Use of a mixture of lignocaine and bupivacaine vs lignocaine alone for male circumcision under local anaesthesia in Rakai, Uganda
Authors: Kigozi Godfrey , Musoke Richard , Anyokorit Margaret , Nkale James , Kighoma Nehemiah , Ssebanenya William , Mwinike Joshua , Watya Stephen , Nalugoda Fred , Kagaayi Joseph , Nalwoga Grace , Nakigozi Gertrude , Kiwanuka Noah , Makumbi Frederick , Lutalo Tom , Serwadda David , Wawer Maria , Gray Ronald 
Published: September 2011

Study Type – Therapy (case control)

Level of Evidence 3a

What's known on the subject? and What does the study add?

Local anaesthetic drugs block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. Lignocaine/Lidocaine has a rapid onset action and an intermediate duration of efficacy whereas Bupivacaine has a slower onset of action with a long duration of efficacy. A combination of the two drugs creates a mixture that has a short onset of action together with a long duration of action both of which are desirable qualities in provision of effective local anaesthesia.

Documenting whether use of lignocaine alone predisposes men to more pain during and after surgery will inform policy makers on the type of local anaesthesia to recommend for male circumcision, especially as circumcision programs roll out. This is important since pain has been associated with reduced acceptance of the male circumcision procedure and therefore can negatively influence male circumcision roll out programs.

OBJECTIVE

To assess self‐reported pain control during and after surgery with a mixture of lignocaine and bupivacaine compared with lignocaine alone among male circumcision (MC) service recipients in Rakai, Uganda.

PATIENTS AND METHODS

The two formulations of local anaesthesia for MC were used alternatively at weekly intervals in 360 patients; 179 received lignocaine alone and 181 received the lignocaine and bupivacaine mixture (LBmix).

The proportions of men reporting pain during or after surgery, and the need for additional anaesthesia during surgery were determined for the LBmix vs lignocaine using Poisson adjusted rate ratios (RRs).

Characteristics including age, weight, surgeon (medical officer vs clinical officer), surgical method and duration of surgery were compared between the arms using two‐sample t‐tests and chi‐square tests.

RESULTS

Patient and provider characteristics were comparable between the two anaesthetic groups.

A higher proportion of patients reported pain during surgery in the lignocaine group (adjusted RR 11.6, 95% confidence interval [CI] 3.5–37.9, P < 0.001), required additional anaesthesia (adjusted RR 4.8, 95% CI 1.4–17.1, P= 0.015), and were more likely to report pain during the immediate postoperative period (adjusted RR 3.4, 95% CI 2.3–5.0, P < 0.001).

These differences were particularly marked among patients with MC times longer than the median (adjusted RR 13.4, 95% CI 3.1–57.0, P < 0.001).

CONCLUSION

The LBmix significantly reduced pain associated with MC and the need for additional anaesthesia during MC.