title: Intravenous patient-controlled fentanyl with and without transversus abdominis plane block in cirrhotic patients post liver resection.
abstract: BACKGROUND
  Coagulation changes can complicate liver resection, particularly in patients with cirrhosis. The aim of this prospective hospital-based comparative study was to compare the postoperative analgesic efficacy of intravenous fentanyl patient-controlled analgesia (IVPCA) with and without transversus abdominis plane (TAP) block.
  
  
  METHODS
  Fifty patients with Child's A cirrhosis undergoing liver resection were randomly divided into two groups for postoperative analgesia, ie, an IVPCA group receiving a 10 μg/mL fentanyl bolus of 15 μg with a 10-minute lockout and a maximum hourly dose of 90 μg, and an IVPCA + TAP group that additionally received TAP block (15 mL of 0.375% bupivacaine) on both sides via a posterior approach with ultrasound guidance before skin incision. Postoperatively, bolus injections of bupivacaine 0.375% were given every 8 hours through a TAP catheter inserted by the surgeon in the open space during closure of the inverted L-shaped right subcostal with midline extension (subcostal approach) guided by the visual analog scale score (<3, 5 mL; 3 to <6, 10 mL; 6-10, 15-20 mL) according to weight (maximum 2 mg/kg). The top-up dosage of local anesthetic could be omitted if the patient was not in pain. Coagulation was monitored using standard coagulation tests.
  
  
  RESULTS
  Age, weight, and sex were comparable between the groups (P>0.05). The visual analog scale score was significantly lower at 12, 18, 24, 48, and 72 hours (P<0.01) in IVPCA + TAP group. The Ramsay sedation score was lower only after 72 hours in the IVPCA + TAP group when compared with the IVPCA group (1.57±0.74 versus 2.2±0.41, respectively, P<0.01). Heart rate, systolic blood pressure, and fentanyl consumption were lower in the IVPCA + TAP group at 24, 48, and 72 hours (P<0.05). Intensive care unit stays were significantly shorter with TAP (2.61±0.74 days versus 4.35±0.79 days, P<0.01). Prothrombin time and International Normalized Ratio indicated temporary hypocoagulability in both groups.
  
  
  CONCLUSIONS
  Combining TAP with IVPCA improved postoperative pain management and reduced fentanyl consumption, with a shorter stay in intensive care. TAP block can be included as part of a balanced multimodal postoperative pain regimen.
authors: Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt.
authors: Manar
authors: M
authors: Serag Eldin
authors: Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt.
authors: Fatma
authors: F
authors: Mahmoud
authors: Department of Anaesthesia, Faculty of Medicine, Menoufiya University, Shebin El-Kom, Egypt.
authors: Rabab
authors: R
authors: El Hassan
authors: Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt.
authors: Mohamed
authors: M
authors: Abdel Raouf
authors: Department of Anaesthesia, Faculty of Medicine, Menoufiya University, Shebin El-Kom, Egypt.
authors: Mohamed H
authors: MH
authors: Afifi
authors: Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt.
authors: Khaled
authors: K
authors: Yassen
authors: Department of Community Medicine and Public Health, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt.
authors: Wesam
authors: W
authors: Morad
keywords: liver resection; postoperative pain; transversus abdominis plane block