|Year : 2015 | Volume
| Issue : 2 | Page : 194-199
Ultrasound-guided single injection transversus abdominis plane block of isobaric bupivacaine with or without dexamethasone for bariatric patients undergoing laparoscopic vertical banded gastroplasty: a comparative study of different doses
Noha M El Sharnouby, Hanaa A A El Gendy
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
|Date of Submission||31-May-2014|
|Date of Acceptance||01-Oct-2014|
|Date of Web Publication||8-May-2015|
Hanaa A A El Gendy
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo
Source of Support: None, Conflict of Interest: None
Dexamethasone has anti-inflammatory properties that can prolong postoperative analgesia when added to isobaric bupivacaine transversus abdominis plane (TAP) block for bariatric patients undergoing laparoscopic vertical banded gastroplasty.
Patients and methods
A total of 111 bariatric patients, scheduled for laparoscopic vertical banded gastroplasty under ultrasound-guided TAP block, were randomized blindly into three parallel groups: Group BC that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+2 ml saline 0.9%; low-dose dexamethasone group (Group DB4) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+4 mg dexamethasone; and high-dose dexamethasone group (Group DB8) that received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25%+8 mg dexamethasone.
Postoperatively, pain scores were significantly lower in Group BD4 and Group BD8 compared with Group BC at rest and on movement at 6, 8, 12, and 24 h. There was a significant difference with respect to the duration of analgesia (P = 0.0001), 24 h consumption of paracetamol (P = 0.0001), 24 h consumption of meperidine hydrochloride (P = 0.001), the number of patients who needed meperidine hydrochloride rescue analgesic (P = 0.008), time to ambulation (P = 0.0001), and incidence of postoperative nausea and/or vomiting (P = 0.03) among groups.
Adding dexamethasone (4 or 8 mg) to isobaric bupivacaine TAP block reduces postoperative pain, reduces analgesic requirement, and promotes early ambulation in bariatric patients undergoing laparoscopic vertical banded gastroplasty in comparison with isobaric bupivacaine TAP block alone.
Keywords: bariatric patients, dexamethasone, isobaric bupivacaine, postoperative analgesia, transversus abdominis plane block, vertical banded gastroplasty
|How to cite this article:|
El Sharnouby NM, El Gendy HA. Ultrasound-guided single injection transversus abdominis plane block of isobaric bupivacaine with or without dexamethasone for bariatric patients undergoing laparoscopic vertical banded gastroplasty: a comparative study of different doses. Ain-Shams J Anaesthesiol 2015;8:194-9
|How to cite this URL:|
El Sharnouby NM, El Gendy HA. Ultrasound-guided single injection transversus abdominis plane block of isobaric bupivacaine with or without dexamethasone for bariatric patients undergoing laparoscopic vertical banded gastroplasty: a comparative study of different doses. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Apr 17];8:194-9. Available from: http://www.asja.eg.net/text.asp?2015/8/2/194/156683
| Introduction|| |
Obesity is a complex multifactorial health problem  for which laparoscopic vertical banded gastroplasty is considered an efficient surgical procedure , . Anesthesiologists are challenged with obesity-associated comorbidities  and effective postoperative analgesia, with early mobilization indicated to decrease the incidence of postoperative complication , . The transversus abdominis plane (TAP) block is a regional anesthetic technique that targets the sensory nerve supply of the anterior-lateral abdominal wall  , and has been used successfully for pain control after various laparoscopic surgery in nonobese patients ,,,, . Unfortunately, there are few studies evaluating the postoperative analgesic effect of TAP block in patients undergoing laparoscopic vertical banded gastroplasty  .
Various adjuvants have been used to prolong local analgesic effect ,,,, . Dexamethasone, through its anti-inflammatory and blocking effects on neural discharge, and nociceptor C fibers transmission could be used as a local anesthetic adjuvant  .
The aim of this prospective study was to investigate the effect of single bolus administration of two different doses of dexamethasone as an adjuvant to isobaric bupivacaine in ultrasound-guided transversus abdominis plane block on postoperative analgesia for bariatric patients undergoing laparoscopic vertical banded gastroplasty.
| Materials and methods|| |
The protocol was approved by our institution review board and patients gave their informed written consent. The patients were enrolled into this prospective randomized, double-blinded trial over a period of 3 years from May 2010 to May 2013. A total of 97 patients (BMI > 35 kg/m 2 ), aged 18-60 years, ASA I or II, scheduled for laparoscopic vertical banded gastroplasty in Ain Shams University Hospitals, were included in this study. Exclusion criteria included patients with pre-existing coagulation disorder, hematological disease, local infection at the site of the block or allergy to the drug under study, history of significant coexisting diseases such as ischemic heart disease, impaired renal functions, impaired liver functions and known allergy to local anesthetic agents, long-term steroid therapy, conversion to open procedure, pregnant patients, patients who received any NSAIDs or opiates 24 h before the surgery, patients who remained intubated after the surgery, failed block, and patient refusal.
Immediately after admission, patients were instructed to use a 10-point linear visual analogue scale (VAS) preoperatively, and were asked to record his or her level of perceived pain intensity on the scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible.
Preoperatively, all patients underwent Mallampati scoring and the degree of cervical extension to predict difficult intubation. All routine preoperative investigations, in addition to ECG, respiratory function test, and transthoracic echocardiography, were carried out. Sedation has been avoided while patients have been premedicated with 4 mg Ondansetron and 150 mg Ranitidine 30 min before the surgery. Deep venous thrombosis prophylaxis (first dose 12 h before surgery) and elastic stockings have been carried out.
Immediately before entering the operating room, patients were randomized using computer-generated randomization list and randomly allocated through sealed envelopes into one of the three parallel groups that received single bolus administration of ultrasound-guided TAP block on each side; the control group (Group BC) (n = 33), whose patients received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25% + 2 ml saline 0.9%; low-dose dexamethasone group (Group BD4) (n = 34), whose patients received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25% +1 ml saline 0.9%+4 mg dexamethasone in 1 ml; and high-dose dexamethasone group (Group BD8) (n = 34), whose patients received TAP block using 20 ml of isobaric bupivacaine hydrochloride 0.25% + 8 mg dexamethasone in 2 ml. All medications were prepared by pharmacists not participating in patient care.
All patients in the study group were anesthetized by the same team of anesthesiologists and operation was performed by the same surgical team. Both the anesthesia and surgical team were unaware of the study medications.
Preoperative antimicrobial prophylaxis with Ceftriaxone 2 g was administered 30 min before the induction of anesthesia. In the operating room, an intravenous access was established using a 20- or 18-G intravenous cannula. All patients were monitored with five-lead ECG, noninvasive blood pressure, anesthetic gas analyzer, pulse oximetry, and end-tidal CO 2 . Hemodynamic parameters were continuously monitored every 5 min for 30 min, every 10 min for the next 30 min, and every 15 min thereafter. All patients received preoxygenation with O 2 100% on 8 L/min for 5 min via face mask and were anesthetized by a standardized anesthetic technique consisting of intravenous 2 mg/kg of 1% propofol (IBW) and 1μ/kg of fentanyl (TBW). Tracheal intubation was facilitated by administration of rocuronium (0.6 mg/kg), and nasogastric tube was inserted to decompress the stomach. The anesthesia was maintained with 1-3% sevoflurane in oxygen air mixture and rocuronium as required. Ventilation was controlled to maintain an end-tidal CO 2 at 35-40 mmHg and SpO 2 between 95 and 100%.
At the end of surgery, after preparing the skin with 2% chlorhexidine solution, TAP block was performed on each side (right and left) under ultrasound guidance using linear ultrasound probe (high-frequency probe 7-12 MHz) connected to a portable ultrasound unit (Sonoscape, Doppler Ultrasoun, CN) placed at the midaxillary line in the transverse plane to the lateral abdominal wall midway between the lower costal margin and the highest point of iliac crest at the level of the umbilicus. A 150-mm Vygon needle (UK) attached with tubing system to a syringe filled with the local anesthetic solution was inserted into a plane with the ultrasound probe and advanced till it reached the plane between the internal oblique and transversus abdominis muscles after careful aspiration to exclude vascular puncture, the local anesthetic solution was injected, which led to separation between the internal oblique, and the transversus abdominis muscles that appeared as a hypoechoic space in ultrasound. On the opposite side, TAP block was then performed using the same technique and injectate.
After completing the surgical procedure, the patients were allowed to wake up, extubated, and transported to the postanesthetic care unit in the semisitting position for 4 h postoperative monitoring. Patients with cardiovascular and respiratory comorbidities were monitored in the ICU for 24 h. Both groups were compared with regard to patients' characteristics, and patients with failed TAP block were excluded from the study.
Postoperative analgesia was assessed by a blinded observer using VAS  . VAS was recorded after surgery at 1, 2, 4, 6, 8, 12, and 24 h. Patients were evaluated at rest and with movement. Postoperatively, intravenous paracetamol (1 g) was administered every 6 h during the first 24 h after surgery (when the VAS score was ≥4), with a maximum daily dose of 4 g/day. If VAS more than 4 persisted for 20 min after paracetamol infusion, meperidine hydrochloride (50 mg) rescue analgesic was administered as intravenous infusion over 1 h, maximum of four doses in 24 h. The duration of effective analgesia was recorded as the time from completion of surgery until the first analgesic dose was required. The analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively was recorded. Postoperative adverse events such as nausea and/or vomiting, hyperglycemic episodes (defined as an increase in the random blood glucose level >200 mg/dl), or uncontrolled hypertension (defined as an increase in the systolic blood pressure >20% from the baseline) were also recorded. Ondansetron 4 mg was administered intravenously in reported cases of nausea and/or vomiting.
The primary outcome of the study was VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12, and 24 h, whereas the secondary outcomes were time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively, time to ambulate, and postoperative adverse events such as nausea and vomiting, hyperglycemic episodes, or uncontrolled hypertension.
The sample size was calculated using the pain score as the primary variable, with a two-sided type I error of 5% and study power at 80%. It was estimated that 30 patients in each group would be enough to detect a 25% difference in the VAS score for pain based on detection of a 10-mm difference between the groups  . Ten percent was added to the sample to cover for dropouts.
Data were analyzed using computer statistical software system, SPSS version 15 (SPSS Inc., Chicago, Illinois, USA). Data were presented as mean and SD. Demographic data were analyzed by using analysis of variance for numerical data and χ2 -test for categorical data. Time to first analgesic requirement and the amount of postoperative analgesics were analyzed using analysis of variance. Pain scores were presented as median (IQR) analyzed by using the Kruskal-Wallis test. A Bonferroni adjustment was made for multiple comparisons.
| Results|| |
A total of 110 ASA I and II bariatric patients scheduled for laparoscopic vertical banded gastroplasty were assessed for randomization. One patient had a coexisting ischemic heart disease, one suffered impaired renal functions, two had impaired liver functions, one was on long-term steroid therapy, and four refused to participate in the study.
A total of 111 bariatric patients, ASA physical status I and II, underwent laparoscopic vertical banded gastroplasty performed by the same surgeon. The study group included 75 (74%) female patients, ASA I/II 68/33, mean age 41 (9), BMI 45 (6), duration of surgery 77 (8), and anesthesia 122 (12). The groups were comparable with respect to age, BMI, sex distribution, duration of surgery, duration of anesthesia, and ASA classification ([Table 1]).
|Table 1 Age, sex, body mass index, duration of anesthesia, and duration of surgery|
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Postoperatively pain scores were significantly lower in Group BD4 and Group BD8 compared with Group BC at 6 h (at rest P = 0.001, and on movement P = 0.0001), 8 h (at rest P = 0.01, and on movement P = 0.0001), 12 h (at rest P = 0.0001, and on movement P = 0.0001), and 24 h (at rest P = 0.03, and on movement P = 0.46), but not significantly different at 1 h (at rest P = 0.4, and on movement = 0.09), 2 h (at rest P = 0.09, and on movement P = 0.6), and 4 h (at rest P = 0.2, and on movement P = 0.1) ([Figure 1] and [Figure 2]). Pain scores were not significantly reduced in Group BD8 compared with Group BD4 at 1 h (at rest P = 0.2, and on movement P = 0.2), 2 h (at rest P = 0.06, and on movement P = 0.9), 4 h (at rest P = 0.1, and on movement P = 0.4), 6 h (at rest P = 0.1, and on movement P = 0.9), 8 h (at rest P = 0.7, and on movement P = 0.6), 12 h (at rest P = 0.5, and on movement P = 0.8), and 24 h (at rest P = 0.9, and on movement P = 0.7).
|Figure 1: Visual analog scale score (VAS) (median) at rest in the three groups postoperatively at 1, 2, 4, 6, 8, 12, and 24 h postoperatively.*P < 0.05 Group BD4 more signifi cant than Group BC, oP < 0.05 Group BD8 more significant than Group BC. Group BC, bupivacaine/saline; Group BD4, bupivacaine/dexamethasone (4 mg); and Group BD8, bupivacaine/dexamethasone (8 m g).|
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|Figure 2: Visual analog scale score (VAS) (median) on movement in the three groups postoperatively at 1, 2, 4, 6, 8, 12, and 24 h postoperatively. *P < 0.05 Group BD8 more signifi cant than Group BC, oP < 0.05 Group BD4 more signifi cant than Group BC. Group BC, bupivacaine/saline; Group BD4, bupivacaine/dexamethasone (4 mg); and Group BD8, bupivacaine/dexamethasone (8 m g).|
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There was a significant difference with respect to the duration of analgesia (P = 0.0001), 24 h consumption of paracetamol (P = 0.0001), 24 h consumption of meperidine hydrochloride (P = 0.001), the number of patients who needed meperidine hydrochloride rescue analgesic (P = 0.008) ([Table 2]), and time to ambulation (P = 0.0001) among groups ([Table 3]).
Group BD8 (P = 0.0001) and Group BD4 (P = 0.0001) had a significantly longer time to first analgesic requirements than Group BC. In addition, Group BD8 [(P = 0.0001), and (P = 0.002)] and BD4 [(P = 0.002), and (P = 0.01)] consumed significantly lower doses of paracetamol, and meperidine hydrochloride rescue analgesia respectively than did Group BC. Moreover, the number of patients who needed meperidine hydrochloride to rescue analgesia were significantly less in Group BD8 (P = 0.009) and BD4 (P = 0.004) than in Group BC ([Table 2]). In addition, Group BD4 (P = 0.0001) and Group BD8 (P = 0.0001) were significantly early ambulated in comparison with Group BC ([Table 3]).
There was no significant difference between Group BD4 and BD8 with respect to time to first analgesic requirement (P = 0.4), paracetamol consumption (P = 0.4), meperidine hydrochloride to rescue analgesic requirement (P = 0.5), the number of patients who needed meperidine hydrochloride to rescue analgesia (P = 0.6), and time to ambulation (P = 0.1).
No side effects were detected from TAP injection of dexamethasone and bupivacaine during the 24-h period after surgery, as no patient experienced hyperglycemic episodes (defined as increase in the random blood glucose level>200 mg/dl), or uncontrolled hypertension (defined as increase in the systolic blood pressure >20% from the baseline). Values were recorded at the same time points as those for VAS. Incidence of postoperative nausea and/or vomiting was significantly reduced among groups (P = 0.03). Group BD8 (P = 0.02) and Group BD4 (P = 0.042) had a significantly reduced incidence of postoperative nausea and/or vomiting in comparison with Group BC; however, there was no significant (P = 0.7) reduction in incidence of postoperative nausea and/or vomiting between Group BD8 and Group BD4 ([Table 3]).
| Discussion|| |
This study revealed a significant analgesic benefit of administration of dexamethasone either 4 or 8 mg combined with 20 ml 0.25% isobaric bupivacaine as a single injection ultrasound-guided TAP block, for postoperative analgesia, and early ambulation in bariatric patients undergoing laparoscopic vertical banded gastroplasty.
Although general anesthesia is the commonly used technique in laparoscopic bariatric surgery  , neuroaxial block or patient-controlled analgesia was used as an adjuvant for postoperative analgesia, with less systemic and thromboembolic complications , . Several previous studies demonstrated that TAP block is a safe and effective multimodal analgesic technique in laparoscopic and lower abdominal surgery ,, . Sinha et al.  studied the efficacy of ultrasound-guided transversus abdominis plane block as a locoregional anesthesia in morbidly obese patients undergoing laparoscopic bariatric surgery. Those patients experienced in the postoperative period reduced opioid requirement, early ambulation (6.3 ± 1.8 vs. 8 ± 1.8 h), and lower median VAS at 1, 3, 6, 12, and 24 h at rest and on movement. In contrast, Albrecht et al.  found no beneficial effect of bilateral TAP blocks for laparoscopic gastric bypass surgery with regard to pain score, postoperative analgesic needs, and rates of nausea or vomiting, which might be due to local anesthetic infiltration to the trocar insertion site received by those patients.
Our study not only confirmed the analgesic benefit of TAP block using bupivacaine, it further revealed that the addition of dexamethasone 4 or 8 mg to bupivacaine provided even more effective analgesia. Patients in the group receiving dexamethasone and bupivacaine had reduced postoperative pain scores at 6, 8, 12, and 24 h postoperatively, a longer analgesic duration, and lower 24 h analgesic use, with decreased incidence of postoperative nausea and/or vomiting, as well as early ambulation compared with the group receiving bupivacaine and saline. Moreover, on comparing the two doses of dexamethasone, there was no additional beneficial effect of adding 4 mg dexamesthasone and bupivacaine in comparison with 8 mg dexamesthasone and bupivacaine.
Neuroaxial steroid has been reported to prolong analgesic effect in previous studies ,, . Corticosteroids induce analgesia through their anti-inflammatory or immunosuppressive effects , . Steroid actions were achieved through their binding to intracellular receptors and modulating nuclear transcription  . Moreover, steroids might potentiate the action of local anesthetics through modulation of the function of potassium channels in the excitable cells  . Tandoc et al.  demonstrated that addition of dexamethasone (4 or 8 mg) to bupivacaine significantly prolonged the duration of postoperative analgesia 4 mg (21.6 ± 2.4 h) and 8 mg (25.2 ± 1.9 h) compared with the control (13.3 ± 1.0 h) after interscalene block. In addition, a case report by Christopher et al.  performing preoperative bilateral TAP blocks with dexamethasone 4 mg in patients undergoing total open abdominal hysterectomy reduced postoperative narcotic requirements and adverse events with shorter length of hospital stay.
In the current study, addition 4 or 8 mg dexamethasone as an adjuvant to isobaric bupivacaine TAP block was safe in bariatric patient as there were no recorded cases of episodes of hyperglycemia or uncontrolled hypertension during the study period. In accordance with our study, previous studies reported the safety of a single dose and short-term (<24 h) use of dexamethasone , .
The current study has potential limitations of lacking an active control comparing the effect of intravenous and TAP block dexamethasone. Perhaps, intravenous dexamethasone with bupivacaine TAP block would have the same effect. In addition, the study lacked along the follow-up period that permits reporting rate postoperative wound infection, which is a concern on using dexamethasone in bariatric patients. Thus, further studies comparing intravenous dexamethasone with bupivacaine TAP block to dexamethasone and bupivacaine TAP block, as well as studies with a longer study period reporting the rate of postoperative wound infection are also recommended.
| Conclusion|| |
We conclude that adding dexamethasone (4 or 8 mg) with isobaric bupivacaine TAP block reduce postoperative pain, reduces analgesic requirement, and promotes early ambulation in bariatric patients undergoing laparoscopic vertical banded gastroplasty in comparison to isobaric bupivacaine TAP block alone.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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