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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:59-66. [PMID: 37429620 PMCID: PMC10850837 DOI: 10.1136/rapm-2023-104666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND/IMPORTANCE Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. OBJECTIVE We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). EVIDENCE REVIEW We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. CONCLUSIONS Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.
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Affiliation(s)
- Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Boretsky
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Childrens Hospital, Boston, Massachusetts, USA
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Anesthetic management of the parturient with opioid addiction. Int Anesthesiol Clin 2021; 59:28-39. [PMID: 34100798 DOI: 10.1097/aia.0000000000000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aaronson J, White R. The Role of Truncal Blocks in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00436-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sultan P, Sultan E, Carvalho B. Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review. Anaesthesia 2021; 76 Suppl 1:136-147. [PMID: 33426655 DOI: 10.1111/anae.15233] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- P Sultan
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - E Sultan
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Transversus abdominis plane block compared with wound infiltration for postoperative analgesia following Cesarean delivery: a systematic review and network meta-analysis. Can J Anaesth 2020; 67:1710-1727. [DOI: 10.1007/s12630-020-01818-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/02/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022] Open
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Landau R. Post-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery. Int J Obstet Anesth 2019; 39:105-116. [DOI: 10.1016/j.ijoa.2019.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/24/2018] [Accepted: 01/18/2019] [Indexed: 12/26/2022]
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Abstract
Placenta accreta spectrum is becoming more common and is the most frequent indication for peripartum hysterectomy. Management of cesarean delivery in the setting of a morbidly adherent placenta has potential for massive hemorrhage, coagulopathies, and other morbidities. Anesthetic management of placenta accreta spectrum presents many challenges including optimizing surgical conditions, providing a safe and satisfying maternal delivery experience, preparing for massive hemorrhage and transfusion, preventing coagulopathies, and optimizing postoperative pain control. Balancing these challenging goals requires meticulous preparation with a thorough preoperative evaluation of the parturient and a well-coordinated multidisciplinary approach in order to optimize outcomes for the mother and fetus.
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Urfalıoğlu A, Bakacak M, Boran ÖF, Yazar FM, Arslan M, Öksüz H. Bloqueio cirúrgico do plano transverso abdominal versus guiado por ultrassom em pacientes obesas após cesárea: estudo prospectivo e randomizado. Braz J Anesthesiol 2017; 67:480-486. [DOI: 10.1016/j.bjan.2017.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/27/2016] [Indexed: 10/19/2022] Open
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Tawfik MM, Mohamed YM, Elbadrawi RE, Abdelkhalek M, Mogahed MM, Ezz HM. Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial. Anesth Analg 2017; 124:1291-1297. [PMID: 27984230 DOI: 10.1213/ane.0000000000001724] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours. METHODS Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, the incidence of side effects (nausea and vomiting and pruritis), and patient satisfaction. RESULTS Data from 78 patients (39 patients in each group) were analyzed. The mean ± SD of cumulative fentanyl consumption at 24 hours was 157.4 ± 63.4 μg in the infiltration group and 153.3 ± 68.3 μg in the TAP group (difference in means [95% confidence interval] is 4.1 [-25.6 to 33.8] μg; P = .8). There were no significant differences between the 2 groups in the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, and patient satisfaction. The incidence of side effects (nausea and vomiting and pruritis) was low in the 2 groups. CONCLUSIONS TAP block and wound infiltration did not significantly differ regarding postoperative fentanyl consumption, pain scores, and patient satisfaction in parturients undergoing cesarean delivery under spinal anesthesia.
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Affiliation(s)
- Mohamed Mohamed Tawfik
- From the Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Egypt
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Gómez-Ríos MÁ, Paech MJ. Postoperative analgesia with transversus abdominis plane catheter infusions of levobupivacaine after major gynecological and obstetrical surgery. A case series. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:165-169. [PMID: 24792371 DOI: 10.1016/j.redar.2014.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/19/2014] [Accepted: 03/24/2014] [Indexed: 06/03/2023]
Abstract
Transversus abdominis plane block has become an important method of postoperative pain management for patients undergoing abdominal surgery but the modest duration is a major limitation. We report the successful use of a novel TAP catheter technique for continuous infusion of levobupivacaine in six gynecologic and obstetric patients. Bilateral TAP catheters were inserted at the end of surgery by ultrasound imaging using a Contiplex® C needle (B. Braun, Melsungen, Germany) in the Triangle of Petit or in a postero-subcostal level based on the location of the surgical incision. Following negative aspiration, 0.25% levobupivacaine 5 mL was injected. After withdrawing the needle, while holding the over-the-needle catheter in place, bilateral continuous infusion of 0.125% levobupivacaine at 2 mL/h from elastomeric pumps (INfusor SV2, Baxter, France) was started and continued for up to 50h. Before removal of the catheter, a bolus of 10 mL levobupivacaine 0.25% was administered. Successful analgesia was achieved in all six cases utilizing continuous infusion of levobupivacaine, minimizing the volume required. TAP infusions produce significant opioid sparing and better patient mobility. This technique may be a reliable alternative to neuraxial analgesia in major gynecological and obstetrical surgery.
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Affiliation(s)
- M Á Gómez-Ríos
- Department of Anaesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - M J Paech
- Pharmacology, Pharmacy and Anaesthesiology Unit, School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
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Dinges E, Ortner C, Bollag L, Davies J, Landau R. Osteogenesis imperfecta: cesarean deliveries in identical twins. Int J Obstet Anesth 2015; 24:64-8. [DOI: 10.1016/j.ijoa.2014.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/08/2014] [Accepted: 07/20/2014] [Indexed: 11/15/2022]
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Unilateral Transversus Abdominis Plane Block Catheter for the Treatment of Abdominal Wall Pain in Pregnancy. Reg Anesth Pain Med 2015; 40:720-2. [DOI: 10.1097/aap.0000000000000296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Ultrasound has permeated the practice of anesthesiology and is becoming an essential tool for the obstetric anesthesiologist in the labor and delivery suite. The most common applications include guidance for neuraxial (epidural and spinal) anesthesia and acute pain nerve blocks, as well as guidance for central and peripheral vascular access. Obstetric anesthesiologists are becoming increasingly familiar with diagnostic applications, including transthoracic echocardiography (TTE) and lung and gastric ultrasound. There is intense interest in developing standard curricula for achieving competency in ultrasound skills during residency training and expanding the role of ultrasound in education and research.
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Affiliation(s)
- Allison Lee
- Department of Anesthesiology, Columbia University, 630 West 168th St PH5, New York, NY 10032.
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Ultrasound-guided bilateral transversus abdominis plane blocks in conjunction with intrathecal morphine for postcesarean analgesia. J Clin Anesth 2013; 25:475-82. [DOI: 10.1016/j.jclinane.2013.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 05/05/2013] [Accepted: 05/11/2013] [Indexed: 01/09/2023]
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Singh S, Dhir S, Marmai K, Rehou S, Silva M, Bradbury C. Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind, dose-comparison, placebo-controlled randomized trial. Int J Obstet Anesth 2013; 22:188-93. [DOI: 10.1016/j.ijoa.2013.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 02/21/2013] [Accepted: 03/01/2013] [Indexed: 11/25/2022]
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Mirza F, Carvalho B. Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series. Can J Anaesth 2012; 60:299-303. [DOI: 10.1007/s12630-012-9866-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/04/2012] [Indexed: 11/28/2022] Open
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Vallejo MC, Steen TL, Cobb BT, Phelps AL, Pomerantz JM, Orebaugh SL, Chelly JE. Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia. ScientificWorldJournal 2012; 2012:107316. [PMID: 23304075 PMCID: PMC3529441 DOI: 10.1100/2012/107316] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/08/2012] [Indexed: 01/03/2023] Open
Abstract
The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours.
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Affiliation(s)
- Manuel C Vallejo
- Department of Anesthesiology, Magee-Womens Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213, USA.
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McDonnell NJ, Paech MJ. The transversus abdominis plane block and post-caesarean analgesia: are we any closer to defining its role? Int J Obstet Anesth 2012; 21:109-11. [PMID: 22405671 DOI: 10.1016/j.ijoa.2012.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 11/26/2022]
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