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Original Investigation | Association of VA Surgeons

Efficacy of Local Anesthetic With Dexamethasone on the Quality of Recovery Following Total Extraperitoneal Bilateral Inguinal Hernia Repair A Randomized Clinical Trial ONLINE FIRST

Bryan Sakamoto, MD, PhD1,2; Gene Harker, MD, PhD1,2; Andrew C. Eppstein, MD3,4; Kenneth Gwirtz, MD1,2
[+] Author Affiliations
1Department of Anesthesia, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana
2Department of Anesthesia, Indiana University School of Medicine, Indianapolis
3Department of Surgery, Richard L. Roudebush, Veterans Affairs Medical Center, Indianapolis, Indiana
4Department of Surgery, Indiana University School of Medicine, Indianapolis
JAMA Surg. Published online September 21, 2016. doi:10.1001/jamasurg.2016.2905
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Importance  Quality of recovery (directly associated with patient satisfaction) is an important clinical outcome measurement and a surrogate of anesthetic/surgical care quality.

Objectives  To compare the efficacy of a transversus abdominis plane (TAP) block with dexamethasone sodium phosphate and preperitoneal instillation of local anesthetic (PILA) with dexamethasone vs control on postoperative quality of recovery following a bilateral total extraperitoneal inguinal hernia repair (TEP-IHR) (>24 hours). Secondary objectives included efficacy of this technique on postoperative opioid use, nausea and vomiting, and pain scores.

Design, Setting, and Participants  Conducted from November 2013 to August 2015, this randomized, prospective, single-blinded study compared 2 groups (a TAP block and PILA) with a standard anesthetic technique with no regional technique (control) following bilateral TEP-IHR. This study at the Veterans Affairs Medical Center (Indianapolis, Indiana) included patients ages 18 to 80 years with an American Society of Anesthesiologists physical status of 1 to 3 scheduled for an outpatient bilateral TEP-IHR. Nurses assigning pain scores and administrating opioids for pain and staff anesthesiologists administering the Quality of Recovery–40 (QoR-40) questionnaire were blinded.

Interventions  Patients randomized to receive a TAP block with local anesthetics and dexamethasone, PILA with dexamethasone, or no regional technique (3 groups).

Main Outcomes and Measures  Patient’s response to the QoR-40 questionnaire following a TEP-IHR surgery.

Results  The mean (SD) ages in the TAP block (n = 19), PILA (n = 24), and control (n = 23) groups were 58.2 (9.4) years, 62.5 (8.1) years, and 62.9 (7.8) years, respectively. The global QoR-40 scores on postoperative day 1 for the TAP block group (median [interquartile range (IQR)], 178 [173-188]) were comparable with the control group (median [IQR], 174 [150-181]), while the PILA group had better global QoR-40 scores (median [IQR], 184 [175.5-190.75]) (P = .002). The effects of the TAP block and PILA on pain in the postoperative care unit (PACU) (median [IQR], 1 [0-5] and 3.5 [0-6.8], respectively), pain after discharge (median [IQR], 3 [2-5] and 3 [1-5.5], respectively), opiate use after discharge (median [IQR], 6.7 [5-10] and 6.7 [3.3-10], respectively), and incidence of nausea and vomiting in the PACU (4 of 19 [21.1%] and 6 of 24 [25%], respectively) were not significantly different from the control group (median [IQR], 4 [3-6] for pain scores in the PACU; 4 [3-7] for pain scores after discharge; 6.7 [3.3-10] for opioid use after discharge; and 6 of 23 [26.1%] for incidence of nausea/vomiting in the PACU). While there was a significant reduction of opioid use in the PACU in the TAP block group (median [IQR], 0 [0-1.3]) when compared with the control group (median [IQR], 4 [1.3-6.7]) (P = .001), this was not seen in the PILA group (median [IQR], 2 [0-6.4]).

Conclusions and Relevance  This study demonstrates a better quality of recovery in patients’ receiving PILA with dexamethasone compared with control for a TEP-IHR surgery.

Trial Registration  clinicaltrials.gov Identifier: NCT02036983

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CONSORT Flow Study Diagram

TAP indicates transversus abdominis plane.

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