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

Postoperative pain scores and opioid use after standard bupivacaine vs. liposomal bupivacaine regional blocks for abdominal cancer surgery: A propensity score matched study

BACKGROUND

Fascial plane blocks (FPBs) are widely used for abdominal surgery with the assumption that liposomal bupivacaine (LB) is more effective than standard bupivacaine (SB).

METHODS

This was a single-institution retrospective cohort study of patients administered FPBs with LB or SB ​+ ​admixtures (dexamethasone/dexmedetomidine) for open abdominal cancer surgery. Propensity score matching generated a 2:1 (LB:SB) matched cohort. Opioid use (mg oral morphine equivalents, OME) and severe pain (≥3 pain scores ≥7 in a 24-h period) were compared.

RESULTS

Opioid use was >150 ​mg OME in 19.9 ​% (29/146) LB and 16.4 ​% (12/73) SB patients (p ​= ​0.586). Severe pain was experienced by 44 ​% (64/146) LB and 53 ​% (39/73) SB patients (p ​= ​0.198). On multivariable analysis, SB vs LB choice was not associated with high opioid volume >150 ​mg or severe pain.

CONCLUSIONS

FPBs with standard bupivacaine were not associated with higher 72-h opioid use or more severe pain compared to liposomal bupivacaine.

Postoperative injectable opioid use and incidence of surgical site complications after use of liposomal bupivacaine in canine gastrointestinal foreign body surgery

OBJECTIVE

To compare postoperative analgesic use and postoperative complications between dogs that received liposomal bupivacaine (LB) during surgical gastrointestinal foreign body (GIFB) removal and those that did not.

STUDY DESIGN

Retrospective study.

ANIMALS

Two hundred five dogs.

METHODS

Medical records for all dogs with GIFB removal at the Purdue University Veterinary Hospital between May 2017 and August 2021 were searched. Incomplete records and dogs with less than 2 weeks' veterinary follow up were excluded. Data collected included: patient information, time until surgery, intraoperative findings, surgical data (including perforation at time of surgery, linear vs. solid, enterotomy vs. enterectomy), use of LB (including time and manner of administration), time to extubation after surgery, in-hospital postoperative analgesic use and duration, and postoperative complications. Fentanyl was noted as used/not used, quantified as mean hourly rate over 12 h intervals. All analyses were performed using commercial statistical software with p < .05 as the significance level.

RESULTS

Dogs that received LB were heavier (n = 65, median 28.5 kg) than those that did not (n = 140, median 24.4 kg) (p = .005). Postoperative fentanyl use (p < .05 between 13 and 72 h) and hourly rates (p < .05 between 13 and 48 h) were less, and postoperative time in the intensive care unit (ICU) (p < .001) and hospital were shorter (p < .001) in dogs receiving LB. Postoperative wound complications were seen in 7/65 dogs (10.8%, 95% CI = 4.4-21.0%) with LB and 4/140 (2.9%, 95% CI = 0.8-7.2%) without LB (p = .039).

CONCLUSION

Use of LB was associated with reduced postoperative analgesic use, and shortened ICU and hospital stay but also with wound complications.

CLINICAL SIGNIFICANCE

Caution should be used when using LB in (clean) contaminated surgeries.

The Role of Ultrasound-Guided Multipoint Fascial Plane Block in ElderlyPatients Undergoing Combined Thoracoscopic-Laparoscopic Esophagectomy: A Prospective Randomized Study

INTRODUCTION

We estimated the safety and efficacy of ultrasound-guided multipoint fascial plane block, including serratus anterior plane block (SAPB) and bilateral transversus abdominis plane block (TAPB) in elderly patients who underwent combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

The authors enrolled 80 patients in this prospective study after patient selection using the inclusion and exclusion criteria who were scheduled for elective TLE from May 2020 to May 2021. Patients were randomly assigned to the treated group (group N) or the control group (group C) (n = 40 per group) using the sealed-envelope method. Multipoint fascial plane blocks, including serratus anterior plane block (SAPB) and bilateral TAPB, were performed on patients undergoing TLE using a solution of 60 mL 0.375% ropivacaine plus 2.5 mg dexamethasone by 3 injections of 20 mL each (group N) or no interventions (group C).

RESULTS

Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at T incision and 30 min after T incision were significantly higher in group C than in group N, and also significantly higher than at baseline (P < 0.01). Blood glucose at 60 min, 2 h after T incision, was significantly higher in group C than in group N and significantly higher than at baseline (P < 0.01). Compared to group N, the dosages of propofol and remifentanil used during surgery in group C were more than those in group N (P < 0.01). The time to first rescue analgesic in group C was earlier than in group N. The total postoperative use of sufentanil, and the number of patients requiring rescue analgesics in group C, were more than in group N (P < 0.01).

CONCLUSIONS

This study showed that applying the multipoint fascia pane block technique in TLE for elderly patients could significantly reduce postoperative pain, decrease the dosages of drugs used in general anesthesia, improve the quality of the awakening, and have no obvious adverse reactions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR-2000033617).

A Retrospective Comparison of Three Patient-Controlled Analgesic Strategies: Intravenous Opioid Analgesia Plus Abdominal Wall Nerve Blocks versus Epidural Analgesia versus Intravenous Opioid Analgesia Alone in Open Liver Surgery

Background: Adequate pain control is of crucial importance to patient recovery and satisfaction following abdominal surgeries. The optimal analgesia regimen remains controversial in liver resections. Methods: Three groups of patients undergoing open hepatectomies were retrospectively analyzed, reviewing intravenous patient-controlled analgesia (IV-PCA) versus IV-PCA in addition to bilateral rectus sheath and subcostal transversus abdominis plane nerve blocks (IV-PCA + NBs) versus patient-controlled thoracic epidural analgesia (TEA). Patient-reported pain scores and clinical data were extracted and correlated with the method of analgesia. Outcomes included total morphine consumption and numerical rating scale (NRS) at rest and on movement over the first three postoperative days, time to remove the nasogastric tube and urinary catheter, time to commence on fluid and soft diet, and length of hospital stay. Results: The TEA group required less morphine over the first three postoperative days than IV-PCA and IV-PCA + NBs groups (9.21 ± 4.91 mg, 83.53 ± 49.51 mg, and 64.17 ± 31.96 mg, respectively, p < 0.001). Even though no statistical difference was demonstrated in NRS scores on the first three postoperative days at rest and on movement, the IV-PCA group showed delayed removal of urinary catheter (removal on postoperative day 4.93 ± 5.08, 3.87 ± 1.31, and 3.70 ± 1.30, respectively) and prolonged length of hospital stay (discharged on postoperative day 12.71 ± 7.26, 11.79 ± 5.71, and 10.02 ± 4.52, respectively) as compared to IV-PCA + NBs and TEA groups. Conclusions: For postoperative pain management, it is expected that the TEA group required the least amount of opioid; however, IV-PCA + NBs and TEA demonstrated comparable postoperative outcomes, namely, the time to remove nasogastric tube/urinary catheter, to start the diet, and the length of hospital stay. IV-PCA with NBs could thus be a reliable analgesic modality for patients undergoing open liver resections.

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence

Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.

Pharmacokinetics and safety of liposomal bupivacaine after local infiltration in healthy Chinese adults: a phase 1 study

Background

Liposomal bupivacaine (LB) is a long-acting formulation of bupivacaine. The safety and efficacy of LB has been demonstrated across surgical procedures. However, pharmacokinetic (PK) parameters and safety of LB in the Chinese population have not been assessed.

Methods

In this single-arm, single center, phase 1, open-label study, PK and safety of local infiltration with LB 266 mg were assessed in healthy Chinese adults. Eligible participants were aged 18 to 55 years with biologic parents and grandparents of Chinese ethnicity, in generally good health (i.e., no clinically significant abnormalities), and with a body mass index (BMI) 19.0 to 24.0 kg/m² (inclusive) and body weight ≥ 50 kg.

Results

Participants (N = 20) were predominantly men (80 %); mean age was 32 years; and mean BMI was 21.8 kg/m². After LB administration, mean plasma levels of bupivacaine rapidly increased during the first hour and continued to increase through 24 h; plasma levels then gradually decreased through 108 h followed by a monoexponential decrease through 312 h. Geometric mean maximum plasma concentration was 170.9 ng/mL; the highest plasma bupivacaine concentration detected in any participant was 374.0 ng/mL. Twenty-two treatment-emergent adverse events were reported (mild, n = 21; moderate, n = 1).

Conclusions

After single-dose administration of LB, PK measures were similar to a previously reported profile in US adults. The highest observed peak plasma concentration of bupivacaine was several-fold below the plasma concentration threshold accepted as being associated with neurotoxicity or cardiotoxicity (2000–4000 ng/mL). These data support that LB is well tolerated and safe in individuals of Chinese descent.

Trial registration

NCT04158102 (ClinicalTrials.gov identifier), Date of registration: November 5, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01407-5.

Transversus Abdominis Plane Block versus Wound Infiltration with Conventional Local Anesthetics in Adult Patients Underwent Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

How to effectively control the postoperative pain of patients is extremely important to clinicians. Transversus abdominis plane (TAP) block is a novel analgesic method reported to greatly decrease postoperative pain. However, in many areas, there still exists a phenomenon of surgeons using wound infiltration (WI) with conventional local anesthetics (not liposome anesthetics) as the main means to decrease postoperative pain because of traditional wisdom or convenience. Here, we compared the analgesic effectiveness of the two different methods to determine which method is more suitable for adult patients. Materials and methods. A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TAP block and WI without liposome anesthetics in adult patients were performed. Frequently used databases were extensively searched. The main outcomes were postoperative pain scores in different situations (at rest or during movement) and the time until the first use of rescue analgesics. The secondary outcomes were postoperative nausea and vomiting (PONV) incidence and patient satisfaction scores.

Results

Fifteen studies with 983 participants met the inclusion criteria and were included in the present study. The heterogeneity in the final analysis regarding the pain score was low to moderate. The major results of the sensitivity analysis were stable. WI had the same analgesic effect as TAP block only at the one-hour postoperative time point (mean difference = -0.32, 95% confidence interval (-0.87, 0.24), P = 0.26) and was associated with a shorter time until the first rescue analgesic and poorer patient satisfaction.

Conclusion

TAP block results in a more effective and steady analgesic effect than WI with conventional local anesthetics in adult patients from the early postoperative period and obtains higher patient satisfaction.

Reduced Opioid Prescription Practices and Duration of Stay after TAP Block for Laparoscopic Appendectomy

BACKGROUND

We evaluated whether TAP blocks performed at the time of appendectomy resulted in reduced total oral morphine equivalent (OME) prescribed and fewer 30-day opioid prescription (OP) refills.

STUDY DESIGN

Single institution review of historical data (2010-2016) was performed. Adults (≥ 18 years) that underwent appendectomy for appendicitis with uniform disease severity (AAST EGS grades I, II) were included. Opioid tolerance was defined as any preoperative OP ordered 1-3 months prior to appendectomy or < 1 month unrelated to appendicitis; opioid naïve patients were without OP. Intraoperative TAP blocks (admixture of liposomal/regular bupivacaine) were performed at surgeon discretion. Risk factors for discharge prescription > 200 OME were assessed using logistic regression and quantified using odds ratios (OR) and 95% confidence intervals (CI).

RESULT

There were 960 patients with uniform appendicitis severity. During appendectomy, 145 (15%) patients received TAP blocks. There were 46 patients that were opioid tolerant (5%) and the majority of the cohort received discharge OP (n = 914, 95%) with a median prescription OME volume of 225 [150-300]. Only 76 patients required 30-day opioid prescription refill. On regression, factors associated with a discharge prescription > 200 OME included ≥ 65 years of age (OR 0.64 (95%CI 0.41-0.98)) and no TAP block (OR 1.7 (95%CI 1.2-2.5)) but not preoperative opioid utilization.

CONCLUSIONS

TAP blocks in low-grade appendicitis were associated with reduced OME prescribed, hospital duration of stay, and fewer refills without impacting operative time or total hospital costs.