Enhanced Recovery via Peripheral Nerve Block for Open Hepatectomy

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Decreased Length of Stay and Opioid Usage After Liver Cancer Surgery With Enhanced Recovery Pathway Implementation

BACKGROUND AND OBJECTIVES

Enhanced recovery after surgery (ERAS) pathways are associated with better postoperative recovery; however, evidence is lacking in liver cancer surgery. This study aimed to evaluate the impact of an ERAS pathway in US veterans undergoing liver cancer surgery.

METHODS

We initiated an ERAS pathway for liver cancer surgery with preoperative, intraoperative, and postoperative interventions, which included a novel regional anesthesia technique, erector spinae plane block, for multimodal analgesia management. A retrospective quality improvement study was conducted with patients undergoing elective open hepatectomy or microwave ablation of liver tumors before and after ERAS pathway implementation.

RESULTS

With 24 patients in the post-ERAS group and 23 patients in the pre-ERAS group, we found a significant decreased length of stay in the ERAS group (4.1 days ± 3.9) compared with traditional care (8.6 days ± 7.1, P = .01) and decreased perioperative opioid consumption including intraoperative opioids (post-ERAS 49.8 mg ± 28.5 vs pre-ERAS 98 mg ± 42.3, P = 4.1E-5), postoperative opioids (post-ERAS 65.3 mg ± 59.9 vs pre-ERAS 175.7 mg ± 210.6, P = .018), and patient-controlled analgesia requirements (post-ERAS 0% vs pre-ERAS 50%, P < .001).

CONCLUSION

The implementation of ERAS for liver cancer surgery in our veteran population translates into decreased length of stay and perioperative opioid consumption. Although this study is limited as a quality improvement project implemented at one institution with a small sample size, our results are clinically and statistically significant and sufficient to warrant further investigation into the efficacy of ERAS as the surgical needs of the US veteran population increase.

Ultrasound-Guided Quadratus Lumborum Block at the Lateral Supra-Arcuate Ligament versus Subcostal Transversus Abdominis Plane Block for Postoperative Analgesia Following Open Hepatectomy: A Randomized Controlled Trial

Purpose

Many studies confirmed that several approaches of quadratus lumborum block (QLB) were superior to transversus abdominis plane block (TAPB) in reducing opioid consumption during postoperative period. As a new QLB approach at the lateral supra-arcuate ligament (QLB-LSAL), the analgesic efficacy and safety in patients undergoing open hepatectomy are still unknown. This study aims to compare postoperative analgesia between the blocks in open hepatectomy.

Patients and Methods

Sixty-two patients undergoing open hepatectomy were enrolled and randomly allocated into the QLB-LSAL group (group Q) and the subcostal TAPB group (group T). Preoperatively, patients received ultrasound-guided bilateral QLB-LSAL or subcostal TAPB with injection of 0.5% ropivacaine (a total volume of 40 mL). The primary outcome was cumulative total morphine equivalent consumption in the first postoperative 24 h. Other outcomes included numerical rating scale (NRS) scores at rest and coughing, cumulative total morphine equivalent consumption at 2, 6, 12, 48 h, Quality of Recovery-15 (QoR-15) scores, time to first patient-controlled intravenous analgesia (PCIA) request, time to first ambulation and adverse effects.

Results

The cumulative total morphine equivalent consumption in group Q was decreased significantly at all postoperative time points (P < 0.01). The postoperative NRS scores at rest and coughing in group Q were lower than those in group T at all postoperative time points except 48 h (P < 0.05). A significant increase was also observed in the QoR-15 scores among patients in group Q. Time to first PCIA request was significantly prolonged in group Q than in group T, and time to first ambulation was shortened. Adverse effects showed no statistical significance between the two groups.

Conclusion

Compared with subcostal TAPB, preoperative bilateral QLB-LSAL provided superior analgesic properties and promoted early postoperative recovery quality in patients undergoing open hepatectomy.

Trial Registration

China Clinical Trials Registration Center (http://www.chictr.org.cn) ChiCTR2200063291, 3/9/2022.

THERE ARE NO ADVANTAGES BETWEEN LAPAROSCOPIC AND OPEN LIVER RESECTIONS WITHIN AN ENHANCED RECOVERY PROGRAM (ERAS)

BACKGROUND

The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results.

AIM

To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them.

METHODS

In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed.

RESULTS

Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery.

CONCLUSION

The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

Effect of Subcostal Anterior Quadratus Lumborum Block vs. Oblique Subcostal Transversus Abdominis Plane Block after Laparoscopic Radical Gastrectomy

OBJECTIVE

To evaluate the analgesic effect of ultrasound-guided subcostal anterior quadratus lumborum block (QLB) for laparoscopic radical gastrectomy surgery.

METHODS

Patients (aged 20-65 years, ASA I - II, and weighing 40-75 kg) scheduled for elective laparoscopic radical gastrectomy were enrolled in the current study. Sixty patients were randomly assigned to two groups by computer-generated randomization codes: an ultrasound-guided oblique subcostal transversus abdominis plane block (TAPB) group (group T, n=30) or an ultrasound-guided subcostal anterior QLB group (group Q, n=30). In both groups, bilateral ultrasound-guided oblique subcostal TAPB and subcostal anterior QLB were performed before general anesthesia with 0.25% ropivacaine 0.5 mL/kg. For postoperative management, all patients received patient-controlled intravenous analgesia (PCIA) with nalbuphine and sufentanil after surgery, maintaining visual analogue scale (VAS) scores ≤4 within 48 h. The intraoperative consumption of remifentanil, the requirement for sufentanil as a rescue analgesic, and the VAS scores at rest and coughing were recorded at 1, 6, 12, 24 and 48 h after surgery. The recovery (extubation time after surgery, first ambulation time, first flatus time and length of postoperative hospital stay) and the adverse events (nausea and vomiting, skin pruritus, respiratory depression and nerve-block related complications) were observed and recorded. The primary outcome was the perioperative consumption of opioids.

RESULTS

Compared with group T, the intraoperative consumption of remifentanil, requirement for sufentanil and the frequency of PCIA were reduced in group Q. Meanwhile, VAS scores at all points of observation were significantly lower in group Q than in group T. Patients in group Q were also associated with shorter time to first out-of-bed activity and flatus, and shorter length of postoperative hospital stay than group T (P<0.05). There were no skin pruritus, respiratory depression or nerve-block related complications in both groups.

CONCLUSION

Compared with ultrasound-guided oblique subcostal TAPB, ultrasound-guided subcostal anterior QLB provided greater opioid-sparing effect, lower visual analogue scores, and shorter postoperative hospital stay for laparoscopic radical gastrectomy.

Ultrasound-guided transmuscular quadratus lumborum block reduced postoperative opioids consumptions in patients after laparoscopic hepatectomy: a three-arm randomized controlled trial

Background

To investigate whether transmuscular quadratus lumborum block (TQLB) combined with oxycodone-based patient-controlled intravenous analgesia (PCIA) compared with sufentanil-based patient-controlled intravenous analgesia could reduce postoperative pain and opioid consumption in patients undergoing laparoscopic hepatectomy.

Methods

Eighty patients undergoing laparoscopic hepatectomy surgery were randomly divided into Group S (Sufentanil for PCIA group), Group O (Oxycodone for PCIA group) and Group QO (transmuscular quadratus lumborum block + oxycodone for PCIA group). Primary outcome was Numerical Rating Scale (NRS) pain score when coughing at 6th hour after the operation. We summarized opioid consumption and recorded complications, opioid drug adverse reaction and analgesia satisfaction.

Results

NRS pain scores were significantly lower in Group QO while patients coughing at 6th hour after the operation compared with Group S and Group O (median (interquartile range [IQR]):Group S vs. Group O vs. Group QO 4.0 [3.0, 5.0] vs. 4.0[3.0,5.0]vs.3.0 [2.0, 3.0], p < 0.05). Within 24 h after surgery, the bolus times of PCIA (patient controlled intravenous analgesia) in the QO group was reduced which was compared with the Group S and Group O (median (interquartile range [IQR]):Group S vs. Group O vs. Group QO 13.0 [10.3, 19.5] vs. 11.5 [7.8, 18.3]vs.6.5[3.5,12.0], p < 0.05). The proportion of patients in the three groups who required additional analgesia was ranked as Group QO < Group O < Group S(p < 0.05). The analgesic satisfaction of patients in Group QO was higher than the Group S (p = 0.001) and Group O (p = 0.012).

Conclusions

TQLB combined with oxycodone-based PCIA provided satisfactory postoperative analgesia and reduced oxycodone consumption in patients following laparoscopic hepatectomy.

Trial registration

ChiCTR1900028467 (22/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01255-3.

Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie's disease surgery: a pilot study

Background

Novel strategies have been proposed to minimize postoperative opioid use, yet many patients experience significant pain after penile surgery. Our objective was to evaluate postoperative opioid use in patients undergoing penile ring block with long-acting liposomal bupivacaine (LB; Exparel) during surgery for Peyronie's disease (PD).

Methods

We identified patients who underwent tunica albuginea plication (TAP) and plaque excision/grafting (PEG) for PD between July 2019 and September 2020. Intraoperatively, a ring block was administered at the penile base penis with 20 cc of LB. Patients were instructed to use over the counter pain medications as first line treatment for postoperative pain, and opioids were available for severe breakthrough pain as needed [7.5 oral morphine equivalents (OME) =5 mg oxycodone]. Opioid use was assessed during the first five days postoperatively.

Results

In total, 28 patients met inclusion criteria including 18/28 (64%) who underwent TAP and 10/28 (36%) who underwent PEG. Median patient age was 56 years (IGR 51;61). Median postoperative 10-point visual analogue pain score was 0 (range 0-3). Duration of penile anesthesia ranged from 1.5-4 days. In total, 9/28 patients (32%) utilized opioids during the first five days postoperatively (range 7.5-75 OME). Two patients (7%) required opioids during the first two days after surgery. 27/28 (96%) were satisfied or highly satisfied with postoperative pain control.

Conclusions

Intraoperative penile ring block with LB resulted in excellent pain control with local anesthetic duration of 1.5-4 days. The majority of patients did not require any opioids during the early postoperative period. Further study comparing outcomes with shorter-acting local anesthetics is necessary to balance pain control benefits with additional cost.

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery.

METHODS

A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance.

RESULTS

The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001).

CONCLUSION

Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.

Ultrasound guided continuous Quadratus Lumborum block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial

Background

Quadratus lumborum (QL) block is increasingly being used as a new abdominal nerve block technique. In some studies of mid and lower abdominal and hip analgesia, continuous QL block achieved favorable outcomes as an alternative to continuous intravenous analgesia with opioids. However, the use of continuous QL block for upper abdominal pain is less well characterized. This study aimed to investigate the effects of continuous anterior QL block (CQLB) on postoperative pain and recovery in patients undergoing open liver resection.

Methods

Sixty-three patients underwent elective open liver resection were randomly divided into continuous anterior QL block (CQLB, n = 32) group and patient-controlled intravenous analgesia (PCIA, n = 31) group. Patients in CQLB group underwent ultrasound-guided anterior QL block at the second lumbar vertebral transverse processes before general anesthesia, followed by postoperative CQLB analgesia. Patients in PCIA group underwent continuous intravenous analgesia postoperatively. Postoperative numerical rating scale (NRS) pain scores upon coughing and at rest, self-administered analgesic counts, rate of rescue analgesic use, time to first out-of-bed activity and anal flatus after surgery, and incidences of analgesic-related adverse effects were recorded.

Results

Postoperative NRS pain scores on coughing in CQLB group at different time points and NRS pain score at rest 48 h after surgery were significantly lower than those in PCIA group (P < 0.05). Time to first out-of-bed activity and anal flatus after surgery in CQLB group were significantly earlier than those in PCIA group (P < 0.05). No significant differences of postoperative self-administered analgesic counts, rate of postoperative rescue analgesic usage, or incidences of analgesic-related adverse effects were found between the two groups (P > 0.05).

Conclusions

Ultrasound-guided anterior QL block significantly alleviated the pain during coughing after surgery, shortened the time to first out-of-bed activity and anal flatus, promoting postoperative recovery of the patients undergoing open liver resection.

Trial registration

This study has been registered in April 1, 2018 on Chinese Clinical Trail Registry, the registration number is ChiCTR1800015454.

Transversus abdominis plane blocks with liposomal bupivacaine after open major hepatectomy is associated with reduced early patient-reported pain scores and opioid administration

BACKGROUND

Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia.

METHODS

We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals.

RESULTS

A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively.

CONCLUSION

In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.