Legeby, M., Jurell, G., Beausang-Linder, M., & Olofsson, C. (2009). Placebo-controlled trial of local anaesthesia for treatment of pain after breast reconstruction. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery/Nordisk Plastikkirurgisk Forening [and] Nordisk Klubb for Handkirurgi, 43(6), 315–319.

To compare, in patients undergoing breast reconstruction, the efficacy of levobupivacaine in conjunction with oral paracetamol and IV morphine to the efficacy of placebo in conjunction with oral paracetamol and IV morphine

Levobupivacaine 2.5 mg/ml or normal saline (NS) was administered through an indwelling catheter every 3 hours for 45 hours with

• Four doses of paracetamol, 1 gm each, starting one hour before surgery
• IV PCA morphine, 2 mg/dose every 6 minutes

• The sample was composed of 34 patients.
• The age range of patients was 34–71 years.
• All patients were female.
• All patients were undergoing delayed breast reconstruction after previous mastectomy for breast cancer. All mastectomies were unilateral, with or without reduction on the other side or augmentation mammaplasty.

• Single setting
• Inpatient
• University hospital, Stockholm, Sweden

Prospective placebo-controlled, double-blind study

• 100 mm visual analog scale (VAS)
• Use of morphine (opioid consumption)
• Measure of nausea
• Measure of infection
• Length of hospital stay
• Time to request for rescue analgesic

When patients were at rest, levobupivacaine significantly reduced pain (p < 0.05) 15 hours postoperatively. With movement, levobupivacaine significantly reduced pain for 6 hours (p = 0.01) and significantly reduced pain for 18–24 hours (p = 0.045). Total dose of morphine used did not differ between groups. Two patients in the levobupivacaine group became infected. Authors noted no significant intergroup differences related to nausea or length of hospital stay.

Compared with patients who received placebo, those who were intermittently injected with levobupivacaine had better pain relief at rest for the first 15 hours after surgery. Those who received intermittently injected levobupivacaine also had better pain relief during mobilization, for the first 6 hours and for 18–24 hours.

• The study had a small sample size, with fewer than 100 participants.
• Variations in pain site and surgical technique could have contributed to the intensity of postoperative pain.

Boluses of local anesthetic, delivered via patient-controlled anesthesia, tend to have good results because patients prefer to control their own treatment.