Transversus abdominis plane block with liposomal bupivacaine for pain control after cesarean delivery: a retrospective chart review

Abstract

BackgroundAdverse effects of opioid analgesics and potential for chronic use are limitations in the cesarean setting. Regional anesthesia using transversus abdominis plane (TAP) block post-cesarean delivery may improve analgesia and reduce opioid consumption. Effectiveness of TAP block using liposomal bupivacaine (LB) to reduce post-cesarean pain is unknown.MethodsWe performed a single-center retrospective chart review of patients aged ≥18 years who underwent cesarean delivery with a multimodal pain management protocol with or without TAP block with LB 266 mg. Assessments included postsurgical opioid consumption; area under the curve (AUC) of numeric rating scale pain scores from 0 to 3 days; proportion of opioid-free patients; discharge- and post-anesthesia care unit (PACU)-ready time; times to ambulation, solid food, and bowel movement; hospital length of stay (LOS); and adverse events (AEs). Data were analyzed in the total population and in first- and repeat-cesarean subgroups using Wilcoxon, chi-squared, and Student’s t-tests.ResultsOf 201 patients, 101 were treated with LB TAP block (LB-TAPB) and 100 without LB-TAPB. Treatment with LB-TAPB vs without LB-TAPB significantly reduced mean post-surgical opioid consumption (total, 47%; first-cesarean, 54%; repeat-cesarean, 42%; P<0.001 each) and mean AUC of pain scores (total, 46%; first-cesarean, 57%; repeat-cesarean, 40%; P<0.001 each). Patients treated with LB-TAPB had significantly shorter mean discharge-ready times (2.9 vs 3.6 days; P=0.006), PACU-ready times (138 vs 163 minutes; P=0.028), and LOS (2.9 vs 3.9 days; P<0.001). LB-TAPB significantly decreased mean times to ambulation and solid food by 39% and 31% (P<0.01 each), respectively, and numerically reduced mean time to bowel movement (26%; P=0.05). Fewer patients treated with LB-TAPB vs without LB-TAPB reported an AE (34% vs 50%; P=0.026).ConclusionThese results suggest multimodal pain management incorporating TAP block with LB 266 mg is an effective approach to reducing opioid requirements and improving analgesia post-cesarean delivery.

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery

“…Our ERAS protocol includes the use of transverse abdominis plane blocks as postoperative analgesia; several studies have noted benefit as a postoperative pain management strategy within the cesarean delivery population, 16 – 20 whereas others have noted no benefit within the cesarean delivery population 21 and other gynecologic surgeries. 22 , 23 The transverse abdominis plane blocks have typically taken no longer than 5 minutes at the completion of each cesarean delivery and have not lead to any issues in procedure timing in the operating room.…”

A review of peripheral nerve blocks for cesarean delivery analgesia

“…Interest in liposomal bupivacaine for cesarean delivery peripheral nerve blocks has grown. Liposomal bupivacaine is a prolonged-release (up to 72 hours) formulation of bupivacaine approved by the US Federal Drug Administration for postoperative analgesia by single-dose infiltration 65. Because of the advantages of prolonged analgesia without a catheter requirement, questions have been raised on its role in cesarean delivery analgesia.…”

“…The sparse available data on liposomal bupivacaine in this population have been methodologically limited and conflicting in results. Two retrospective studies, one on intra-incisional liposomal bupivacaine and one on liposomal bupivacaine TAP blocks, showed reduced postoperative opioid requirements and postcesarean pain scores 65 66. In contrast, a randomized control trial by Prahbu et al 67 compared liposomal bupivacaine and placebo by fascial and skin infiltration, prior to fascial closure.…”

Utility of erector spinae plane block in thoracic surgery

“…Utilization of regional blocks has been associated with a reduction in postoperative narcotic requirements and associated adverse effects, such as ileus, constipation, delirium, or urinary retention that can lead to prolonged lengths of stay (LOS) in the hospital. In addition to the financial benefits associated with shorter LOS, regional anesthesia blocks lead to a quicker recovery and faster return to baseline levels of activity compared to completely enteral or parenteral narcotic pain management strategies [12][13][14]. The ESP block is a novel approach for post-operative and post-traumatic thoracic pain management.…”