Abstract
Background: Coagulation changes can complicate liver resection, particularly in patients with cirrhosis. The aim of this prospective hospital-based comparative study was to compare the postoperative analgesic efficacy of intravenous fentanyl patient-controlled analgesia (IVPCA) with and without transversus abdominis plane (TAP) block.
Methods: Fifty patients with Child's A cirrhosis undergoing liver resection were randomly divided into two groups for postoperative analgesia, ie, an IVPCA group receiving a 10 mu g/mL fentanyl bolus of 15 mu g with a 10-minute lockout and a maximum hourly dose of 90 mu g, and an IVPCA + TAP group that additionally received TAP block (15 mL of 0.375% bupivacaine) on both sides via a posterior approach with ultrasound guidance before skin incision. Postoperatively, bolus injections of bupivacaine 0.375% were given every 8 hours through a TAP catheter inserted by the surgeon in the open space during closure of the inverted L-shaped right subcostal with midline extension (subcostal approach) guided by the visual analog scale score (< 3, 5 mL; 3 to < 6, 10 mL; 6-10, 15-20 mL) according to weight (maximum 2 mg/kg). The top-up dosage of local anesthetic could be omitted if the patient was not in pain. Coagulation was monitored using standard coagulation tests.
Results: Age, weight, and sex were comparable between the groups (P > 0.05). The visual analog scale score was significantly lower at 12, 18, 24, 48, and 72 hours (P < 0.01) in IVPCA + TAP group. The Ramsay sedation score was lower only after 72 hours in the IVPCA + TAP group when compared with the IVPCA group (1.57 +/- 0.74 versus 2.2 +/- 0.41, respectively, P < 0.01). Heart rate, systolic blood pressure, and fentanyl consumption were lower in the IVPCA + TAP group at 24, 48, and 72 hours (P < 0.05). Intensive care unit stays were significantly shorter with TAP (2.61 +/- 0.74 days versus 4.35 +/- 0.79 days, P < 0.01). Prothrombin time and International Normalized Ratio indicated temporary hypocoagulability in both groups.
Conclusion: Combining TAP with IVPCA improved postoperative pain management and reduced fentanyl consumption, with a shorter stay in intensive care. TAP block can be included as part of a balanced multimodal postoperative pain regimen.