Randomized Controlled Trial Comparing Liposomal to Plain Bupivacaine in the Transversus Abdominis Plane for DIEP Flap Breast Reconstruction.

BACKGROUND: Pain control after autologous breast reconstruction is important for patient satisfaction and early recovery. Transversus abdominis plane (TAP) blocks are commonly used as part of an enhanced recovery after surgery (ERAS) pathway for breast reconstruction. It is uncertain whether liposomal bupivacaine used in TAP blocks offers additional advantages. This study aimed to compare the efficacy of liposomal bupivacaine versus plain bupivacaine for patients undergoing deep inferior epigastric perforator flap reconstruction. METHODS: This double-blinded randomized controlled trial studied patients undergoing abdominally based autologous breast reconstruction between June of 2019 and August of 2020. Subjects were randomly assigned liposomal or plain bupivacaine, performed using ultrasound-guided TAP block technique. All patients were managed according to an ERAS protocol. Primary outcomes were postoperative narcotic analgesia required, measured in oral morphine equivalents from postoperative days 1 to 7. Secondary outcomes included numeric pain scale score on postoperative days 1 to 7, nonnarcotic pain medication use, time to first narcotic use, return of bowel function, and length of stay. RESULTS: Sixty patients were enrolled: 30 received liposomal bupivacaine and 30 received plain bupivacaine. There were no significant differences in demographics, daily oral morphine equivalent narcotic use, nonnarcotic pain medication use, time to narcotic use, numeric pain scale score, time to bowel function, or length of stay. CONCLUSION: Liposomal bupivacaine does not confer advantages over plain bupivacaine when used in TAP blocks for abdominally based microvascular breast reconstruction in patients under ERAS protocols and multimodal approaches for pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Significant discrepancies exist between clinician assessment and patient self-assessment of functional capacity by validated scoring tools during preoperative evaluation.

BACKGROUND: Preoperative assessment of functional capacity is necessary to direct decisions regarding cardiac evaluation and may help identify patients at high risk for perioperative complications. Patient self-triage regarding functional capacity could be useful for discerning which patients benefit from a clinician evaluation at a Preoperative Evaluation Center prior to the day of surgery. We evaluated the feasibility of preoperative, patient self-triage regarding functional capacity. METHODS: Patients were recruited immediately prior to their preoperative evaluation. Study participants completed electronic versions of the Duke Activity Status Index (DASI) and the Patient-Reported Outcomes Measurement System (PROMIS)-Short Form 12a-Physical Function. DASI and PROMIS questionnaire responses were scored and evaluated for correlation with clinician assessments of functional capacity. Correlation was analyzed around the dichotomous outcome of <4 metabolic equivalents of task (METs) or ≥4 METs. Patients also evaluated the usability of the questionnaires. RESULTS: After IRB approval, 204 patients were enrolled and completed both DASI and PROMIS questionnaires. Clinicians assessed functional capacity at <4 METs for 109 patients (53.4 %) compared to 18 (8.8 %) patient self-assessments <4 METs as estimated by DASI. These results represent a significant discrepancy between assessments (Fisher's exact, two-tailed P value <0.0001). The standard T-score of PROMIS estimates of functional capacity correlated with DASI estimates (R (2) 0.76). The mean and standard deviation for PROMIS T-scores were 43.3 and 9.86, respectively (mean 50.0; SD 10.0 for the general population). Of the 203 patients who completed the entire study survey, 192 (94.6 %) stated that they did not require assistance from another person, and 187 (94 %) responded either "agree" or "strongly agree" to the DASI questionnaire being "easy to understand" and "easy to complete;" 186 (93 %) and 188 (94 %), respectively, responded similarly to the PROMIS questionnaire. CONCLUSIONS: While both electronic questionnaires were easy to understand and complete for most study participants, there was a significant discrepancy between clinician assessments and patient self-assessments of functional capacity. Further study is needed to determine if either patient self-triage by means of activity questionnaires or clinician evaluation is valid and reliable in the preoperative setting.