Gabapentin for post op abdominal surgery?

[europeman]

At my institution whenever we consult pain service, no matter what, they add on gabapentin.

Why? I'm a surgeon so that's why I ask you.

Isn't it for neuropathic pain? Why would it help for someone post laparotomy? (For example if it's a colon or something I'll say ngt or po meds is okay).

I understand multimodal therapy.... Narcs, Tylenol, NSAIDs, etc but why neuropathic meds?


I had another patient with several broken ribs. Consulted for epidural. Patient ended up not getting epidural for variety of reasons but they also started gabapenrin.


Is it because there are nerves in the rib bundle? For the belly is it to help superficial skin nerve pain?

Is there evidence for this? Is this drug expensive? What are clinically big side effects?

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[BLADEMDA]

ManeufManeufYP, Gonzalez MI, Sutton KS, Chung FZ, YP, PinnockPinnockRD, Lee K. Cellular and molecular RD, action of the putative GABA GABA-mimetic, gabapentin gabapentin. . Cell Mol Life Sci Sci. . 2003;60:742 742–750. doi doi: :
10.1007/s00018 s00018-003 003-2108
Dahl JB, MathiesenMathiesenO, O, Møiniche iniche S. "Protective premedication premedication": an option with ": gabapentin
and related drugs? A review of gabapentin and pregabalin in the treatment of post post-operative
pain. Acta Anaesthesiol AnaesthesiolScand. Scand. 2004;48:1130 1130–1136. doi doi: 10.1111/j.1399 : 1399-6576.2004.00484
SeibSeibRK, Paul JE. Preoperative RK, gabapentin for postoperative analgesia: a meta meta-analysis. Can J
Anesth Anesth. . 2006;53:461 461–469
Hurley RW, Cohen SP, Williams KA, Rowlingson RowlingsonAJ, Wu CL. The analgesic effects of AJ, perioperative gabapentin on postoperative pain: a meta meta-analysis. Reg Anesth Pain Med.
2006;31:237 237–247.
MathiesenMathiesen, O. et al. , GabapentinGabapentinand postoperative pain: a qualitative and quantitative and systematic review, with focus on procedure. Regional Anesthesia and Pain Medicine.
2006;31:237 237-247.
PengPengPW, PW, WijeysunderaWijeysunderaDN, Li CC. Use of DN, gabapentin for perioperative pain control – a
meta meta-analysis. Pain Res Manag Manag. 2007;12(2):85 . 85-92.
Ho KY, GanGanTJ, TJ, HabibHabibAS. AS. Gabapentin and postoperative pain pain-- --a systematic review of
randomized controlled trials. Pain 2006;126:91 91-101.

 

[BLADEMDA]

Reg Anesth Pain Med. 2006 May-Jun;31(3):237-47.
The analgesic effects of perioperative gabapentin on postoperative pain: a meta-analysis.
Hurley RW, Cohen SP, Williams KA, Rowlingson AJ, Wu CL.
Source
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD 21287, USA. [email protected]
Abstract
BACKGROUND AND OBJECTIVES:
Gabapentin is an anticonvulsant that has been shown to be effective in the treatment of neuropathic and inflammatory pain in animal and human studies. The analgesic effect of its perioperative use has not been fully elucidated.
METHODS:
This systematic review (meta-analysis) included 12 randomized controlled trials of 896 patients undergoing a variety of surgical procedures that investigated the impact of perioperative administration of gabapentin on postoperative outcome.
RESULTS:
The pooled visual analog scores for pain at 4 hours and 24 hours were significantly less in those patients who received gabapentin (weighted mean difference [WMD] = -1.57; 95% confidence interval [CI], -2.14 to -0.99 and WMD = -0.74; CI, -1.03 to -0.45, respectively). A concomitant decrease in opioid usage by those patients who received gabapentin was also noted (odds ratio [OR] = -17.84; CI, -23.50 to -12.18). Gabapentin administration was associated with sedation and anxiolysis (OR = 3.28; CI, 1.21-8.87) but not associated with a difference in lightheadedness, dizziness, nausea, or vomiting.
CONCLUSIONS:
Based on this systematic review, perioperative oral gabapentin is a useful adjunct for the management of postoperative pain that provides analgesia through a different mechanism than opioids and other analgesic agents and would make a reasonable addition to a multimodal analgesic treatment plan

 

[BLADEMDA]

Acta Anaesthesiol Scand. 2010 May;54(5):529-35. doi: 10.1111/j.1399-6576.2010.02215.x. Epub 2010 Feb 17.
The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review.
Petersen PL, Mathiesen O, Torup H, Dahl JB.
Source
Department of Anaesthesia, Copenhagen University Hospital, Ndr. Ringvej, DK-2600 Glostrup, Denmark. [email protected]
Abstract
The transversus abdominis plane (TAP) block is a newly described peripheral block involving the nerves of the anterior abdominal wall. The block has been developed for post-operative pain control after gynaecologic and abdominal surgery. The initial technique described the lumbar triangle of Petit as the landmark used to access the TAP in order to facilitate the deposition of local anaesthetic solution in the neurovascular plane. Other techniques include ultrasound-guided access to the neurovascular plane via the mid-axillary line between the iliac crest and the costal margin, and a subcostal access termed the 'oblique subcostal' access. A systematic search of the literature identified a total of seven randomized clinical trials investigating the effect of TAP block on post-operative pain, including a total of 364 patients, of whom 180 received TAP blockade. The surgical procedures included large bowel resection with a midline abdominal incision, caesarean delivery via the Pfannenstiel incision, abdominal hysterectomy via a transverse lower abdominal wall incision, open appendectomy and laparoscopic cholecystectomy. Overall, the results are encouraging and most studies have demonstrated clinically significant reductions of post-operative opioid requirements and pain, as well as some effects on opioid-related side effects (sedation and post-operative nausea and vomiting). Further studies are warranted to support the findings of the primary published trials and to establish general recommendations for the use of a TAP block.

 

[BLADEMDA]

At my institution whenever we consult pain service, no matter what, they add on gabapentin.

Why? I'm a surgeon so that's why I ask you.

Isn't it for neuropathic pain? Why would it help for someone post laparotomy? (For example if it's a colon or something I'll say ngt or po meds is okay).

I understand multimodal therapy.... Narcs, Tylenol, NSAIDs, etc but why neuropathic meds?


I had another patient with several broken ribs. Consulted for epidural. Patient ended up not getting epidural for variety of reasons but they also started gabapenrin.


Is it because there are nerves in the rib bundle? For the belly is it to help superficial skin nerve pain?

Is there evidence for this? Is this drug expensive? What are clinically big side effects?

At my Institution I utilize Subcostal TAP/TAP with Exparel (plus decadron plus Buprenorphine) for major, open Exploratory Laparotomy. The majority of patients are pain free (75%) with another subgroup (15%) scoring their pain below 4 (VAS of 4). Only 10% of patients report a VAS of 4 or greater after this block. This Subcostal TAP/TAP as described in the literature by Hebbard wil last about 40-48 hours postoperatively with the mixture described above. I urge you to speak with the Regional Guru Anesthesiologist at your institution to implement this block immediately for your patients. He/She can do a literature search or contact me here on SDN.

http://www.csen.com/Hebbard.pdf

 

[BLADEMDA]

Pain Relief Technique Helps Speed One Third of Colorectal Surgical Patients to Hospital Discharge the Day After Bowel Resection
TAP block procedure poses no significant risks to patients and also cuts postoperative use of narcotics according to Journal of the American College of Surgeons study
Chicago (August 28, 2013) — Surgeons at University Hospitals Case Medical Center, Cleveland, are working to reduce serious complications that have been known to occur with colorectal operations. In addition to using a set of pre-and postoperative standards that speed recovery which they have been publishing on for more than a decade, the researchers have validated yet another step surgeons can take to further reduce patients’ hospital stays: adding a procedure called the transversus abdominis plane (TAP) block to patients’ surgical care. The results of their study appear in the September issue of the Journal of the American College of Surgeons.

 

[BLADEMDA]

“If things continue to go well, my expectation is that we’ll eventually be giving the TAP to everyone, because it helps with reducing the pain,” Dr. Delaney said. “As quality and outcomes improve, we will also continue to see an increasing percentage of patients who are fit to be discharged the day after colorectal resection."

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/22632762

http://www.ncbi.nlm.nih.gov/pubmed/23810575

 

[HollATme]

What's your thoughts on epidural vs. TAP? I'm finding with anticoagulation issues and accidental catheter movement/removal from entry site that they inevitably end up on a PCA anyway. However, TAP lasting 48 hours may not be enough for pts who remain in the hospital beyond POD 2.

 

[BLADEMDA]

What's your thoughts on epidural vs. TAP? I'm finding with anticoagulation issues and accidental catheter movement/removal from entry site that they inevitably end up on a PCA anyway. However, TAP lasting 48 hours may not be enough for pts who remain in the hospital beyond POD 2.

48 hours is pretty good if the VAS is zero. Would I prefer 72 or 96 hours? Of course. The fact remains that Subcostal Tap with Standard TAP provides 100% analgesia for 75% of all surgical patients undergoing abdominal surgery and there are no anticoagulation issues. Yes, a Hebbard TAP isn't as good as an Epidural if you want/need more than 48 hours of solid analgesia but 2 days of narcotic free analgesia is still much better than standard PCA for the entire hospital stay.

 

[HollATme]

48 hours is pretty good if the VAS is zero. Would I prefer 72 or 96 hours? Of course. The fact remains that Subcostal Tap with Standard TAP provides 100% analgesia for 75% of all surgical patients undergoing abdominal surgery and there are no anticoagulation issues. Yes, a Hebbard TAP isn't as good as an Epidural if you want/need more than 48 hours of solid analgesia but 2 days of narcotic free analgesia is still much better than standard PCA for the entire hospital stay.

I agree with your point on the TAP Block.

Would it be overkill in this situation to do a TAP and an epidural? In the case you're not sure you have good coverage with the epidural, at least you're getting 2 days of solid coverage. Start epidural when the TAP eventually starts wearing off.

 

[kazuma]

I agree with your point on the TAP Block.

Would it be overkill in this situation to do a TAP and an epidural? In the case you're not sure you have good coverage with the epidural, at least you're getting 2 days of solid coverage. Start epidural when the TAP eventually starts wearing off.

I've done a few TAPs on patients undergoing c-section (after incision closure) with a spinal. We don't have exparel at our shop but even bupivicaine offers them some good post-op pain after the spinal wears off and reduces PO/IV narcotic usage.

 

[BLADEMDA]

I agree with your point on the TAP Block.

Would it be overkill in this situation to do a TAP and an epidural? In the case you're not sure you have good coverage with the epidural, at least you're getting 2 days of solid coverage. Start epidural when the TAP eventually starts wearing off.

I've done exactly that in patients: Hebbard TAP plus Classic Tab and an Epidural. If VAS is les than 2 I remove the Epidural in PACU. If VAS is greater than 2 I start a low dose infusion of local (dilute) plus opioid in the PACU. I inform the surgeon if I am keeping the Epidural for 48 hours (no Lovenox for 48 hrs)

 

[urge]

TAP block procedure poses no significant risks to patients and also cuts postoperative use of narcotics according to Journal of the American College of Surgeons study Chicago (August 28, 2013)

They haven't seen what I have seen. When you watch somebody shove that needle in, taking repeated stabs without seeing anything on ultrasound, you will have a different perception. Someone in the hospital even saved a picture of a "successful" block where the needle is clearly through the peritoneum. True story.

 

[HollATme]

They haven't seen what I have seen. When you watch somebody shove that needle in, taking repeated stabs without seeing anything on ultrasound, you will have a different perception. Someone in the hospital even saved a picture of a "successful" block where the needle is clearly through the peritoneum. True story.

Clearly, with any ultrasound-guided procedure one does, one should be able to visualize the needle (importantly, the tip). We don't advance if we don't see the needle and we adjust the probe until we do. TAP blocks aren't difficult, and I've only done a few thus far, but have done several peripheral nerve blocks so the experience is there - and I plan to incorporate more TAPs in my practice if possible the next time I have a case that involves the use of an epidural/spinal in a belly case. But, if you don't know what you're doing then yes, as with anything, you can totally screw the pooch.

I'm sure Blade was referring to no risk of hypotension, low risk of hematoma, infection, etc. However, if you don't know how to use US to do a block, then yes you may cause a pneumothorax if doing a peripheral block or in the case of a TAP, perforate the peritoneum.

 

[HollATme]

I've done a few TAPs on patients undergoing c-section (after incision closure) with a spinal. We don't have exparel at our shop but even bupivicaine offers them some good post-op pain after the spinal wears off and reduces PO/IV narcotic usage.

My shop is concerned with GTFO of the OR due to the inevitable need for more "emergent" c-sections called by OB or more "urgent" epidural requests on the floor called by OB nurses, err, residents. However, if one has some time, not a bad idea to do it. It's just our patients (on average) don't seem to need a whole lot post-op (I've trended this) and we always give ketoralac after skin closure (OB loves it). I also put in orders for oxycontin and acetaminophen. That seems to do the trick in minimizing the amount of IV and PO narcotic usage. I agree that TAP would be better than all this polypharm but time seems to be the issue where I'm at.

 

[europeman]

So then basically for all my abdominal wacks and thoracotomy wacks I should start in gabapentin?

 

[urge]

So then basically for all my abdominal wacks and thoracotomy wacks I should start in gabapentin?

Not a bad idea for the thoracotomies.

 

[Idiopathic]

these patients are at risk for significant chronic pain (thoracotomies especially) and delayed bowel function 2/2 opiates (colectomies especially). why wouldnt you want to add on a drug that has both pain-relieving and sedating effects to lessen your opioid dose and potentially reduce your long term pain complications? i only say this because i believe that neurontin is fairly safe and therefore wouldnt have a problem starting it on most patients.

 

[Idiopathic]

also, ive seen two local anesthetic systemic toxicity cases firsthand. both occurred following TAP. I dont include these blocks in my practice.

 

[Idiopathic]

and who on earth is getting 48 hours out of a TAP block?

 

[BLADEMDA]

and who on earth is getting 48 hours out of a TAP block?

I am utilizing Exparel mixed with Decadron.

 

[BLADEMDA]

also, ive seen two local anesthetic systemic toxicity cases firsthand. both occurred following TAP. I dont include these blocks in my practice.

Ridiculous. I've seen codes and arrests from brachial plexus blocks over my past two decades. This doesn't mean I stopped doing those blocks.

My "N" for TAP blocks is over 250 without a single complication. The literature strongly supports that this TAP block via u/s is both and safe and effective. Of course, the usual precautions for any block must be taken into consideration including maximum local anesthetic dosage.

 

[europeman]

How do u dose neurontin to a naive patient post op? 100 tid to start and then increase how often how much and based on what?

 

[Mman]

How do u dose neurontin to a naive patient post op? 100 tid to start and then increase how often how much and based on what?

Dosing starts QHS because sedation is the most significant side effect when starting or increasing doses. I'm thinking 300 QHS for a non elderly patient is probably a reasonable starting dose.

 

[Random Anesthesiologist]

There is a lot of of ofirmev + robaxin at my intern institution to try to avoid opiates when I can; not enough block attempts IMO. I like ofirmev though. Also not using GABA analogues much. So much I would love to try with post op pain management but the surgeons seem to be stuck on norco with dilaudid if breakthrough. Occasionally a morphine or dilaudid pca, and woe to whoever deviates from the template.

I can't wait to start my anesthesiology training. :/

 

[Oggg]

November issue of Anesthesiology has a CME article at the end about using gabapentin or pregabalin for postop pain. At my hospital, our worst pain scores are after spine surgery. Maybe I will suggest they add gabapentin to every single patient... Anyone do this or have surgeons who like this?

 

[urge]

November issue of Anesthesiology has a CME article at the end about using gabapentin or pregabalin for postop pain. At my hospital, our worst pain scores are after spine surgery. Maybe I will suggest they add gabapentin to every single patient... Anyone do this or have surgeons who like this?

In my previous job we would give the thoracotomy patients 1200mg po in holding. That, and an epidural, seemed to work.