COMPARING ANALGESIC EFFICACY IN ERAS PATHWAY PATIENTS- EPIDURAL CATHETER VS TRANSVERSE ABDOMINIS PLANE CATHETER
Justin T. Van Backer*1, Robert Brookover1, David Miller2, Peter Andriakos2, Igor Galay2, Farzana Afroze2, Kim Williams3, Brian T. Valerian1, Edward Lee1
1Surgery, Albany Medical Center, Loudonville, NY; 2Anesthesia, Albany Medical Center, Albany, NY; 3Quality Management, Albany Medical Center, Albany, NY
Introduction
Implementation of Enhanced Recovery After Surgery (ERAS) pathways for patients undergoing major open abdominal surgery has resulted in improved outcomes for patients. Major tenets of ERAS programs are pain control and ambulation. An epidural catheter has been the main mode of regional analgesia for open abdominal surgery. However, a Transverse Abdominal Plane (TAP) catheter provides a continuous infusion of local anesthetic to the anterior abdominal afferent nerves and has potential advantages since it has no contraindication to anticoagulation, early foley removal or early postoperative ambulation. We hypothesized that pain scores and amount of opiates required postoperatively would not be different between patients who received a TAP catheter and epidural.
Methods
We performed a retrospective review of patients undergoing open colorectal surgery on a tertiary care academic medical center ERAS pathway from November 2016 through March 2018 who received epidurals or TAP catheters for postoperative pain management. Patient demographics, milligram morphine equivalents (MME), direct and indirect costs, length of stay, and visual analog scale (VAS) scores were compared between groups. Patients were excluded if they were given a patient-controlled analgesia device, TAP block, paravertebral catheter, or epidural plus TAP catheters.
Results
There were 470 patients who underwent surgery on our ERAS pathway during the study period. Surgery for 29/470 patients was converted to open (6.2%) with 43/470 (9.1%) of surgeries started open. Epidurals were placed in 3/470 laparoscopic cases (0.6%). Of these 75 procedures, 51 patients received TAP catheters and 24 received epidurals. There was no difference between age or sex, but TAP catheters had a lower BMI (27 vs 32.8, p = 0.01). Postoperative VAS scores were not significantly different between groups (TAP Catheter group 4.5 vs Epidural group 5.0, p = 0.28). Similarly, there were no differences between direct costs (median $7,083 in TAP Catheter group vs $7,479 in Epidural group, p = 0.66), indirect costs (median $5,644 in TAP Catheter group vs $6,521 in Epidural group, p = 0.22), or length of stay (5.4 days in TAP Catheter group vs 5.7 days in Epidural group, p = 0.66). However, those who received TAP catheters required significantly less morphine milligram equivalents compared to the epidural group (59 MME vs 172 MME, p < 0.005).
Conclusion
TAP catheters have many potential advantages over epidural catheters in the postoperative period including earlier patient mobilization, foley removal and initiation of anticoagulation or deep venous thromboprophylaxis therapy. In addition, we demonstrate the superior efficacy of TAP catheters for postoperative pain control after open colorectal surgery on an ERAS pathway. TAP catheters should be utilized more in patients undergoing open abdominal surgery.
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