Anesth Pain Med.  2022 Jan;17(1):75-86. 10.17085/apm.21094.

Analgesic effects of ultrasound-guided fourquadrant transversus abdominis plane in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study

• Song J
• Choi N
• Kang M
• Ji SM
• Kim Dw
• Kwon MA

• KMID: 2526531
• DOI: http://doi.org/10.17085/apm.21094

Abstract

Background
Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control.
Methods
Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications.
Results
During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups.
Conclusions
The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.

Keyword

Cytoreduction surgical procedure; Hyperthermic intraperitoneal chemotherapy; Nerve block; Postoperative complications; Postoperative pain

Figure

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  Fig. 1. Flow chart of the study. 4Q-TAP: four-quadrant transabdominal plane.

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  Fig. 2. Numeric rating scale (NRS) every 6 h for 5 postoperative days. Repeatedly measured NRS for 5 postoperative days was not different for both the groups (repeated measures of analysis of variance with Greenhous-Geisser correction, between-subject effect, P = 0.407, within-subject effect, P = 0.008, and interaction effect, P = 0.686). 4Q-TAP: four-quadrant transabdominal plane.

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  Fig. 3. Fentanyl requirement in intravenous patient-controlled analgesia (IV PCA) for 5 postoperative days. Fentanyl doses administered by IV PCA for 5 days after surgery were significantly lower in the 4Q-TAP group than in the control group (repeated measures of analysis of variance with Greenhous-Geisser correction, between-subject effect, P = 0.038). Moreover, fentanyl doses were significantly different according to the time (within-subject effect, P < 0.001), and there was also a significant interaction effect of both variables (P = 0.029) (4Q-TAP group: four-quadrant transabdominal plane block group, Control group: control group). *P < 0.05 in the comparison between two groups at each point of time.

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