Authors: Turan A et al.
Journal: Anesthesiology, December 1, 2025. DOI: 10.1097/ALN.0000000000005869
Summary
This multicenter randomized controlled trial (the CLEVELAND Trial) evaluated whether liposomal bupivacaine provides superior or prolonged analgesia compared with plain bupivacaine or saline when used in single-injection, four-quadrant transversus abdominis plane (TAP) blocks for major abdominal surgery. Given widespread use of liposomal bupivacaine in ERAS pathways despite limited high-quality evidence, the investigators tested its effect on postoperative opioid consumption across early and late postoperative periods.
A total of 261 patients undergoing a broad mix of open and laparoscopic abdominal procedures were randomized in a blinded fashion to receive TAP blocks with liposomal bupivacaine, plain bupivacaine, or saline placebo. All patients had access to patient-controlled intravenous opioids, and perioperative care teams and outcome assessors were blinded to group assignment. Two co-primary hypotheses addressed opioid consumption in the first 24 hours and from 24–48 hours postoperatively.
Postoperative opioid requirements were similar across all three groups at every assessed time interval. Neither liposomal nor plain bupivacaine reduced opioid consumption compared with saline during the first 24 hours, nor did liposomal bupivacaine confer any advantage beyond 24 hours. Secondary outcomes—including pain scores, duration of sensory block, and later opioid use—were likewise indistinguishable among treatment arms.
These findings suggest that routine pre-incision, single-shot TAP blocks—regardless of local anesthetic formulation—provide minimal analgesic benefit in a heterogeneous abdominal surgery population. The results challenge assumptions underlying widespread use of liposomal bupivacaine TAP blocks and underscore the need for better patient selection or alternative analgesic strategies.
Key Points
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Liposomal bupivacaine did not reduce opioid consumption compared with plain bupivacaine or saline.
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No analgesic benefit was observed at 24, 48, or 72 hours postoperatively.
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Pain scores and block duration were similar across all treatment groups.
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Findings question the routine use of single-shot TAP blocks in mixed abdominal surgery populations.
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Liposomal bupivacaine did not demonstrate prolonged or superior analgesia in this setting.
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Results have important cost-effectiveness and ERAS pathway implications.
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