title: Efficacy of Local Anesthetic With Dexamethasone on the Quality of Recovery Following Total Extraperitoneal Bilateral Inguinal Hernia Repair: A Randomized Clinical Trial.
abstract: Quality of recovery (directly associated with patient satisfaction) is an important clinical outcome measurement and a surrogate of anesthetic/surgical care quality.
  
  
  
  To compare the efficacy of a transversus abdominis plane (TAP) block with dexamethasone sodium phosphate and preperitoneal instillation of local anesthetic (PILA) with dexamethasone vs control on postoperative quality of recovery following a bilateral total extraperitoneal inguinal hernia repair (TEP-IHR) (>24 hours). Secondary objectives included efficacy of this technique on postoperative opioid use, nausea and vomiting, and pain scores.
  
  
  
  Conducted from November 2013 to August 2015, this randomized, prospective, single-blinded study compared 2 groups (a TAP block and PILA) with a standard anesthetic technique with no regional technique (control) following bilateral TEP-IHR. This study at the Veterans Affairs Medical Center (Indianapolis, Indiana) included patients ages 18 to 80 years with an American Society of Anesthesiologists physical status of 1 to 3 scheduled for an outpatient bilateral TEP-IHR. Nurses assigning pain scores and administrating opioids for pain and staff anesthesiologists administering the Quality of Recovery-40 (QoR-40) questionnaire were blinded.
  
  
  
  Patients randomized to receive a TAP block with local anesthetics and dexamethasone, PILA with dexamethasone, or no regional technique (3 groups).
  
  
  
  Patient's response to the QoR-40 questionnaire following a TEP-IHR surgery.
  
  
  
  The mean (SD) ages in the TAP block (n = 19), PILA (n = 24), and control (n = 23) groups were 58.2 (9.4) years, 62.5 (8.1) years, and 62.9 (7.8) years, respectively. The global QoR-40 scores on postoperative day 1 for the TAP block group (median [interquartile range (IQR)], 178 [173-188]) were comparable with the control group (median [IQR], 174 [150-181]), while the PILA group had better global QoR-40 scores (median [IQR], 184 [175.5-190.75]) (P = .002). The effects of the TAP block and PILA on pain in the postoperative care unit (PACU) (median [IQR], 1 [0-5] and 3.5 [0-6.8], respectively), pain after discharge (median [IQR], 3 [2-5] and 3 [1-5.5], respectively), opiate use after discharge (median [IQR], 6.7 [5-10] and 6.7 [3.3-10], respectively), and incidence of nausea and vomiting in the PACU (4 of 19 [21.1%] and 6 of 24 [25%], respectively) were not significantly different from the control group (median [IQR], 4 [3-6] for pain scores in the PACU; 4 [3-7] for pain scores after discharge; 6.7 [3.3-10] for opioid use after discharge; and 6 of 23 [26.1%] for incidence of nausea/vomiting in the PACU). While there was a significant reduction of opioid use in the PACU in the TAP block group (median [IQR], 0 [0-1.3]) when compared with the control group (median [IQR], 4 [1.3-6.7]) (P = .001), this was not seen in the PILA group (median [IQR], 2 [0-6.4]).
  
  
  
  This study demonstrates a better quality of recovery in patients' receiving PILA with dexamethasone compared with control for a TEP-IHR surgery.
  
  
  
  clinicaltrials.gov Identifier: NCT02036983.
authors.affiliation: Department of Anesthesia, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Anesthesia, Indiana University School of Medicine, Indianapolis.
authors.forename: Bryan
authors.initials: B
authors.lastname: Sakamoto
authors.affiliation: Department of Anesthesia, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Anesthesia, Indiana University School of Medicine, Indianapolis.
authors.forename: Gene
authors.initials: G
authors.lastname: Harker
authors.affiliation: Department of Surgery, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana4Department of Surgery, Indiana University School of Medicine, Indianapolis.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Eppstein
authors.affiliation: Department of Anesthesia, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana2Department of Anesthesia, Indiana University School of Medicine, Indianapolis.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Gwirtz
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000772:Anesthesia, Local / Q000379:methods*; D000779:Anesthetics, Local; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D002045:Bupivacaine; D003289:Convalescence; D003907:Dexamethasone / Q000008:administration & dosage / Q000031:analogs & derivatives*; D005260:Female; D059685:Herniorrhaphy / Q000009:adverse effects*; D006801:Humans; D007264:Inguinal Canal / Q000601:surgery; D007322:Instillation, Drug; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000209:etiology; D009407:Nerve Block; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy / Q000517:prevention & control*; D011446:Prospective Studies; D016037:Single-Blind Method; D014839:Vomiting / Q000209:etiology
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D000893:Anti-Inflammatory Agents; C004180:dexamethasone 21-phosphate; D003907:Dexamethasone; D002045:Bupivacaine