Reduction of opioid use using regional anesthetic blocks after inguinal hernia repair in a high risk, safety net population

Sayeeda Rab, BS; Sudeepti Vedula, BS; Aziz M. Merchant, MD, FACS

doi:10.5055/jom.2021.0665

Authors

Sayeeda Rab, BS
Sudeepti Vedula, BS
Aziz M. Merchant, MD, FACS https://orcid.org/0000-0003-1091-938X

DOI:

https://doi.org/10.5055/jom.2021.0665

Keywords:

transversus abdominus block, visual analog scale, inguinal hernia repair, opioid epidemic, postoperative analgesia

Abstract

Objective: The transversus abdominis plane (TAP) block is currently being used perioperatively to reduce postoperative opioid requirements. It is unclear whether TAP blocks reduce postoperative opioid requirements for inguinal hernia repairs. The purpose of this retrospective chart study was to determine whether a TAP block reduces postoperative opioid requirements after an inguinal hernia repair in a safety net hospital.

Design: This was a retrospective chart review that evaluated patients at University Hospital in Newark, NJ, who had inguinal hernia repairs from January 2011 to July 2019. Patients were divided into two groups depending on whether they had a TAP block or not. The primary outcome was the amount of opioid required in the first 24 hours postoperatively by a patient reported as morphine equivalent dosing (MED).

Results: The group that received the TAP block had a mean (95 percent CI) MED of 7.01 mg (6.70, 7.33), and the control group (no TAP block) had a mean MED of 11.6 mg within 24 hours of the inguinal hernia (p = 0.03). There was no significant difference for postoperative visual analog scale (VAS) pain score, presence of nausea, or length of stay.

Conclusions: Patients with TAP block required less morphine equivalence of opioid within a 24 hours period after an inguinal hernia repair.

Author Biographies

Sayeeda Rab, BS

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey

Sudeepti Vedula, BS

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey

Aziz M. Merchant, MD, FACS

Associate Professor of Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey

References

Levy B, Paulozzi L, Mack KA, et al.: Trends in opioid analgesic-prescribing rates by specialty, US, 2007-2012. Am J Prev Med. 2015; 49(3): 409-413. DOI: 10.1016/j.amepre.2015.02.020.

Hah JM, Bateman BT, Ratliff J, et al.: Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesth Analg. 2017; 125(5): 1733-1740. DOI: 10.1213/ANE.0000000000002458.

Beldi G, Haupt N, Ipaktchi R, et al.: Postoperative hypoesthesia and pain: Qualitative assessment after open and laparoscopic inguinal hernia repair. Surg Endosc Other Interv Tech. 2008; 22(1): 129-133. DOI: 10.1007/s00464-007-9388-4.

General surgery–inguinal hernia. Available at https://generalsurgery.ucsf.edu/conditions--procedures/inguinal-hernia.aspx. Accessed January 5, 2020.

Hill MV, Mcmahon ML, Stucke RS, et al.: Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017; 265(4): 709-714. DOI: 10.1097/SLA.0000000000001993.

Brummett CM, Waljee JF, Goesling J, et al.: New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017; 152(6): 170504. DOI: 10.1001/jamasurg.2017.0504.

Scholl L, Seth P, Kariisa M, et al.: Drug and opioid-involved overdose deaths—United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018; 67(5152). DOI: 10.15585/mmwr.mm6751521e1.

Hedegaard H, Miniño AM, Warner M: Urban-rural differences in drug overdose death rates, by sex, age, and type of drugs involved, 2017 key findings data from the National Vital Statistics System, Mortality. 2017. Available at https://www.cdc.gov/nchs/products/index.htm. Accessed January 17, 2020.

Sutton JP, Washington RE, Fingar KR, et al.: Characteristics of safety-net hospitals, 2014. 2014. Available at http://healthaffairs.org/blog/2015/03/16/can-safety-net-hospital-systems-redesign-. Accessed January 17, 2020.

Anderson R, Cunningham P, Hofmann P, et al.: Protecting the hospital safety net. Inquiry. 2009; 46(1): 7-16. DOI: 10.5034/inquiryjrnl_46.01.7.

Department of Health & Human Services: Addressing prescription drug abuse in the United States current activities and future opportunities. Available at http://wonder.cdc.gov. Accessed January 5, 2020.

Sun EC, Darnall BD, Baker LC, et al.: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016; 176(9): 1286-1293. DOI: 10.1001/jamainternmed.2016.3298.

Bonnet F, Berger J, Aveline C: Transversus abdominis plane block: What is its role in postoperative analgesia? Br J Anaesth. 2009; 103(4): 468-470. DOI: 10.1093/bja/aep243.

Young MJ, Gorlin AW, Modest VE, et al.: Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract. 2012; 2012. DOI: 10.1155/2012/731645.

Rafi AN: Abdominal field block: A new approach via the lumbar triangle. Anaesthesia. 2008; 56(10): 1024-1026. DOI: 10.1111/j.1365-2044.2001.2279-40.x.

McDonnell JG, O’Donnell B, Curley G, et al.: The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg. 2007; 104(1): 193-197. DOI: 10.1213/01.ane.0000250223.49963.0f.

Siddiqui MRS, Sajid MS, Uncles DR, et al.: A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 2011; 23(1): 7-14. DOI: 10.1016/j.jclinane.2010.05.008.

Johns N, O’Neill S, Ventham NT, et al.: Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: A systematic review and meta-analysis. Color Dis. 2012; 14(10): e635-e642. DOI: 10.1111/j.1463-1318.2012.03104.x.

Gao T, Zhang JJ, Xi FC, et al.: Evaluation of transversus abdominis plane (TAP) block in hernia surgery. Clin J Pain. 2017; 33(4): 369-375. DOI: 10.1097/AJP.0000000000000412.

Petersen PL, Mathiesen O, Stjernholm P, et al.: The effect of transversus abdominis plane block or local anaesthetic infiltration in inguinal hernia repair: A randomised clinical trial. Eur J Anaesthesiol. 2013; 30(7): 415-421. DOI: 10.1097/EJA.0b013e32835fc86f.

Jenkins JT, O’Dwyer PJ: Inguinal hernias. BMJ. 2008; 336(7638): 269-272. DOI: 10.1136/bmj.39450.428275.AD.

Wolters Kluwer: Morphine equivalent dosing in RxPertsIndustry Insights. Available at https://www.wolterskluwercdi.com/sites/default/files/documents/ebooks/morphineequivalent-dosing-ebook.pdf?v3. Accessed January 18, 2020.

American Society of Addiction Medicine: Public Policy Statement on Morphine Equivalent Units/Morphine Milligram Equivalents Background. Chevy Chase, MD: American Society of Addiction Medicine, 2016. DOI: 10.15585/mmwr.rr6501e1.

McDonnell JG, Curley G, Carney J, et al.: The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg. 2008; 106(1): 186-191. DOI: 10.1213/01.ane.0000290294.64090.f3.

Tan TT, Teoh WHL, Woo DCM, et al.: A randomised trial of the analgesic efficacy of ultrasoundguided transversus abdominis plane block after caesarean delivery under general anaesthesia. Eur J Anaesthesiol. 2012; 29: 88-94. DOI: 10.1097/EJA.0b013e32834f015f.

El-Dawlatly AA, Turkistani A, Kettner SC, et al.: Ultrasound guided transversus abdominis plane block: Description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 2009; 102(6):763-767. DOI: 10.1093/bja/aep067.

Aguirre-Ospina OD, Gómez-Salgado JC, Chaverra D, et al.: TAP block in inguinal hernia repair. Randomized controlled trial. Colomb J Anesthesiol. 2017; 45(3): 159-165. DOI: 10.1016/j.rcae.2017.04.001.

Carney J, Finnerty O, Rauf J, et al.: Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia. 2011; 66(11): 1023-1030. DOI: 10.1111/j.1365-2044.2011.06855.x.