Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane Blocks in Abdominally Based Microvascular Breast Reconstruction

Abstract

Background: Transversus abdominis plane blocks can improve pain control and decrease opioid use within an enhanced recovery after surgery (ERAS) protocol in patients undergoing abdominally based autologous breast reconstruction. The authors have transitioned to using a local analgesic cocktail for transversus abdominis plane blocks. The purpose of this study was to compare postoperative opioid use in patients who received the blocks. Methods: Patients who underwent abdominally based autologous breast reconstruction between November of 2015 and December of 2019 were retrospectively reviewed. The study group received bupivacaine, ketorolac, dexmedetomidine, and dexamethasone; the control group received liposomal bupivacaine with or without bupivacaine, ketorolac, or dexmedetomidine, as a transversus abdominis plane block. The primary outcome of interest was postoperative opioid use and pain scores. Results: One hundred four women met inclusion criteria: 36 in group A (before ERAS, before transversus abdominis plane block), 38 in group B (ERAS, transversus abdominis plane block with liposomal bupivacaine), and 30 in group C (ERAS, transversus abdominis plane block with local anesthetic cocktail). Total daily oral morphine equivalent consumption (group A, 633; group B, 240; group C, 135; p < 0.0001) and average daily oral morphine equivalent consumption (group A, 137; group B, 56; group C, 29; p < 0.0001) were significantly less for group C in the inpatient phase. Patients in group C were prescribed significantly fewer outpatient oral morphine equivalents (group A, 79; group B, 74; group C, 52; p = 0.01). Conclusions: Transversus abdominis plane blocks are a significant component of an ERAS protocol for abdominally based breast reconstruction. Liposomal bupivacaine is a popular option for transversus abdominis plane blocks. The authors’ results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease postoperative opioid use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction

“… 13 , 14 , 15 , 16 A TAP block can be administered via ultrasound guidance or direct visualization by locating the triangle of petit and or by marking a point 8 cm above the ASIS and inserting the needle between the transverse abdominis and internal abdominal oblique muscles, allowing for placement of anesthetic from the T10-L1 dermatomes. 13 , 17 A PEC I block is administered in the plane between the pectoralis major and minor muscles and at the level of the 3 rd rib to anesthetize the medial and lateral pectoral nerves. 13 , 14 A PEC II block technique includes a second injection in addition to the PEC I block between the pectoralis minor and serratus anterior muscles, anesthetizing the long thoracic nerve and part of the intercostal nerves T2 to T4 ( Figure 1 ).…”

Conscious Sedation Methods for Blepharoplasty in Day Surgery

“…The adjuvants are coadministered with local anesthetic agents to improve the onset and/or duration of analgesia, which include both opioids and nonopioids, including epinephrine and an alpha-2 agonist. In the literature [ 17 , 18 , 19 ], dexmedetomidine blunted pain signals by inhibiting epinephrine release and exhibiting analgesic properties. Pharmacokinetically, continuous infusion better controls intraoperative pain management compared to a bolus injection [ 20 ].…”