Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: A prospective randomized controlled study

Advances in the use of local anesthetic extended-release systems in pain management

Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.

Liposomal bupivacaine in transversus abdominis plane blocks for lower abdominal surgery

BACKGROUND

Transversus abdominis plane blocks are an established method of postoperative analgesia for abdominopelvic surgeries. Liposomal bupivacaine is an extended-release formulation of bupivacaine providing up to 72 h of analgesia. This study aims to determine if transversus abdominis plane blocks performed with liposomal bupivacaine are associated with reduced opioid consumption and level of pain intensity compared to conventional bupivacaine in patients undergoing lower abdominal surgery.

METHODS

This retrospective cohort study was conducted at a single institution between December 2020 and December 2021. After institutional review board approval, we identified patients who underwent lower abdominopelvic surgery with transversus abdominis plane blocks done with liposomal or conventional bupivacaine and collected demographic, clinical, and procedural information for analysis. We compared total opioid consumption over 72-h postoperatively in milligram morphine equivalents (MME), frequency of opioid utilization, and average level of pain intensity between groups. These outcomes were also evaluated after adjusting for covariates. Data were presented as mean ± SD, median [IQR] or frequency (%), as appropriate; p < 0.05 was accepted as significant.

RESULTS

A total of 178 patients met inclusion criteria, with 79 patients receiving an admixture of liposomal bupivacaine and conventional bupivacaine and 99 patients receiving conventional bupivacaine. The liposomal bupivacaine group had a median opioid consumption 72-h postoperatively of 47.5 [18-91.8] MME compared to 88 [43.8-160] MME in the conventional bupivacaine group, p = 0.045. Differences in opioid consumption between the groups did not reach statistical significance after adjustment for demographic and clinical characteristics, p = 0.11. There was no significant difference in frequency of opioid use or average pain intensity.

CONCLUSION

Transversus abdominis plane blocks using an admixture of liposomal bupivacaine conventional bupivacaine are not associated with decreased opioid consumption or reduced pain up to 72 h following elective abdominopelvic surgery.

Comparative Study of Levobupivacaine Versus Levobupivacaine With Dexmedetomidine as an Adjuvant in Transversus Abdominis Block for Postoperative Pain Relief in Abdominal Hysterectomy Patients: A Randomized, Double-Blind Study

Background Adjuvants have been discovered to prolong the analgesic impact of local anesthetics (LA), while the transversus abdominis plane (TAP) block offers sufficient postoperative pain relief after various abdominal procedures. Nevertheless, the impact of the given LA will determine the duration of the TAP block. Thus, in this investigation, we aimed to estimate the analgesic impact of combining dexmedetomidine (DEX) with levobupivacaine in the TAP block for patients having an infraumbilical incision for an abdominal hysterectomy while under spinal anesthetic. Aim This study aimed to determine the analgesic effect of DEX (0.5 mcg/kg) to 20 ml of 0.25% levobupivacaine on each side in the TAP block in patients undergoing total abdominal hysterectomy (TAH). Materials and methods Two groups of 30 patients each, with ASA grades 1 and 2, were randomly selected from patients. Group N, comprising 30 patients, had a bilateral TAP block using 2 mL of normal saline and 20 mL of 0.25% levobupivacaine. Group D (n = 30 patients) was given DEX at a dose of 0.5 mcg/kg (2 mL) in addition to 20 mL of 0.25% levobupivacaine given bilaterally. The TAP block was administered just after skin closure. Time of the initial analgesic dose administration; total fentanyl doses utilized as rescue analgesia; pain scores (numerical rating scale (NRS)) at 2, 4, 6, 8, 12, and 24 hours; and pre- and postoperative cortisol levels were also noted. For each group, 1 gram IV paracetamol was administered every eight hours. Drugs used for rescue analgesia (RA) were diclofenac 75 mg IV stat and fentanyl 1 mcg/kg. Results and discussion In addition to Group N having lower NRS scores at rest, Group D had a considerably longer time for initial rescue analgesia than Group N. There was also a significant decrease in the total fentanyl consumption and postoperative serum cortisol levels in Group D in contrast to Group N. Conclusion Potential adjuvant DEX prolongs postoperative analgesia in patients experiencing abdominal hysterectomy when used alongside LA in TAP.

Analgesic Effectiveness of Liposomal Bupivacaine versus Plain Local Anesthetics for Abdominal Fascial Plane Blocks: A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

Liposomal bupivacaine is reported to prolong the duration of analgesia when used for abdominal fascial plane blocks compared to plain local anesthetics; however, evidence from randomized trials is mixed. This meta-analysis aims to compare the analgesic effectiveness of liposomal bupivacaine to plain local anesthetics in adults receiving abdominal fascial plane blocks.

METHODS

Randomized trials comparing liposomal bupivacaine and plain (nonliposomal) local anesthetics in abdominal fascial plane blocks were sought. The primary outcome was area under the curve rest pain between 24 to 72 h postoperatively. Secondary outcomes included rest pain at individual timepoints (1, 6, 12, 24, 48, and 72 h); analgesic consumption at 0 to 24, 25 to 48, and 49 to 72 h; time to analgesic request; hospital stay duration; and opioid-related side effects. Data were pooled using the Hartung-Knapp-Sidik-Jonkman random effects method.

RESULTS

Sixteen trials encompassing 1,287 patients (liposomal bupivacaine, 667; plain local anesthetics, 620) were included. The liposomal bupivacaine group received liposomal bupivacaine mixed with plain bupivacaine in 10 studies, liposomal bupivacaine alone in 5 studies, and both preparations in 1 three-armed study. No difference was observed between the two groups for area under the curve pain scores, with a standardized mean difference (95% CI) of -0.21 cm.h (-0.43 to 0.01; P = 0.058; I2 = 48%). Results were robust to subgroup analysis based on (1) potential conflict of interest and (2) mixing of plain local anesthetics with liposomal bupivacaine. The two groups were not different for any of the day 2 or day 3 secondary outcomes.

CONCLUSIONS

This systematic review and meta-analysis suggests similar analgesic effectiveness between liposomal bupivacaine and plain local anesthetics when used for fascial plane block of the abdominal wall. The authors' analysis does not support an evidence-based preference for liposomal bupivacaine compared to plain local anesthetics for abdominal fascial plane blocks.

EDITOR’S PERSPECTIVE

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.

Learning curve of ultrasound-guided surgeon-administered transversus abdominis plane (UGSA-TAP) block on a porcine model

Background

Surgeons commonly perform ultrasound-guided Transversus Abdominis Plane blocks to manage acute pain following abdominal surgeries. There is no consensus on whether surgeons should undergo basic hands-on training to perform TAP blocks or if video-based learning is sufficient. We theorized that simulation-based learning is superior to video-based learning. In the present study, we present the analysis of technical skills of UGSA-TAP block performance on a live porcine model by general surgery trainees after undergoing video or simulation-based learning.

Methods

We performed a prospective, double-blinded, randomized study. Ten surgery residents and two surgery critical-care fellows (n = 12) without prior experience in performing the TAP block were recruited. The participants were randomized either into a video-based or simulation-based training group. After that, all participants performed a TAP block on a live anesthetized pig, which was recorded and scored by three blinded anesthesiologists. All participants completed a post-performance survey to assess their confidence in gaining competency in the UGSA-TAP block. Statistical analyses were performed to assess the differences between the two groups. P < 0.05 was considered statistically significant.

Results

All simulation-based learning participants successfully performed a survey scan, identified the three muscular layers of the abdominal wall, and identified the transversus abdominis plane compared to 50 %, 50 %, and 33 % video-based learning group participants for the respective parameters (p < 0.05). While some performance metrics showed no statistically significant differences between the groups, substantial effect sizes (Cohen's ℎ up to 1.07) highlighted notable differences in participants' performance. Both groups exhibited confidence in core competencies, with varied rates of satisfactory skill execution. Performance assessed using a global rating scale revealed a higher passing rate for the simulation group (83 % vs. 33 %). Participant feedback via the Likert scale reflected confidence post-training. Inter-rater reliability (0.83-1) confirmed the robustness of study evaluations.

Conclusion

The UGSA-TAP block curriculum should be introduced into the surgical residency programs with an emphasis on simulation-based learning to enhance the procedural skills of the trainees before transitioning to surgical patients.

Spinal Anesthesia Prior to Laparoscopic Hysterectomy Resulted in Decreased Postoperative Pain and Opioid Use

Study Objective

To determine if a pre-operative morphine/bupivacaine spinal injection prior to laparoscopic hysterectomy reduced postoperative pain and resulted in less opioid consumption during the hospital stay.

Methods

A retrospective cohort study (Canadian Task Force Classification II-2) was conducted at a single institution regional referral center (community hospital) in North Carolina. Three hundred nineteen patients met criteria for inclusion: 192 received spinal anesthesia and 127 did not. Baseline demographics were similar between the two groups. Median pain scores were significantly lower in the treatment than the control group on day of surgery (DOS) (2 vs. 6; P < 0.001) and postoperative day 1 (POD1) (2 vs. 4; P < 0.001).

Results

Primary outcomes were pain scores on DOS and POD1 and inpatient opioid use. Pain scores were obtained using the 0 to 10 Numerical Rating Scale. Opioids were converted to oral morphine milliequivalents (OME). Median opioid use was also significantly lower in the treatment than the control group on DOS (0 vs. 15.00 OME; P < 0.001) and POD1 (0 vs. 7.5 OME; P < 0.001). Median length of stay between the groups was not significantly different.

Conclusion

Pre-operative morphine spinal injection for laparoscopic hysterectomy led to significantly lower pain scores and inpatient opioid consumption. Pre-operative spinal anesthesia for benign laparoscopic hysterectomy appears helpful for enhancing the postoperative experience.

The postoperative analgesic efficacy of liposomal bupivacaine versus long-acting local anaesthetics for peripheral nerve and field blocks: A systematic review and meta-analysis, with trial sequential analysis

BACKGROUND

Liposomal bupivacaine is claimed by the manufacturer to provide analgesia for up to 72 h postoperatively.

OBJECTIVES

To compare the postoperative analgesic efficacy of liposomal bupivacaine versus long-acting local anaesthetics for peripheral nerve or field blocks.

DESIGN

A systematic review and meta-analysis with trial sequential analysis.

DATA SOURCES

MEDLINE, Embase and Web of Science, among others, up to June 2022.

ELIGIBILITY CRITERIA

We retrieved randomised controlled trials comparing liposomal bupivacaine versus bupivacaine, levobupivacaine or ropivacaine for peripheral nerve and field blocks after all types of surgery. Our primary endpoint was rest pain score (analogue scale 0 to 10) at 24 h. Secondary endpoints included rest pain score at 48 and 72 h, and morphine consumption at 24, 48 and 72 h.

RESULTS

Twenty-seven trials including 2122 patients were identified. Rest pain scores at 24 h were significantly reduced by liposomal bupivacaine with a mean difference (95% CI) of -0.9 (-1.4 to -0.4), I2  = 87%, P  < 0.001. This reduction in pain scores persisted at 48 h and 72 h with mean differences (95% CI) of -0.7 (-1.1 to -0.3), I2  = 82%, P  = 0.001 and -0.7 (-1.1 to -0.3), I2  = 80%, P  < 0.001, respectively. There were no differences in interval morphine consumption at 24 h ( P  = 0.15), 48 h ( P  = 0.15) and 72 h ( P  = 0.07). The quality of evidence was moderate.

CONCLUSIONS

There is moderate level evidence that liposomal bupivacaine reduces rest pain scores by 0.9 out of 10 units, when compared with long-acting local anaesthetics at 24 hours after surgery, and by 0.7 up to 72 hours after surgery.

Bilateral transversus abdominis plane and rectus sheath blocks with liposomal bupivacaine for patients undergoing robotic prostatectomy

As robotic prostatectomy surgery becomes more prevalent, it is important to identify any regional techniques to optimize patient's recovery. We evaluated the effectiveness of bilateral transversus abdominis plane (TAP) and rectus sheath (RS) blocks with liposomal bupivacaine. We hypothesized that these blocks would reduce perioperative opioid use and pain scores. A retrospective cohort of patients from May 2018 and May 2021 at a single large VA hospital were studied. We compared those not receiving a nerve block against those receiving the TAP and RS as part of an Enhanced Recovery After Surgery (ERAS) pathway starting in May 2019. The primary outcome was post-operative opioid use. Secondary outcomes were post-operative pain scores and hospital length of stay. One hundred and thirty-four patients were included in the final analysis. Eighty-one patients did not receive a block and fifty-three patients did receive a block. No difference existed between the groups in regard to median oral morphine equivalents (mg) used in PACU or any post-operative day. No difference existed in median opioid usage (mg) or pain scores between the two groups on any post-operative day. There was no difference in temporal association of median pain scores or narcotic usage between the two groups. Bilateral TAP and RS with liposomal bupivacaine did not significantly decrease post-operative opioid use, improve pain scores, or decrease hospital length of stay for patients undergoing robotic prostatectomy. Further studies need to be done to evaluate the effect of these blocks with liposomal bupivacaine.

Liposomal Bupivacaine Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Resections: A Single-Institution Randomized Controlled Trial

BACKGROUND

Transversus abdominis plane blocks improve postoperative pain after colon and rectal resections, but the benefits of liposomal bupivacaine use for these blocks have not been clearly demonstrated.

OBJECTIVE

This study aimed to determine whether using liposomal bupivacaine in transversus abdominis plane blocks improves postoperative pain and reduces opioid use after colorectal surgery compared to standard bupivacaine.

DESIGN

This study was a single-blinded, single-institution, prospective randomized controlled trial comparing liposomal bupivacaine to standard bupivacaine in transversus abdominis plane blocks in patients undergoing elective colon and rectal resections.

SETTINGS

This study was conducted at a single-institution academic medical center with 6 staff colorectal surgeons and 2 colorectal surgery fellows.

PATIENTS

Ninety-six patients aged 18 to 85 years were assessed for eligibility; 76 were included and randomly assigned to 2 groups of 38 patients.

INTERVENTIONS

Patients in the experimental group received liposomal bupivacaine transversus abdominis plane blocks, whereas the control group received standard bupivacaine blocks.

MAIN OUTCOME MEASURES

The primary outcome was maximum pain score on postoperative day 2. Secondary outcomes included daily maximum and average pain scores in the 3 days after surgery, as well as daily morphine milligram equivalent use and length of hospital stay.

RESULTS

Patients receiving liposomal bupivacaine blocks had lower maximum pain scores on the day of surgery (mean, 6.5 vs 7.7; p = 0.008). No other difference was found between groups with respect to maximum or average pain scores at any time point postoperatively, nor was there any difference in morphine milligram equivalents used or length of stay (median, 3.1 d).

LIMITATIONS

This was a single-institution study with only patients blinded to group assignment.

CONCLUSIONS

Liposomal bupivacaine use in transversus abdominis plane blocks for patients undergoing laparoscopic colorectal resections does not seem to improve postoperative pain, nor does it reduce narcotic use or decrease length of stay. Given its cost, use of liposomal bupivacaine in transversus abdominis plane blocks is not justified for colon and rectal resections. See Video Abstract at http://links.lww.com/DCR/B979 .

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov . Identifier: NCT04781075.

BLOQUEOS TAP DE BUPIVACANA LIPOSOMAL EN RESECCIONES COLORRECTALES LAPAROSCPICAS UN ENSAYO CONTROLADO ALEATORIO DE UNA SOLA INSTITUCIN

ANTECEDENTES:Los bloqueos del plano transverso del abdomen, mejoran el dolor posoperatorio después de las resecciones de colon y recto, pero los beneficios del uso de bupivacaína liposomal para estos bloqueos, no se han demostrado claramente.OBJETIVO:Investigar la eficacia de la inyección con tejido adiposo autólogo recién recolectado en fístulas anales criptoglandulares complejas.DISEÑO:Ensayo controlado, aleatorio, prospectivo, simple ciego, de una sola institución, que compara la bupivacaína liposomal con la bupivacaína estándar en bloqueos del plano transverso del abdomen, en pacientes sometidos a resecciones electivas de colon y recto. Identificador de ClinicalTrials.gov : NCT04781075.ENTORNO CLINICO:Centro médico académico de una sola institución con seis cirujanos de plantilla y becarios de cirugía colorrectal.PACIENTES:Se evaluó la elegibilidad de 96 pacientes de 18 a 85 años; 76 fueron incluidos y aleatorizados en dos grupos de 38 pacientes.INTERVENCIONES:Los pacientes del grupo experimental recibieron bloqueos del plano transverso del abdomen con bupivacaína liposomal, mientras que el grupo de control recibió bloqueos de bupivacaína estándar.PRINCIPALES MEDIDAS DE VALORACION:El resultado primario fue la puntuación máxima de dolor en el segundo día posoperatorio. Los resultados secundarios incluyeron las puntuaciones máximas y medias diarias de dolor en los 3 días posteriores a la cirugía, así como el uso diario equivalente en miligramos de morfina y la duración de la estancia hospitalaria.RESULTADOS:Los pacientes que recibieron bloqueos de bupivacaína liposomal, tuvieron puntuaciones máximas de dolor más bajas, el día de la cirugía (media 6,5 frente a 7,7, p = 0,008). No hubo ninguna otra diferencia entre los grupos con respecto a las puntuaciones de dolor máximas o promedio en cualquier momento después de la operación, ni hubo ninguna diferencia en los equivalentes de miligramos de morfina utilizados o la duración de la estancia (mediana de 3,1 días).LIMITACIONES:Estudio de una sola institución con cegamiento de un solo paciente.CONCLUSIONES:El uso de bupivacaína liposomal en bloqueos del plano transverso del abdomen, para pacientes sometidos a resecciones colorrectales laparoscópicas, no parece mejorar el dolor posoperatorio, ni reduce el uso de narcóticos ni la duración de la estancia hospitalaria. Dado su costo, el uso de bupivacaína liposomal en bloqueos TAP no está justificado para resecciones de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B797 . Traducción Dr. Fidel Ruiz Healy.

Repurposing of parenterally administered active substances used to treat pain both systemically and locally

Pain is a constant in our lives. The efficacy of drug therapy administered by the parenteral route is often limited either by the physicochemical characteristics of the drug itself or its adsorption-distribution-metabolism-excretion (ADME) mechanisms. One promising alternative is the design of innovative drug delivery systems that can improve the pharmacokinetics |(PK) and/or reduce the toxicity of traditionally used drugs. In this review, we discuss several products that have been approved by the main regulatory agencies (i.e., nano- and microsystems, implants, and oil-based solutions), highlighting the newest technologies that govern both locally and systemically the delivery of drugs. Finally, we also discuss the risk assessment of the scale-up process required, given the impact that this approach could have on drug manufacturing. Teaser: The management of pain by way of the parenteral route can be improved using complex drug delivery systems (e.g., micro- and nanosystems) which require high-level assessment and shorten the regulatory pathway.

Laparoscopic guided liposomal bupivacaine injection compared to transversus abdominus plane block for postoperative pain after robotic gynecologic oncology surgery

OBJECTIVE

The purpose of this study was to determine if laparoscopically guided transversus abdominis plane block (Lap-Tap) with liposomal bupivacaine provides superior postoperative pain control when compared to ultrasound-guided block (US-Tap) with liposomal bupivacaine at the time of robotic surgery for gynecology oncology patients.

METHODS

This was a prospective randomized controlled trial assigning patients to one of two cohorts: Cohort 1 consisted of US-Tap administered before the procedure using liposomal bupivacaine, Cohort 2 consisted of Lap-Tap administration with laparoscopic visualization using the medication above. Primary outcomes were pain scores and total opioid use in Oral Morphine Equivalents (OME) during the first 72 h after surgery. Secondary outcomes were postoperative pain satisfaction and oral narcotic requirements.

RESULTS

There was a significant increase in oral narcotic use in the first 24 h in the US-Tap cohort compared to the Lap-Tap cohort: Lap-Tap mean = 6.73 ± 8.22 OME versus US-Tap mean = 12.69 ± 12.94 p = 0.018 OME. The increase was equivalent to one additional Hydrocodone-Acetaminophen 7.5 mg/325 mg in the first 24 h after surgery. However, total oral narcotic use over the first 72 h was not significantly different between the two cohorts: Lap-Tap mean = 21.73 ± 19.83 OME, US-Tap mean = 32.50 ± 29.47, p = 0.062 OME. In addition, there was no significant difference in satisfaction or pain scores between the US-Tap and Lap-Tap groups at 24, 48, or 72-hours.

CONCLUSIONS

Lap-Taps are comparable to US-Tap for postoperative analgesia during the first 72-h after surgery when performing robotic-assisted gynecologic oncology surgery.

[Liposomal bupivacaine-No breakthrough in postoperative pain management]

One of the main limitations concerning the use of local anesthetics is due to their restricted duration of action. In recent years, liposomal formulations with prolonged release kinetics have been developed to extend the pharmacological duration of action of the 1‑stage peripheral regional anesthesia (single-shot procedure) and thus bring about a longer duration of action. The focus here is particularly on achieving postoperative freedom from pain for at least 24 h (or even better 48 h) and thus early mobilization of patients using on-demand medication causing (at most) minor local sensory blockade without causing motor impairments (at least that is the ideal). Therefore, methods of utilizing slow-release drugs as seen in liposomal carrier systems have experienced increasing scientific attention in the last few years. A common modern pharmacological example with a theoretically significantly longer duration of action is liposomal bupivacaine, an amide local anesthetic. Due to a multivesicular liposome structure, the retarded release of the active component bupivacaine HCl leads to a theoretical pharmacological effectiveness of up to 72 h. Previous studies consistently showed a safety profile comparable to conventional bupivacaine HCl. Liposomal bupivacaine has been approved by the U.S. Food and Drug Administration (FDA) under the trade name Exparel© (Pacira Pharmaceuticals, Parsippany, NJ, USA) since 2011; however, its use is currently limited to local wound infiltration, transverse abdominis plane (TAP) blocks, and interscalene nerve blocks of the brachial plexus. In 2020, the European Medicines Agency (EMA) also approved the use of liposomal bupivacaine for blockade of the brachial plexus or the femoral nerve and as a field block or for wound infiltration to treat postoperative pain. So far, studies on the clinical effectiveness of liposomal bupivacaine have been very heterogeneous and there have been no conclusive meta-analyses with sufficient rigor or significance. Recent systematic reviews and meta-analyses, combining the results of clinical studies regarding the analgesic efficiency of liposomal bupivacaine in different fields of application, consistently refuted any benefit of clinical relevance provided by the liposomal formulation. There is currently sufficient evidence to now end the ongoing debate around liposomal bupivacaine. The aim of this work is to give the reader a current, evidence-based overview of this substance.

Peripheral nerve blocks with liposomal bupivacaine are associated with increased opioid use compared to thoracic epidural in patients with an epigastric incision

BACKGROUND

Thoracic epidurals are commonly recommended in enhanced recovery protocols, though they may cause hypotension and urinary retention. Peripheral nerve blocks using liposomal bupivacaine are a potential alternative, though they have not been extensively studied in major cancer operations with an epigastric incision.

METHODS

We conducted a retrospective review of prospectively collected data following the transition from thoracic epidural to liposomal peripheral nerve blocks in patients undergoing major oncologic surgery. Patients receiving peripheral nerve blocks were compared to those receiving thoracic epidural. Outcome variables included postoperative opioid use (milligram morphine equivalents [MME]), severe pain, and postoperative complications.

RESULTS

Forty-seven of 102 patients studied (46%) received peripheral nerve blocks. Opioid use was higher in the peripheral nerve block group during the 0-24 h (116 vs. 94 MME, p = 0.04) and 24-48 h postoperative period (94 vs. 23 MME, p < 0.01). There was no significant difference in severe pain, hypotension, urinary retention, or ileus. Peripheral nerve blocks were associated with earlier ambulation (1 vs. 2 days, p = 0.04), though other milestones were similar.

CONCLUSIONS

Liposomal peripheral nerve blocks were associated with increased opioid use compared to thoracic epidural. On the basis of our results, thoracic epidural might be preferred in surgical oncology patients with an epigastric incision.

Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

 To summarize the available evidence of TAP Block in efficacy in laparoscopic or robotic hysterectomy.

DATA SOURCES

 We searched databases and gray literature for randomized controlled trials in which transversus abdominis plane (TAP) block was compared with placebo or with no treatment in patients who underwent laparoscopic or robot-assisted hysterectomy.

METHOD OF STUDY SELECTION

 Two researchers independently evaluated the eligibility of the selected articles.

TABULATION, INTEGRATION, AND RESULTS

 Seven studies were selected, involving 518 patients. Early postoperative pain showed a difference in the mean mean difference (MD): - 1.17 (95% confidence interval [CI]: - 1.87-0.46) in pain scale scores (I² = 68%), which was statistically significant in favor of using TAP block, but without clinical relevance; late postoperative pain: DM 0.001 (95%CI: - 0.43-0.44; I² = 69%); opioid requirement: DM 0.36 (95%CI: - 0.94-1.68; I² = 80%); and incidence of nausea and vomiting with a difference of 95%CI = - 0.11 (- 0.215-0.006) in favor of TAP.

CONCLUSION

 With moderate strength of evidence, due to the high heterogeneity and imbalance in baseline characteristics among studies, the results indicate that TAP block should not be considered as a clinically relevant analgesic technique to improve postoperative pain in laparoscopic or robotic hysterectomy, despite statistical significance in early postoperative pain scale scores.

CLINICAL TRIAL NUMBER AND REGISTRY

 PROSPERO ID - CRD42018103573.

Effects of modified multimodal analgesia on postoperative pain, sedation, and prognosis of gynecological patients

Patient-controlled intravenous analgesia is one of the most common pain relief methods in  the postoperative period, but its adverse reactions remain high. This study aimed to explore the role of improved combined analgesia methods in pain, sedation, postoperative nausea, and vomiting (PONV) in patients undergoing gynecological surgeries. This study was a prospective, randomized, double-blind controlled study. A study population of 72 patients undergoing gynecological surgery were randomly assigned to either the TAPB + S group or the TAPB + N group. All patients in both groups underwent a transversus abdominis plane block (TAPB) after induction of anesthesia. The TAPB + S group received a continuous intravenous infusion (2 ml/h) of sufentanil (1 μg/kg) plus metoclopramide (30 mg) through 100 ml elastomeric pumps postoperatively. The TAPB + N group received a continuous intravenous infusion (2 ml/h) of nalbuphine hydrochloride (1 mg/kg) plus metoclopramide (30 mg) postoperatively. The main outcome measures were as follows: postoperative pain intensity, Ramsay sedation score (RSS) after surgery, PONV occurrence rate, and rescue analgesics. The RSS of the TAPB + S group was significantly higher than that of the TAPB + N group at 2, 4, and 6 h after the operation. However, the visual analog scale score of the TAPB + S group was much higher than that of the TAPB + N group. No significant differences were found between the two groups in terms of consumption of opioids and other narcotic drugs at 2, 4, 6, 24, and 48 h after the operation. No statistically significant differences were found with respect to PONV and other adverse events in both groups. Taken together, our data indicate that the TAPB + N program can provide better postoperative analgesia and also reduce the use of strong opioids. The more optimized scheme of perioperative analgesia still needs to be researched further.

Rectus sheath block for acute pain management after robot-assisted laparoscopic prostatectomy

BACKGROUND

Robot-assisted laparoscopic prostatectomy (RALP) is a favored surgical approach for treating prostate cancer. However, RALP does not decrease postoperative pain significantly despite its minimal invasiveness. The pain associated with robot-assisted surgery is most severe during the immediate postoperative period. We aimed to demonstrate that preoperative rectus sheath block (RSB) can reduce acute pain after RALP.

METHODS

A prospective non-randomized study with two parallel groups was performed from June 2020 to August 2020. A total of 100 patients undergoing RALP were divided into two groups: the RSB group (n = 50) and the non-RSB group (n = 50). Ultrasound-guided RSB was performed preoperatively only in the RSB group. The primary outcome of the study was the visual analog scale (VAS) pain score during coughing (VAS-C) 1 h after surgery. In addition, the VAS pain score at rest (VAS-R) and the VAS-C were assessed up to 24 h after surgery. The doses of postoperative opioids consumed were also recorded.

RESULTS

The RSB group had a significantly lower VAS-C 1 h after RALP (58 [47-73] vs. 74 [63-83] mm, p = 0.001). In addition, the RSB group had significantly lower VAS-R and VAS-C scores, and postoperative opioid requirement, up to 6 h after surgery compared to the non-RSB group. Moreover, the VAS-R was significantly lower in the RSB group than in the non-RSB group 24 h after surgery.

CONCLUSION

Preoperative RSB significantly improved analgesia during the early period after RALP. The long-term analgesic efficacy of RSB needs further study.

Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial

BACKGROUND

Pelvic reconstructive surgery may cause significant postoperative pain, especially with posterior colporrhaphy, contributing to a longer hospital stay and increased pain medication utilization. Regional blocks are being increasingly utilized in gynecologic surgery to improve postoperative pain and decrease opioid usage, yet preoperative pudendal blocks have not been used routinely during posterior colporrhaphy.

OBJECTIVE

This study aimed to compare the effect of preoperative regional pudendal nerve block using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and 3. We hypothesized that there would be a reduction in vaginal pain scores for the study group vs the control group over the first 72 hours.

STUDY DESIGN

This was a double-blinded, randomized controlled trial that included patients undergoing a posterior colporrhaphy, either independently or in conjunction with other vaginal or abdominal reconstructive procedures. Patients were block randomized to receive 20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study) or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before the start of surgery. Double blinding was achieved by covering four 5-mL syringes containing the randomized local anesthetic. After induction of anesthesia, a pudendal nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary outcomes included total analgesic medication usage through postoperative day 3, postoperative voiding and defecatory dysfunction, and impact of vaginal pain on quality of life factors.

RESULTS

A total of 120 patients were enrolled (60 in each group). There were no significant differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined liposomal and bupivacaine group at all time points vs the plain bupivacaine group. Median pain scores for the study and control groups, respectively, were 0 (0-2) and 2 (0-4) for postoperative day 1 (P=.03), 2 (1-4) and 3 (2-5) for postoperative day 2 (P=.05), and 2 (1-4) and 3 (2-5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days 2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%, P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity).

CONCLUSION

Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine provided more effective vaginal pain control than plain bupivacaine alone for reconstructive surgery that included posterior colporrhaphy. Given the statistically significant decrease in vaginal pain in the study group, this block may be considered as a potential adjunct for multimodal pain reduction in this patient population.

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Comparison of Liposomal Bupivacaine and Conventional Local Anesthetic Agents in Regional Anesthesia: A Systematic Review

BACKGROUND

Pain is one of the most common adverse events after surgery. Regional anesthesia techniques are effective for pain control but have limited duration of action. Liposomal bupivacaine is a long-acting formulation of bupivacaine. We conduct this systematic review to assess whether liposomal bupivacaine may prolong the analgesic duration of regional anesthesia compared to conventional local anesthetic agents.

METHODS

We systematically searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, Web of Science citation index, US clinical trials register, and recent conference abstracts for relevant studies.

RESULTS

We identified 13 randomized controlled trials that compared the use of liposomal bupivacaine to conventional local anesthetics in regional anesthesia. There were 5 studies on transversus abdominis plane (TAP) block, 3 of which reported longer duration of analgesia with liposomal bupivacaine. One study reported comparable analgesia with liposomal bupivacaine TAP block compared to TAP block catheter. There were 3 studies on brachial plexus block, 2 of which reported that liposomal bupivacaine may provide longer analgesia. Studies on other techniques did not report significantly longer analgesia with liposomal bupivacaine.

CONCLUSIONS

Currently, there is limited evidence suggesting that liposomal bupivacaine provides longer analgesia than conventional local anesthetics when used in regional anesthesia. The analyses of multiple studies on liposomal bupivacaine for TAP blocks and brachial plexus blocks have yielded conflicting results. As a result, no definitive conclusions can be drawn about its efficacy compared to plain bupivacaine.

Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption

BACKGROUND

Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain.

OBJECTIVES

The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks.

METHODS

A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks.

RESULTS

There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily.

CONCLUSIONS

Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy.

LEVEL OF EVIDENCE: 4

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial

BACKGROUND

Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive.

OBJECTIVE

The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone.

DESIGN

This was a parallel-group, single-institution, randomized clinical trial.

SETTINGS

The study was conducted at a single tertiary medical center.

PATIENTS

Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included.

INTERVENTIONS

Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone.

MAIN OUTCOME MEASURES

The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications.

RESULTS

A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes.

LIMITATIONS

This study was not placebo controlled or blinded.

CONCLUSIONS

This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533.

ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE

ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.

A randomized-controlled trial comparing liposomal bupivacaine, plain bupivacaine, and the mixture of liposomal bupivacaine and plain bupivacaine in transversus abdominus plane block for postoperative analgesia for open abdominal hysterectomies

PURPOSE

Transversus abdominus plane (TAP) blocks are widely used for postoperative analgesia for abdominal surgical procedures. The purpose of this study was to compare the analgesic efficacy of plain bupivacaine, liposomal bupivacaine, and the mixture of plain bupivacaine with liposomal bupivacaine when used in a TAP block.

METHODS

This study was a single centre, prospective, patient-, observer-, and surgeon-blinded, randomized-controlled trial in which 90 patients undergoing an open abdominal hysterectomy with a midline incision were randomized to receive a TAP block with plain bupivacaine (group bupivacaine), liposomal bupivacaine (group liposomal), or a mixture of liposomal bupivacaine and plain bupivacaine (group mixture). Primary outcomes included time to the first rescue opioid analgesic and total opioid consumption during the first 72 postoperative hours. Secondary outcomes included pain scores, patient satisfaction, incidence of hemodynamic instability, presence of local anesthetic systemic toxicity, and length of hospital stay.

RESULTS

The median [interquartile range] time to first opioid was 51 [28-66] min in group bupivacaine, 63 [44-102] min in group liposomal, and 51 [24-84] min in group mixture (P = 0.20). The median [interquartile range] total opioid consumption in the first 72 postoperative hours was 208 [155-270] mg in group bupivacaine, 203 [153-283] mg in group liposomal, and 202 [116-325] mg in group mixture (P = 0.92). There were no significant differences in secondary outcomes between groups.

CONCLUSIONS

In this small study at risk of being under-powered, the mixture of liposomal bupivacaine with plain bupivacaine for TAP block did not improve analgesia compared with either liposomal bupivacaine or plain bupivacaine on their own.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03250507); registered 5 April 2017.

Role of paracervical block in reducing postoperative pain after laparoscopic hysterectomy: A systematic reivew and meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to perform a systematic review and meta-analysis in order to evaluate the effect of paracervical anesthetic block among women undergoing laparoscopic hysterectomy.

METHODS

A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during January 2021. We selected randomized clinical trials (RCTs) compared paracervical anesthetic block versus normal saline (control group) among women undergoing laparoscopic hysterectomy. We pooled the continuous data as mean difference (MD) and dichotomous data as risk ratio (RR) with the corresponding 95% confidence intervals using Revman software. Our primary outcome was pain scores evaluated by visual analog scale (VAS) at 30 min and 1 hour. Our secondary outcomes were postoperative additional opioids requirement and length of hospital stay.

RESULTS

Three RCTs met our inclusion criteria with a total number of 233 patients. We found that paracervical anesthetic block was linked to a significant reduction in VAS pain score at 30 min and 1 hour post-hysterectomy (MD= -2.13, 95% CI [-3.09, -1.16], p>0.001 & MD= -1.87, 95% CI [-3.22, -0.52], p = 0.006). There was a significant decrease in additional opioids requirement postoperatively among paracervical anesthetic block group in comparison with control group (p = 0.002). No significant difference was found between both groups regarding the length of hospital stay.

CONCLUSION

Paracervical anesthetic block is effective in reducing postoperative pain after laparoscopic hysterectomy with decrease in opioids administration postoperatively.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND/IMPORTANCE

Liposomal bupivacaine (LB) is a prolonged release formulation of conventional bupivacaine designed for prolonging local or peripheral regional single injection anesthesia. To this day, the benefit of the new substance on relevant end points is discussed controversial.

OBJECTIVE

The objective was to determine whether there is a difference in postoperative pain scores and morphine consumption between patients treated with LB and bupivacaine hydrochloride in a systematic review and meta-analysis.

EVIDENCE REVIEW

Randomized controlled trials (RCT) were identified in Embase, CENTRAL, MEDLINE and Web of Science up to May 2020. Risk of bias was assessed using Cochrane methodology. Primary end points were the mean pain score difference and the relative morphine equivalent (MEQ) consumption expressed as the ratio of means (ROM) 24 and 72 hours postoperatively.

FINDINGS

23 RCTs including 1867 patients were eligible for meta-analysis. The mean pain score difference at 24 hours postoperatively was significantly lower in the LB group, at -0.37 (95% CI -0.56 to -0.19). The relative MEQ consumption after 24 hours was also significantly lower in the LB group, at 0.85 (0.82 to 0.89). At 72 hours, the pain score difference was not significant at -0.25 (-0.71 to 0.20) and the MEQ ratio was 0.85 (0.77 to 0.95).

CONCLUSION

The beneficial effect on pain scores and opioid consumption was small but not clinically relevant, despite statistical significance. The effect was stable among all studies, indicating that it is independent of the application modality.

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

BACKGROUND

Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics.

METHODS

The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h.

RESULTS

Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported.

CONCLUSIONS

Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.

EDITOR’S PERSPECTIVE

Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.

The Impact of Thoracic Epidural Analgesia Versus Four Quadrant Transversus Abdominis Plane Block on Quality of Recovery After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Surgery: A Single-Center, Noninferiority, Randomized, Controlled Trial

BACKGROUND

Recovery after CRS-HIPEC influenced by several factors, including pain and opioid consumption. We hypothesized that 4Q-TAP blocks provide not inferior quality of recovery compared with TEA after CRS-HIPEC. We conducted a randomized, controlled trial to determine whether 4-quadrant transversus abdominis plane (4Q-TAP) block analgesia was noninferior to thoracic epidural (TEA) among patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC).

METHODS

Patients 18 years or older who underwent a CRS-HIPEC surgery were randomly assigned to have either TEA or 4Q-TAP blocks. The primary outcome of this study was the change in quality of recovery 2 days after surgery. Secondary outcomes included quality of recovery on Days 1, 3, 5, 7, 10, and 30 postoperatively, opioid consumption, pain intensity, length of stay, and postoperative complications. Analyses were performed on a per-protocol basis.

RESULTS

Sixty-eight patients were included in the analysis. The difference between 4Q-TAP and TEA in the mean QoR-15 change from surgery at postoperative Days 1, 2, and 3 was 0.80 (P = 0.004), -4.5 (P = 0.134), and 3.4 (P = 0.003), respectively. All differences through postoperative day 30 were significantly within the noninferiority boundary of -10 except at postoperative Day 2 (P = 0.134). Length of stay, opioid-related adverse events, and frequency and grade of complications were not significantly different between TEA and 4Q-TAP patients.

CONCLUSIONS

Despite the significantly higher use of opioids after CRS-HIPEC in patients with 4Q-TAP blocks, their short-term quality of recovery was not inferior to those treated with TEA. Patients undergoing CRS-HIPEC can be effectively managed with 4Q-TAP blocks.

Bupivacaine Pharmacokinetics and Breast Milk Excretion of Liposomal Bupivacaine Administered After Cesarean Birth

Very little plasma bupivacaine was transferred into breast milk after liposomal bupivacaine wound infiltration in patients who had undergone cesarean delivery.

To evaluate bupivacaine concentrations in maternal plasma and transfer into breast milk in women undergoing liposomal bupivacaine infiltration in the transversus abdominis plane after cesarean birth.

Transversus Abdominis Plane Block With Liposomal Bupivacaine vs. Regular Anesthetics for Pain Control After Surgery: A Systematic Review and Meta-Analysis

Background: Transverse abdominal plane (TAP) blocks are used to provide pain relief after abdominopelvic surgeries. The role of liposomal bupivacaine (LB) for TAP blocks is unclear. Therefore, this study aimed to synthesize evidence on the efficacy of LB vs. regular anesthetics in improving outcomes of TAP block. Methods: PubMed, Science Direct, Embase, Springer, and CENTRAL databases were searched up to July 24, 2020. Studies comparing LB with any regular anesthetic for TAP block for any surgical procedure and reporting total analgesic consumption (TAC) or pain scores were included. Results: Seven studies including five randomized controlled trials (RCTs) were reviewed. LB was compared with regular bupivacaine (RB) in all studies. A descriptive analysis was conducted for TAC due to heterogeneity in data presentation. There were variations in the outcomes of studies reporting TAC. Meta-analysis of pain scores indicated statistically significant reduction of pain with the use of LB at 12 h (MD: -0.89 95% CI: -1.44, -0.34 I2 = 0% p = 0.01), 24 h (MD: -0.64 95% CI: -1.21, -0.06 I2 = 0% p = 0.03), 48 h (MD: -0.40 95% CI: -0.77, 0.04 I2 = 0% p = 0.03) but not at 72 h (MD: -0.37 95% CI: -1.31, 0.56 I2 = 57% p = 0.43). Pooled analysis indicated no difference in the duration of hospital stay between LB and RB (MD: -0.18 95% CI: -0.49, 0.14 I2 = 61% p = 0.27). LB significantly reduced the number of days to first ambulation postsurgery (MD: -0.28 95% CI: -0.50, -0.06 I2 = 0% p = 0.01). Conclusions: Current evidence on the role of LB for providing prolonged analgesia with TAP blocks is unclear. Conflicting results have been reported for TAC. LB may result in a small reduction in pain scores up to 48 h but not at 72 h. Further, high-quality homogenous RCTs are needed to establish high-quality evidence.

Transversus abdominis plane block versus thoracic epidural analgesia in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

The efficacy of transversus abdominis plane (TAP) block compared with thoracic epidural analgesia (TEA) in abdominal surgery has been controversial. We conducted this systematic review and meta-analysis to assess outcomes of TAP block and TEA in a procedure-specific manner in colorectal surgery.

METHODS

A systematic literature search of the PubMed, Embase, Cochrane Library, and Scopus databases was conducted through July 10, 2020, to identify randomized controlled trials (RCTs) comparing TAP block with TEA in colorectal surgery. Primary outcomes were pain scores at rest and movement at 24 h postoperatively. Secondary outcomes included postoperative pain scores at 0-2 and 48 h, opioid consumption, postoperative nausea and vomiting (PONV), functional recovery, hospital stay, and adverse events.

RESULTS

Six RCTs with 568 patients were included. Methodological quality of these RCTs ranged from moderate to high. TAP block provided comparable pain control, lower 24 h and total opioid consumption, shorter time to ambulation and urinary catheter time, and lower incidence of sensory disturbance and postoperative hypotension compared with TEA. Meanwhile, the 48-h opioid consumption, PONV incidence, and hospital stay were similar between groups. When laparoscopic surgery was the only surgical approach employed, TAP block provided additional benefits of shorter time to first flatus and lower incidence of PONV compared with TEA.

CONCLUSIONS

Perhaps more germane to minimally invasive procedures, TAP block is equivalent to TEA in terms of postoperative pain control and provides better functional recovery with lower incidence of adverse events in patients undergoing colorectal surgery.

Effect of the Combination of Ketorolac and Bupivacaine on Transversus Abdominis Plane Block for Postoperative Analgesia After Gynecological Laparoscopic Surgery

Background

This study assessed the additional benefits of bupivacaine when combined with ketorolac for transversus abdominis plane (TAP) block after gynecological laparoscopic surgery.

Material/Methods

This randomized, observer-blind trial recruited 153 patients who underwent gynecological laparoscopic surgery. Patients were randomly assigned to receive bupivacaine combined with ketorolac 15 mg/side for TAP block (TK group), bupivacaine for TAP block and 30 mg postoperative intravenous ketorolac (T group), or 30 mg postoperative intravenous ketorolac alone (C group). The primary endpoints included consumption of sufentanil for 24 h postoperatively, actual press times of the patient-controlled analgesia (PCA) pump, and effective press times of the PCA pump, whereas the secondary endpoints included numerical rating scale (NRS) pain scores at rest and during activity, satisfaction with analgesia, episodes of nausea and vomiting and length of hospital stay.

Results

Sufentanil consumption, actual press times of the PCA pump, and effective press times of the PCA pump were lower in the TK and T groups than in the C group. NRS scores at rest and during activity at 1, 2, 4, 6, and 24 hours were significantly lower in the TK and T groups than in the C group. The TK and T groups showed greater satisfaction with analgesia than the C group, while the TK group showed greater overall satisfaction than the C group. Lengths of stay, rates of nausea and vomiting, and venting times did not differ significantly among the three groups.

Conclusions

Combined ketorolac and bupivacaine as TAP block improved the effectiveness of analgesia without increasing adverse events. Trial registration number: ChiCTR1900022577.

Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study

INTRODUCTION

Burn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.

METHODS

A retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.

RESULTS

Fifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p<0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p<0.0001).

CONCLUSION

Patients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.

Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review

We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m² (17.2-53.3 kg/m²). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.

Reducing the pain: A cost-effectiveness analysis of transversus abdominis plane block using liposomal bupivacaine for outpatient laparoscopic ventral hernia repair

Background

Transversus abdominis plane block with liposomal bupivacaine has been studied as an effective method of reducing the need for postoperative opioids and increasing same-day discharge rates. However, less is known about the cost-effectiveness of this strategy relative to opioids alone for hernia repair. We performed an economic evaluation of these strategies using a computer simulation model.

Methods

A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios per quality-adjusted life-year. Base-case costs, quality-adjusted life-year values, and probabilities were derived from published studies and Medicare fee schedules. For input parameters for which we could not find values in the published literature, we used expert opinion. A 1-month time horizon was selected to focus on the immediate postoperative period. Finally, we performed 1-way, 2-way, and probabilistic sensitivity analyses.

Results

The liposomal bupivacaine transversus abdominis plane block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in quality-adjusted life-years relative to opioids alone. In 1-way sensitivity analysis of cost incremental cost-effectiveness ratio, values were most sensitive to variations in the amount saved by same-day discharge and the cost of bupivacaine. In probabilistic sensitivity analyses, transversus abdominis plane strategy was cost-effective at a willingness-to-pay threshold of $50,000/quality-adjusted life-year in 94.5% of iterations and at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in 97.1% of iterations.

Conclusion

The use of liposomal bupivacaine transversus abdominis plane block resulted in cost savings and improved quality-adjusted life-years in base-case analyses and was cost-effective at conventional willingness-to-pay thresholds in the majority of iterations in probabilistic sensitivity analyses.

•

A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios (ICER) per quality-adjusted life-year (QALY).

•

The liposomal bupivacaine TAP block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in QALYs relative to opioids alone.

•

In 1-way sensitivity analysis of cost, ICER values were most sensitive to variations in the amount saved by SDD and the cost of bupivacaine.

•

In probabilistic sensitivity analyses, TAP strategy was cost-effective at a willingness-to-pay threshold of $50,000/QALY in 94.5% of iterations and pay threshold of $100,000/QALY in 97.1% of iterations.

Transversus Abdominis Plane Block

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.

Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.

Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.

Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery

Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.

Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study

Purpose

To determine if a transversus abdominis plane (TAP) block with liposomal bupivacaine reduces total postoperative opioid use in the first 72 hrs following laparoscopic or robotic hysterectomy compared to port-site infiltration with 0.25% bupivacaine.

Methods

Patients received either a true TAP block procedure with 266 mg liposomal bupivacaine and 50 mg of 0.25% bupivacaine and sham port infiltration or sham TAP block procedure with true port-site infiltration with 100–125 mg of 0.25% bupivacaine. All patients had a standardized, scheduled, non-opioid pain management plan. The primary outcome was total IV morphine equivalents used in the first 72 hrs following surgery. Secondary outcomes included assessment of postoperative pain over the study period and quality of recovery measures.

Results

Patients undergoing TAP blockade required fewer total opioid equivalents during the observation period than patients allocated to infiltration (median 21 versus 25 mg IV Morphine equivalents, P=0.03). Opioid use was highest in the first 24 hrs after surgery, with less difference between the groups during days 2 and 3 postoperatively. There were 5 in the TAP group and 0 in the infiltration group were opioid free at 72 hrs. Those in the TAP group had improved quality of recovery (QoR15) with no change in overall benefit of analgesia score.

Conclusion

TAP blockade reduced the requirement for opioid pain medication in the first 72 hrs after surgery, had more patients opioid free at 72 hrs, and improved patients’ quality of their recovery.

Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation

Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.

Joint consensus on anesthesia in urologic and gynecologic robotic surgery: specific issues in management from a task force of the SIAARTI, SIGO, and SIU

INTRODUCTION

Proper management of patients undergoing robotic-assisted urologic and gynecologic surgery must consider a series of peculiarities in the procedures for anesthesiology, critical care medicine, respiratory care, and pain management. Although the indications for robotic-assisted urogynecologic surgeries have increased in recent years, specific guidance documents are still lacking.

EVIDENCE ACQUISITION

A multidisciplinary group including anesthesiologists, gynecologists, urologists, and a clinical epidemiologist systematically reviewed the relevant literature and provided a set of recommendations and unmet needs on peculiar aspects of anesthesia in this field.

EVIDENCE SYNTHESIS

Nine core contents were identified, according to their requirements in urogynecologic robotic-assisted surgery: patient position, pneumoperitoneum and ventilation strategies, hemodynamic variations and fluid therapy, neuromuscular block, renal surgery and prevention of acute kidney injury, monitoring the Department of anesthesia, postoperative delirium and cognitive dysfunction, prevention of postoperative nausea and vomiting, and pain management in endometriosis.

CONCLUSIONS

This consensus document provides guidance for the management of urologic and gynecologic patients scheduled for robotic-assisted surgery. Moreover, the identified unmet needs highlight the requirement for further prospective randomized studies.