From the Department of Anesthesiology, Northwestern University, Chicago, Illinois.
Anesth Analg. 2014 Feb;118(2):454-463. doi: 10.1213/ANE.0000000000000066.
Transversus abdominis plane (TAP) block has been used as a multimodal strategy to optimize postoperative pain outcomes; however, it remains unclear which type of surgical procedures can benefit from the administration of a TAP block. Several studies have examined the effect of the TAP block on postoperative pain outcomes after laparoscopic surgical procedures and generated conflicting results. Our main objective in the current investigation was to evaluate the effect of TAP block on postoperative analgesia outcomes for laparoscopic surgical procedures.
A search was performed to identify randomized controlled trials that evaluated the effects of the TAP block compared with an inactive group (placebo or "no treatment") on postoperative pain outcomes in laparoscopic surgical procedures. Primary outcomes included early (0-4 hours) and late (24 hours) postoperative pain at rest and on movement and postoperative opioid consumption (up to 24 hours). Meta-analysis was performed using a random-effects model. Publication bias was evaluated by examining the presence of asymmetric funnel plots using Egger regression test. Meta-regression analysis was performed to establish an association between the local anesthetic dose and the evaluated outcomes.
Ten randomized clinical trials with 633 subjects were included in the analysis. The weighted mean difference (99% confidence interval) of the combined effects favored TAP block over control for pain at rest (≤4 hours, -2.41 [-3.6 to -1.16]) and (at 24 hours, -1.33 [-2.19 to -0.48]) (0-10 numerical scale). Postoperative opioid consumption was decreased in the TAP block group compared with control, weighted mean difference (99% confidence interval) of -5.74 (-8.48 to -2.99) mg morphine IV equivalents. Publication bias was not present in any of the analysis. Preoperative TAP block administration resulted in greater effects on early pain and opioid consumption compared with postoperative administration. Meta-regression analysis revealed an association between local anesthetic dose and the TAP block effect on late pain at rest and postoperative opioid consumption. None of the studies reported symptoms of local anesthetic toxicity.
TAP block is an effective strategy to improve early and late pain at rest and to reduce opioid consumption after laparoscopic surgical procedures. In contrast, the TAP block was not superior compared with control to reduce early and late pain during movement. Preoperative administration of a TAP block seems to result in greater effects on postoperative pain outcomes. We also detected a local anesthetic dose response on late pain and postoperative opioid consumption.
腹横肌平面（TAP）阻滞已被用作一种多模式策略来优化术后疼痛结局；然而，哪种手术类型可以从 TAP 阻滞中获益仍不清楚。一些研究已经检查了 TAP 阻滞对腹腔镜手术术后疼痛结局的影响，结果相互矛盾。我们在当前研究中的主要目的是评估 TAP 阻滞对腹腔镜手术术后镇痛结局的影响。
进行了搜索，以确定评估 TAP 阻滞与非活性组（安慰剂或“无治疗”）相比对腹腔镜手术术后疼痛结局影响的随机对照试验。主要结局包括早期（0-4 小时）和晚期（24 小时）静息和运动时的术后疼痛以及术后阿片类药物消耗（最多 24 小时）。使用随机效应模型进行荟萃分析。通过 Egger 回归检验检查不对称漏斗图的存在来评估发表偏倚。进行了 meta 回归分析，以确定局部麻醉剂剂量与评估结果之间的关联。
纳入的 10 项随机临床试验共有 633 名受试者。联合效应的加权均数差值（99%置信区间）有利于 TAP 阻滞组在静息时的疼痛（≤4 小时，-2.41[-3.6 至-1.16]）和（24 小时，-1.33[-2.19 至-0.48]）（0-10 数字评分）。与对照组相比，TAP 阻滞组术后阿片类药物消耗减少，加权均数差值（99%置信区间）为-5.74（-8.48 至-2.99）mg 静脉吗啡当量。任何分析均未出现发表偏倚。与术后给药相比，术前 TAP 阻滞给药对早期疼痛和阿片类药物消耗的影响更大。Meta 回归分析显示，局部麻醉剂剂量与 TAP 阻滞对静息时晚期疼痛和术后阿片类药物消耗的影响之间存在关联。没有研究报告局部麻醉剂毒性的症状。
TAP 阻滞是改善腹腔镜手术后静息期早期和晚期疼痛以及减少阿片类药物消耗的有效策略。相比之下，TAP 阻滞在减少运动时的早期和晚期疼痛方面并不优于对照组。TAP 阻滞术前给药似乎对术后疼痛结局有更大的影响。我们还检测到局部麻醉剂剂量对晚期疼痛和术后阿片类药物消耗的反应。
