title: Cesarean analgesia using levobupivacaine continuous wound infiltration: a randomized trial.
abstract: OBJECTIVE
  Neuraxial morphine is considered as a "gold standard" for pain relief after cesarean section, however it causes bothersome side effects. Alternative analgesia including nonsteroidal antiinflammatory drugs (NSAID) has been proposed. We aimed to assess the morphine sparing effect of continuous wound infiltration with a local anesthetic, when added to multimodal systemic analgesia including NSAID without subarachnoid morphine.
  
  
  METHODS
  Sixty-eight women scheduled for elective cesarean section under spinal anesthesia were included in a randomized controlled open-label trial. Patients received bupivacaine spinal anesthesia without intrathecal morphine. Postoperative analgesia consisted for all patients in multimodal systemic analgesia with acetaminophen, nefopam, celecoxib, and patient-controlled intravenous morphine for 24h. The intervention group also received subfascial levobupivacaine infiltration through a multi-holed catheter, at 6.25mg/h for 48h. The primary endpoint was total morphine consumption at 24h postoperatively; and secondary endpoints were pain scores, side effects, breastfeeding comfort, maternal satisfaction, and nurse workload. Student t test, Mann-Whitney test or χ(2) test were used when appropriate.
  
  
  RESULTS
  The intervention group had 6.7mg less morphine consumption (95%CI -1.3mg; -12mg, P=0.02), and 0.8 pain point less at rest on the numerical rating scale 0-10 (95%CI -0.3; -1.3, P=0.002). The intervention was associated with significantly better breastfeeding comfort (+1.7 at numerical rating scale score 0-10, 95%CI +0; +3.3, P=0.0498). Wound dressing changes were required in a significantly higher proportion of intervention-group women (12/34 vs. 1/34, P=0.002).
  
  
  CONCLUSIONS
  Adding continuous levobupivacaine infiltration to multimodal analgesia after cesarean section without subarachnoid morphine decreased postoperative morphine consumption and pain, facilitated breastfeeding initial comfort, and slightly increased nurse workload.
authors.affiliation: Department of Anesthesiology and Intensive Care, Centre Hospitalier Intercommunal Poissy Saint Germain en Laye, France. Electronic address: claude.jolly@gmail.com.
authors.forename: Claude
authors.initials: C
authors.lastname: Jolly
authors.affiliation: Paris Ile de France Ouest School of Medicine, Versailles Saint-Quentin en Yvelines University, Guyancourt, France.
authors.forename: François
authors.initials: F
authors.lastname: Jathières
authors.affiliation: Department of Anesthesiology and Intensive Care, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, Colombe, France; University Paris Diderot, Sorbonne Paris Cité, EA Recherche clinique coordonnée ville-hôpital, Méthodologies et Société (REMES), 75010 Paris, France.
authors.forename: Hawa
authors.initials: H
authors.lastname: Keïta
authors.affiliation: Department of Anesthesiology and Intensive Care, Centre Hospitalier Intercommunal Poissy Saint Germain en Laye, France.
authors.forename: Envel
authors.initials: E
authors.lastname: Jaouen
authors.affiliation: Department of Obstetrics & Gynecology, Centre Hospitalier Intercommunal Poissy Saint Germain en Laye, France.
authors.forename: Bernard
authors.initials: B
authors.lastname: Guyot
authors.affiliation: Department of Obstetrics & Gynecology, Centre Hospitalier Intercommunal Poissy Saint Germain en Laye, France; Paris Ile de France Ouest School of Medicine, Versailles Saint-Quentin en Yvelines University, Guyancourt, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Torre
mesh_terms: D000082:Acetaminophen / Q000627:therapeutic use; D000328:Adult; D000698:Analgesia / Q000379:methods*; D016058:Analgesia, Patient-Controlled; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001942:Breast Feeding; D002045:Bupivacaine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D000068579:Celecoxib / Q000627:therapeutic use; D002585:Cesarean Section / Q000009:adverse effects / Q000451:nursing; D052246:Cyclooxygenase 2 Inhibitors / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D000077554:Levobupivacaine; D009020:Morphine / Q000008:administration & dosage*; D009340:Nefopam / Q000627:therapeutic use; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy* / Q000209:etiology; D017060:Patient Satisfaction; D055815:Young Adult
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D000082:Acetaminophen; D009340:Nefopam; D009020:Morphine; D000077554:Levobupivacaine; D000068579:Celecoxib; D002045:Bupivacaine
keywords: Anesthesia, Local; Cesarean section; Levobupivacaine; Pain postoperative