title: Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia.
abstract: Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.
authors.affiliation: Department of Anesthesiology and Pain Management, Fairview Hospital; Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute Cleveland, Ohio.
authors.forename: Sabry
authors.initials: S
authors.lastname: Ayad
authors.affiliation: Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas and Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Rovnat
authors.initials: R
authors.lastname: Babazade
authors.affiliation: Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Hesham
authors.initials: H
authors.lastname: Elsharkawy
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Vinayak
authors.initials: V
authors.lastname: Nadar
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Chetan
authors.initials: C
authors.lastname: Lokhande
authors.affiliation: Departments of Qualitative Health Sciences and Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Natalya
authors.initials: N
authors.lastname: Makarova
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Rashi
authors.initials: R
authors.lastname: Khanna
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.affiliation: Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio.
authors.forename: Alparslan
authors.initials: A
authors.lastname: Turan
mesh_terms: D000009:Abdominal Muscles / Q000187:drug effects; D000328:Adult; D000368:Aged; D000465:Algorithms; D015360:Analgesia, Epidural / Q000379:methods*; D016058:Analgesia, Patient-Controlled / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D002045:Bupivacaine / Q000008:administration & dosage*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D007902:Length of Stay; D008081:Liposomes; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D059408:Pain Management / Q000379:methods; D010147:Pain Measurement; D010149:Postoperative Pain / Q000628:therapy; D012042:Registries; D012189:Retrospective Studies; D013256:Steroids / Q000627:therapeutic use
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D008081:Liposomes; D013256:Steroids; D009020:Morphine; D005283:Fentanyl; D002045:Bupivacaine