Transversus abdominis block utilizing liposomal bupivacaine as a non-opioid analgesic for postoperative pain management

Efficacy and safety of patient-controlled thoracic epidural analgesia alone versus patient-controlled intravenous analgesia with acetaminophen after laparoscopic distal gastrectomy for gastric cancer: a propensity score-matched analysis

BACKGROUND

Laparoscopic gastrectomy is a common procedure for early gastric cancer treatment. Improving postoperative pain control enhances patient recovery after surgery. The use of multimodal analgesia can potentially enhance the analgesic effect, minimize side effects, and change the postoperative management. The purpose of this study was to evaluate and compare the efficacies of the use of patient-controlled intravenous analgesia with regular acetaminophen (PCIA + Ace) and patient-controlled thoracic epidural analgesia (PCEA) for postoperative pain control.

METHODS

We retrospectively collected the data of 226 patients who underwent laparoscopic distal gastrectomy (LDG) with delta-shaped anastomosis between 2016 and 2019. After 1:1 propensity-score matching, we compared 83 patients who used PCEA alone (PCEA group) with 83 patients who used PCIA + Ace (PCIA + Ace group). Postoperative pain was assessed using a numeric rating scale (NRS) with scores ranging from 0 to 10. An NRS score ≥ 4 was considered the threshold for additional intravenous rescue medication administration.

RESULTS

Although NRS scores at rest were comparable between the PCEA and PCIA + Ace groups, NRS scores of patients in the PCIA + Ace group during coughing or movement were significantly better than those of patients in the PCEA group on postoperative days 2 and 3. The frequency of additional rescue analgesic use was significantly lower in the PCIA + Ace group than in the PCEA group (1.1 vs. 2.7, respectively, p < 0.001). The rate of reduction or interruption of the patient-controlled analgesic dose was higher in the PCEA group than in the PCIA + Ace group (74.6% vs. 95.1%, respectively, p = 0.0002), mainly due to hypotension occurrence in the PCEA group. Physical recovery time, postoperative complication occurrence, and liver enzyme elevation incidence were not significantly different between groups.

CONCLUSIONS

PCIA + Ace can be safely applied without an increase in complications or deterioration in gastrointestinal function; moreover, PCIA + Ace use may provide better pain control than PCEA use in patients following LDG.

Does Liposomal Bupivacaine Decrease Postoperative Opioid Use in Conjunction with an Enhanced Recovery After Bariatric Surgery Pathway? A Prospective, Double-blind, Randomized Controlled Trial

BACKGROUND

Minimization of opiate use is an important focus in the setting of the severe national opioid crisis. This study evaluated the role of liposomal bupivacaine (LB) in decreasing postoperative opioid use before and after implementation of a bariatric enhanced recovery after surgery (ERAS) program.

METHODS

We performed an IRB-approved, prospective, double-blind, randomized controlled trial of LB versus plain bupivacaine (PB) in patients undergoing elective, minimally invasive, weight loss surgery at a comprehensive metabolic and bariatric surgery program from November 2017 to December 2019. Primary outcomes were postoperative morphine milligram equivalents per day (MME/day) and average subjective inpatient pain level. Secondary outcomes were length of hospital stay (LOS) and adverse events (AEs).

RESULTS

Of the 100 patients enrolled, 78 were randomly assigned to LB (42) or PB (36). Thirty-four received the ERAS protocol, and 44 did not. The mean MME/day use did not differ significantly by the bupivacaine group [median, IQR PB: 20.3 (40.95); LB: 33.0 (42.9); p = .314], but it did differ by the ERAS group [median, IQR no ERAS 33.2 (47.1), ERAS 24.0 (34.0); p = .049]. Length of stay, inpatient pain score, and AEs did not differ significantly by either the bupivacaine or the ERAS group.

CONCLUSIONS

In our study, liposomal bupivacaine did not significantly decrease postoperative opioid use either before implementation of ERAS or as part of an enhanced recovery after surgery program for minimally invasive bariatric surgery procedures.

Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Background

Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy.

Study Design

This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively.

Results

In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred.

Conclusion

PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Graphical abstract

Applications of the ultrasound-guided nerve block technique for nonanalgesic effects

The nerve block technique guided by ultrasound has been able to accurately block tiny nerves throughout the body in recent years. It has been increasingly used to treat multisystem diseases or analgesia in surgical patients, but the latter accounted for the vast majority of cases. The nonanalgesic effect of nerve blocks is also in wide demand. After searching ultrasound-guided nerve block works on the PubMed database, we systematically summarized the current clinical application of the nerve block technique and the unique role and related mechanism of nerve block in the prevention and treatment of multi-system diseases or symptoms, including disorders of the circulatory and respiratory systems, postoperative cognitive dysfunction, immune function, posttraumatic stress disorder, and postoperative digestive system, to put forward the potential prospective application in future and serve as a reference for future research of nerve block therapy in these diseases mentioned.

Effect of Intraperitoneal Local Anesthetics in Laparoscopic Bariatric Surgery: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The effectiveness of intraperitoneal local anesthesia (IPLA) has been confirmed in other fields, but its use in bariatric surgery remains debatable. This study aimed to evaluate the analgesic effect of IPLA in bariatric surgery.

METHODS

PubMed, Web of Science, Embase, and the Cochrane Library were searched from inception to February 2022. All randomized controlled trials (RCTs) assessing IPLA's analgesic effect in bariatric surgery were included in this study. Pain-related indicators were the outcome.

RESULTS

Ten RCTs with 979 patients were included. Postoperative pain scores were significantly lower in IPLA group. Subgroup analysis demonstrated that IPLA was associated with lower pain scores in 6 h and at 24 h compared to the control group, without significant differences at 8, 12, and 48 h. Meanwhile, IPLA reduced the dose of opioids taken postoperatively. Additionally, there were no differences in adverse events between the two groups. As far as the number of postoperative analgesics used and hospital stays were concerned, our results did not show statistical differences between the two groups.

CONCLUSION

IPLA can reduce postoperative pain safely and effectively, particularly during the early postoperative stage.

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.

Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study

OBJECTIVE

Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery.

DESIGN

The authors retrospectively analyzed Premier Healthcare Database records.

SETTING

The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations.

PARTICIPANTS

The records included data from patients aged 12-to-<18 years.

INTERVENTIONS

The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery.

MEASUREMENTS AND MAIN RESULTS

Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia.

CONCLUSIONS

These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.

Reducing Opioid Dependence and Improving Patient Experience for Living Kidney Donors with Transversus Abdominis Plane Block

Rapid recovery after laparoscopic living donor nephrectomy (LLDN) for kidney donation is highly desirable for living kidney donors. To uphold rapid recovery, good analgesia with minimal adverse effects, including those related to opioid dependence, is essential. A pre-operative transversus abdominis plane (TAP) block with liposomal bupivacaine can effectively aid in perioperative pain management, while reducing opioid requirements. We conducted a single-center retrospective study involving patients 18 years and older who underwent LLDN to determine whether a TAP block with liposomal bupivacaine is efficacious in pain management after LLDN, while reducing opioid use. The study group comprised of patients who received a preoperative TAP block with liposomal bupivacaine in place of hydromorphone patient-controlled analgesia (PCA) and the control group included patients who received hydromorphone PCA post-operatively. Both groups were supplemented with oral and intravenous analgesics for breakthrough pain, as needed. The primary endpoint was reduction in post-operative opioid use in morphine milligram equivalents (MME). Secondary endpoints included: post-operative pain scores, postoperative length of stay, and re-hospitalizations within 7 days of discharge. Sixty-six patients were included in our study, with 33 in each group. Patients in both groups were well matched demographically. The study group who received TAP block demonstrated a significant reduction in post-operative opioid use (92.05 MME vs. 53.98 MME, p < 0.05) when compared to the control group who received hydromorphone PCA. Both groups achieved similar analgesia with comparable pain scores. There was no difference between postoperative hospital lengths of stay for both groups. Two patients in the control group were re-admitted due to small bowel obstruction within seven days of discharge. In conclusion, TAP block with liposomal bupivacaine significantly reduced postoperative opioid use, while also proving to be safe, efficacious and feasible in patients undergoing LLDN.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plane Block Is Associated With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plane (TAP) blocks on inpatient narcotic use in patients undergoing LSG.

METHODS

A retrospective review of LSG performed at a single institution by 3 bariatric surgeons was performed. All cases over a 15-month period were included, and anesthesia records were reviewed to stratify patients that received a TAP block and those that did not. Demographic, as well as surgical, outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the 2 groups.

RESULTS

384 LSG patients were identified, of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay, or readmission between groups. Median narcotic utilization in hospital days 1 and 2 in patients with TAP blocks was 49 ME (Interquartile Range (IQR) 14.5-84.5) to 82.5 ME (IQR 57.4-106) in the no-TAP group (P < .001). After controlling for multiple demographic- and patient-related cofactors, multiple linear regression analysis demonstrated TAP block patients utilized 22.48 ME less than the no-TAP group (P < .001) in the first 2 days of their hospitalization.

DISCUSSION

Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in-hospital narcotics than those patients that did not receive a TAP block. TAP blocks should be considered as part of a multimodal pain control strategy for patients undergoing LSG.