Randomized trial of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery with or without intrathecal morphine

The analgesic effects of novel fascial plane blocks compared with intrathecal morphine after Caesarean delivery: a systematic review and meta-analysis

BACKGROUND

Intrathecal morphine is the mainstay for post-Caesarean multimodal analgesia but is associated with important side-effects. Novel ultrasound-guided abdominal wall fascial plane blocks are proposed as intrathecal morphine alternatives, but evidence of effectiveness is conflicting. We compared the analgesic effects of fascial plane blocks with those of intrathecal morphine after Caesarean delivery.

METHODS

We sought trials comparing the analgesic effects of intrathecal morphine with quadratus lumborum (QL), transversus abdominus plane (TAP), or erector spinae plane (ESP) blocks after Caesarean delivery. The primary outcome was rest pain intensity at 6 h on a visual analogue scale (VAS) ranging from 0 to 10 cm, with 10 cm indicating severe pain. Secondary outcomes included pain at 12 and 24 h; cumulative 24-h opioid consumption in milligrams of oral morphine; times to first analgesic request, ambulation, and breast feeding in hours; lengths of recovery room and hospital stay in hours; incidence of opioid-related side-effects; and block-related complications.

RESULTS

Eighteen trials (1525 subjects) were included. TAP block was evaluated in 11 studies, QL block in five, and ESP block in two. Intrathecal morphine was superior to TAP block for pain at 6 and 12 h, with mean differences (Hartung-Knapp-Sidik-Jonkman [HKSJ] 95% confidence interval [CI]) of 1.21 cm (0.42-2.00) (P=0.01, I2=80%) and 1.03 cm (0.05-2.01) (P=0.04, I2=86%), respectively. There were no differences in pain at 6 or 12 h between QL or ESP block compared with intrathecal morphine. Both TAP block and QL block reduced the odds of nausea and vomiting by 0.41 (0.21-0.79) (P=0.01) and 0.33 (0.23-0.48) (P=0.002), respectively, compared with intrathecal morphine. There were no differences in other outcomes. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) certainty of evidence was low across these pooled outcomes.

CONCLUSIONS

Quadratus lumborum block, rather than erector spinae or transversus abdominus plane blocks, may be a better intrathecal morphine alternative owing to similar post-Caesarean analgesic effects and reduced opioid-related side-effects.

SYSTEMATIC REVIEW PROTOCOL

CRD42024543371.

Erector spinae plane block versus transversus abdominis plane block for analgesia after cesarean section: a systematic review and meta-analysis

BACKGROUND

Peripheral abdominal nerve blocks are key components of multimodal analgesia, enhancing recovery after cesarean sections. This systematic review and meta-analysis aimed to assess analgesic efficacy of Erector Spinae Plane Block (ESPB) versus Transversus Abdominis Plane Block (TAPB) under ultrasound guidance following Cesarean Section (CS) under spinal anesthesia.

METHODS

A comprehensive search was conducted across PubMed, Scopus, Cochrane Library, and ISI Web of Science to identify relevant trials. The inclusion criteria followed the PICOS framework: Population (women undergoing elective cesarean delivery), Intervention (ESPB), Comparator (TAPB), Outcomes (postoperative pain, opioid consumption, analgesic duration, and satisfaction), and Study Design (randomized controlled trials).

RESULTS

Seven RCTs (380-patients) met the inclusion criteria. The ESPB group had significantly lower postoperative pain scores at rest and during movement, reduced 24-hour opioid consumption (MD = -2.62 MME; 95% CI -4.11 to -1.13; p = 0.006), and longer analgesic duration (SMD = 1.77; 95% CI 1.11 to 2.44; p < 0.001) than the TAPB group. Patient satisfaction was also significantly higher in the ESPB group (OR = 4.75; 95% CI 2.26 to 9.99; p < 0.001). While most outcomes demonstrated low heterogeneity, significant variability was observed in analgesic duration (I2 = 83%), requiring cautious interpretation.

CONCLUSIONS

The ESP block offers superior pain relief, reduces opioid use, and enhances satisfaction compared to the TAP block in cesarean sections. These findings suggest that the implementation of the ESP block in postoperative analgesia protocols could significantly improve patient outcomes, potentially leading to enhanced recovery and reduced reliance on opioids.

The effectiveness of liposomal bupivacaine in ultrasound-guided abdominal wall blocks after open abdominal surgery: A systematic review

BACKGROUND AND OBJECTIVE

Thoracic epidural analgesia has traditionally been used for pain management after open abdominal surgery, but its use has declined. The quest for efficient alternatives has resulted in the increasing use of regional techniques. These can be applied as single-shot or continuous blocks using catheters. Long-acting liposomal bupivacaine could preclude the use of catheters. This review aimed to evaluate the effectiveness of ultrasound-guided abdominal wall blocks with liposomal bupivacaine for open abdominal surgery.

DATABASES AND DATA TREATMENT

Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were systematically searched. Screening, data extraction, and quality assessment were done by two independent researchers. Inclusion criteria were (1) liposomal bupivacaine in ultrasound-guided abdominal wall blocks for open abdominal surgery, (2) outcome of pain and/or opioid consumption, (3) patients >18 years, and (4) reports published in English.

RESULTS

Of the 1277 studies found, 22 met the inclusion criteria. The Cochrane Risk of Bias (Version 2) tool was used to assess randomized controlled trials. Studies were grouped for clarity. Transversus abdominis plane (TAP) blocks were mostly investigated. Data were heterogenic regarding types of surgery, approach to block placement, anesthetic solution injected, and use of intrathecal morphine (ITM).

CONCLUSIONS

Patients undergoing cesarean section with neuraxial anesthesia and intrathecal morphine benefit from TAP blocks with liposomal bupivacaine, demonstrating reduced opioid consumption and comparable pain. Evidence for other open abdominal surgeries was inconclusive. Abdominal wall blocks with liposomal bupivacaine could be a viable alternative when epidural analgesia is contraindicated.

Postoperative Cesarean Section Pain Management Using Transversus Abdominis Plane Block Versus Intrathecal Morphine: A Systematic Review and Meta-analysis

PURPOSE

Compare and evaluate the effectiveness of transversus abdominis plane (TAP) block versus intrathecal morphine (ITM) on elective postcesarean section pain, opioid consumption, and related side effects.

DESIGN

Systematic review and meta-analysis.

METHODS

A search for evidence was conducted in PubMed, Google Scholar, CINAHL, Cochrane Collaboration Database, UpToDate, Health Source, and gray literature. Only randomized controlled trials (RCTs) were included in the study. The methodological quality of evidence assessment was conducted using the Risk of Bias and Grades of Recommendation, Assessment, Development, and Evaluation system. The meta-analysis used Review Manager (RevMan 5.4, The Cochrane Collaboration).

FINDINGS

A total of 11 RCTs involving 1,129 patients were analyzed. Compared to ITM, TAP has a similar effect on static (mean difference [MD]; 0.37; 95% confidence interval [CI], -0.04 to 0.79; P = .08) and dynamic pain scores (MD, 0.43; 95% CI, -0.06 to 0.92; P = .09) within the first 48 hours after surgery. Additionally, the TAP block had a lower incidence of postoperative nausea and vomiting (risk ratio, 0.45; 95% CI, 0.31 to 0.66; P < .0001) and increased opioid consumption (MD, 6.78; 95% CI, 3.79 to 9.77; P < .00001). Overall, TAP block and ITM did not differ in the time to first to rescue analgesia, incidence of sedation, and pruritus.

CONCLUSIONS

Evidence suggests that TAP blocks are equivalent to ITM in pain scores and more effective at lowering the incidence of postoperative nausea and vomiting, yet ITM has been shown to be more effective in reducing postoperative opioid consumption.

Simulated bupivacaine pharmacokinetics after labor epidural analgesia followed by transversus abdominis plane block with liposomal bupivacaine for intrapartum cesarean delivery

STUDY OBJECTIVE

To simulate bupivacaine pharmacokinetics in scenarios of labor epidural analgesia (LEA) extended for intrapartum cesarean delivery (CD) with epidural or intrathecal boluses, followed by transversus abdominis plane (TAP) block with liposomal bupivacaine (LB) for postcesarean analgesia.

DESIGN

Bupivacaine plasma concentrations were simulated using a 2-compartment distribution model fit to previous study data.

SETTING

Virtual pharmacokinetic simulations.

PATIENTS

Virtual individuals (1000, each scenario) had uniform weight (80 kg) but varying absorption parameters.

INTERVENTIONS

The 6 scenarios varied in LEA infusion duration (6 or 24 h), local anesthetic used for bolus to extend LEA (epidural lidocaine or intrathecal bupivacaine), TAP block regimen, and time between bolus and TAP block.

MEASUREMENTS

Scenario outcomes included geometric mean (GM) peak bupivacaine plasma concentration (Cmax) with 95% prediction interval (PI), median (range) Cmax, and number of virtual individuals (per 1000) with Cmax reaching estimated toxicity thresholds (neurotoxicity: 2000 μg/L; cardiotoxicity: 4000 μg/L).

MAIN RESULTS

In simulated scenarios of LEA infusion for 24 h with an epidural bolus of lidocaine 400 mg for CD followed 1 h later by TAP block, the GM Cmax for the scenarios with TAP blocks including either LB 266 mg plus bupivacaine hydrochloride 52 mg or bupivacaine hydrochloride 104 mg was 1860 (95% PI, 1107-3124) and 1851 (95% PI, 1085-3157) μg/L, respectively. Among 1000 virtual individuals for each scenario, 404 and 401 had Cmax reaching 2000 μg/L, respectively; 1 and 0 had Cmax reaching 4000 μg/L, respectively. For other scenarios, GM Cmax remained <1000 μg/L.

CONCLUSIONS

Across 6 different simulations of TAP blocks for intrapartum CD analgesia, LEA with bupivacaine (with or without boluses for extension and including a conservative modeling of lidocaine without epinephrine), followed by TAP block with LB and/or bupivacaine hydrochloride 0, 1, or 2 h after CD, is unlikely to result in bupivacaine plasma concentrations reaching local anesthetic systemic toxicity thresholds in healthy patients.

Recovery quality of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery: A randomized trial

STUDY OBJECTIVE

This study aimed to investigate the effect of liposomal bupivacaine in transversus abdominis plane block (TAP) on recovery quality after cesarean delivery.

DESIGN

A randomized trial.

SETTING

An operating room, a post-anesthesia care unit, and a hospital ward.

PATIENTS

A total of 147 women scheduled for cesarean delivery under spinal anesthesia were enrolled and randomized to receive a TAP block with plain bupivacaine (bupivacaine group), liposomal bupivacaine (liposomal group), or a mixture of plain bupivacaine and liposomal bupivacaine (mixture group).

INTERVENTIONS

The bupivacaine group received bilateral TAP blocks with plain bupivacaine 50 mg alone. The liposomal group received bilateral TAP blocks with liposomal bupivacaine 266 mg alone. The mixture group received bilateral TAP blocks with plain bupivacaine 50 mg followed by liposomal bupivacaine 266 mg.

MEASUREMENTS

The primary outcome was the Quality of Recovery-15 (QoR - 15) score assessed 24 h postoperatively. Secondary outcomes encompassed the QoR - 15 score at 48 h post-surgery, the VAS pain score at rest and with movement at 24, 48, and 72 h postoperatively, opioid consumption within the 0-24 h and 24-48 h periods following surgery, as well as patient's satisfaction with analgesic.

MAIN RESULTS

The QoR - 15 score at 24 h postoperatively was significantly higher in both the liposomal group and the mixture group compared to the bupivacaine group. Specifically, the QoR - 15 score for the liposomal group versus the bupivacaine group (median [IQR]: 120 [107, 128] vs. 109 [104, 120]; median difference, 7; 95 % CI, 2 to 13; P = 0.011) and for the mixture group versus the bupivacaine group (median [IQR]: 122 [112, 128] vs. 109 [104, 120]; median difference, 9; 95 % CI, 4 to 14; P = 0.001). The QoR - 15 score in both the liposomal group and the mixture group were also higher than those in the bupivacaine group at 48 h postoperatively, though the difference was not clinically meaningful. Additionally, both the liposomal and mixture groups exhibited lower pain score at 24 h and 48 h postoperatively compared to the bupivacaine group, but no significant clinical differences were achieved in either pain scores or opioid consumption. Patients in both the liposomal and mixture groups reported higher satisfaction score with analgesia than those in the bupivacaine group.

CONCLUSIONS

TAP block using either liposomal bupivacaine or a mixture of plain bupivacaine and liposomal bupivacaine provided superior quality of recovery at 24 h after cesarean delivery compared to using plain bupivacaine alone.

Optimal approach for ultrasound-guided transversus abdominis plane (TAP) blocks for abdominal surgeries: a protocol for systematic review and meta-analysis

INTRODUCTION

Transversus abdominis plane (TAP) blocks are commonly used for postoperative analgesia after various abdominal surgeries. There are several different approaches for performing TAP blocks, mainly including posterior, lateral and subcostal approaches. An increasing number of randomised controlled trials (RCTs) have compared the analgesic effects of different TAP block approaches, but the results have not been consistent. This protocol aims to determine the optimal approach of ultrasound-guided TAP blocks for postoperative analgesia after abdominal surgery.

METHODS AND ANALYSIS

Four databases, including Web of Science, PubMed, EMBASE and the Cochrane Library will be systematically searched to identify RCTs that compared the analgesic effects of different ultrasound-guided TAP block approaches. The search interval will range from the inception of the databases to 30 July 2024. The postoperative opioid consumption over 24 hours will be defined as the primary outcome. The secondary outcomes will include the analgesia duration, postoperative pain scores at rest and during movement at different timepoints and the incidence of adverse effects. All the statistical analyses will be conducted using RevMan V.5.4. The quality of evidence will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval will not be needed. The results will be submitted to one peer-reviewed journal when completed.

PROSPERO REGISTRATION NUMBER

CRD42024510141.

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial

BACKGROUND

Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown.

OBJECTIVE

This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine.

STUDY DESIGN

This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test.

RESULTS

Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar.

CONCLUSION

Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients

Introduction

With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section.

Methods

A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate.

Results

In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population.

Conclusion

Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.

Peripheral Nerve Blocks for Cesarean Delivery Analgesia: A Narrative Review

Effective postoperative analgesia using multimodal approach improves maternal and neonatal outcomes after cesarean delivery. The use of neuraxial approach (local anesthetic and opioids) and intravenous adjunctive drugs, such as nonsteroidal anti-inflammatory drugs and acetaminophen, currently represents the standard regimen for post-cesarean delivery analgesia. Peripheral nerve blocks may be considered in patients who are unable to receive neuraxial techniques; these blocks may also be used as a rescue technique in selected patients. This review discusses the relevant anatomy, current evidence, and advantages and disadvantages of the various peripheral nerve block techniques. Further research is warranted to compare the analgesic efficacy of these techniques, especially newer blocks (e.g., quadratus lumborum blocks and erector spinae plane blocks). Moreover, future studies should determine the safety profile of these blocks (e.g., fascial plane blocks) in the obstetric population because of its increased susceptibility to local anesthetic toxicity.

Outcomes in pediatric liver transplant recipients receiving bilateral continuous erector spinae plane blocks

BACKGROUND

Regional anesthesia allows for opioid-sparing and enhanced recovery after many major surgeries. Erector spinae blockade, with reduced bleeding risk and the option for continuous infusion, offers an opportunity to promote this principle in pediatric liver transplant patients. Our goal was to evaluate pain scores, opioid use, and return of bowel function following continuous ESP blockade in pediatric liver transplant recipients.

METHODS

This retrospective cohort study included extubated patients who received a liver transplant at St. Louis Children's Hospital from July 2016 to July 2021. The control group, which did not meet the criteria for ESP blockade and received standard analgesia regimens, was compared to the group receiving continuous ESP blockade. Measured outcomes included pain scores, opioid consumption through postoperative day two, date of first bowel movement, and length of stay in the ICU and the hospital.

RESULTS

Patient demographics between control and ESP groups showed no significant differences. Pain scores between control and ESP groups also showed no significant differences. Intraoperative and postoperative opioid requirements, studied in oral morphine equivalents per kilogram (OME/kg), were significantly lower for patients with ESP blockade. Time to first bowel movement was also significantly earlier for the ESP group. No significant differences were found in length of ICU or hospital stay. There were no safety concerns or complications related to ESP blockade.

CONCLUSIONS

Use of continuous ESP blockade resulted in reduced opioid consumption through postoperative day two and earlier return of bowel function.

The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials

Liposomal bupivacaine (LB) has consistently been considered a potential analgesic for surgical wound infiltration. However, the evidence of its analgesic effectiveness remains unclear. In this meta-analysis, we attempted to identify the potential clinical role of LB wound infiltration in different surgical procedures. Randomised controlled trials (RCTs) comparing LB with non-liposomal local anaesthetics and placebos were retrieved from six electronic databases. The primary outcome was cumulative morphine equivalent consumption within 24, 48, and 72 hours after surgery. Approximately 2659 patients from 22 studies were included in the meta-analysis. Compared to the control, LB-wound infiltration did not reduce the postoperative morphine consumption at 24 hours (weighted mean difference [WMD], -0.60 mg; 97.5% confidence interval [CI], -2.78 to 1.59 mg; P = 0.54), 48 hours (WMD, -1.00 mg; 97.5% CI, -3.23 to 1.24; P = 0.32) or 72 hours (WMD, 0.50 mg; 97.5% CI, -0.67 to 1.67; P = 0.33). Similarly, secondary outcome analysis did not reveal any additional benefits of LB in any other pain-related outcomes. LB was not associated with any adverse effects. Overall, LB does not appear to improve the postoperative analgesic, rehabilitation, or safety outcomes. Current evidence does not support the routine use of LB for wound infiltration following surgical procedures.