with bupivacaine reduces early
and late opioid requirement after hysterectomy. Anesth An-
alg 1996: 83: 376–381.
5. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson
ER, White PF. Effect of preincision versus postincision infil-
tration with bupivacaine on postoperative pain. J Clin Anesth
1995: 7: 192–196.
6. Dahl V, Raeder JC, Erno PE, Kovdal A. Pre-emptive effect
of pre-incisional versus post-incisional infiltration of local
anaesthesia on children undergoing hernioplasty. Acta
Anaesthesiol Scand 1996: 40: 847–851.
7. Johansson B, Glise H, Hallerbäck B, Dalman P, Kristoffers-
son A. Preoperative local infiltration with ropivacaine for
postoperative pain relief after cholecystectomy. Anesth Analg
1994: 78: 210–214.
8. Scott DB, Lee A, Fagan D, Bowler OM, Bloomfield P, Lundh
R. Acute toxicity of ropivacaine compared with that of
bupivacaine. Anesth Analg 1989: 69: 563–569.
9. Douglas GA. Statistics and ethics in medical research. Br
Med J 1980: 281: 1336–1338.
10. Trotter TN, Hayes-Gregson P. Wound infiltration of local an-
aesthetic after lower segment caesarean section. Anaesthesia
1991: 46: 404–407.
11. Oddby-Muhrbeck E, Jakobsson J, Andersson L, Askergren J.
Postoperative nausea and vomiting: a comparison between
intravenous and inhalation anaesthesia in breast surgery.
Acta Anaesthesiol Scand 1994: 38: 52–56.
12. Fujii Y, Tanaka H, Toyooka H. Effective dose of granisetron
in the reduction of nausea and vomiting after breast surgery.
Acta Anaesthesiol Scand 1997: 41: 1167–1170.
13. Fujii Y, Tanaka H, Yoyooka H. Prophylactic antiemetic ther-
apy with granisetron-dexmethasone combination in women
undergoing breast surgery. Acta Anaesthesiol Scand 1998: 42:
1038–1042.
14. Enquist B, Björklund C, Engman M, Jakobssom J. Preopera-
tive hypnosis reduces postoperative vomiting after surgery
of the breast. A prospective, randomised and blinded study.
Acta Anaesthesiol Scand 1997: 41: 1028–1032.
15. Rosaeg OP, Bell M, Cicutti NJ, Dennehy KC, Lui AC, Krepski
B. Pre-incision infiltration with lidocaine reduces pain and
opioid consumption after reduction mammoplasty. Reg
Anesth Pain Med 1998: 23: 575–579.
16. Gold BS, Kitz DS, Lecky JH, Neuhaus JM. Unanticipated
admission to the hospital following ambulatory surgery.
JAMA 1989: 262: 3008–3010.
17. Whatcha MF, White PF. Postoperative nausea and vomiting.
Its etiology, treatment and prevention. Anesthesiology 1992:
77: 162–184.
18. Andrews PLR. Physiology of nausea and vomiting. Br J
Anaesth 1992: 69 (Suppl. 1): 2S–19S.
19. Cohen MM, Duncan PG, DeBoer DP, Tweed WA. The post-
operative interview: assessing risk factors for nausea and
vomiting. Anesth Analg 1994: 78: 7–16.
20. Camu F, Lauwers MH, Verbessem D. Incidence and aeti-
ology of postoperative nausea and vomiting. Eur J Anaes-
thesiol 1992: 9(Suppl. 6): 25–31.
21. Pettersson N, Emanuelsson BM, ScPharm M, Reventlid H,
Hahn RG. High-dose ropivacaine wound infiltration for
pain relief after inguinal hernia repair. Reg Anesth Pain Med
1998: 23: 189–196.
22. Levack ID, Holmes JD, Robertson GS. Abdominal wound
A. Johansson et al.
perfusion for the relief of postoperative pain. Br J Anaesth
1986: 58: 615–619.
23. Dierking GW, Dahl JB, Kanstrup J, Dahl A, Kehlet H. Effect
of pre- vs postoperative inguinal field block on postopera-
tive pain after herniorraphy. Br J Anaesth 1992: 68: 344–348.
24. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson
ER, White PF. Effect of preincision versus postincision infil-
tration with bupivacaine on postoperative pain. J Clin Anesth
1995: 7: 192–196.
25. Bourget JL, Clark J, Joy N. Comprising preincisional with
postincisional bupivacaine infiltration in the management of
postoperative pain. Arch Surg 1997: 132: 766–769.
26. Coderre TJ, Vaccarino AL, Melzack R. Central nervous sys-
tem plasticity in the tonic pain response to subcutaneous
formalin injection. Brain Res 1990: 535: 155–158.
27. Del Favero A, Roila F, Basurto C, Minotti V, Ballatori E, Pato-
ia L et al. Assessment of nausea. Eur J Clin Pharmacol 1990:
38: 115–120.
28. Raja S, Meyer JN, Meyer RA. Peripheral mechanisms of so-
matic pain. Anesthesiology 1998: 68: 571–590.
1098
29. Mitchell JA, Akarasereenont P, Thiemermann C, Flower RJ,
Vane JR. Selectivity of nonsteroidal anti-inflammatory drugs
as inhibitors of constitutive and inducible cyclooxygenase.
Proc Natl Acad Sci USA 1993: 90: 11693–11697.
30. Mulroy MF, Burgess FW, Emanuelsson BM. Ropivacaine
0.25% and 0.5%, but not 0.125%, provide effective wound
infiltration analgesia after outpatient hernia repair, but with
sustained plasma drug levels. Reg Anesth Pain Med 1999: 24:
136–141.
Address:
Anders Johansson, CCRN, CRNA
Department of Anaesthesiology and Intensive Care
Lund University Hospital
S-221 85 Lund
Sweden
e-mail: 046250952/telia.com
