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Effect of transversus abdominis plane block in combination with general anesthesia on perioperative opioid consumption, hemodynamics, and recovery in living liver donors: The prospective, double-blinded, randomized study

Clin Transplant. 2017 Apr;31(4) doi: 10.1111/ctr.12931.

Abstract

BACKGROUND:

Transversus abdominis plane (TAP) block provides effective postoperative analgesia after abdominal surgeries. It can be also a useful strategy to reduce perioperative opioid consumption, support intraoperative hemodynamic stability, and promote early recovery from anesthesia. The aim of this prospective randomized double-blind study was to assess the effect of subcostal TAP blocks on perioperative opioid consumption, hemodynamic, and recovery time in living liver donors.

METHODS:

The prospective, double-blinded, randomized controlled study was conducted with 49 living liver donors, aged 18-65 years, who were scheduled to undergo right hepatectomy. Patients who received subcostal TAP block in combination with general anesthesia were allocated into Group 1, and patients who received general anesthesia alone were allocated into Group 2. The TAP blocks were performed bilaterally by obtaining an image with real-time ultrasound guidance using 0.5% bupivacaine diluted with saline to reach a total volume of 40 mL. The primary outcome measure in our study was perioperative remifentanil consumption. Secondary outcomes were mean blood pressure (MBP), heart rate (HR), mean desflurane requirement, anesthesia recovery time, frequency of emergency vasopressor use, total morphine use, and length of hospital stay.

RESULTS:

Total remifentanil consumption and the anesthesia recovery time were significantly lower in Group 1 compared with Group 2. Postoperative total morphine use and length of hospital stay were also reduced. Changes in the MAP and HR were similar in the both groups. There were no significant differences in HR and MBP between groups at any time.

CONCLUSIONS:

Combining subcostal TAP blocks with general anesthesia significantly reduced perioperative and postoperative opioid consumption, provided shorter anesthesia recovery time, and length of hospital stay in living liver donors.

CET Conclusion

Reviewer:	Mr John O'Callaghan, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.
Conclusion:	This study was a double-blinded, randomized controlled trial. Although it is not clear how the anaesthesiologist collecting the data was blinded to the allocation, did they leave the operating theatre, whilst the TAP block was done (or not done) by the surgeons? Just 44 living liver donors in total were included in the study, which at first seems to be too few, however there was such a difference in mean remifentanil use, that a statistical significance was demonstrated. There was no pre-study sample size calculation presented in the paper, just a post-hoc calculation of 99% power. The authors concluded that TAP blocks reduced total remifentanil use intra-op, anaesthesia recovery time, total morphine use and length of hospital stay. There were no significant differences in heart rate and mean blood pressure. Post-operative pain scores were not recorded.

Reviewer:

Mr John O'Callaghan, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.

Conclusion:

This study was a double-blinded, randomized controlled trial. Although it is not clear how the anaesthesiologist collecting the data was blinded to the allocation, did they leave the operating theatre, whilst the TAP block was done (or not done) by the surgeons? Just 44 living liver donors in total were included in the study, which at first seems to be too few, however there was such a difference in mean remifentanil use, that a statistical significance was demonstrated. There was no pre-study sample size calculation presented in the paper, just a post-hoc calculation of 99% power. The authors concluded that TAP blocks reduced total remifentanil use intra-op, anaesthesia recovery time, total morphine use and length of hospital stay. There were no significant differences in heart rate and mean blood pressure. Post-operative pain scores were not recorded.

Methodological quality

Jadad score	5
Allocation concealment	YES
Data analysis	INTENTION TO TREAT

Study Details

Aims:	To assess the effect of subcostal transversus abdominis plane (TAP) blocks on perioperative opioid consumption, hemodynamic stability and anaesthesia recovery time in living liver donors.
Interventions:	Participants were randomised into two groups and received either the US-guided subcostal TAP blocks with a combination of standard general anaesthesia, versus standard general anaesthesia alone, without TAP block.
Participants:	44 patients aged 18-65 years scheduled to undergo a right hepatectomy for living-donor liver transplantation.
Outcomes:	The primary outcome measured was total perioperative remifentanil consumption. Other outcomes measured included anaethesia recovery time, desflurane requirement, total morphine use, length of hospital stay, frequency of emergency vasopressor use, mean blood pressure and heart rate.
Follow Up:	End of hospital stay

Metadata

Funding:	No funding was received for this study
Publication type:	Randomized Controlled Trial, Randomised Controlled Trial
Organ:	Liver
Language:	English
Author email:	drmalierdogan@gmail.com
MeSH terms:	Abdominal Muscles; Adolescent; Adult; Aged; Analgesics, Opioid; Anesthesia, General; Double-Blind Method; Female; Follow-Up Studies; Hemodynamics; Humans; Liver Transplantation; Living Donors; Male; Middle Aged; Nerve Block; Pain, Postoperative; Prognosis; Prospective Studies; Risk Factors; Young Adult; 0 (Analgesics, Opioid)