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Transversus Abdominis Plane Blocks and Systemic Absorption

Groudine, Scott, MD

doi: 10.1213/ANE.0000000000000327
Letters to the Editor: Letter to the Editor
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Department of Anesthesiology, Albany Medical College, Albany, New York, GroudiS@mail.amc.edu

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To the Editor

De Oliveira Jr et al.1 recently performed a meta-analysis on the effectiveness of transversus abdominis plane (TAP) blocks in patients undergoing laparoscopic surgery and concluded that these blocks were effective, worked best when performed preoperatively, and had greater opioid-sparing effects at 24 hours with larger injected doses. Although these conclusions might be true, the reviewed studies also support the hypothesis that systemic local anesthetics can decrease postoperative pain. None of the reviewed studies controlled for systemic absorption of the local anesthetic. Therefore, whether these benefits are a result of where the amide anesthetics are deposited or a result of their systemic absorptions remains unanswered. Large doses of amide anesthetics have significant systemic effects.2 Lidocaine2 and ropivacaine3 in addition to their anesthetic action both share antiinflammatory properties. Latzke et al.4 demonstrated in healthy volunteers that a TAP block with 150 mg ropivacaine can result in significant concentrations of plasma ropivacaine. Additionally, tissue concentrations remote from the injection site in some subjects were comparable with the tissue concentrations near the injection site, suggesting that a reverse distribution from plasma to remote tissue occurred. Others have demonstrated significant serum concentrations of ropivacaine lasting >12 hours postblock.5 The systemic effects would be greater with a larger absorbed dose, and this meta-analysis demonstrated an increased dose effect at 24 hours. Lidocaine given only during the perioperative period has opioid-sparing effects and is associated with earlier hospital discharge even days after the infusion is stopped.2,6 Serum lidocaine levels in patients benefitting from lidocaine in 1 trial ranged between 1.3 and 3.7 μg/mL.2 Because ropivacaine has 3.6 to 4 times the anesthetic potency of lidocaine,7 these concentrations are significantly less potent than the mean serum ropivacaine concentrations seen in healthy volunteers after a TAP block (Cmax, 1.88 μg/mL mean).4

De Oliveira Jr et al.1 demonstrated an opioid-sparing effect of ropivacaine administered during laparoscopy. This meta-analysis and the included studies do not provide evidence that this dose of amide anesthetic has to be given in the form of a TAP block. Controlled studies demonstrating that the benefits seen are indeed from the block and not systemic absorption have yet to be performed.

Scott Groudine, MD

Department of Anesthesiology

Albany Medical College

Albany, New York

GroudiS@mail.amc.edu

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REFERENCES

1. De Oliveira GS Jr, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2014;118:454–63
2. Groudine SB, Fisher HA, Kaufman RP Jr, Patel MK, Wilkins LJ, Mehta SA, Lumb PD. Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg. 1998;86:235–9
3. Blumenthal S, Borgeat A, Pasch T, Reyes L, Booy C, Lambert M, Schimmer RC, Beck-Schimmer B. Ropivacaine decreases inflammation in experimental endotoxin-induced lung injury. Anesthesiology. 2006;104:961–9
4. Latzke D, Marhofer P, Kettner SC, Koppatz K, Turnheim K, Lackner E, Sauermann R, Müller M, Zeitlinger M. Pharmacokinetics of the local anesthetic ropivacaine after transversus abdominis plane block in healthy volunteers. Eur J Clin Pharmacol. 2012;68:419–25
5. Griffiths JD, Barron FA, Grant S, Bjorksten AR, Hebbard P, Royse CF. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth. 2010;105:853–6
6. Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. 2008;95:1331–8
7. Lin Y, Liu SSBarash PG. Local anesthetics. Clinical Anesthesia. 20137th ed Philadelphia, PA Wolters Kluwer/Lippincott Williams & Wilkins:567 In:
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