Multi-modal pain management in a clinical quality improvement program for laparoscopic ventral/incisional hernia repair

Bruce Ramshaw1, Jonathan Dean2, Andrew Gamenthaler2, Michael Fabian2. 1University of Tennessee, Knoxville, 2Halifax Health

Background: Patients undergoing laparoscopic ventral/incisional hernia repair can have significant post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain due to CO2.  In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was begun and multi-modal pain strategies were initiated over time.

Methods: CQI tools were applied for consecutive patients who underwent laparoscopic ventral/incisional hernia repair from June 2012 through March 2015 (33 months).  Initiatives for improved patient care during this period included the administration of a transversus abdominis plane (TAP) block as a part of a perioperative multi-modal pain strategy in an attempt to minimize somatic pain and a low pressure pneumoperitoneum system in an attempt to minimize visceral pain from CO2.  Outcome measures to assess pain and short-term recovery were collected and analyzed.

Results: One hundred and twelve patients who had a laparoscopic ventral/incisional hernia repair were included in the analysis. Fifty patients had no TAP block and had conventional insufflation at 15 mmHg.  Outcomes for this group included an average time in PACU of 168.4 minutes (0-426), an average length of stay of 4.4 days (0-19), an average use of opioid morphine equivalents in PACU of 11.0 (0-41) and an average total use of opioid morphine equivalents of 163.6 (0-1019.3).  Forty-two patients had a TAP block with a long-acting local anesthetic and conventional insufflation at 15 mmHg.  Outcomes for this group included an average time in PACU of 158.4 minutes (13-1434), an average length of stay of 3.9 days (0-17), an average use of opioid morphine equivalents in PACU of 9.8 (0-18.3) and an average total use of opioid morphine equivalents of 146.9 (0-1714.1).  Twenty patients had a TAP block with a long-acting local anesthetic and a low pressure pneumoperitoneum system with standard pressure of 8 mmHg.  Outcomes for this group included an average time in PACU of 91.1 minutes (36-212), an average length of stay of 1.5 days (0-5), an average use of opioid morphine equivalents in PACU of 5.3 (0-28.3) and an average total use of opioid morphine equivalents of 35.6 (0-138.3).

Conclusion: Implementation of CQI program including TAP blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients undergoing laparoscopic ventral/incisional hernia repair was associated with decreased PACU time, decreased length of stay and less opioid use in PACU as well as for the entire hospital stay.

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