High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-Caesarean delivery analgesia: a meta-analysis

Peripheral nerve blocks for analgesia following cesarean delivery A narrative review

Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the same for many years. In recent times, many peripheral nerve blocks (PNBs) have been tried for postoperative analgesia following cesarean delivery (PACD). This article has reviewed the common PNBs used for PACD. The role of PNBs along with ITM has been studied and the current best strategy for PACD has also been explored. Currently, Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine have been found to be the most effective strategy, providing lower rest pain at 6 hours as compared to ITM alone. In patients not receiving intrathecal morphine, recommended PNBs are lateral transversus abdominis plane block, single shot local anesthetic wound infiltration, or continuous wound infiltration with catheter below rectus fascia. PNBs are recommended for PACD. They have an opioid-sparing effect and are devoid of adverse effects associated with central neuraxial blocks such as hypotension, bradycardia, and urine retention. However, caution must be observed with PNBs for possible local anesthetic toxicity due to the large volumes of drug required.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review

BACKGROUND

Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy.

METHOD

We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST.

RESULTS

After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died.

CONCLUSION

Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.

Transversus abdominis plane block improves postoperative recovery following cesarean delivery under general anesthesia: A propensity score matched retrospective cohort study

OBJECTIVE

To evaluate the effects of transversus abdominis plane (TAP) block on postoperative recovery 24 h after cesarean delivery under general anesthesia.

METHODS

A propensity-score-matched, retrospective cohort study was used. A total of 173 pregnancies resulting in elective cesarean delivery under general anesthesia between March 2021 and March 2022 were analyzed retrospectively. Patients receiving TAP block were compared with those receiving only intravenous analgesia. The Quality of Recovery 15 (QoR-15) score, assessed 24 h postoperatively using a 15-item questionnaire, was the primary outcome. Secondary outcomes included time to first ambulation, time to first flatus postoperatively, ability to tolerate ambulation, visual analog scale (VAS) score, hospitalization cost, and postoperative nausea and/or vomiting.

RESULTS

The total QoR-15 score 24 h postoperatively in the TAP group was significantly higher than in the Control group (P < 0.001). Patients in the TAP group had higher Bruggemann comfort scale scores (P < 0.001), could better tolerate early postoperative ambulation (P < 0.001), and had shorter time to first ambulation (P < 0.001) and flatus (P < 0.001). Correlation analysis demonstrated an inverse relationship between the cumulative VAS pain scores, time to first postoperative ambulation, time to first flatus, and total QoR-15 score 24 h postoperatively.

CONCLUSIONS

Following cesarean delivery under general anesthesia, TAP block combined with intravenous analgesia can improve postoperative recovery and shorten the time to postoperative ambulation and recovery of intestinal function.

Peripheral Nerve Blocks for Cesarean Delivery Analgesia: A Narrative Review

Effective postoperative analgesia using multimodal approach improves maternal and neonatal outcomes after cesarean delivery. The use of neuraxial approach (local anesthetic and opioids) and intravenous adjunctive drugs, such as nonsteroidal anti-inflammatory drugs and acetaminophen, currently represents the standard regimen for post-cesarean delivery analgesia. Peripheral nerve blocks may be considered in patients who are unable to receive neuraxial techniques; these blocks may also be used as a rescue technique in selected patients. This review discusses the relevant anatomy, current evidence, and advantages and disadvantages of the various peripheral nerve block techniques. Further research is warranted to compare the analgesic efficacy of these techniques, especially newer blocks (e.g., quadratus lumborum blocks and erector spinae plane blocks). Moreover, future studies should determine the safety profile of these blocks (e.g., fascial plane blocks) in the obstetric population because of its increased susceptibility to local anesthetic toxicity.

Efficacy of Ultrasound-Guided Quadratus Lumborum Block for Postoperative Analgesia After Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Ultrasound-guided quadratus lumborum (QL) block as a novel regional anesthetic technique was proposed in 2007 that can be applied in patients following hip arthroplasty. This study aimed to evaluate the efficacy of the QL block for pain control in patients undergoing hip arthroplasty.

METHODS

We performed a comprehensive search of PubMed, Web of Science, Scopus, Cochrane Library, Embase databases, Google Scholar, and CNKI for randomized controlled trials up to December 2021. According to the inclusion and exclusion criteria established in advance, "QL block" and "hip arthroplasty" related MeSH terms and free-text words were used.

RESULTS

Our meta-analysis included 11 randomized controlled trials involving a total of 830 patients between 2018 and 2021. The results indicated that compared to the non-QL block group, Visual Analog Scale (VAS) score at mobilization in the QL block group demonstrated statistical and clinical significance at all time points (12, 24, and 48 hours), but VAS score at rest failed to reach the MCID (minimal clinically important difference). Meanwhile, opioid consumption in the QL block group only demonstrated statistical and clinical significance at 48 hours postoperatively, but did not reach the MCID at 12 or 24 hours postoperatively. The QL block increased satisfaction scores. There was a statistically significant reduction in the incidence of postoperative nausea and vomiting, but no difference in the incidence of pruritus and urinary retention.

CONCLUSION

The QL block significantly reduced postoperative VAS score at mobilization, and opioid consumption at 48 hours in patients after hip arthroplasty compared to no block, which reached the MCID. The QL block also decreased postoperative nausea and vomiting and increased satisfaction scores. Although these are promising results, the clinical relevance of the efficacy of the QL block remains to be further understood as larger studies are needed.

Efficacy of quadratus lumborum block on postoperative pain and side effects in patients who underwent urological surgery: A meta-analysis

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB) is considered a novel nerve block for postoperative pain control. However, its efficacy after urological surgery remains unclear.

OBJECTIVES

The purpose of the current meta-analysis was to evaluate the effects of the QLB block versus control (placebo or no injection) on postoperative pain and other adverse outcomes after urological surgery, providing extensive evidence of whether quadratus lumborum block is suitable for pain management after urological surgery.

STUDY DESIGN

Systematic review with meta-analysis of randomized clinical trials.

METHODS

We searched PubMed, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov to collect studies investigating the effects of QLB on analgesia after urological surgery. The primary outcomes included visual analog scale (VAS) at rest and during movement, 24-h postoperative morphine consumption, and the incidence of postoperative nausea and vomiting (PONV).

RESULTS

Overall, 13 randomized controlled trials (RCTs) were reviewed, including 751 patients who underwent urological surgery. The QLB group exhibited a lower VAS score postoperatively at rest or on movement at 0, 6, 12, and 24 h, with less 24-h postoperative morphine consumption and lower incidence of PONV.

LIMITATIONS

Although the result is stable, heterogeneity exists in the current research.

CONCLUSIONS

QLB exhibited a favorable effect of postoperative analgesia with reduced postoperative complications at rest or during movement after urological surgery. However, it is still a novel technology at a primary stage, which needs further research to develop.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block after cesarean delivery: A systematic review and meta-analysis

PURPOSE

The meta-analysis is aimed to further access the analgesic efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block after cesarean section (CS).

METHODS

Electronic databases were searched for eligible studies. Primary objectives were pain-related outcomes. Weighted mean differences (WMDs) or standardized mean differences (SMDs), as well as risk ratios (RRs) with 95% confidence intervals (CIs), were used to calculate estimates. Subgroup analyses were done based on whether USG-TAP blocks were performed with long-acting intrathecal opioids (ITO).

RESULTS

A total of 17 studies were included. When compared with control groups (placebo or no blocks), USG-TAP block resulted in lower cumulative opioid consumption at 6 h (WMD: -8.32; 95% CI: -14.86, -1.79), 12 h (WMD: -10.75; 95% CI: -20.93, -0.57), and 24 h (WMD: -12.71, 95% CI: -21.28, -4.14). No significant differences were demonstrated among dynamic or resting pain scores. Patients in USG-TAP groups needed longer time to request first analgesic (WMD: 3.56; 95% CI: 1.43, 5.68) and showed a lower requirement of opioid rescue analgesia for breakthrough severe pain during 24 h (RR: 0.40; 95% CI: 0.18, 0.86). Subgroup analyses showed USG-TAP blocks did not afford additional benefit in the presence of intrathecal morphine. Also, reduced need for antiemetics after CS and higher maternal satisfaction were provided by USG-TAP blocks.

CONCLUSION

USG-TAP block can provide significantly effective analgesia for patients who underwent CS in the absence of long-acting ITO and therefore are worth promoting in the setting of long-acting ITO being unfeasible.

The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Objective

Cesarean section (CS) is one of the most frequently performed major surgical interventions. Local anesthetic techniques, a universal component of perioperative multimodal analgesia, are reportedly effective in reducing pain scores and opioid requirements. However, the optimal local anesthetic technique for postoperative CS pain remains unclear.

Methods

Six databases were searched, and a Bayesian network meta-analysis was performed. The outcomes included cumulative morphine consumption and pain scores at four time points, time to first analgesic request, postoperative nausea and vomiting, pruritus, and sedation.

Results

Sixty-eight studies with 5039 pregnant women were included. Six local anesthetic techniques were involved, including transversus abdominis plane block (TAPB), ilioinguinal and iliohypogastric nerve block, quadratus lumborum blocks, transversalis fascia plane block, erector spinae block, and wound infiltration. Compared to inactive controls, TAPB reduced cumulative morphine consumption at 6, 12, 24, and 48 h, pain scores at 6, 12, and 24 h (with the exception of 24 h at rest), the risk of postoperative nausea and vomiting, and sedation. Compared with inactive controls, ilioinguinal and iliohypogastric nerve block reduced cumulative morphine consumption at 6 and 24 h and pain scores at 6, 12, and 24 h during movement. Compared with inactive controls, quadratus lumborum blocks reduced cumulative morphine consumption at 24 and 48 h and pain scores at 6 and 12 h and lengthened the time to first analgesic request. Compared with inactive controls, wound infiltration reduced cumulative morphine consumption at 12 and 24 h, pain scores at 12 and 24 h during movement, and risk of sedation. Compared with inactive controls, erector spinae block reduced pain scores at 6 and 12 h. Transversalis fascia plane block was found to have similar outcomes to inactive controls.

Conclusion

TAPB is the most comprehensive local anesthetic technique for postoperative CS analgesia in the absence of intrathecal morphine.

Transversus abdominis plane block versus wound infiltration for post-cesarean section analgesia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Transversus abdominis plane (TAP) block and wound infiltration (WI) with local anesthetics are used for postoperative analgesia after cesarean section (CS), reducing the need for administration of opioids.

OBJECTIVE

To compare the analgesic effect of TAP block related to WI.

SEARCH STRATEGY

MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Cochrane Library, and CINAHL were searched from inception until April 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) about women who underwent TAP block or WI after CS.

DATA COLLECTION AND ANALYSIS

Relevant data were extracted and tabulated. Review Manager 5.3 was used for data analysis. Primary outcome was cumulative opioid consumption (COC) 24 and 48 h after CS.

MAIN RESULTS

Five RCTs, enrolling 268 women, were included. There were no significant differences between the interventions regarding COC at 24 (mean difference [MD] -1.68, 95% confidence interval [CI] -6.29 to 2.93) and 48 hours (MD 1.28, 95% CI -10.44 to 13.00). Adverse effects (relative risk [RR] 0.93, 95% CI 0.75-1.16), gastrointestinal reactions (RR 1.30, 95% CI 0.46-3.68), or mild-moderate sedation (RR 1.12, 95% CI 0.72-1.74), pain scores, satisfaction of women, and withdrawals were similar between groups.

CONCLUSIONS

There might be no significant advantages selecting TAP block over WI for post-CS analgesia.

Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial

In women undergoing cesarean delivery under spinal anesthesia with intrathecal morphine, transversus abdominis plane (TAP) block with bupivacaine hydrochloride (HCl) may not improve postsurgical analgesia. This lack of benefit could be related to the short duration of action of bupivacaine HCl. A retrospective study reported that TAP block with long-acting liposomal bupivacaine (LB) reduced opioid consumption and improved analgesia following cesarean delivery. Therefore, we performed a prospective multicenter, randomized, double-blind trial examining efficacy and safety of TAP block with LB plus bupivacaine HCl versus bupivacaine HCl alone.

Transversus Abdominis Plane Block With Liposomal Bupivacaine vs. Regular Anesthetics for Pain Control After Surgery: A Systematic Review and Meta-Analysis

Background: Transverse abdominal plane (TAP) blocks are used to provide pain relief after abdominopelvic surgeries. The role of liposomal bupivacaine (LB) for TAP blocks is unclear. Therefore, this study aimed to synthesize evidence on the efficacy of LB vs. regular anesthetics in improving outcomes of TAP block. Methods: PubMed, Science Direct, Embase, Springer, and CENTRAL databases were searched up to July 24, 2020. Studies comparing LB with any regular anesthetic for TAP block for any surgical procedure and reporting total analgesic consumption (TAC) or pain scores were included. Results: Seven studies including five randomized controlled trials (RCTs) were reviewed. LB was compared with regular bupivacaine (RB) in all studies. A descriptive analysis was conducted for TAC due to heterogeneity in data presentation. There were variations in the outcomes of studies reporting TAC. Meta-analysis of pain scores indicated statistically significant reduction of pain with the use of LB at 12 h (MD: -0.89 95% CI: -1.44, -0.34 I² = 0% p = 0.01), 24 h (MD: -0.64 95% CI: -1.21, -0.06 I² = 0% p = 0.03), 48 h (MD: -0.40 95% CI: -0.77, 0.04 I² = 0% p = 0.03) but not at 72 h (MD: -0.37 95% CI: -1.31, 0.56 I² = 57% p = 0.43). Pooled analysis indicated no difference in the duration of hospital stay between LB and RB (MD: -0.18 95% CI: -0.49, 0.14 I² = 61% p = 0.27). LB significantly reduced the number of days to first ambulation postsurgery (MD: -0.28 95% CI: -0.50, -0.06 I² = 0% p = 0.01). Conclusions: Current evidence on the role of LB for providing prolonged analgesia with TAP blocks is unclear. Conflicting results have been reported for TAC. LB may result in a small reduction in pain scores up to 48 h but not at 72 h. Further, high-quality homogenous RCTs are needed to establish high-quality evidence.

Gerard W. Ostheimer Lecture: What's New in Obstetric Anesthesia 2018

This article summarizes the Gerard W. Ostheimer Lecture given at the 2019 Society for Obstetric Anesthesia and Perinatology annual meeting. The article summarizes key articles published in 2018 that were presented in the 2019 Ostheimer Lecture, with a focus on maternal mortality, maternal complications, analgesic and anesthetic management of vaginal and cesarean deliveries, postpartum care, and the impact of anesthesia on maternal outcomes. The reviewed literature highlights many opportunities for anesthesiologists to impact maternal care and outcomes. The major themes presented in this manuscript are maternal mortality including amniotic fluid and cardiac arrest; postpartum hemorrhage; venous thromboembolism; management of spinal-induced hypotension; postpartum care including opioid use, postcesarean analgesia, and postpartum depression. A proposed list of action items and research topics based on the literature from 2018 is also presented. Specifically, anesthesiologists should use prophylactic vasopressor infusions during elective cesarean delivery; use a structured algorithm to diagnose pulmonary embolus, and reevaluate the use of D-dimer measurements; target postpartum opioid analgesia and prescribing; use multimodal postcesarean delivery analgesia, preferably with neuraxial hydrophilic opioids; and study any association between labor analgesia on postpartum depression.

Ultrasound-Guided Transversus Abdominis Plane Block in Shetland Ponies: A Description of a Three-Point Injection Technique and Evaluation of Potential Analgesic Effects

Colic surgery is one of the most painful procedures carried out in horses. Common strategies to alleviate immediate postsurgical abdominal pain include the administration of potent systemic analgesics; however, these may cause unwanted adverse effects such as cardiovascular depression, ileus, and ataxia. The administration of local anesthetics at the incision site in form of an ultrasound-guided subcostal transversus abdominis plane (TAP) block may therefore be preferred to provide adequate analgesia without significant side effects. To date, no technique for a TAP block in horses undergoing median celiotomy has been described. The objective of the study was to develop a TAP block technique, which will lead to the desensitization of the ventrolateral abdominal wall and adjacent skin area of experimental Shetland Ponies using bupivacaine 0.125%. This is a prospective, blinded, self-controlled trial. A cadaver study was performed to determine the ideal injection points and the volume required to stain the nerves responsible for the sensation of the ventrolateral abdominal wall and skin in Shetland pony cadavers (i.e., T9-L 2). Subsequently, using the ideal injectate volume and the landmarks obtained in the first phase of the study, six Shetland ponies received a bilateral TAP injection, either with a local anesthetic solution (bupivacaine 0.125%) or with saline in a randomized, crossover, blinded fashion. Effectiveness was determined over a 4 hour postinjection time, by using a pinprick technique. Significant differences were found to the responses of the pinprick evaluation between the bupivacaine- and saline-treated sides after 30 minutes of TAP block injection. Reported "learned behavior" could have affected the results of the pinprick testing. The TAP block technique reported in this study using bupivacaine 0.125% appeared effective in desensitizing the lower abdomen of ponies for up to 2 hours. Further research is required to apply this technique in horses undergoing celiotomy. Potentially larger volumes and/or higher concentrations of bupivacaine may be necessary to provide longer duration of action of the block.

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.

A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy

BACKGROUND

Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy.

METHODS

Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed.

RESULT

The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group.

CONCLUSION

The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Transversus Abdominis Plane Block

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.

Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.

Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.

A review of peripheral nerve blocks for cesarean delivery analgesia

Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.

Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study

Purpose

To determine if a transversus abdominis plane (TAP) block with liposomal bupivacaine reduces total postoperative opioid use in the first 72 hrs following laparoscopic or robotic hysterectomy compared to port-site infiltration with 0.25% bupivacaine.

Methods

Patients received either a true TAP block procedure with 266 mg liposomal bupivacaine and 50 mg of 0.25% bupivacaine and sham port infiltration or sham TAP block procedure with true port-site infiltration with 100–125 mg of 0.25% bupivacaine. All patients had a standardized, scheduled, non-opioid pain management plan. The primary outcome was total IV morphine equivalents used in the first 72 hrs following surgery. Secondary outcomes included assessment of postoperative pain over the study period and quality of recovery measures.

Results

Patients undergoing TAP blockade required fewer total opioid equivalents during the observation period than patients allocated to infiltration (median 21 versus 25 mg IV Morphine equivalents, P=0.03). Opioid use was highest in the first 24 hrs after surgery, with less difference between the groups during days 2 and 3 postoperatively. There were 5 in the TAP group and 0 in the infiltration group were opioid free at 72 hrs. Those in the TAP group had improved quality of recovery (QoR15) with no change in overall benefit of analgesia score.

Conclusion

TAP blockade reduced the requirement for opioid pain medication in the first 72 hrs after surgery, had more patients opioid free at 72 hrs, and improved patients’ quality of their recovery.

Post-caesarean delivery analgesia in resource-limited settings: a narrative review

Post-caesarean pain is an important and often neglected outcome. It causes suffering, affects breastfeeding and is associated with postpartum depression and the development of chronic pain syndromes. Pain control is often difficult even in resource-rich environments; it is likely far worse in resource-limited settings, where emphasis is on reducing the high maternal mortality rate. Lack of adequate staffing, education, and postoperative monitoring severely limit the options in resource-limited settings. Resource-limited settings are further compromised by limited access to essential analgesic drugs and equipment for their administration. Solutions using affordable and accessible medications as part of a multimodal analgesic strategy are possible, supplemented by education and training programmes. More research is required, both to establish current practice and to test methods for improving maternal pain control. While government involvement is necessary to improve infrastructure and resources in individual countries, other solutions should also be sought, empowering local institutions and harnessing individual cultural characteristics.