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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Lin Z, Chen Z, Li Y. Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial. World J Surg Oncol 2024; 22:54. [PMID: 38360661 PMCID: PMC10868092 DOI: 10.1186/s12957-023-03298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/29/2023] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence. METHODS This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications. RESULTS After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001). CONCLUSIONS After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model. TRIAL REGISTRATION ChiCTR2100051784.
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Affiliation(s)
- Zhimin Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China
| | - Zhongbiao Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
| | - Yongliang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China.
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Li C, Shi J, Jia H. Ultrasound-guided transversus abdominis plane block as an effective anesthetic technique for transverse colostomy in a high-risk elderly patient: A case report. Front Med (Lausanne) 2023; 10:1102540. [PMID: 36993801 PMCID: PMC10040580 DOI: 10.3389/fmed.2023.1102540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/14/2023] [Indexed: 03/14/2023] Open
Abstract
Ultrasound-guided transversus abdominis plane (TAP) block is considered to be one of most prevalent and effective adjuvant analgesic methods for various abdominal surgeries. However, whether TAP blocks can be used alone as an effective anesthetic technique in minor abdominal operations has rarely been reported. Here we presented a 66-year-old male who had sustained right somatic dysfunction and mild brain dysfunction caused by cerebral infarctions and poorly treated hypertension. The patient received a confine operation of transverse colostomy to alleviate an intestinal obstruction caused by rectal cancer. A 22G needle was advanced in the plane under ultrasound guidance until it reached the TAP. A total of 10 mL 0.375% ropivacaine with 5 mg dexamethasone and 10 μg dexmedetomidine was injected into the TAP. The operation went stably and smoothly without any complaints. After the operation, the patient returned to the care of the surgical recovery staff with patient-controlled intravenous analgesia (PCIA) containing 0.7 mg/kg oxycodone and 2.5 μg/kg dexmedetomidine. During the perioperative period, the elderly patient did not experience apparent or unbearable pain. All these evidences indicated the ultrasound-guided subcostal and lateral TAP block was a simple and effective procedure for transverse colostomy in a high-risk elderly patient.
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Analgesic efficacy of postoperative bilateral, ultrasound-guided, posterior transversus abdominis plane block for laparoscopic colorectal cancer surgery: a randomized, prospective, controlled study. BMC Anesthesiol 2021; 21:107. [PMID: 33823786 PMCID: PMC8022542 DOI: 10.1186/s12871-021-01317-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background We assessed whether a postoperative bilateral, ultrasound-guided, posterior transversus abdominis plane (TAP) block could reduce 24 h rescue tramadol requirement compared with placebo in patients undergoing elective laparoscopic colorectal cancer surgery. Methods Patients scheduled to undergo elective laparoscopic surgery following the diagnosis of colorectal cancer were included in this study and randomized into Group and Group Control. The patients received a postoperative bilateral, ultrasound-guided, posterior TAP block in either 20 mL of 0.5% ropivacaine (Group TAP) per side or an equivalent volume of normal saline (Group Control). The primary outcome was the cumulative consumption of rescue tramadol within 24 h after the surgery. Secondary endpoints included (1) resting and movement numerical rating scale (NRS) pain scores at 2, 4, 6, 12, 24, 48, and 72 h; (2) incidences of related side effects; (3) time to the first request for rescue tramadol; (4) patient satisfaction regarding postoperative analgesia; (5) time to restoration of intestinal function; (6) time to mobilization; and (7) the length of hospital stay. Results In total, 92 patients were randomized, and 82 patients completed the analysis. The total rescue tramadol requirement (median [interquartile range]) within the first 24 h was lower in Group TAP (0 [0, 87.5] mg) than in Group Control (100 [100, 200] mg), P < 0.001. The posterior TAP block reduced resting and movement NRS pain scores at 2, 4, 6, 12, and 24 h after surgery (all P < 0.001) but showed similar scores at 48 h or 72 h. A higher level of satisfaction with postoperative analgesia was observed in Group TAP on day 1 (P = 0.002), which was similar on days 2 (P = 0.702) and 3 (P = 0.551), compared with the Group Control. A few incidences of opioid-related side effects (P < 0.001) and a lower percentage of patients requiring rescue tramadol analgesia within 24 h (P < 0.001) were observed in Group TAP. The time to the first request for rescue analgesia was prolonged, and the time to mobilization and flatus was reduced with a shorter hospital stay in Group TAP as compared with Group Control. Conclusions A postoperative bilateral, ultrasound-guided, posterior TAP block resulted in better pain management and a faster recovery in patients undergoing laparoscopic colorectal cancer surgery, without adverse effects. Trial registration The study was registered at http://www.chictr.org.cn (ChiCTR-IPR-17012650; Sep 12, 2017).
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Analgesic Efficacy of Preemptive Transversus Abdominis Plane Block in Patients Undergoing Laparoscopic Colorectal Cancer Surgery. J Clin Med 2020; 9:jcm9051577. [PMID: 32455933 PMCID: PMC7291263 DOI: 10.3390/jcm9051577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022] Open
Abstract
Despite rapid advancements in laparoscopic surgical devices and techniques, pain remains a significant issue. We examined the efficacy of preemptive transversus abdominis plane (TAP) block for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed 153 patients who underwent laparoscopic colorectal cancer surgery with or without TAP block; among them, 142 were allocated to the TAP or non-TAP group. We performed between-group comparisons of demographic, clinical, and anesthetic data and pain scores at a postoperative anesthesia care unit (PACU) and at postoperative days 1, 3, and 5. There were no significant between-group differences in demographic and clinical characteristics. The mean arterial pressure, heart rate, and minimum alveolar concentration (MAC) were significantly lower in the TAP group at the start and end of surgery. The post-extubation bispectral index was significantly higher in the TAP group. There were no significant between-group differences in the pain scores and opioid consumption at the PACU or at postoperative days 1, 3, and 5, or in the time to pass flatus, the hospital stay length, and postoperative complications. Preemptive TAP block showed an intraoperative, but not postoperative, analgesic effect, characterized by a low mean arterial pressure, heart rate, and MAC.
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Abstract
Ventral hernia repair with abdominal wall reconstruction can be a challenging endeavor, as patients commonly present not only with complex and recurrent hernias but also often with comorbidities that increase the risk of postoperative complications including wound morbidity and hernia recurrence, among other risks. By optimizing patient comorbidities in the preoperative setting and managing postoperative care in a regimented fashion, enhanced recovery after surgery pathways allow for a systematic approach to reduce complications and speed up recovery following ventral hernia repair.
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Imani F, Rahimzadeh P, Faiz HR, Abdullahzadeh-Baghaei A. An Evaluation of the Adding Magnesium Sulfate to Ropivacaine on Ultrasound-Guided Transverse Abdominis Plane Block After Abdominal Hysterectomy. Anesth Pain Med 2018; 8:e74124. [PMID: 30250819 PMCID: PMC6139531 DOI: 10.5812/aapm.74124] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/10/2018] [Accepted: 06/13/2018] [Indexed: 11/16/2022] Open
Abstract
Background Post-hysterectomy pain is extremely annoying and using transverse abdominis plane (TAP) block can be a useful method to manage postoperative pain, but its duration of effect is challenging. Magnesium sulfate increases, in some cases, the effects of local anesthetics on the peripheral nerve blocks. Objectives The current study aimed at investigating the effects of adding magnesium sulfate to ropivacaine in the transverse abdominis plane block after hysterectomy. Methods The current randomized, double blind, clinical trial, to manage postoperative pain, was conducted on a total of 60 patients, 30 - 60 years old, ASA (American Society of Anesthesiologists) class I-II undergone elective abdominal hysterectomy candidates to receive ultrasound-guided bilateral transverse abdominis abdominis plane (TAP) blocks. Patients with coagulation disorders, infection, history of any addiction, sensitivity to the local anesthetics and magnesium sulfate were excluded. The subjects were equally allocated into two groups, the control group, ropivacaine plus normal saline (R), and the study group, ropivacaine plus magnesium sulfate (RM). The injection contained 19 mL ropivacaine 0.2% plus 1 mL normal saline in the group R, and 19 mL ropivacaine 0.2% plus 1 mL magnesium sulfate 50% in the RM group on each side. As well as the patients' characteristics, the level of pain score (visual analogue scale = VAS), rescue analgesic demand (diclofenac suppository), and possible adverse effects were evaluated at 1, 2, 6, 12, and 24 hours after the operation in the two groups. Results The mean pain scores of the patients at the first hour after surgery were 5.7 ± 0.9 and 5.9 ± 1.1 in R and RM groups, respectively. The scores reached 2.9 ± 0.5 and 2.7 ± 0.4 at the second hour after surgery (the first post-block measurement) and 3.1 ± 0.7 and 2.8 ± 0.7 within the next 24 hours, respectively. Although the pain scores were generally lower at all hours in the RM group, none was statistically significant. The rescue analgesic consumption gradually increased in the two groups, and it was less in the study group than in the control group in the first hours after the block (second hour after surgery); however, it was not statistically significant. No adverse effects were observed in the two groups. Conclusions Results of the current study suggested that the addition of magnesium sulfate to ropivacaine in TAP block does not affect the post-hysterectomy pain.
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Affiliation(s)
- Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-66515758,
| | - Poupak Rahimzadeh
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid-Reza Faiz
- Anesthesiology Department, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Abdullahzadeh-Baghaei
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Science, Bandarabbas, Iran
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Matulewicz RS, Patel M, Jordan BJ, Morano J, Frainey B, Bhanji Y, Bux M, Nader A, Kundu SD, Meeks JJ. Transversus Abdominis Plane Blockade as Part of a Multimodal Postoperative Analgesia Plan in Patients Undergoing Radical Cystectomy. Bladder Cancer 2018; 4:161-167. [PMID: 29732387 PMCID: PMC5929302 DOI: 10.3233/blc-170157] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Radical cystectomy (RC) is a morbid procedure with frequent complications that may benefit from implementation of an enhanced recovery after surgery (ERAS) protocol. Objective: To examine the benefits of a multimodal analgesic plan that uses continuous transversus abdominis plane (TAP) blockade as part of an ERAS protocol after RC. Methods: A retrospective comparison of consecutive patients undergoing RC over a 4-year period was conducted. Patients were designated as having surgery either before or after implementation of an ERAS protocol. A major component of the ERAS protocol was a multi-modal analgesia plan with TAP blockade. Patient demographics, comorbidities, operative details, and outcomes, including days to flatus, bowel movement (BM), narcotic usage, and length of stay (LOS) were compared. Results: In total, 171 patients were included: 100 pre-ERAS and 71 ERAS. There were no differences in age, smoking status, operative approach, or diversion type. The patients in the ERAS cohort were less likely to be male, had a higher median BMI, and more likely to have received neoadjuvant chemotherapy. Total and early postoperative narcotic use were lower in the ERAS cohort: 89 vs. 336 mg (p < 0.001) and 62 vs 203 mg (p = 0.001), respectively. The ERAS cohort had fewer days to flatus (3 vs. 4, p < 0.001) and fewer days to bowel movement (4 vs. 5, p < 0.001). Median LOS was shorter in the ERAS cohort (7 vs. 8.5d, p = 0.001). There were no differences in complications or readmission rates between the two cohorts. Conclusions: TAP blockade as part of an ERAS multi-modal pain plan is associated with low narcotic usage, and significant improvement in time to flatus, BM, and LOS compared to traditional post-RC pain management.
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Affiliation(s)
- Richard S Matulewicz
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Mehul Patel
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Brian J Jordan
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Jacqueline Morano
- Department of Anesthesia, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Brendan Frainey
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Yasin Bhanji
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Mahreen Bux
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Antoun Nader
- Department of Anesthesia, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Shilajit D Kundu
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua J Meeks
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8284363. [PMID: 29226150 PMCID: PMC5684553 DOI: 10.1155/2017/8284363] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/19/2017] [Accepted: 06/28/2017] [Indexed: 02/02/2023]
Abstract
Purpose of Review Transversus abdominis plane (TAP) block is a regional technique for analgesia of the anterolateral abdominal wall. This review highlights the nomenclature system and recent advances in TAP block techniques and proposes directions for future research. Recent Findings Ultrasound guidance is now considered the gold standard in TAP blocks. It is easy to acquire ultrasound images; it can be used in many surgeries involving the anterolateral abdominal wall. However, the efficacy of ultrasound-guided TAP blocks is not consistent, which might be due to the use of different approaches. The choice of technique influences the involved area and block duration. To investigate the actual analgesic effects of TAP blocks, we unified the nomenclature system and clarified the definition of each technique. Although a single-shot TAP block is limited in duration, it is still the candidate of the analgesic standard for abdominal wall surgery because the use of the catheter technique and liposomal bupivacaine may overcome this limitation. Summary Ultrasound-guided TAP blocks are commonly used. With the unified nomenclature and the development of catheter technique and/or liposomal local anesthetics, TAP blocks can be applied more appropriately to achieve better pain control.
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Khatibi B, Said ET, Sztain JF, Monahan AM, Gabriel RA, Furnish TJ, Tran JT, Donohue MC, Ilfeld BM. Continuous Transversus Abdominis Plane Nerve Blocks: Does Varying Local Anesthetic Delivery Method-Automatic Repeated Bolus Versus Continuous Basal Infusion-Influence the Extent of Sensation to Cold?: A Randomized, Triple-Masked, Crossover Study in Volunteers. Anesth Analg 2017; 124:1298-1303. [PMID: 28319550 DOI: 10.1213/ane.0000000000001939] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It remains unknown whether continuous or scheduled intermittent bolus local anesthetic administration is preferable for transversus abdominis plane (TAP) catheters. We therefore tested the hypothesis that when using TAP catheters, providing local anesthetic in repeated bolus doses increases the cephalad-caudad cutaneous effects compared with a basal-only infusion. METHODS Bilateral TAP catheters (posterior approach) were inserted in 24 healthy volunteers followed by ropivacaine 2 mg/mL administration for a total of 6 hours. The right side was randomly assigned to either a basal infusion (8 mL/h) or bolus doses (24 mL administered every 3 hours for a total of 2 bolus doses) in a double-masked manner. The left side received the alternate treatment. The primary end point was the extent of sensory deficit as measured by cool roller along the axillary line at hour 6 (6 hours after the local anesthetic administration was initiated). Secondary end points included the extent of sensory deficit as measured by cool roller and Von Frey filaments along the axillary line and along a transverse line at the level of the anterior superior iliac spine at hours 0 to 6. RESULTS Although there were statistically significant differences between treatments within the earlier part of the administration period, by hour 6 the difference in extent of sensory deficit to cold failed to reach statistical significance along the axillary line (mean = 0.9 cm; SD = 6.8; 95% confidence interval -2.0 to 3.8; P = .515) and transverse line (mean = 2.5 cm; SD = 10.1; 95% confidence interval -1.8 to 6.8; P = .244). Although the difference between treatments was statistically significant at various early time points for the horizontal, vertical, and estimated area measurements of both cold and mechanical pressure sensory deficits, no comparison remained statistically significant by hour 6. CONCLUSIONS No evidence was found in this study involving healthy volunteers to support the hypothesis that changing the local anesthetic administration technique (continuous basal versus hourly bolus) when using ropivacaine 0.2% and TAP catheters at 8 mL/h and 24 mL every 3 hours significantly influences the cutaneous effects after 6 hours of administration. Additional research is required to determine whether changing variables (eg, local anesthetic concentration, basal infusion rate, bolus dose volume, and/or interval) would provide different results.
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Affiliation(s)
- Bahareh Khatibi
- *Department of Anesthesiology, University of California, San Diego, La Jolla, California; †School of Medicine, University of California San Diego, La Jolla, California; ‡Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California; and §Outcomes Research Consortium
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Rashid A, Gorissen KJ, Ris F, Gosselink MP, Shorthouse JR, Smith AD, Pandit JJ, Lindsey I, Crabtree NA. No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial. Colorectal Dis 2017; 19:681-689. [PMID: 27943522 DOI: 10.1111/codi.13578] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
AIM Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double-blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA). METHOD Seventy-one patients were randomized to receive either TAP block or wound infiltration. The TAP blocks were performed by experienced anaesthetists who used ultrasound guidance to deliver 40 ml of 0.25% bupivacaine post-induction into the transverse abdominis plane. In the control group, 40 ml of 0.25% bupivacaine was injected around the trocar and the extraction site by the surgeon. Both groups received patient-controlled analgesia (PCA) with intravenous morphine. Patients and nursing staff assessed pain scores 6, 12, 24 and 48 h after surgery. The primary outcome was overall morphine use in the first 48 h. RESULTS Of the 71 patients, 20 underwent a right hemicolectomy and 51 a high anterior resection. The modified intention-to-treat analysis showed no significant differences in overall morphine use [47.3 (36.2-58.5) mg vs 46.7 (36.2-57.3) mg; mean (95% CI), P = 0.8663] in the first 48 h. Pain scores were similar at 6, 12, 24 and 48 h. No differences were found regarding time to mobilization, resumption of diet and length of hospital stay. CONCLUSION In elective laparoscopic colectomies, standardized wound infiltration with LA has the same analgesic effect as TAP blocks post-induction using bupivacaine at 48 h.
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Affiliation(s)
- A Rashid
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K J Gorissen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F Ris
- Service of Visceral Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - M P Gosselink
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J R Shorthouse
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A D Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - I Lindsey
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N A Crabtree
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yoshida T, Furutani K, Watanabe Y, Ohashi N, Baba H. Analgesic efficacy of bilateral continuous transversus abdominis plane blocks using an oblique subcostal approach in patients undergoing laparotomy for gynaecological cancer: a prospective, randomized, triple-blind, placebo-controlled study. Br J Anaesth 2016; 117:812-820. [DOI: 10.1093/bja/aew339] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 01/22/2023] Open
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Bava EP, Ramachandran R, Rewari V, Chandralekha, Bansal VK, Trikha A. Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial. Anesth Essays Res 2016; 10:561-567. [PMID: 27746552 PMCID: PMC5062234 DOI: 10.4103/0259-1162.186620] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Transversus abdominis plane (TAP) block has been used to provide intra- and post-operative analgesia with single incision laparoscopic (SIL) bariatric and gynecological surgery with mixed results. Its efficacy in providing analgesia for SIL cholecystectomy (SILC) via the same approach remains unexplored. Aims: The primary objective of our study was to compare the efficacy of bilateral TAP block with local anesthetic infiltration for perioperative analgesia in patients undergoing SILC. Settings and Design: This was a prospective, randomized, controlled, double-blinded trial performed in a tertiary care hospital. Materials and Methods: Forty-two patients undergoing SILC were randomized to receive either ultrasound-guided (USG) bilateral mid-axillary TAP blocks with 0.375% ropivacaine or local anesthetic infiltration of the port site. The primary outcome measure was the requirement of morphine in the first 24 h postoperatively. Statistical Analysis: The data were analyzed using t-test, Mann–Whitney test or Chi-square test. Results: The 24 h morphine requirement (mean ± standard deviation) was 34.57 ± 14.64 mg in TAP group and 32.76 ± 14.34 mg in local infiltration group (P = 0.688). The number of patients requiring intraoperative supplemental fentanyl in TAP group was 8 and in local infiltration group was 16 (P = 0.028). The visual analog scale scores at rest and on coughing were significantly higher in the local infiltration group in the immediate postoperative period (P = 0.034 and P = 0.007, respectively). Conclusion: USG bilateral TAP blocks were not effective in decreasing 24 h morphine requirement as compared to local anesthetic infiltration in patients undergoing SILC although it provided some analgesic benefit intraoperatively and in the initial 4 h postoperatively. Hence, the benefits of TAP blocks are not worth the effort and time spent for administering them for this surgery.
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Affiliation(s)
- Ejas P Bava
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ramachandran
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vimi Rewari
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Chandralekha
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anjan Trikha
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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14
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Smith SR, Draganic B, Pockney P, Holz P, Holmes R, Mcmanus B, Carroll R. Transversus abdominis plane blockade in laparoscopic colorectal surgery: a double-blind randomized clinical trial. Int J Colorectal Dis 2015; 30:1237-45. [PMID: 26099316 DOI: 10.1007/s00384-015-2286-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Adequate postoperative analgesia is essential for recovery following colorectal surgery. Transversus abdominis plane (TAP) blocks have been found to be beneficial in improving pain following a variety of abdominal operations. The objective of this study was to determine if TAP blocks are useful in improving postoperative recovery following laparoscopic colorectal surgery. MATERIALS AND METHODS A prospective double-blind randomized clinical trial, involving 226 consecutive patients having laparoscopic colorectal surgery, was performed by a university colorectal surgical department. Patients were randomized to either TAP blockade using ultrasound guidance, or control, with the primary outcome being postoperative pain, as measured by analgesic consumption. Secondary outcomes assessed were pain visual analogue score (VAS), respiratory function, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. RESULTS A total of 142 patients were followed up to trial completion (74 controls, 68 interventions). Patients were well matched with regard to demographics. No complications occurred as a result of the intervention of TAP blockade. There was no difference between groups with regards to analgesic consumption (161 mEq morphine control vs 175 mEq morphine TAP; p = 0.596). There was no difference between the two groups with regards to the secondary outcomes of daily VAS, respiratory outcome, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. CONCLUSION We conclude that TAP blockade appears to be a safe intervention but confers no specific advantage following laparoscopic colorectal surgery.
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Affiliation(s)
- Stephen Ridley Smith
- Division of Surgery, John Hunter Hospital, University of Newcastle, Locked Bag 1, Hunter Regional Mail Centre, Newcastle, NSW, 2310, Australia,
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15
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Unilateral Transversus Abdominis Plane Block Catheter for the Treatment of Abdominal Wall Pain in Pregnancy. Reg Anesth Pain Med 2015; 40:720-2. [DOI: 10.1097/aap.0000000000000296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Wilkinson KM, Krige A, Brearley SG, Lane S, Scott M, Gordon AC, Carlson GL. Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial. Trials 2014; 15:400. [PMID: 25336055 PMCID: PMC4223757 DOI: 10.1186/1745-6215-15-400] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/03/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is recommended for post-operative pain relief in patients undergoing major abdominal surgery via a midline incision. However, the effectiveness of TEA is variable with high failure rates reported post-operatively. Common side effects such as low blood pressure and motor block can reduce mobility and hinder recovery, and a number of rare but serious complications can also occur following their use.Rectus sheath catheters (RSC) may provide a novel alternative approach to somatic analgesia without the associated adverse effects of TEA. The aim of this study is to compare the efficacy of both techniques in terms of pain relief, patient experience, post-operative functional recovery, safety and cost-effectiveness. METHODS/DESIGN This is a single-centre randomised controlled non-blinded trial, which also includes a nested qualitative study. Over a two-year period, 132 patients undergoing major abdominal surgery via a midline incision will be randomised to receive either TEA or RSC for post-operative analgesia. The primary outcome measures pain scores on moving from a supine to a sitting position at 24 hours post wound closure, and the patient experience between groups evaluated through in-depth interviews. Secondary outcomes include pain scores at rest and on movement at other time points, opiate consumption, functional recovery, morbidity and cost-effectiveness. DISCUSSION This will be the first randomised controlled trial comparing thoracic epidurals to ultrasound-guided rectus sheath catheters in adults undergoing elective midline laparotomy. The standardised care provided by an Enhanced Recovery Programme makes this a comparison between two complex pain packages and not simply two analgesic techniques, in order to ascertain if RSC is a viable alternative to TEA. TRIAL REGISTRATION Current Controlled Trials ISRCTN81223298 (16 January 2014).
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Affiliation(s)
- Kate M Wilkinson
- />Department of Anaesthesia and Critical Care, Royal Blackburn Hospital, Blackburn, BB2 3HH UK
| | - Anton Krige
- />Department of Anaesthesia and Critical Care, Royal Blackburn Hospital, Blackburn, BB2 3HH UK
| | - Sarah G Brearley
- />Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YT UK
| | - Steven Lane
- />Department of Biostatistics, University of Liverpool, Duncan Building, Liverpool, L69 3GA UK
| | - Michael Scott
- />Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital, University of Surrey, Guildford, GU2 7XX UK
| | - Anthony C Gordon
- />Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College, London, SW7 2AZ UK
| | - Gordon L Carlson
- />Department of Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD UK
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