Background & Aims

Background: Previous research by Onisimo in 2016 showed that pain management following Total Abdominal Hysterectomy (TAH) is an ongoing major issue requiring improvements at Lautoka Hospital, a Divisional Hospital in Fiji. Bilateral Tranversus Abdominis Plane Block (TAP block) or Local Wound Infiltrations (LWI) are components of multimodal analgesia for postoperative TAH pain management.
Aim: To compare bilateral ultrasound guided TAP blocks with LWI for postoperative analgesia in women undergoing TAH under general anesthesia at Lautoka Hospital.
Objectives: The primary objectives were to measure postoperative pain scores using the numerical rating scale and to calculate and compare postoperative opioid consumption in the first 24 hours. The secondary objectives were to; compare length of stay in recovery unit (PARU), evaluate patient satisfaction scores at 24 hours post surgery, compare time to mobilize out of bed and length of postoperative hospital stay.

Methods

A single center, prospective, double blinded, randomized controlled trial was conducted at Lautoka Hospital during a 6 month period between February, 2021 and July, 2021.Sample size of minimum 28 participants was calculated using a sample size calculator. Thirty women undergoing TAH were randomized into two groups: in TAP group, 15 women received bilateral ultrasound guided TAP blocks with 20ml of 0.25% bupivacaine on each side; in the LWI group, 15 women received 40 ml of 0.25% bupivacaine directly into the incisional wound edges, both performed at the end of TAH under general anesthesia. Postoperatively, participants received multimodal analgesia including regular paracetamol and diclofenac and as required dosing (prn) of intravenous morphine. The outcomes were measured according to the objectives in PARU and ward. Nonparametric inferential methodology was used to analyze continuous data while Fisher’s exact two tailed test was used to analyze categorical data using SSPS software.

Results

There were no significant differences in the demographic characteristic of population between two groups except for age. The median age (IQR) in TAP group was 49 (23) years as compared to 45 (11) years in the LWI group (P=0.002).
Primary Outcomes: Compared to LWI, bilateral ultrasound guided TAP blocks resulted in: lower pain scores on rested in at 1-hour post operation (P = 0.037); lower pain scores on movement up to 24 hours (P < 0.05); reduced postoperative opioid consumption (P = 0.001); reduced breakthrough pain relief required in the ward (P < 0.0001). Secondary Outcomes: There was no statistically significant differences in the length of PARU stay between the groups. However, TAP group showed; earlier time to mobilization out of bed (P= 0.01), improved patient satisfaction scores (P < 0.0001) and not statistically but clinically significant reduction in length of Post-operative hospital stay (P = 0.267)

Conclusions

As a component of multimodal analgesia, TAP block is superior to LWI for postoperative TAH pain management. Specifically, TAP block compared to LWI was associated with: reduced pain scores, reduced opioid consumption; earlier mobilization and improved patient satisfaction.
This study, supported the following recommendations:
– Routine uptake of TAP blocks for TAH.
– Encourage multimodal analgesia to optimize postoperative outcomes.
– Consideration of broader utilization of TAP Blocks for all lower abdominal surgeries.
– Development of standardized local postoperative analgesia guidelines.
– Procurement of equipment and drugs to ensure accessibility including:
– Ultrasound scan machine specifically for theatre use.
– Include diclofenac suppositories in essential drug list for postoperative use in theatre and ward.
– Procedure designed specific block needles for regional technique safety.
-Future research can investigate barriers, cost effectiveness and long term outcomes.

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Presenting Author

Yogen Deo

Poster Authors

Yogen Deo

MMED in Anaesthesia

Fiji National University

Lead Author

Topics

  • Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science