ORIGINAL ARTICLE

Comparison of Bupivacaine Moistened Dressing and Conventional

Dressing for Pain Relief on Skin Graft Donor Sites
Muhammad Sheraz Raza, Tauqeer Nazim and Farid Ahmad Khan

ABSTRACT
Objective: To compare the effectiveness of bupivacaine moistened dressing and conventional dressing in patients
requiring split thickness skin graft for reconstruction of various defects.
Study Design: Randomized controlled trial.
Place and Duration of Study: Department of Plastic Surgery and Burns Unit, Mayo Hospital, King Edward Medical
University, Lahore, from January 2011 to January 2013.
Methodology: One hundred and fifty patients requiring split thickness skin grafting for various soft tissue defects were
divided into two groups A and B, with 75 patients in each group. In Group A, skin graft donor site dressing was kept moist
with 12 mL/100 cm2 of 0.25% bupivacaine solution and in Group B, dressing was moistened with same amount of normal
saline. Outcome was measured by calculating rescue analgesia requirements in the two groups after 24 hours.
Significance was determined by comparing analgesia sparing effect of each dressing using chi-square test.
Results: In Group A, 5 out of 75 (6.7%) patients required rescue analgesia. In Group B, 72 out of 75 (96%) patients
required rescue analgesia (p < 0.0001). There was 93.3% effectiveness of bupivacaine soaked dressing while only 4%
effectiveness of conventional dressing.
Conclusion: Bupivacaine soaked dressing is much more effective in pain relief and in reducing the requirement of rescue
analgesia, in early postoperative period, at split thickness skin graft donor site compared to the conventional dressing.

Key Words: Bupivacaine. Split thickness skin graft. Donor site. Postoperative pain. Rescue analgesia.

INTRODUCTION morbidity that may include pain, infection and delayed

Skin grafting is the most commonly done surgical healing. Pain at the split thickness skin graft donor site
procedure for soft tissue defects. Its wide range of can be a real problem for most patients especially in first
applications make it valuable not only to plastic and five postoperative days.9-11 Donor-site pain is probably
reconstructive surgeons but also to other surgical the most disturbing complication in the early post-
specialties.1,2 Split thickness skin grafts are used in most operative period.12 If split thickness skin graft donor
burns, reconstructive procedures and extensive wound site is more painful postoperatively than the recipient
management.2 They are used to resurface large site then good graft take is likely (Moriarity Sign).13
wounds, line cavities, re-surface mucosal deficits, close Alleviation of this pain can achieve considerable
donor sites of flaps, re-surface muscle flaps and to cover reduction in postoperative morbidity and fast recovery
tissue loss across joints in areas where contraction will of the donor site.14,15 These methods include ice
cause deformity.3 They are also used to achieve application at the donor site, Fascia Iliaca compartment
temporary closure of wounds created by the removal of block, and a number of dressings.16,17
lesions that require pathologic examination prior to Bupivacaine is an anesthetic agent that blocks the nerve
definitive reconstruction.4,5 The grafting can reduce the impulses that transmit pain sensation to brain. It is most
course of treatment needed (and time in the hospital) as commonly used for spinal blocks but can also be used
well as improve the function and appearance of the area for local infiltration anesthesia and peripheral nerve
of the body which receives the skin graft.6,7 While any blocks.18 So bupivacaine soaked dressing is an applic-
part of the body can be used as a donor site of split-
able option for split thickness skin graft donor site for
thickness skin grafts, the posterolateral thigh is most
early postoperative analgesia.
commonly used.8
The aim of this study was to compare the effectiveness
The aim of donor site management is to maintain an
of bupivacaine-moistened dressing and conventional
environment that promotes optimal healing and prevents
dressing in patients requiring split thickness skin graft for
Department of Plastic Surgery and Burn Unit, Mayo Hospital, reconstruction of various defects.
KEMU, Lahore.
Correspondence: Dr. Muhammad Sheraz Raza, 36-Mamdot METHODOLOGY
Block, Mustafa Town, Lahore. This study was conducted at Department of Plastic
E-mail: doc.sheraz007@gmail.com Surgery and Burn Unit, Mayo Hospital, King Edward
Received: February 12, 2013; Accepted: February 14, 2014. Medical University, Lahore, from January 2011 to

416 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 416-419
Comparison of bupivacaine moistened dressing and conventional dressing for pain relief on skin graft donor sites

January 2013. This study was carried out on cases RESULTS

requiring skin grafting that were randomly divided into In total, 154 patients were chosen randomly who were to
two groups with 75 cases in each group. Random undergo split thickness skin grafting for various soft
number table was used for this purpose. The two groups tissue defects. In 2 patients, the instillation for soakage
were named as Group A and Group B. Inclusion criteria of dressing was missed at the 12-hour mark. In one
was adult patients of both genders aged 16 - 60 years patient, peroperatively, it was decided to harvest graft
who required split thickness skin grafting for from abdomen as well since thighs were not sufficient as
reconstruction of various defects in whom only thigh was donor site. In another patient, there was early staining
used as split thickness skin graft donor site. Exclusion and soakage of outer dressing so the dressing had to be
criteria were unwillingness to participate in trial and changed at 6 hours so continuously soaked dressing
patients with previous history of allergy to local could not be achieved. All those patients were excluded
anesthetics. from the study. The final data was obtained from and
Each patient was informed in detail about the study, the analyzed for 150 patients.
procedure and both dressings and written consent was
The two groups were similar demographically with
taken from each patient. In both groups, split thickness
respect to age and gender. In Group A, the mean age of
skin grafts were harvested with pressure driven
patients was 32.79 ± 13.34 years while in Group B, the
dermatome. Once the desired amount of the graft was
mean age of patients was 31.83 ± 13.05 years. In Group
harvested the donor site wound was first covered with
A, there were 40 males and 35 females while in Group
bactigras, which was covered by a thin layer of sterilized
B, there were 44 males and 31 females.
gauze, a catheter was longitudinally placed on this layer
of gauze on the wound which was in turn covered with There was a remarkable difference in the requirement of
abundant amount of sterilized gauzes and finally crepe rescue analgesia between two groups. In Group A, only
bandage was applied to prevent external contamination. 5 out of 75 patients required rescue analgesia which
In Group A, the donor site dressing was kept soaked by makes around 6.7%. In Group B, 72 out of 75 (96%)
instilling an aqueous solution of bupivacaine hydro- patients required rescue analgesia (p < 0.001). Since
chloride in a concentration of 0.25% through the catheter reduction in the need for rescue analgesia was
placed in dressing gauzes. The amount instilled equivalent to effectiveness, 70 out of 75 patients in
depended on the size of the graft taken. For every Group A, did not require rescue analgesia which gave
100 cm2 of the donor site wound, 12 mL of the around 93.3% effectiveness of bupivacaine soaked
bupivacaine solution was instilled once immediately dressing in reduction of postoperative pain at split
after the surgery and then repeated after 12 hours of the thickness skin graft donor site and thus analgesia
first instillation. In Group B, the donor site dressing was sparing. In Group B, only 3 out of 75 patients did not
kept soaked by instilling normal saline through the require rescue analgesia which gives only around 4%
catheter placed in dressing gauzes. Just like Group A, in effectiveness of conventional dressing in reduction of
Group B for every 100 cm2 of the donor site wound 12 postoperative pain at split thickness skin graft donor site
mL of the normal saline was instilled once immediately and thus analgesia sparing. So bupivacaine soaked
after the surgery and then repeated after 12 hours of the dressing was found far more effective in postoperative
first instillation. pain reduction at split thickness skin graft donor site than
For the assessment of pain, patients were interviewed conventional dressing with a p < 0.001.
for pain using Visual Analogue Scale every 6 hours.
Patients who were complaining of pain or in whom pain
score was more than 4 (i.e. need for analgesia), were
given intravenous (IV) analgesia in the form of 10 mg
Pethidine injection. Final conclusion of analgesia
sparing effect of dressings was made at 24 hours post-
operatively. All the information was collected through a
proforma.
Statistical Package for Social Sciences (SPSS) version Figure 1: Split thickness skin graft
donor site.
Figure 2: Dressing with perfusion
catheter.
11.0 was used for analysis purpose. Variables of interest
such as rescue analgesic requirement in the two groups
was compared using chi-square test taking p-value DISCUSSION
< 0.05 as significant. Qualitative variables like age are There can be a number of complications of the donor
presented by calculating mean and standard deviations. site of split thickness skin graft. These complications
Quantitative variables like gender and rescue analgesic may be peroperative, early postoperative and late
requirement are presented by calculating frequency and postoperative. Peroperative complications include
percentages. bleeding. Early postoperative complications include pain

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 416-419 417
Muhammad Sheraz Raza, Tauqeer Nazim and Farid Ahmad Khan

and infection. Late postoperative complications include advantage over dry dressing both in terms of healing
repeated wound breakdown, delayed healing, blistering, and pain management. This has also been proven in a
poor quality skin, abnormal pigmentation and hyper- recent study by Wiechula who studied these dressings in
trophic scarring. detail.19 In accordance with this, in this study moist
Pain at the split thickness skin graft donor site can be a dressing was used in both groups so as to rule out that
real problem for most patients especially in first five post- pain relieving effect was due to moist nature of the
operative days. Donor-site pain is probably the most dressing and not due to the local anesthetic effect.
disturbing complication in the early postoperative period. Other local anesthetic agents both short acting as well
This study compared the use of bupivacaine soaked as long acting have also been tried topically to reduce
dressing with conventional dressing for pain relief in split pain at split thickness skin graft donor sites by plastic
thickness skin graft donor site. The basis of this study surgeons mostly with good results. Cenetoglu et al. used
was that with use of a local anesthetic agent locally at topical lignocaine gel at split thickness skin graft donor
the split thickness skin graft donor site there should be site and found very encouraging results as far as the
considerable pain relief in early postoperative period due pain relief was concerned. The effect was of shorter
to blockage of nerve endings, which transmit pain duration since lignocaine is a short acting anesthetic
signals to the nervous system. This study demonstrated agent though its onset of action is early.20 This explains
that when the split thickness skin graft donor site the purpose of choosing bupivacaine over lignocaine in
dressing was kept moist through the instillation of 0.25% this study because bupivacaine has a longer duration of
aqueous solution of bupivacaine hydrochloride with the action. To overcome the late onset of action of
help of a catheter placed in it, it produced considerably bupivacaine the first instillation for soaking the dressing
more pain relief. This considerably reduced the need for was done while patient was still under the effect of
rescue analgesia compared to conventional dressing. general anesthesia so local anesthetic took effect till the
patient was awake postoperatively.
Controversy exists at present as to the efficacy of
bupivacaine wound perfusion in the relief of post- Bupivacaine has also been used topically for purpose of
operative pain. There is available evidence though that analgesia postoperatively in past in a number of
this local instillation of bupivacaine on wounds can be conditions and in a number of locations. Recently,
applied to achieve pain relief in early postoperative pain. Scimeca et al. published a case report of a 55-year-old
gentleman with a complex past medical history, 2-year
In a recent study, performed in Thailand by Jenwitheesuk history of opioid dependency and a 2-week history of
et al.,11 0.5% bupivacaine hydrochloride solution was intractable pain associated with the combination of
used to keep the dressing at split thickness skin graft debilitating painful diabetic neuropathy and painful lower
donor site moist for first five postoperative days in one extremity wounds.21 After surgical debridement of the
group (G1) and similar amount of normal saline was lower extremity wounds, substantial analgesia was
used to keep donor site dressing moist in second group achieved postoperatively through the implantation of a
(G2). In this study, bupivacaine soaked dressing was portable direct infusion pump device. The device
found to be significantly more effective in pain relief at supplied 2 ml/hour of 0.25% bupivacaine and resulted in
donor site in early postoperative period with p < 0.001 in a reduction in pain within the first hour of implantation. In
first four postoperative days and p < 0.05 on the fifth day. another study, Kadar and Obaid studied, the topical
In another study performed in Nigeria,13 Oluwatosin and effects of bupivacaine post-tonsillectomy in tonsillar
colleagues also used 0.5% aqueous solution of fossa in 70 cases.22 The mean postoperative pain
bupivacaine hydrochloride to treat the split thickness scores for the subject fossae after 4 hours, before bed,
skin graft donor site. In this study, it was found that the before breakfast, before lunch and before discharge
patients in whom donor site was treated with were less than control fossae scores, showing better
bupivacaine solution had significantly less pain pain relief with bupivacaine.
compared to those in whom donor site was not treated
Zohar et al. from Tel Aviv University studied the role of
with any solution, with p < 0.00001 on the first and
bupivacaine for pain relief in 36 patients after total
second postoperative days, p < 0.0005 on the third and
abdominal hysterectomy and bilateral salpingo-
fourth day and p < 0.0013 on the fifth day. This study is
oophorectomy.23 They divided patients in two groups. In
comparable to those studies except that 0.25% solution
one group (G1), they instilled 0.25% bupivacaine
of bupivacaine was used rather than 0.5%. The reason
solution and in second group (G2), they instilled sterile
for using 0.25% bupivacaine was that larger amounts of
water. When compared G1 required significantly less
this solution could be used with little fear of toxicity even
rescue analgesia (p < 0.001) than G2. In another study,
if absorption occurs. So this method can be safely used
Andrei et al. from Paris studied the role of local
for larger donor site areas. Results of this study are still
anesthetics in preventing postoperative pain after
in agreement with these studies.
laparoscopic gynecologic surgery. In each patient, the
It has been almost universally accepted that moist operating surgeon instilled 20 ml of either 0.5%
dressing at split thickness skin graft donor site has an bupivacaine solution, 0.75% ropivacaine solution or

418 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 416-419
Comparison of bupivacaine moistened dressing and conventional dressing for pain relief on skin graft donor sites

normal saline depending upon the group. It was found 9. Kilinc H, Sensoz O, Ozdemir R, Unlu RE, Baran C. Which
that analgesia (morphine) requirement was considerably dressing for split thickness skin graft donor site? Ann Plast
Surg 2001; 46:409-14.
less in bupivacaine group than normal saline group
(p < 0.05). 10. Grossman T, Jack A. A simplified technique for split-thickness
skin graft donor-site care. Plast Reconst Surg 2004; 113:
Grief et al. concluded in their study on 37 patients that 796-7.
20 mL of pleural bupivacaine 0.25% every 6 hours
11. Jenwitheesuk K, Chuangsuwanich A, Areewatana S. Bupiva-
provided a substantial opioid-sparing effect during caine moistened dressing for pain relief on skin graft donor
recovery from nephrectomy and extended the time until sites. Thai J Surg 2002; 23:83-6.
opioids were needed for pain relief.24 In older literature
12. Akan M, Lu AM, Yildirim S, Cakir B, Taylan G, Akoz T. Ice
as well there is documented role of perfusion of wounds application to minimize pain in the split-thickness skin graft
with local anesthetics in postoperative pain relief. In donor site. Aesthetic Plast Surg 2003; 27:305-7.
1989, Chester et al.25 published their study. Thirty 13. Oluwatosin OM, Abikoye FO, Ademola SA, Sansui AA,
consecutive patients undergoing elective cholecystec- Soyannwo OA. Does topical application of bupivacaine
tomy were studied. Patients undergoing wound (marcaine) to skin graft donor site have any effect on moriarty
perfusion with normal saline consistently suffered more sign? Nig J Surg Res 2000; 2:131-4.
severe pain than those perfused with bupivacaine. All 14. Uygur F, Evınc R, Ulkur E, Celıkoz B. Use of lyophilized bovine
these studies have proven that bupivacaine solutions collagen for split-thickness skin graft donor site management.
are effective when used topically as instillation or as Burns 2008; 34:1011-4.
soakage of dressing on wounds, as in this study, to 15. Voineskos, Sophocles H, Ayeni, Olubimpe A, McKnight, Leslie,
provide analgesia. This also disproves the older concept et al. Systematic review of skin graft donor-site dressings.
that bupivacaine has no topical analgesic effect. Plast Reconst Surg 2009; 124:298-306.

A number of methods and different types of dressings 16. Olivier C, Jean P, Jenna B, Diane D. The efficacy of continuous
fascia iliaca compartment block for pain management in burn
have been employed in the past to address this post-
patients undergoing skin grafting procedures. Anesth Analg
operative split thickness skin graft donor site pain 2004; 98:1077-81.
especially in early postoperative period. These methods
17. Weber RS, Hankins P, Limitone E, Callender D, Frankenthaler
include ice application at the donor site,12 fascia iliaca
RM, Goepfert H. Split-thickness skin graft donor site manage-
compartment block for early postoperative pain relief,16 ment. Arch Otolarygol Head Neck Surg 1995; 121: 1145-9.
and a number of dressings have been used for this pain
18. Lee A. Local anaesthetic technique. In: Aitkenhead AR,
relief at donor site. Rowbotham DG, Smith G, editors. Textbook of anaesthesia.

CONCLUSION
4th ed. London: Churchill Livingstone; 2001.p.560.
19. Wiechula R. The use of moist wound-healing dressings in the
Bupivacaine-soaked dressing was much more effective management of split-thickness skin graft donor sites: a
in pain relief and in reducing the requirement of rescue systematic review. Int J Nurs Pract 2003; 9:9-17.
analgesia in the early postoperative period, at split 20. Cenetoglu S, Ozmen S, Tuncer S, Latifoglu O, Yavuzer R.
thickness skin graft donor site, compared to the Topical lignocaine gel for split-thickness skin graft donor-site
conventional dressing. pain management. Plast Reconstr Surg 2000; 105:2633.

REFERENCES 21. Scimeca CL, Fisher TK, Bharara M, Armstrong DG. Chronic,
painful lower extremity wounds: postoperative pain manage-
1. Grande DJ. Skin grafting [Internet]. eMedicine specialities, ment through the use of continuous infusion of regional
Plastic Surgery 2008. Available from: http://emedicine. anaesthesia supplied by a portable pump device. Int Wound J
medscape.com/article/1129479-overview 2010; 7:195-8.
2. Kamran K, Moazzam NT, Farrukh M, Falak S, Muhammad YM, 22. Kadar AA and Obaid MA. Effect on postoperative pain after
Ata UH. Scalp as donor site for split thickness skin graft. local application of bupivacaine in the Tonsillar Fossa; a
J Ayub Med Coll Abbottabad 2008; 20:66-9. prospective single blind controlled trial. J Pak Med Assoc 2003;
3. Donato MC, Novicki DC, Blume PA. Skin grafting: historic and 53:422-6.
practical approaches. Clin Podiatr Med Surg 2000; 17:561-98. 23. Zohar E, Fredman B, Phillipov A, Jedeikin R, Shapiro A. The
4. Ratner D. Skin grafting: from here to there. Dermatol Clin analgesic efficacy of patient-controlled bupivacaine wound
1998; 16:75-90. instillation after total abdominal hysterectomy with bilateral
salpingo-oophorectomy. Anesth Analg 2001; 93:482-7.
5. Mahmood K, Gill M, Baber AM. Role of split thickness skin
grafting in various surgical conditions. Pak J Surg 2003; 19:30-3. 24. Greif R, Wasinger T, Reiter K, Chwala M, Neumark J. Pleural
bupivacaine for pain treatment after nephrectomy. Anesth
6. Choi M, Panthaki ZJ. Tangential excision of burn wounds. Analg 1999; 89:440.
J Craniofac Surg 2008; 19:1056-60.
25. Chester JF, Ravindranath K, White B, Shanahan D, Taylor R
7. Dabernig J, Watson S. Flap skin as a donor site for split skin and Williams K. Wound perfusion with bupivacaine: objective
grafts. Ann Plast Surg 2005; 55:439-40.
evidence for efficacy in postoperative pain relief. Ann Royal
8. Kelton P Jr. Skin grafts: select readings. Plast Surg 1992; 7:1-25. Coll Surg Eng 1989; 71:394-396.

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 416-419 419