Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In this randomized controlled trial, adding a transversus abdominis plane (TAP) block to the multimodal analgesia protocol decreased the rescue morphine use compared to patients who did not receive the TAP block in patients receiving elective open gynecologic surgery

Evidence Rating Level: 1 (Excellent)

Enhanced recovery after surgery (ERAS) protocols are designed to minimize stress created by surgery and to improve patient recovery following surgery. Most ERAS pathways avoid opioid use with multimodal pain management, which can lead to decreased opioid-related adverse effects such as nausea and vomiting. Ultrasound-guided transversus abdominis plane (TAP) block is performed by injecting local anesthetic between muscle layers of the trunk and has been performed in various abdominal surgeries as a pain relief tool. Open gynecological surgeries have been known to cause moderate to severe postoperative pain, and this randomized controlled trial aimed to investigate whether adding TAP block to a multimodal analgesia (MMA) protocol would confer additional benefits after open gynecologic surgery. 63 patients were enrolled in this study between November 2020 and August 2021 and randomized in a 1:1 ratio to receive a TAP block with either 20 mL ropivacaine 0.375% or the same volume of 0.9% saline. The primary outcome measured was rescued morphine within 24 hours following surgery. In the first 24 hours postoperatively, the study group had significantly less rescued morphine than the control group (P=.013). The study group also had statistically lower NRS pain scores at 1, 2, and 6 hours, and a lower incidence of nausea at 48 hours compared with the control group. Otherwise, there was no significant difference in the pain scores at 24 and 48 hours, as well as the incidence of vomiting or need for rescue anti-emetics. The findings from this study demonstrate the benefit of preoperative TAP block when used as part of MMA for open gynecologic surgery, resulting in less use of rescue morphine within the first 24 hours postoperatively. However, a limitation of this study includes that the TAP block was performed after anesthesia induction, so the range of the block could not be assessed. The findings from this study are an excellent first step in improving MMA for patients undergoing open gynecologic surgery, and further research should investigate ideal concentrations of local anesthetic for TAP blocks in this context to confer the greatest effect.

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