Transversus abdominis plane block

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Discussion A systematic review and meta-analysis assessing the efficacy of TAP blocks in cesarean sections was done by Mishriky et al in 2012. From their nine studies that fit their inclusion criteria, they concluded when “Transversus abdominis plane block significantly improved postoperative analgesia in women undergoing CD who did not receive ITM but showed no improvement in those who received ITM.” 15 This is the first study, however, comparing the use of ITM in the setting of patients receiving an LB TAP for postoperative analgesia after cesarean section. Our findings suggest that patients undergo- ing cesarean section with ITM and a postoperative LB TAP block had superior analgesia than an LB TAP along, based on significantly less ME over 24 hours, total ME over 72 hours and, while small, a statistically significantly shorter hospital stays. Thus, it suggests that even with a longer acting TAP block with liposomal bupivacaine, ITM is still beneficial.

Conclusions: TAP block using ultrasound provides substantial reduction in Tramadol consumption, time to first dose of rescue tramadol when compared with control group. This study reinforces the recommendation for TAP as a part of multimodal post-operative analgesic regimen. Keywords: Bupivacaine, Postcesarean analgesia, Tap, Transversus abdominis plane block Department of Anaesthesia, Konaseema Institute of Medical Science Amalapuram, India Received: 23 February 2019

1 Department of Anesthesiology, The First Affiliated Hospital of Hainan Medical College, Haikou 570102, China; 2 Department of Anesthesiology, Hainan Provincial Maternal and Child Health Hospital, Haikou 570206, China; 3 Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China Received November 25, 2015; Accepted April 9, 2016; Epub February 15, 2017; Published February 28, 2017 Abstract: Background: To observe the skin temperature changes on the blocked area and its response to pinprick testing in ultrasound-guided transversus abdominis plane block (TAP block), and to explore the accurate predictor of the temperature measurement for TAP block success. Methods: A total of 30 patients underwent lower abdominal surgery were enrolled. Bilateral ultrasound-guided TAP blocks were performed before the surgery, after obtaining the view of transversus abdominis plane and the needle tip, 30 mL of 0.25% ropivacaine was injected for each side.

14. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343:d5928. 15. Blanco R, Ansari T, Riad W, Shetty N. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial. Reg Anesth Pain Med. 2016; 41(6):757-62.

CERTIFICATE This is to certify that the dissertation entitled, “An evaluation of the postoperative analgesic efficacy and opioid sparing effect of Transversus abdominis plane block after caesarean sections”, submitted by Dr. P. RATESH THANGAM in partial fulfilment for the award of the degree of Doctor of Medicine in Anaesthesiology by the Tamilnadu Dr.M.G.R. Medical University, Chennai is a bonafide record of the work done by him in the Department of Anaesthesiology, Government Thanjavur medical College, during the academic year 2008-2011.

Keywords: Laparoscopic guided, Transversus abdominis plane block, Trocar site, Local anesthetic infiltration gynecologic laparoscopy Background Laparoscopic intervention, with very low mortality, min- imal morbidity, fast recovery, the best cosmetic outcome, and the least postoperative pain, has gained a major par- ticipation in gynecologic surgery throughout the past two decades [1]. During laparoscopic surgery, inflation of the abdomen provides the surgeon a perfect view of the struc- tures and a room to work [2]. Relieving postoperative pain and prompt resumption of physical activity are of the

nausea and sedation scores; and Quality of Recovery score; time to first bowel movement, ambulation, and duration of hospital stay. Discussion: Autologous breast reconstruction using abdominal tissue is rapidly becoming the reconstructive option of choice for postmastectomy patients across North America. A substantial component of the pain experienced by patients after this abdominally based procedure is derived from the abdominal wall incision. By potentially decreasing the need for systemic opioids and their associated side effects, this transversus abdominis plane block study will utilize the most scientifically rigorous double-blind, placebo-controlled, randomized controlled trial methodology to potentially improve both clinical care and health outcomes in breast cancer surgery patients.

BACKGROUND Effective postoperative analgesia after lower abdominal surgeries enhances early recovery, ambulation and duration of hospital stay. The effectiveness of transversus abdominis plane for post operative pain relief in abdominal surgeries have been well established.Quadratus lumborum block in recent years have gained much popularity in poatoperative pain management.However,not much studies have been conducted to directly compare and contrast the effecacies of these two blocks. . In the current study,it has been hypothesized that quadratus lumborum block would be equal to or better than the transversus abdominis plane block with regard to pain relief and its duration of action after lower abdominal surgeries.

52 BACKGROUND Effective postoperative analgesia after lower abdominal surgeries enhances early recovery, ambulation and duration of hospital stay.The effectiveness of transversus abdominis plane for post operative pain relief in abdominal surgeries have been well established.Quadratus lumborum block in recent years have gained much popularity in poatoperative pain management.However,not much studies have been conducted to directly compare and contrast the effecacies of these two blocks. . In the current study,it has been hypothesized that quadratus lumborum block would be equal to or better than the transversus abdominis plane block with regard to pain relief and its duration of action after lower abdominal surgeries.

The transversus abdominis plane block is a deposition of local anesthetic into the fascial plane superficial to the transversus abdominis muscle at the level of the T7-L1 dermatomes [6]. Although the extent of sensory blockade achieved by the TAP block has been debating, [7-10] ultrasound-guided TAP block has been used for providing pain relief following abdomi- nal surgeries, and mainly for lower abdominal surgery [6, 11-17]. However, there has been no systematic review evaluating the efficacy of the TAP block compared with no TAP block or sham groups for pain after laparoscopic cholecystec- tomy. So we conduct this meta-analysis to assess the efficacy of TAP block in people undergoing elective laparoscopic cholecystec- tomy.

Please cite this article in press as: Urfalıo˘ glu A, et al. Ultrasound-guided versus surgical transversus abdominis plane Transversus abdominis plane block methods for caesarean section 3 time to first analgesic requirement and reducing total anal- gesic consumption following various surgical procedures. 11,12 However, serious technical difficulties, similar to those reported for classic TAP block, have been reported with the use of USG-TAP, particularly in obese patients who have excess subcutaneous adipose tissue. The use of the TAP block method, described by Owen et al., is currently considered as the most appropriate method for achieving a block in obese patients because complications can be prevented through the use of an intra-abdominal approach. 13 Subsequently, sur- gical TAP block technique has been used following several laparoscopic surgical procedures. 14---16

received 0.125% bupivacaine at 0.2 mL/kg in each side for a total of 0.4 mL/kg under sonographic guidance. In this study posterior approach was used as magnetic resonance imaging study 34 showed better spread with posterior approach. Patient Controlled Analgesia (PCA pump) morphine consumption at set time intervals -1, 2, 4, 6,12, 24, and 48 hours after the operation was monitored . Quadratus Lumborum group had lesser morphine demands than the Transversus Abdominis Plane group (P < 0.05) at 12, 24, and 48 hours . The differences were 37.5%, 55%, and 48%, respectively . Similarly in my study the total tramadol consumption in Quadratus Lumborum plane group was 1.5 times less than that of Transversus Abdominis Plane block group. The Scale result of area under the curve for pain relief was similar in both groups in this study and there was no difference in the VAS scores between two groups. In contrast my study had lower postoperative NRS scores in Quadratus Lumborum block group.

The TAP block group received a landmark-orientated bilateral TAP block in the triangle of Petit with 0.3 ml/kg body weight 0.25% isobaric bupivacaine in each side and the injection sites were covered with sterile gauze. Continuous aspiration of the syringes after every 5 ml of bupivacaine administration was maintained to avoid accidental injection of the drug to the blood vessels. Additionally, all mothers were strictly followed by the practitioner who performed the TAP block for any sign of local anaesthetic systemic toxicity (LAST) for one hour after administration of the drug. The TAP block was done immediately after the last suture. Therefore, the injection was painless and could not be detected by the patients as they were still under spinal anaesthesia and drapes from surgery still obstructed their view. After some non-invasive manipulations, the control group received only a sterile cover at the potential injection site. Postoperative pain was evaluated, and possible complications were assessed, by trained, procedure-blinded nurse anaesthetists and physicians. Therefore, this clinical trial was conducted in a double- blinded manner, in which participants and the observers were blinded to group assignments. The practitioner who performed the TAP block did not participate in evaluating patients’ outcome. Hence, to decrease the risk of possible complications secondary to the procedure such as internal organ injury, researchers agreed to avoid placebo administration to the control group.

infusion is undesirable, these techniques fail or are contraindicated, or sympathetic or visceral block is not desirable. As the L1 segmental nerve may exit the muscle layer more anteriorly 14 , TAP blocks may be inferior to ilio-hypogastric/ilio-inguinal blocks for inguinal surgery in a percentage of patients. The patient in this series with no demonstrable block to ice had an adequate volume injected (per Suresh and Chan’s guidelines). With the 0.5% concentration used and assessment at 60 minutes, a degree of demonstrable block would be expected in the lower thoracic dermatomes and thus the aforementioned L1 anatomical variation is not an explanation. A later dermatomal assessment in this patient would have helped clarify this, in light of his lack of pain and analgesic requirement, but was not performed. The lower extent of a percentage of blocks to involve the mid-thigh usually attributed to the ‘L2 dermatome’

Two potential limitations should be considered. First, the study limited assessment of postoperative analgesia to the first 24 postoperative hours. However, the TAP block has been demonstrated to produce clinically useful levels of analgesia for at least 48 h postoperatively. Second, there are difficulties in adequately blinding studies such as these, given that the TAP block produces loss of sensation of the abdominal wall. However, neither the patient nor the anesthesiologist conduct- ing postoperative assessments was aware of the group alloca- tion. The patient’s abdomen was not examined during these assessments, and the TAP block sites were covered by dress- ings in all patients.

Dovepress Faiz et al Discussion According to the results of previous studies, the efficacy of using local anesthesia has been shown to reduce the need for analgesic medications and to reduce pain after surgery. 4 Using TAP block for pain reduction after cesarean section and hys- terectomy improved the recovery of these patients. 7,10 Based on the results of this study, ultrasound-guided posterior TAP block compared with the lateral TAP block was more effective in pain control after cesarean section, and created a longer analgesia with higher patient satisfaction; the mean values of pain score of posterior TAP block was lower in all intervals after surgery but only the 12-hour postoperative coughing NAS score was significantly lower in the posterior TAP block group (p < 0.001) and the summation of excellent and very good satisfaction scores was 52.7% in the posterior vs 18.4% in the lateral TAP group, this result was shown the better effect of posterior TAP block in clinical situation. In terms of longer duration of analgesia our results were in line with the results of the meta-analysis by Abdallah et al. 7 In addition, patients in the posterior TAP block group required lower dose of drugs during the 36 hours after the cesarean section. In a study by Rafi et al in 2001, 11–13 the TAP block was conducted by anatomical landmark and triangle of petit resulting in a better analgesia in lower parts of the abdomen; however, using anatomical land- marks for this block method has a higher risk of complications such as nerve and organ damage.

Howard et al investigated postoperative morphine require- ments in 10,000 patients. 13 Unfortunately the results are dif- ficult to compare with ours, as surgical procedures are not specified per age group in that study. However, the average morphine requirements that we found were less than those indicated by Howard et al. The fact that only 47% of our patients needed IV opioids postoperatively despite having undergone major abdominal surgery suggests that a preop- eratively sited TAP block indeed reduces opioid requirement.

volume in more diluted form can be used. As this is an advanced block, adequate skills for guiding the needle is required to safely achieve this block. Continuous catheter technique For prolonged analgesia catheter can be inserted in transverses abdominus neurofascial plane. It is important to place the catheter under ultrasound guidance. In this technique 18G tuohy needle is inserted in to the plane , after expanding the transverses abdominis plane with local anaesthetic 19G catheter is inserted 4-6 cm beyond the needle tip, which is confirmed by local anaesthetic accumulation on injection. Then needle is removed and catheter is fixed in skin It is mainly useful when neuraxial anesthesia is contraindicated. Main advantages of TAP catheter are better patient comfort, reduced use of opioids thus decreasing nausea, vomiting, sedation or respiratory depression. In unilateral surgery, it can be given unilaterally. When compared to epidural block, TAP block has no sympathetic or motor deficit and no damage to the spinal cord.

Abstract Background: The efficacy of transversus abdominis plane (TAP) block has been demonstrated in postoperative analgesia, but few studies have evaluated its intraoperative effects. We aimed to describe the intraoperative hemody- namic and analgesic effects of pre-incisional TAP block in patients undergo- ing total abdominal hysterectomy. Methods: Seventy women proposed for total abdominal hysterectomy indicated for uterine fibroids, classified ASA I and II were randomized in a double-blinded model to Group A (n = 35) re- ceiving bilateral ultrasound-guided TAP block with ropivacaine and Group B (n = 35) receiving bilateral ultrasound-guided TAP block with normal saline, followed by general anesthesia. The variations of the heart rate (HR) and mean arterial blood pressure (MABP) and intraoperative fentanyl consump- tion were studied. Results: At the arrival in the operating room, there was no significant difference in heart rate and mean arterial pressure noted in both groups. (HR: 85.38 ± 8.44 pulsations/min versus 86.30 ± 10.05 pulsations/min, p = 0.621; MABP: 94.97 ± 13.46 mmHg versus 96.36 ± 12.41 mmHg, p = 0.533). Before surgical incision, no statistically significant difference was de- tected between the two groups regarding the heart rate and the mean arterial blood pressure. After surgical incision, both the heart rate and mean arterial blood pressure were significantly higher in the Group B. There was a signifi- cant decrease in intraoperative fentanyl requirements in the Group A com- pared to the Group B (293.58 ± 60.59 mcg versus 449.44 ± 71.31 mcg, p <