title: Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: a prospective cohort study of 45 patients.
abstract: BACKGROUND
  The transversus abdominis plane (TAP) block is a peripheral nerve block of T6-L1 intercostal nerves of the abdominal wall. The purpose of this study was to evaluate the usefulness of intermittent TAP blockade for the first two postoperative days following free muscle sparing-transverse rectus abdominis muscle (MS-TRAM) or deep inferior epigastric perforator (DIEP) flap reconstruction of the breast. Therapeutic--Level II evidence.
  
  
  METHODS
  This prospective cohort consisted of 45 consecutive patients who underwent DIEP or MS-TRAM free-flap breast reconstruction. Intra-operatively, a multi-orifice epidural catheter was inserted under direct vision into the TAP. Ten millilitres of 0.25% bupivacaine was injected into each TAP catheter every 12 h until removal on day 3. The control group consisted of 80 consecutive patients who underwent free MS-TRAM or DIEP free-flap breast reconstructions by the same two surgeons without TAP block. Postoperatively, both groups had patient-controlled analgesia (PCA) and the primary outcome was intravenous (IV) PCA opioid consumption in the first 48 h.
  
  
  RESULTS
  There were no complications associated with using TAP catheters. The 48-h PCA-delivered opioid requirement was significantly less (p<0.001) in the TAP block group (17.10±17.23 mg IV morphine equivalent) compared to the control group (48.44±39.53 mg).
  
  
  CONCLUSIONS
  Intermittent delivery of bupivacaine through the TAP block significantly reduced postoperative parenteral opioid requirements following free MS-TRAM or DIEP flap reconstruction of the breast. This is the first report of the TAP block being inserted under direct vision to provide postoperative analgesia at the abdominal flap donor site following microsurgical breast reconstruction.
authors.affiliation: Division of Plastic and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada. toni.zhong@uhn.ca
authors.forename: Toni
authors.initials: T
authors.lastname: Zhong
authors.forename: Karen W
authors.initials: KW
authors.lastname: Wong
authors.forename: Homan
authors.initials: H
authors.lastname: Cheng
authors.forename: Marie
authors.initials: M
authors.lastname: Ojha
authors.forename: Coimbatore
authors.initials: C
authors.lastname: Srinivas
authors.forename: Stuart A
authors.initials: SA
authors.lastname: McCluskey
authors.forename: Hance
authors.initials: H
authors.lastname: Clarke
authors.forename: Lindsay
authors.initials: L
authors.lastname: Jacks
authors.forename: Stefan O P
authors.initials: SO
authors.lastname: Hofer
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001943:Breast Neoplasms / Q000601:surgery; D002045:Bupivacaine / Q000008:administration & dosage; D016022:Case-Control Studies; D057785:Catheters; D015331:Cohort Studies; D019074:Epigastric Arteries / Q000637:transplantation; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D015999:Multivariate Analysis; D009407:Nerve Block / Q000379:methods*; D010147:Pain Measurement / Q000187:drug effects; D010149:Postoperative Pain / Q000517:prevention & control*; D017060:Patient Satisfaction; D011446:Prospective Studies; D017568:Rectus Abdominis / Q000601:surgery* / Q000637:transplantation; D012016:Reference Values; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D013524:Surgical Flaps / Q000098:blood supply* / Q000294:innervation; D060053:Transplant Donor Site; D016896:Treatment Outcome
chemical_list: D002045:Bupivacaine