Preemptive Analgesia With Bupivacaine for Segmental Mastectomy Manuel C. Vallejo, M.D., Amy L. Phelps, Ph.D., Neera Sah, M.D., Ryan C. Romeo, M.D., Jeffrey S. Falk, M.D., Ronald R. Johnson, M.D., Donald M. Keenan, M.D., Margueritte A. Bonaventura, M.D., and Howard D. Edington, M.D. Background and Objectives: Preemptive analgesia is the concept of providing analgesia before surgical incision, resulting in less postoperative pain. The purpose of this study is to determine if preemptive and/or postoperative local anesthetic infiltration of bupivacaine in patients undergoing segmental mastectomy results in less postoperative pain compared with patients receiving placebo. Methods: In this prospective, double-blinded study, 120 patients were randomized into 4 groups: group 1, preincisional (10 mL) and postoperative (10 mL) wound infiltration of 0.5% bupivicaine, (+Pre+Post); group 2, preincisional bupivacaine (10 mL) and postoperative infiltration (10 mL) of placebo (normal saline solution), (+Pre-Post); group 3, preincisional placebo (10 mL) and postoperative bupivacaine (10 mL), (-Pre+Post); or group 4, preincisional (10 mL) and postoperative infiltration of placebo (10 mL), (-Pre-Post). All patients received a standardized laryngeal mask general anesthetic. Data were recorded at the following time intervals: preoperative admission, postanesthesia care unit (PACU) admission, PACU stay, stepdown-unit admission, stepdown-unit stay, hospital discharge, and 24 hours post operation. Results: No difference was noted with respect to preoperative pain visual analog scale (VAS, 0-100 mm), surgical duration, PACU stay time, stepdown-unit stay time, incidence of postoperative nausea, or treatment for nausea in all measured time periods. The placebo group (group 4) had significantly higher mean pain VAS scores during the early postoperative period (PACU admission and PACU stay) compared to the other groups (PACU admission: group 1 = 2  8, group 2 = 4  11, group 3 = 3  15, group 4 = 17  21, P  .01; PACU stay: group 1 = 6  13, group 2 = 6  10, group 3 = 10  21, group 4 = 20  18, P  .01). Likewise, the number of patients who reported pain (pain frequency) was significantly higher in group 4 (placebo) compared with all other groups at PACU admission, PACU stay, stepdown-unit admission, and stepdown-unit stay (P  .01). Conclusion: Preincisional and/or postoperative wound bupivacaine infiltration lacks preemptive analgesic effects for segmental mastectomy. Reg Anesth Pain Med 2006;31:227-232. Key Words: Preemptive analgesia, Pain VAS, Segmental mastectomy, Bupivacaine, Pain medication, PONV, Chronic pain. P reemptive analgesia is the concept of providing analgesia before surgical incision, potentially resulting in less postoperative pain. 1-3 Fassoulaki et al. 4 showed the application of eutectic mixture of local anesthetic cream to patients undergoing breast surgery reduced postoperative analgesic require- ments as well as the incidence and intensity of chronic pain (up to 3 months after surgery). How- ever, in that same study, acute pain (up to 24 hours), pain at 6 days after surgery, and analgesic consumption did not differ significantly. 4 O’Hanlon et al. 5 compared preincisional local anesthetic infil- tration to postoperative wound infiltration in pa- tients undergoing ambulatory breast surgery and found no advantage to preincisional local anesthetic administration over postoperative local anesthetic administration. Presently, the use of preemptive analgesia involv- ing segmental mastectomy in our institution is vari- able; some surgeons do not use preemptive analge- sia, others inject local anesthesia during wound/ incision closure, and others believe in the concept From the Departments of Anesthesiology (M.V., A.P., N.S., R.R.) and Surgery (J.F., R.J., D.K., M.B., H.E.), University of Pittsburgh, Pittsburgh, PA. Supported in part by Baxter Healthcare Corporation. Accepted for publication January 10, 2006. Presented at the 2005 ASA Poster Presentation, Atlanta, Geor- gia, October 24, 2005. Reprint requests: Manuel C. Vallejo, M.D., University of Pitts- burgh, Magee-Womens Hospital, Department of Anesthesiology, Pittsburgh, PA 15213. E-mail: vallejomc@anes.upmc.edu © 2006 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/06/3103-0009$32.00/0 doi:10.1016/j.rapm.2006.02.007 Regional Anesthesia and Pain Medicine, Vol 31, No 3 (May–June), 2006: pp 227–232 227