Liposomal Bupivacaine Versus Bupivacaine for
Intercostal Nerve Blocks in Thoracic Surgery:
A Retrospective Analysis
Authors: Patel Kinjal M. 
Published: February 2021

Background: Liposomal bupivacaine (LipoB), delivered via intercostal nerve blocks (ICNBs), is
increasingly being used for postoperative pain control in thoracic surgery patients, but there is limited
data on its effectiveness when compared to standard bupivacaine.
Objective: We sought to compare postoperative opioid use, pain control, and length of stay (LOS)
in patients undergoing thoracic surgery with LipoB ICNBs vs patients undergoing thoracic surgery
with ICNBs using standard bupivacaine.
Study Design: A retrospective analysis.
Setting: Research took place in a tertiary academic medical center.
Methods: A transition in the standard of care from standard bupivacaine to LipoB for ICNBs in
March of 2014 allowed us to compare 2 cohorts: patients who received bupivacaine ICNBs from
January 2013 through February of 2014 and patients who received LipoB ICNBs from March 2015
through November 2017. We included patients who underwent thoracic surgery for lung cancer
using robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS), or traditional
open thoracotomy, and documentation of ICNB in the operative note. We collected data on pain
scores (Visual Analog Scale [VAS]) and opioid consumption (converted to oral morphine equivalents
[OMEs]) intraoperatively, on postoperative day (POD) 0, POD 1, POD 2, and POD 3. We also analyzed
data on length of stay [LOS]. A primary analysis was performed on the effects of LipoB vs bupivacaine
across all surgery types on opioid consumption, pain scores, and LOS with a secondary analysis on
the same endpoints per individual surgery type.
Results: A total of 129 patients were included from the predefined study periods (n = 62 LipoB and
n = 67 standard bupivacaine). Across all surgery types, LipoB decreased opioid utilization vs standard
bupivacaine (P < .01). Post-hoc testing revealed that this difference existed intraoperatively (55 ± 5 vs
69 ± 4 mg OME, P = .03) and on POD 0 (44 ± 6 vs 68 ± 6 mg OME, P < .01). Surgical subtype analysis
revealed that this difference was mostly driven by lower opioid consumption in patients undergoing
RATS. When compared across all surgery types, LipoB vs bupivacaine did not affect postoperative
pain scores. However, subgroup analysis showed that pain scores were lower in the LipoB vs standard
bupivacaine group undergoing VATS on POD 0, 1, and 2. The LOS across all thoracic surgery types
was lower in the LipoB group when compared to the standard bupivacaine group (median, 4 days
[IQR 2.0-6.0] vs median, 5 days [IQR 3.0-8.0], P < .01). Subgroup analysis showed that the LOS in
patients undergoing VATS with LipoB ICNBs was shorter compared to patients receiving bupivacaine
ICNBs.
Limitations: The retrospective nature of this study makes it prone to several types of bias.
Conclusion: ICNBs with LipoB for thoracic surgery leads to lower opioid consumption and shorter
LOS when compared to ICNBs with standard bupivacaine. The benefit of LipoB over standard
bupivacaine for ICNBs appears especially relevant in VATS or RATS procedures.
Key words: Intercostal nerve block, liposomal bupivacaine, RATS, regional anesthesia, roboticassisted thoracoscopic surgery, thoracotomy, VATS, video-assisted thoracoscopic surgery