Liposomal bupivacaine infiltration into the transversus abdominis plane for postsurgical analgesia in open abdominal umbilical hernia repair: results from a cohort of 13 patients

Journal of Pain Research Dovepress open access to scientific and medical research Original Research Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Open Access Full Text Article Liposomal bupivacaine infiltration into the transversus abdominis plane for postsurgical analgesia in open abdominal umbilical hernia repair: results from a cohort of 13 patients This article was published in the following Dove Press journal: Journal of Pain Research 16 August 2014 Number of times this article has been viewed Dennis E Feierman Mark Kronenfeld Piyush M Gupta Natalie Younger Eduard Logvinskiy Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA Correspondence: Dennis E Feierman Department of Anesthesiology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA Tel +1 718 283 7611 Fax +1 718 283 8377 Email Introduction Achieving adequate postsurgical pain control remains a significant challenge for surgical teams. Despite efforts to reduce both the incidence and severity of postsurgical pain, results from patient surveys conducted during the past two decades suggest that there has been little improvement in these parameters, with high incidence rates of moderate to severe pain after surgery.1–3 477 submit your manuscript | www.dovepress.com Journal of Pain Research 2014:7 477–482 Dovepress © 2014 Feierman et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php http://dx.doi.org/10.2147/JPR.S65151 Powered by TCPDF (www.tcpdf.org) Background: Achieving adequate control of postsurgical pain remains a challenge in patients undergoing abdominal surgery. Transversus abdominis plane (TAP) infiltration has been shown to provide postsurgical analgesia following lower abdominal surgery. We assessed the safety and efficacy of a prolonged-release liposomal formulation of the local anesthetic bupivacaine administered via infiltration into the TAP in a cohort of patients undergoing open abdominal umbilical hernia repair. Methods: Patients included in the study were 18–75 years of age, had American Society of Anesthesiologists physical classification status 1–3, and underwent open abdominal umbilical hernia repair with ultrasound-guided TAP infiltration immediately after surgery using an equal-volume bilateral infusion of liposomal bupivacaine 266 mg (diluted to 30 mL in normal saline). Outcome measures included patient-reported pain intensity (11-point numeric rating scale), satisfaction with postsurgical analgesia (5-point Likert scale), incidence of opioid-related adverse events, and time to first use of supplemental rescue analgesia. Results: Thirteen patients underwent surgery and received bilateral TAP infiltration with liposomal bupivacaine; TAP infiltration failed in the first patient. Mean numeric rating scale pain scores were 0.6 immediately before TAP infiltration and remained 2.3 through 120 hours after infiltration; mean scores at 120 hours and 10 days were 0.9 and 0.4, respectively. Ten patients (77%) required supplemental analgesia; median time to first use was 11 hours. At discharge and day 10, 54% and 62% of patients, respectively, were “extremely satisfied” with postsurgical analgesia (Likert score 5). There were no opioid-related or other adverse events. Conclusion: Although the current study was limited by both its lack of a control group and its small size, to our knowledge, it is the first published report on use of liposomal bupivacaine for TAP infiltration. In this cohort, liposomal bupivacaine was observed to be well tolerated with encouraging analgesic efficacy. Keywords: analgesia, bupivacaine, hernia repair surgery, postoperative pain, infiltration anesthesia Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Feierman et al Transversus abdominis plane (TAP) infiltration, which involves infiltration of local anesthetic into the TAP between the internal oblique and transversus abdominis muscles, has been used to provide postsurgical analgesia in a range of surgical procedures involving the middle or lower abdominal wall.4,5 This analgesic technique is aimed at sensory afferents of the lower thoracic and upper lumbar nerves. It was introduced as a landmark-based method in 2001, and has since been refined with the use of ultrasound guidance to improve the accuracy of anesthetic placement.4,5 A 2012 meta-analysis of nine studies evaluating TAP infiltration in abdominal surgery found that its use was associated with significant reductions in postsurgical opioid use and in the incidence of postoperative nausea and vomiting compared with placebo, as well as a trend toward reduced visual analog scale (VAS) pain scores.4 In patients undergoing inguinal hernia repair, randomized studies have shown that ultrasound-guided TAP infiltration significantly reduces postsurgical pain scores and postsurgical opioid use, compared with ilioinguinal/iliohypogastric nerve block6 or with conventional wound infiltration with local anesthetic.7 In our surgical practice, we have employed ultrasoundguided TAP infiltration using the local anesthetic bupivacaine HCl for patients undergoing inguinal hernia repair. There is little evidence in the published literature showing postsurgical analgesia lasting longer than 24 hours following TAP infiltration with traditional formulations of local anesthetics.6–9 In our practice, we have observed that TAP infiltration with bupivacaine HCl typically results in persistent analgesia for approximately 12–18 hours after surgery. A liposomal formulation of bupivacaine (Exparel®; bupivacaine liposome injectable suspension, Pacira Pharmaceuticals Inc., Parsippany, NJ, USA) was approved in 2011 for administration into the surgical site to produce postsurgical analgesia.10 In randomized, double-blind, controlled studies across a range of surgical models, liposomal bupivacaine has been found to reduce pain intensity scores and postsurgical opioid consumption, and to extend the time to first use of rescue analgesics, compared with placebo or bupivacaine HCl.11 A pooled analysis of data from ten clinical studies of liposomal bupivacaine showed that liposomal bupivacaine doses 266 mg were well tolerated, with rates of adverse events and serious adverse events that were lower than for bupivacaine HCl and comparable with placebo.12 In a (...truncated)