D. M. Hall1, S. Christian1, C. Moore1, J. Deneve1, P. Dickson1, R. S. Daugherty1, S. W. Behrman1, M. Kent2, B. Bicknell2, D. Shibata1, L. Douthitt2, E. Glazer1 1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2Medical Anesthesia Group,Anesthesia,Memphis, TN, USA
Introduction: Minimizing opiate use after major abdominal operations has shown promise as part of enhanced recovery after surgery programs (ERAS). Alternatives to epidural (EP) such as intrathecal/spinal (IS) analgesia blocks or transversus abdominus plane (TAP) injections often allow a reduction in opioid usage. At our institution, intrathecal/spinal block + TAP (S-TAP) has not yet been compared to EP in patients undergoing major abdominal operations. We hypothesized that intrathecal/spinal block + TAP (S-TAP) injections might provide similar post-operative analgesia, similar pain scores, and a similar amount of opiate use compared to EP and multimodality therapy when utilized in patients undergoing major abdominal operations.
Methods: We retrospectively reviewed all patients treated by our ERAS protocol over a 6-month time period who underwent major gastrointestinal and hepatopancreatobiliary operations. Patients were included if they received an EP, S-TAP block, or if the ERAS service was consulted. Pain scores (PS) (scored 0 -10 for the first 5 post-operative days), daily opioid use for the first 5 post-operative days, and total length of stay (LOS) were compared amongst patients with epidurals (bupivacaine), S-TAP (dilaudid & bupivacaine), and a group receiving multimodality oral/intravenous analgesia (acetaminophen, opioids, ketamine, gabapentin, and/or NSAIDs). Patients in the EP and S-TAP groups also received multimodality analgesics. Means were compared with ANOVA and Student’s t-test. Multivariate analysis was performed with linear regression.
Results: 120 patients were identified (average age of 60 ± 13 years; 53% were male). Only those who underwent open operations (n = 88) were investigated. 40 (45%) patients underwent operations for cancer. 27 patients were in the EP group, 20 patients were in the S-TAP group, and 41 patients were in the multimodality group. Pain scores were similar amongst the groups (P>0.12 each day) with the exception of POD0 where the multimodality group PS was 8.5 compared with 6.5 for the EP (P=0.03) and 6.36 for S-TAP (P=0.02). The EP group used significantly fewer opiate equivalents (total 70 mg morphine equivalents) compared to the S-TAP group (total 165 mg, P=0.04) and multimodality group (134 mg, P=0.03). The mean LOS for the S-TAP group (6.75 days) was significantly shorter than the multimodality group (11 days, P=0.03) but not significantly different from the epidural group (8.5 days, P=0.20).
Conclusion: The patients in the EP group, S-TAP group, and multimodality group had similar pain scores, similar length of stay, but a significant difference in opiate use after major abdominal operations. Based on these results in our institutional population, S-TAP optimization in an ERAS protocol may help provide equivalence to epidural use in select environments and patient populations.
