Peri-operative acute pain management of total abdominal hysterectomy …. Chart review
Author …Mohamed Rida Alsaden,MD
Islam Abdel-Rahman, MD
Perioperative pain is a major concern for Gyn/Oncology patients. 80% of patients undergoing surgery experience postoperative pain, fewer than half report adequate pain relief. (1) Poorly managed perioperative pain lead to prolonged recovery time, prolonged hospital stay, increased cost, increased stress factors on cardiac, respiratory and endocrine systems and may lead to Chronic pain syndrom. Pain management can be challenging among Gyn/Oncology patient who is planned to have TAH and laparotomies.
Materials and methods:
Charts of 192 patients who underwent total abdominal hysterectomy between 2015-2016 has been reviewed. patients has been divided into 3 groups.... Group A where patient has GA only with opioid pain control (60 patients), Group B where patients had combined GA and epidural (36 patients), Group C where patients received GA and TAP block (96 patients). We comapred the three groups in terms of: 1-total opioid consumption, 2-Pain score at 12,24,48 hours, 3-average MAP at 6,12,24 hours. 4-length of hospital stay. IRB approval/waiver has been obtained.
Among the three identified groups, there was no significant differences in the length of hospital stay, total opioid consumption, or average pain score. It has been noted that opioid consumption is higher for Group A (GA only) in the first 12 hours. Also it has been noted that Group B (GA+Epidural) tends to run lower MAP than any other group at any time.
For long time Epidural anaesthesia alone or in combination with other modalities has been an important part of the anesthesia and perioperative pain management of Gyn/Oncology patients undergoing abdominal surgery. While epidural offers many advantages, it has also many disadvantages including postoperative hypotension which has been a major concern for the surgical team. This study was triggered to determine whether epidural was a contributing factor in postoperative hypotension. Postoperative hypotension has many reasons first is the tendency of the surgeons to keep the patient on strict fluid management to avoid postoperative complications and sympathectomy-induced by epidural analgesia. TAP block has emerged as an alternative way for analgesia however no clear benefits has been documented so far (2). There is no clear cut advantage for one particular aesthetic regime over the other, hence the idea of using multi-modal approach and tailoring the analgesic plans for each selective case depending on the associated co-morbidities and the presence or absence of chronic pain.
In selective cases, Epidural is still a good mode for post-operative analgesia, though it is limited by post-operative hypotension which is multifactorial. TAP Block with Multimodal analgesia could be an alternative to Epidural analgesia. No significant difference in terms of pain scores, Opioid consumption or length of Hospital stay between the different modalities. This is a limited study and more research is needed in this topic
1- Simon, Lee S. "Relieving pain in America: A blueprint for transforming prevention, care, education, and research." Journal of pain & palliative care pharmacotherapy 26.2 (2012): 197-198.
2- Baeriswyl, Moira, et al. "The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a meta-analysis." Anesthesia & Analgesia 121.6 (2015): 1640-1654.