Intravenous patient-controlled fentanyl with and without transversus abdominis plane block in cirrhotic patients post liver resection

Abstract

BackgroundCoagulation changes can complicate liver resection, particularly in patients with cirrhosis. The aim of this prospective hospital-based comparative study was to compare the postoperative analgesic efficacy of intravenous fentanyl patient-controlled analgesia (IVPCA) with and without transversus abdominis plane (TAP) block.MethodsFifty patients with Child’s A cirrhosis undergoing liver resection were randomly divided into two groups for postoperative analgesia, ie, an IVPCA group receiving a 10 μg/mL fentanyl bolus of 15 μg with a 10-minute lockout and a maximum hourly dose of 90 μg, and an IVPCA + TAP group that additionally received TAP block (15 mL of 0.375% bupivacaine) on both sides via a posterior approach with ultrasound guidance before skin incision. Postoperatively, bolus injections of bupivacaine 0.375% were given every 8 hours through a TAP catheter inserted by the surgeon in the open space during closure of the inverted L-shaped right subcostal with midline extension (subcostal approach) guided by the visual analog scale score (<3, 5 mL; 3 to <6, 10 mL; 6–10, 15–20 mL) according to weight (maximum 2 mg/kg). The top-up dosage of local anesthetic could be omitted if the patient was not in pain. Coagulation was monitored using standard coagulation tests.ResultsAge, weight, and sex were comparable between the groups (P>0.05). The visual analog scale score was significantly lower at 12, 18, 24, 48, and 72 hours (P<0.01) in IVPCA + TAP group. The Ramsay sedation score was lower only after 72 hours in the IVPCA + TAP group when compared with the IVPCA group (1.57±0.74 versus 2.2±0.41, respectively, P<0.01). Heart rate, systolic blood pressure, and fentanyl consumption were lower in the IVPCA + TAP group at 24, 48, and 72 hours (P<0.05). Intensive care unit stays were significantly shorter with TAP (2.61±0.74 days versus 4.35±0.79 days, P<0.01). Prothrombin time and International Normalized Ratio indicated temporary hypocoagulability in both groups.ConclusionCombining TAP with IVPCA improved postoperative pain management and reduced fentanyl consumption, with a shorter stay in intensive care. TAP block can be included as part of a balanced multimodal postoperative pain regimen.

The analgesic efficacy of subcostal transversus abdominis plane block with Mercedes incision

“…Postoperative variables included NRS scores, cumulative sufentanil consumption, the incidence of PONV. Ramsay Sedation Scale scores [ 11 ] collected 5 min after extubation, and 2 h, 4 h, 12 h and 24 h after the operation was evaluated as: [ 1 ] the patient is anxious and agitated or restless, or both; [ 2 ] the patient is co-operative, oriented and tranquil; [ 3 ] the patient responds to commands only; [ 4 ] the patient exhibits brisk response to light glabellar tap or loud auditory stimulus; [ 5 ] the patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus; and [ 6 ] the patient exhibits no response.…”

“…Epidural analgesia, another routinely used analgesic technique, offers equivalent or superior pain scores when compared toconventional systemic opioids. However, its utilizationis limited by perioperative coagulation dysfunction, which is typical in the patients for liver surgery and subsequent catastrophic neurologic injuries resulting from epidural haematoma [ 3 – 5 ]. In addition, epidural analgesia is independently associated with an increased use of blood transfusions and a longer hospital stay [ 5 ].…”

“…The oblique subcostal transversus abdominis plane (OSTAP) block has been demonstrated to improve pain-related outcomes after upper abdominal surgeries, such as laparoscopic cholecystectomy [ 2 – 4 , 6 – 9 ]. To our knowledge, the analgesic efficacy of ultrasound-guided OSTAP blocks has not been extensively investigated in the setting of open liver surgery for patients suffering from liver cancer, especially for the roof-shaped incision, including the Mercedes incision [ 3 , 6 , 9 , 10 ]. Therefore, we tested the hypothesis that ultrasound-guided OSTAP blocks can reduce cumulativeopioid consumption for the patients undergoing liver resection with the Mercedes incision when added to conventional multi-model intravenous analgesic technique.…”

Transversus Abdominis Plane (TAP) and Rectus Sheath Blocks: a Technical Description and Evidence Review

“…In laparotomy, RSB has been shown to significantly reduce morphine use (0.7 mg vs. 6.4 mg) [8] and pain scores (VAS score at 6 h, 2 vs. 3) when compared with placebo [9]. These studies either used a single-shot technique [8][9][10][11], combined with TAP block [12,13], or with continuous catheters [13, 14•]. A retrospective case-control study suggested the analgesic efficacy of RSB for open pyloromyotomy in infants [15].…”

Patient-controlled analgesia with and without transverse abdominis plane and rectus sheath space block in cirrhotic patients undergoing liver resection

“…Recently, Melloul et al published guidelines to enhanced recovery after liver surgery and concluded that no evidence exists to prefer epidural, and wound infiltration and intrathecal opioids are good alternatives when combined with multimodal analgesia. [ 6 ] Transversus abdominis plane (TAP) block can help provide analgesia,[ 7 8 ] but the safety of injecting local anesthetics in this plane was questioned. [ 9 ]…”