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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1361-1367

Efficacy of dexamethasone addition to bupivacaine for transversus abdominis plane block in upper abdominal surgery


1 Department of Anesthesiology and Intensive Care, National Liver Institute, Menoufia, Egypt
2 Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission06-Mar-2022
Date of Decision15-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Eman M. A. Sultan
Birkt Elsabaa, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_75_22

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  Abstract 


Background
Ultrasound subcostal transversus abdominis plane block is an efficacious field block in abdominal surgeries. Various adjuvants have been used to prolong the local anesthetic effect.
Objectives
To evaluate the effect of adding dexamethasone to bupivacaine on pethidine consumption in the first 24 h postoperatively as a primary objective.
Patients and methods
Our randomized controlled double-blinded trial was conducted on 44 patients with American Society of Anesthesiologists physical status I and II, aged more than or equal to 18 and less than or equal to 60 years, scheduled for upper abdominal surgery under general anesthesia. The study was conducted at the National Liver Institute and Menoufia University Hospitals. Patients were randomly divided into two groups, with 22 patients each. Patients in group LD received 20 ml of 0.25% bupivacaine and 2 ml of dexamethasone (8 mg). Group L received 20 ml of 0.25% bupivacaine.
Results
Pethidine consumption in 24 h was higher among the L group than the LD group. Its mean in the LD group was 119.44 ± 62.16 and was 160 ± 55.25 in the L group; this difference was statistically significant. The first time of analgesia was significantly longer among the LD than the L group (3.62 ± 1.63 in group LD and 2.43 ± 1.25 in group L); the difference was statistically significant. Visual analog scale score was significantly higher in the L group at 1 h than in the LD group. Median (interquartile range) was 2 (2–3) in the LD group and was 3 (2–3) in the L group; this difference was statistically significant.
Conclusion
The results showed that dexamethasone is a good additive to subcostal transversus abdominis plane block as it prolongs the duration of analgesia and reduces postoperative pain scores after upper abdominal surgeries.

Keywords: bupivacaine, dexamethasone, upper abdominal surgeries, ultrasound-guided subcostal transversus abdominis plane block


How to cite this article:
Sultan EM, Abd-Allah SI, Mowafy NI, Hassan GA. Efficacy of dexamethasone addition to bupivacaine for transversus abdominis plane block in upper abdominal surgery. Menoufia Med J 2022;35:1361-7

How to cite this URL:
Sultan EM, Abd-Allah SI, Mowafy NI, Hassan GA. Efficacy of dexamethasone addition to bupivacaine for transversus abdominis plane block in upper abdominal surgery. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1361-7. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1361/359522




  Introduction Top


Abdominal wall incision is a major contributor to the pain experienced by patients after abdominal surgery[1].

Inadequate control of postoperative pain leads to several unwanted adverse events ranging from patient discomfort, prolonged immobilization, to thromboembolic phenomenon and pulmonary complications[2].

This leads to chronic postsurgical pain (CPSP), which is a largely unrecognized problem that occurs in 10–65% of postoperative patients, with 2–10% of these patient experiencing severe CPSP. CPSP leads to long-term behavioral and neurobiological changes[3].

Analgesic multimodalities have been recommended to relieve the postoperative pain[4].

Although opioids provide satisfactory analgesia, they are associated with unwanted adverse effects[5].

Pain and other sensations from the abdominal wall are transmitted to the brain by the anterior branches of approximately seven spinal nerves (T6–T12). These nerves travel in a plane between the internal oblique and transverse abdominis muscles. This plane is known as the transversus abdominis plane (TAP)[6].

Subcostal TAP block has been reported to provide analgesia for incisions extending above the umbilicus[7].

Adjuvant medications were added to local anesthetic to prolong the effect of TAP block. Various adjuvants have been used to increase quality and prolong the local anesthetic effects, such as fentanyl, clonidine, buprenorphine, dexamethasone, and others[8].

Dexamethasone is a highly potent long-acting glucocorticoid. It has been shown to prolong peripheral nerve blockade[9].

Dexamethasone inhibits potassium conductance, which decreases nociceptive C-fiber activity. It also extends the duration of analgesia via local vasoconstriction and systemic anti-inflammatory effects[10].

Ultrasound is becoming important in regional anesthesia, as it allows real-time imaging of nerves and their surrounding structures. This increases the rates of achieving a successful block by allowing visualization of the injectate entering the correct plane. It can also reduce complication rates as surrounding structures can be avoided[11].

There is no one standard approach to evaluate pain in the ICU. In conscious patients, visual analog scale (VAS) is the gold standard for pain assessment[12].

This study aimed to determine total meperidine consumption in the first 24 h postoperatively (primary outcome) and to determine intraoperative fentanyl consumption, first time to request analgesia, and VAS postoperatively after addition of dexamethasone to bupivacaine in bilateral ultrasound-guided subcostal TAP block for upper abdominal surgery (secondary outcome).


  Patients and methods Top


After approval by the local research and ethical committee of the Anesthesia Department, Faculty of Medicine, and National Liver Institute, Menoufia University Hospitals, Egypt, for the study, a written informed consent was obtained from all participants. A total of 44 patients with American Society of Anesthesiologists physical status I–II, of both sexes, aged more than or equal to 18 and less than or equal to 60 years, who underwent upper abdominal surgeries were included in the study. They were randomly divided into two equal groups (22 patients each) to receive bupivacaine and dexamethasone (group LD) and bupivacaine (group L). Patients with any of the following were excluded from the study: BMI more than or equal to 35 kg/m2 or less than or equal to 15 kg/m2, history of relevant drug allergy, history of alcohol or analgesics dependence, patients with coagulopathy and peripheral neuropathy, and patients with infection at the site of injection. Randomization of patients was done by a computer-generated program into two equal parallel groups of 22 patients in each. Group LD received 20 ml of bupivacaine (0.25%) and 2 ml (8 mg) of dexamethasone. Group L received 20 ml of 0.25% bupivacaine and 2 ml of saline. All patients fulfilling the study inclusion criteria underwent clinical evaluation including laboratory assessment of complete blood count, coagulation profile, and liver and renal functions at the clinical pathology units at Menoufia University Hospitals. Another diagnostic workup was requested by the attending anesthesiologist and surgeon according to the patient clinical condition and the proposed surgical intervention. The patients were instructed to use a 10-point VAS (end points labeled 'no pain' and 'worst possible pain'). On arrival at Operating theater (OR), routine intraoperative monitoring (ECG, noninvasive blood pressure, pulse oximetry, and capnography) was established. A peripheral intravenous cannula of 20 G was inserted in a dorsal vein of the nondominant hand for anesthetic induction. Preoxygenation with 100% O2 for 3–5 min was done before general anesthesia (GA) induction. GA was induced by fentanyl in a dose of 1–2 μ/kg, propofol 1.5–2 mg/kg, and a nondepolarizing neuromuscular blocking drug (rocuronium) (0.6 mg/kg) intravenously, followed by endotracheal intubation. Bilateral ultrasound-guided TAP block was conducted after GA induction. After preparing the skin with 2% chlorhexidine solution, we placed a high-frequency (5–10 MHz) ultrasound probe (SonoSite x-Porte transducer United Medical Instruments, Inc. (UMI), California, USA) obliquely on the upper abdominal wall, along the subcostal margin near the midline. After identifying the rectus abdominis muscle, we gradually moved the ultrasound probe laterally along the subcostal margin until we identified the transverses abdominis muscle lying posterior to the rectus muscle. A 22-G Quinck needle was then introduced medially in the plane of the ultrasound beam and directed toward the transverse abdominis plane. On entering the neurofacial plane, an assistant started to inject a few millimeters of the bupivacaine to ensure field opening followed by continuous injection of 20 ml of bupivacaine 0.25% in the group L and 20 ml of bupivacaine plus dexamethasone (4 mg on each side) in the group LD. We repeated the same technique on the other side. Maintenance of GA was done with a mixture of sevoflurane and 40% oxygen in the air. All patients were mechanically ventilated with an anesthesia machine using a semiclosed system, adjusted to keep SaO2 more than or equal to 95% and end-tidal CO2 between 35 and 45 mmHg. Additional rocuronium was administrated as appropriate in bolus doses. We recorded the hemodynamic data of the patient at baseline before induction (T0), after induction (T1), and then every 20 min till the end of surgery (T10). Intraoperative fentanyl consumption (mic) was recorded, which was administered according to increased hemodynamics more than or equal to 25% from baseline. At the end of the surgery, neuromuscular reversal was provided with the administration of 0.05 mg/kg of neostigmine and 0.02 mg/kg of intravenous atropine. Overall, 100% oxygen was administered and tracheal extubation was done after fulfillment of the extubation criteria. On emergence from anesthesia, we transferred the patients to the postoperative care unit. Hemodynamics data were recorded on arrival and at 1, 3, 6, and 24 h after admission. VAS score was assessed at 1, 3, 6, and 24 h to ensure that the patients were pain free. If VAS was more than or equal to 4, we started analgesia with 1 g of perfelgan. After 15 min, pain assessment was done again, and if VAS score was more than or equal to 4, we gave bolus doses of meperidine (0.3 mg/kg). We assessed postoperative analgesic consumption in 24 h, total intraoperative fentanyl, and postoperative pain using a VAS. Rescue analgesia was given whenever VAS pain score was more than or equal to 4.

Statistical analysis

PASS 13 was used to calculate the sample size based on the data from a previous study[13]. It was estimated that 15 patients per group would achieve 83% power to detect a difference of 16 mg of meperidine between both groups postoperatively; the mean of group 1 was 65.0 and the mean of group 2 was 81.0, with estimated group SDs of 13.0 and 16.0, respectively, and with a significance level (alpha) of 0.05 using a two-sided two-sample size t test. A total of 20 patients per group were to be included to replace missing data. Data were collected, tabulated, and statistically analyzed using Statistical Package for the Social Sciences program, version 20 (SPSS Inc., Chicago, Illinois, USA). A χ2 test was used to measure the association between qualitative variables. Fisher exact test was used for 2 × 2 qualitative variables when more than 25% of the cells have an expected count of less than five. Student t test was used to compare the mean and SD of two sets of quantitative normally distributed data, whereas the Mann–Whitney test was used when these data were not normally distributed.


  Results Top


A total of 44 patients were enrolled in the study; two were excluded, one due to MV discharge and the other due to pulmonary embolism complications [Figure 1]. Demographic data of patients (age, sex, BMI, and type of surgeries) were comparable between both groups [Table 1].
Figure 1: Consort flow chart showing patient's allocation at different stages of the study.

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Table 1: Demographic data (age, sex, weight, height, and BMI) differences between LD group and L group

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Meperidine consumption in 24 h was significantly higher among the L group than the LD group. (P = 0.002). Moreover, intraoperative fentanyl consumption was higher in the L group (P = 0.273) [Table 2].
Table 2: Surgery duration, first rescue analgesia, analgesic consumption, and postoperative nausea and vomiting differences between LD group and L group

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The first time of request of analgesia was significantly longer among the LD group than the L group, with mean time for LD group being 3.62 ± 1.63 and 2.43 ± 1.25 for the L group (P = 0.011) [Table 2].

Regarding the postoperative VAS, it was less in group LD at first hour postoperatively than group L, with a mean of 2 (2–3) for the LD group and 3 (2–3) for the L group (P = 0.034). For VAS score at the 6th hour, it was less in group LD (P = 0.153). Both groups achieved the same VAS at the 3rd and 24th hour (P = 0.877 and P = 0.897, respectively), as group L consumed more meperidine (mg) that made both group with same VAS [Figure 2].
Figure 2: VAS score between group LD and group L. VAS, visual analog scale.

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Heart rate and mean arterial pressure were recorded at different times intraoperatively and 24 h postoperatively. There was no statistically significant difference in heart rate and mean arterial pressure measurements intraoperatively and postoperatively except at 1 h postoperatively, which was not of any clinical importance [Table 3] and [Table 4].
Table 3: Heart rate difference between group LD and group L

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Table 4: Mean arterial blood pressure difference between group LD and group L

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  Discussion Top


The enhanced recovery after surgery society recommended the multimodal regime regarding postoperative pain control. They stated that multimodal, evidence-based, and procedure-specific analgesic regimens should be the standard of care, with the aim to achieve optimal analgesia with minimal adverse effects and to facilitate the achievement of important enhanced recovery after surgery milestones such as early mobilization and oral feeding[14].

The use of the peripheral regional analgesic technique as a single or continuous infusion can provide analgesia superior to that with systemic opioids and result in the reduction of undesired adverse effects of opioids such as sedation, respiratory depression, nausea, and vomiting and improvement in some outcomes[15],[16].

TAP block is considered a straightforward and efficient regional anesthetic technique that minimizes pain and demand for analgesics in abdominal surgeries. Using local anesthetic alone is satisfactory; however, adding an adjuvant to local anesthesia was found to prolong the duration of the sensory block provided by regional anesthesia and has shown promising results in reducing postoperative pain and improving the quality of analgesia[17].

In this current study, the results demonstrated that the patients who received dexamethasone with US-guided TAP required less amount of postoperative analgesia than the patients who did not receive dexamethasone.

In an earlier published study in 2012, Ammar and Mahmoud[18] studied the effect of adding dexamethasone to bupivacaine on TAP block on 60 adult patients undergoing elective open abdominal hysterectomy. Morphine requirements in the postoperative 48 h were significantly lesser in the dexamethasone group. Time to first analgesia was significantly longer in this group.

Biyani G, et al.[19] demonstrated that the 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). A study was done on 90 patients undergoing shoulder surgery using interscalene block with 0.5% bupivacaine.

The results of the aforementioned studies prove that dexamethasone added to local anesthetics in US-guided TAP block was a safe and effective strategy for postoperative analgesia. This was explained by the binding of dexamethasone to glucocorticoid receptors and inhibiting potassium conductance, thus reducing stimulus transmission in unmyelinated c-fibers, which carry nociceptive information by inhibiting the activity of the potassium channels on these fibers. In addition, dexamethasone causes a degree of vasoconstriction to the tissues, and local anesthetics have a slower uptake and absorption, thus prolonging its duration and comfort felt by the patient. Moreover, dexamethasone exhibits a potent anti-inflammatory effect by suppressing the synthesis and secretion of various inflammatory mediators such as interleukins and cytokines, which prolongs the period of analgesia up to 48 h[9].

Not all of the studies and medical centers share this positive impression about dexamethasone as an additive to Las. Huang et al.[20] failed to disclose a statistically significant difference in postoperative total analgesic consumption. They conducted a study on 60 patients who underwent laparoscopic cholecystectomy and were randomly divided into three groups. Compared with group I, the first-time requirement of rescue analgesia in groups II and III was significantly delayed. Compared with those in group I, patients in groups II and III were associated with lower numerical rating scale pain scores and less postoperative analgesic consumption. There was no significant difference in the aforementioned variables between groups II and III. This result may be owing to the different types of surgery performed, which was laparoscopic in their study, whereas our study was done on open incisions, and the incision extended in some patients below the level of umbilicus beyond the suggested level of the block.

Wegner et al.[21] conducted a randomized controlled trial on 82 patients who underwent inguinal hernia repair or spermatocelectomy and obtained a result that contradicted our findings. They divided the patients into two groups: 41 patients received a TAP block with ropivacaine and saline and the other 41 received ropivacaine and dexamethasone immediately after surgery. For the dexamethasone group, there was no statistically significant extension of analgesia. Both groups showed an improvement in pain scores from the baseline to 12 h after the block was administered. The difference between the two groups was not statistically significant, despite the fact that the dexamethasone group had a lower pain score than the saline group. The disparity between our results and those of Wegner and colleagues is due to the fact that the study was conducted on an inguinal hernia, which is a distinct location that requires an additional inguinal nerve block.

This decrease in opioid requirement when dexamethasone was added to TAP block was also supported by Raghukumar and Majigoudar[22], who conducted a randomized clinical comparative study on 60 patients undergoing elective cesarean delivery under spinal anesthesia. The study determined the efficacy of adding clonidine or dexamethasone to bupivacaine (0.5%) in prolonging the duration of postoperative analgesia with ultrasound-guided TAP block in cesarean delivery. A total of 20 patients were included in each of the three groups. On each side, the patients received a ultrasound-guided TAP block of 20 ml 0.125% bupivacaine + 50 μg clonidine (group C), 20 ml 0.125% bupivacaine + 4 mg dexamethasone (group D), or 20 ml 0.125% bupivacaine plain (group B). The pain VAS score in the dexamethasone group was much lower at the postoperative time, and tramadol requirement was significantly higher in group B when compared with group C and group D up to 48 h.

In another context, effective pain control was reported when Deshpande et al.[23] performed a prospective, randomized, double-blind, and controlled clinical study on 60 patients aged 40–60 years posted for elective open transabdominal hysterectomy. Patients were randomly allocated into two equal groups: bilateral TAP block using 20 ml of 0.5% ropivacaine + 1 ml of 0.9% saline (control group R) or 20 ml of 0.5% ropivacaine + 4 mg dexamethasone (group RD). The addition of dexamethasone to ropivacaine TAP block provided a lower postoperative VAS pain score, with a statistically significant longer time to first (time to first analgesia) request (13.2 ± 7.6 vs. 7.1 ± 4.6 h). Lesser significant tramadol (50.2 ± 34 vs. 94 ± 35 mg) requirements during postoperative 24 h and lower nonsignificant incidence of nausea and vomiting (two vs. four patients) were found in group RD as compared with the control group, which came in agreement with our study.

The efficiency of perineural and intravenous dexamethasone combined with bupivacaine for TAP block in postcesarean delivery was investigated by Zemedkun et al.[24]. Patients were divided into three groups: those who had bilateral TAP block with bupivacaine alone (0.25%) (n = 29), those who received intravenous dexamethasone (8 mg) (n = 29), and those who received perineural dexamethasone (8 mg) (n = 29). When comparing TAP-IVD, Transversus abdominis plane (TAP) interventricular disc TAP-PD. Transversus abdominis plane Posterior direction alone, the time to first analgesic request was considerably significantly longer in TAP-IVD and TAP-PD, and the postoperative Neurological rating scale (NRS) score at rest and on coughing was considerably lower in the TAP-PD and TAP-IVD group. When compared with TAP alone, total analgesic intake in the first 24 h was significantly lower in the TAP-IVD and TAP-PD groups.

In agreement with our findings, Zhang et al.[25] conducted nine randomized controlled trials on 575 adult patients following abdominal surgery to assess dexamethasone added to local anesthetics in ultrasound-guided TAP block versus TAP block alone for postoperative analgesia. At rest, 4, 6, and 12 h after surgery, dexamethasone administered to local anesthetics significantly reduced VAS scores. In addition, in the dexamethasone group, the period between the initial request for more analgesics was significantly longer. Additionally, opioid usage was significantly reduced for the first 24 h after surgery[19].

This pain treatment strategy, which included the use of an anterior abdominal block with dexamethasone as an addition, was comparable to that described by Abdelwahab et al.[26], who completed a prospective randomized controlled double-blind clinical research on 52 patients aged 1–6 years who were scheduled for major abdominal surgery and had no medical history. Dexamethasone as an adjuvant to bupivacaine in bilateral TAP block in children was evaluated for safety and efficacy. Both sexes were separated into two groups (each with 26 patients), with group A receiving bilateral TAP block with bupivacaine and dexamethasone (0.3 mg/kg), and group B receiving bilateral TAP block with bupivacaine and a volume of saline equal to the amount of dexamethasone given in group A. In the dexamethasone group, the time until the first request analgesia was significantly longer. The total amount of acetaminophen consumed in the 36 h following surgery was also reduced.

Furthermore, Aga et al.[27] conducted a prospective cohort analysis of 58 patients undergoing elective cesarean section with spinal anesthesia, hypothesizing to perform bilateral TAP block utilizing perineural dexamethasone as an additive agent, which was similar to our work. The patients were separated into two groups: one received 8 mg of perineural dexamethasone as an additive drug to 0.25% bupivacaine 40 ml (group TAPD). The other group (group TAPA) received simply bupivacaine 0.25% 40 ml in TAP block. The TAPD group had a significant longer time to first analgesic request, and the total analgesic usage over 24 h postoperatively was lower in group TAPD than in group TAPA.

Postoperative rehabilitation may be aided by peripheral regional analgesia, as evidenced by accelerated passive joint range-of-motion resumption, shorter time to discharge readiness, and earlier discharge from the hospital or rehabilitation center, as well as reduced morbidities associated with chronic postoperative pain[28].


  Conclusion Top


Adding dexamethasone to bupivacaine in subcostal TAP block reduces postoperative pain and analgesic requirements compared with bupivacaine alone in patients undergoing upper abdominal surgery.

Recommendations

  1. It is wise to consider peripheral nerve blocks such as TAP block combined with intravenous opioids for pain management postoperatively in patients scheduled for upper abdominal surgery.
  2. Dexamethasone, when used as an adjuvant to bupivacaine in a subcostal TAP block, showed encouraging outcomes, including a considerable reduction in VAS scores and an improvement in pain management during the perioperative period in patients undergoing upper abdominal surgery.
  3. Further studies should be performed with other adjuvant drugs such as dexmedetomidine, Mg sulfate, and/or meperidine to the local anesthetic in the specific type of surgery to reach the optimal local anesthetic mixture with the best outcome.
  4. The efficacy of dexamethasone added to TAP block should be compared in the short-duration surgeries with long-duration surgery.
  5. It is recommended always to be ready for any signs of local anesthetic toxicity and look for it.
  6. Patients should be informed about the pros and cons of each technique used for postoperative pain management.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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