Do TAP Blocks Affect Opioid Administration in the Postoperative Period?

Do TAP Blocks Affect Opioid Administration in the Postoperative Period?

K. Allen, SRNA, L. Allison, SRNA, L. Camp, SRNA, J. Carlisle, SRNA, M. Cochiaosue, SRNA, A. Hughes, SRNA, J. Jimenez, SRNA Middle Tennessee School of Anesthesia

Introduction

How our subject came to fruition

Purpose

A brief history

Anatomy

How does it work?

Background

Results from research

Possible clinical implications

We hope you enjoy the presentation

TAP Blocks: A Brief History

1855-Friedrich Gaedcke: First to chemically isolate cocaine, naming it erythroxyline

1884-Karl Koller: Tested anesthetic effectiveness of 2% cocaine solution

1885-William Halsted: First brachial plexus blocked performed

1885 - James Leonard Corning: Injected cocaine between the lumbar spinous processes, first to publish descriptions of spinal anesthesia

1898 - August Bier: Considered the "Father of Spinal Anesthesia", performed the first surgery under spinal anesthesia

TAP Blocks: A Brief History

2001-A.N. Rafi: Published "Abdominal field block: a new approach via the lumbar triangle"

The article described a single shot abdominal block, using the lumbar triangle of Petit as an anatomical landmark

At the time of publication, Rafi had been using this blind technique for 2 years, on over 200 patients

Referred to as the RAFI technique, Regional Abdominal Field Infiltration

2004-2007-J.G. McDonnell et al., used computerized tomography and MRI to study the spread and effectiveness of the single shot abdominal blockCoined the term transversus abdominal plane (TAP) block

Background

The transversus abdominis plane block is a regional anesthetic technique first described in 2001

It is useful in procedures requiring nerve block in the anterior abdominal wall region, from T6 to L1

It was first used as a blind landmark technique but more recently it has been used under ultrasound guidance

TAP blocks are important because they can be used as an alternative analgesic solution in surgery

Background

The ultimate goal of TAP blocks is to increase analgesia with the use of local anesthetic

Absolute contraindications include infection at the site, allergy to local anesthetic and patient refusal

Although complications are rare, TAP blocks are underutilized

Beneficial for hysterectomies, prostatectomies, Caesarean sections, laparoscopic cholecystectomies and other abdominal surgeries

Background

The purpose of this research analysis was to investigate the potential benefits of the TAP block.

Seven journal articles were reviewed.

Some research studies focused on how effective TAP blocks were in reducing postoperative opioid use in various populations.

Anatomy

http://www.hindawi.com/journals/arp/2012/731645/fig2/

Transverse section of the abdominal wall demonstrating the relevant muscular structures and course of nerves (T7 T12) within the TAP.

Anatomy

http://image.slidesharecdn.com/920307ultrasound-guidedtransversusabdominisplanetapblockrasoul-141227030506-conversion-gate02/95/ultrasound-guided-transversus-abdominis-plane-tap-block-12-638.jpg?cb=1419650072

TAP Block Technique

Ultrasound Anatomy

https://www.youtube.com/watch?v=9TIHDn7uBZI&feature=youtu.be&t=92 (at 1:31)

TAP Block Technique https://www.youtube.com/watch?v=ab8Dvjauk_U&feature=youtu.be&t=14

STUDY SAMPLE SIZESTUDY DESIGNVARIABLES OF INTERESTFINDINGSRECOMMENDATION

Baeriswyl, M., et al.1611Meta analysis of 31 randomized controlled studiesCumulative IV morphine consumption postoperatively.Pain scores at rest and on movement at 6 and 24 hours postoperatively.Cumulative IV morphine consumption was reduced by an average of 6 mg in favor of the ultrasound-guided TAP block group at 6 hours postoperatively. The use of TAP blocks provides increased postoperative pain relief and reduces morphine requirements.

Belavy, D., et al.50Randomized, double-blind, placebo-controlledPatients receiving an active TAP block and morphine PCA compared to patients receiving a placebo block and morphine PCA.In the 24 hours following caesarean delivery the median morphine dose was 43% lower in the active block group compared to the placebo group.

The use of TAP blocks provides higher pain relief and reduces morphine requirements.

Fields, A.C., et al.

100Randomized, double-blind, placebo-controlledTAP block vs. placebo injection for laparoscopic ventral hernia repair (LVHR)Patients who received TAP blocks had decreased cumulative opioid use and pain scores compared with patients who received a placebo.The study supports using TAP blocks in LVHR. It significantly decreases both short-term postoperative opioid use and pain experienced by patients.

Mrunalini, P., et al.

60Double-blind, randomized, controlled trialTAP block vs. placebo on post op pain score and tramadol PCA pump use. Mean total pain scores were significantly lower in the TAP block group when compared to the control group.TAP block is effective for reducing post-op pain and opioid usage after laparotomy.

Peterson, P. L., et al.

80Randomized, double-blind, placebo-controlledPatients were assessed at 0, 2, 4, 6, 8, and 24 hours for post-op pain levels (when coughing and at rest), opioid consumption, and side effects.Pain levels were reduced in the TAP versus the placebo group while coughing but not at rest. Median morphine consumption was 7.5 mg in the placebo group versus 5 mg in the TAP group.TAP block after laparoscopic cholecystectomy may have some beneficial effect in reducing pain while coughing and on opioid requirements.

Siddiqui, M.R., et al.

174Meta-analysis of 4 randomized control studies

Mean 24 hour opioid use, time elapsed before first request for post-op analgesia, pain scores at three post-op intervals.Reduction in post-operative opioid use, increased time between first request for analgesia, and reduction of pain scores in PACU in TAP block group.TAP block is comparable to morphine for post-operative analgesia. Growing evidence points towards a role in routine abdominal surgery.

Wu, Y., et al. 90Randomized, double blind, intention to treat basisTAP block vs. placebo on morphine consumption at 24 hours and pain scores.TAP block with general anesthesia effectively reduces morphine consumption and lowers pain scores in the first 24 hours compared with general anesthesia alone.

TAP block along with general anesthesia may reduce postoperative pain.

Results

Average opioid amount given was lower in TAP block groups

Average lower postoperative pain scores in TAP block groups

Increase time to first request for further analgesia in TAP block groups

Recommendations

By utilizing the TAP block patients may be able to consume less opioids and experience less pain postoperatively than if the case was strictly a general anesthesia case with opioids as the sole pain relief adjunct

Article AuthorStrengthsWeaknessesGrade

Baeriswyl, M., et al.

This meta-analysis examined 31 controlled trials including 1611 adult participants. This study included all types of abdominal surgeries in adult patients. The large and varied sample size allows results to be generalized to a large population.Evidence of publication bias in favor of TAP blocks. Large amount of heterogeneity between stuides.

1A

Belavy, D., et al.There was no evidence of researcher bias throughout the study. The study only had one independent variable so the internal validity was high.Study had small sample size, & only compared pts undergoing cesareans.1B

Fields, A.C., et al.Internal validity high, independent variable consistent throughout the study. External validity-because of this study generalizations can be made about pts undergoing LVHR will benefit from receiving TAP block , by reducing post-op pain & opioid use.Surgeons had knowledge of group assignments, some pts excluded from study, & data not collected on clinical differences.1A

Mrunalini, P., et al. Internal validity high. Confounding information not included like morbidly obese, drug dependence on opioids, and psychiatric disorders. Researcher bias not present. Findings limited to 24hr post op. Ultrasound guided not used. External validity. Not easily generalized to all patients undergoing laparoscopic procedures.1A

Peterson, P.L., et al.Internal validity high, external validity also high for any patients having laparoscopic abdominal surgery. Sampling technique: randomized, double-blind. Data collected at regular intervals and consistent. No evidence of researcher bias throughout the study.No assessment data b/ 8-24hrs, no sensory assessment done after blocks were performed to compare their effectiveness. 1A

Siddiqui, M.R., et al. Inclusion was completed by three separate researchers, eliminating personal bias. Despite small sample size, meta-analysis provides opportunity to for comparison of results among separate studies.Small sample size for meta-analysis. Heterogeneity of studies associated with different surgeries & timing/length of block administration. 1A

Wu, Y., et al.Internal validity high, external validity also high. Independent variables were consistent throughout the study. Sampling technique was randomized and single-blind. No evidence of research bias was notable.Pts w/ ASA>III & BMI>30 were excluded, which limits the external generalizability. Only single-injection subcostal TAP block was studied vs. continuous-infusion TAP block, even though a continuous epidural was used for comparison.1A

Clinical Implications

Opioid Amount?

VAS Pain Scores?

Time to Request (More Analgesia)

Conclusion

In our studies the use of TAP blocks provided higher pain relief and reduced opioid consumption when compared to placebo groups

TAP blocks were found especially beneficial during times of activity or coughing postoperative lay

Conclusion

While all the studies suggest a decrease in pain scores and opioid administration there is a wide variation on the degree of benefit across the literature review.

Additionally, none of the studies in the review show a significant decrease in opioid related side effects such as nausea, vomiting, or decrease GI motility.

References

Belavy, D., Colishaw, P., Howes, M. & Phillips, F. (2009). Ultrasound-guided transversus abdominis plane block for analgesia after Caesarean Delivery. British Journal of Anesthesia, 103(5), 726-730. doi:10.1093Baeriswyl, M., Kirkham, K. R., Kern, C., & Albrecht, E. (2015). The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients. Anesthesia & Analgesia, 121(6), 1640-1654. Retrieved December 21, 2015.

Fields, A.C., Gonzalez, D.O., Chin, E.H., Nguyen, S.Q., Zhang, L.P., Divino, C.M. (2015). Laparoscopic-assisted transversus abdominis plane block for postoperative pain control in laparoscopic ventral hernia repair: a randomized controlled trial. American College of Surgeons, 221(2), 462-469. doi: 10.1016/j.jamcollsurgMrunalini, P., Raju, N.V.R., Nath, V.N., Saheb, S.M. (2014). Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies. Anesthesia: Essays and Researches, 8(3), 377-382. doi: 10.4103/0259-1162.143153 Peterson, P. L., Stjernholm, P., Kristiansen, V. B., Torup, H., Hansen, E. G., Mitchell, A. U., . . . Mathiesen, O. (2012). The beneficial effect of transversus abdominis plane block after laparoscopic cholecystectomy in day-case surgery: a randomized clinical trial. Anesthesia & Analgesia, 115(3), 527-533. doi: 10.1213/ANE.0b013e318261f16eSiddiqui, M.R., Sajid, M.S., Uncles, D.R., Cheek, L., Baig, M.K. (2011). A meta-analysis on the clinical effectiveness of transversus abdominis plane block. Journal of Clinical Anesthesia, 23(1), 714. [PubMed: 21296242] Wu, Y., Liu, F., Tang, H., Wang, Q., Chen, L., Wu, H., . . . Xu, X. (2013). The Analgesic Efficacy of Subcostal Transversus Abdominis Plane Block Compared with Thoracic Epidural Analgesia and Intravenous Opioid Analgesia After Radical Gastrectomy. Regional Anesthesia, 117(2), 507-513. doi:10.1213/ANE.0b013e318297fcee

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