Real-world insights on the use of transversus abdominis plane block with liposomal bupivacaine in the multimodal management of somatic versus visceral pain in the colorectal surgery setting

Journal of Pain Research Dovepress open access to scientific and medical research E D I TO R I A L Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. Open Access Full Text Article Real-world insights on the use of transversus abdominis plane block with liposomal bupivacaine in the multimodal management of somatic versus visceral pain in the colorectal surgery setting This article was published in the following Dove Press journal: Journal of Pain Research Nicholas C Connolly Introduction Bend Anesthesiology Group, Bend, OR, USA Multimodal approaches are recommended to achieve effective postsurgical analgesia with reduced opioid reliance and are integral to enhanced recovery after surgery (ERAS) protocols. Transversus abdominis plane (TAP) block is a regional analgesia technique commonly used in colorectal ERAS protocols, particularly in the laparoscopic surgery setting. Clinical trial data demonstrate TAP block with liposomal bupivacaine ([LB]; Exparel®, bupivacaine liposome injectable suspension; Pacira Pharmaceuticals, Inc., Parsippany, NJ, USA) to be an effective opioid-sparing approach for controlling pain after colorectal surgery. However, clinical trials poorly address patient factors that might affect outcomes using this approach. This editorial provides the author’s personal experience and opinions regarding the optimal use of LB in multimodal management of somatic versus visceral pain and in complex cases, including patients with ulcerative colitis (UC) or other intense visceral inflammatory processes. Such patients are difficult to manage because of visceral pain, chronic opioid use, and increased opioid requirements and may require epidural analgesia and dose escalation. The author’s clinical experience suggests that TAP block with LB may not fully address visceral pain but can improve the somatic component, reducing the necessary epidural analgesia dose and allowing for the safe expansion of treatment options to include modalities that control visceral pain. Additional data are needed to further determine how patient factors such as comorbid disease affect efficacy and safety outcomes with this approach. Multimodal pain management in colorectal surgery Correspondence: Nicholas C Connolly Bend Anesthesiology Group, 2500 Northeast Neff Road, Bend, OR 97701, USA Tel +1 801 432 2600 Fax +1 801 676 5961 Email 1141 submit your manuscript | www.dovepress.com Journal of Pain Research 2018:11 1141–1146 Dovepress © 2018 Connolly. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/JPR.S168817 Powered by TCPDF (www.tcpdf.org) Effective control of postsurgical pain can reduce the likelihood of complications, improve patient satisfaction and recovery, and decrease hospital length of stay and costs.1–3 Opioid analgesics are central to pain management in many surgical settings.1 However, their use puts patients at risk for opioid-related adverse events (ORAEs) and chronic opioid use.4,5 Multimodal analgesia incorporating systemic therapies, regional anesthesia techniques with local anesthetics, and neuraxial anesthesia techniques with or without opioids is recommended as an opioid-sparing approach to manage postsurgical pain2,6 and is an important component of ERAS protocols for colorectal surgery, aiming to minimize postoperative ileus and sedation.7,8 Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. Connolly Epidural anesthesia and TAP block are commonly used regional anesthesia techniques in ERAS protocols for colorectal surgery.8 Usage of these techniques is still evolving and varies according to the procedure. Although epidural anesthesia is strongly recommended for open colorectal procedures, its risks are generally considered to outweigh its benefits in laparoscopic procedures.9 In the laparoscopic setting, alternatives such as TAP block, which provides analgesia to the anterior abdominal wall,10 may be favored over epidural techniques.8 There is considerable heterogeneity in studies of TAP block in colorectal surgery, and most studies have involved laparoscopic procedures. However, data support effectiveness of TAP block in reducing opioid reliance after colorectal surgery.7 Advantages over epidural anesthesia include procedural simplicity; preservation of lower limb motor function, urinary function, and hemodynamic stability; and ability to use in patients with contraindications to epidural analgesia such as anticoagulant use.7 The optimal local anesthetic for TAP block is not currently agreed upon,11 but available data suggest that LB, a prolonged-release formulation of bupivacaine,12 may offer improved effectiveness compared with non-liposomal local anesthetic.13 Across a variety of procedural settings, surgical site infiltration with LB has been demonstrated to provide analgesia for up to 72 hours with reduced postsurgical opioid consumption.14,15 Results of a pooled analysis of 10 clinical studies show a similar safety profile for LB and bupivacaine HCl, with no signs of cardiac or central nervous system (CNS) toxicity; the most commonly reported adverse events were nausea, constipation, and vomiting, which are typically associated with opioid use.16 As with all local anesthetics, LB carries a risk for local anesthetic systemic toxicity (LAST), a potentially life-threatening event that can occur subsequent to accidental intravascular injection.17 However, the pharmacokinetic profile of LB, namely, the lower peak plasma bupivacaine concentration,18 suggests that the risk of acute systemic toxicity may be lower than with bupivacaine HCl. LB in colorectal surgery In the colorectal surgery setting, LB has been evaluated primarily for local infiltration analgesia,15,19–22 with two recent studies in TAP block.13,23 The first, a retrospective cohort study, demonstrated significant reductions in requirements for postsurgical ketorolac and opioids after colorectal surgery in patients receiving TAP block with LB compared with those receiving TAP block with bupivacaine HCl. No significant difference in length of stay, a secondary outcome, was observed.13 In the second prospective cohort study, patients who underwent laparoscopic colorectal resection with a 1142 Powered by TCPDF (www.tcpdf.org) submit (...truncated)