Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section

Postoperative Cesarean Section Pain Management Using Transversus Abdominis Plane Block Versus Intrathecal Morphine: A Systematic Review and Meta-analysis

PURPOSE

Compare and evaluate the effectiveness of transversus abdominis plane (TAP) block versus intrathecal morphine (ITM) on elective postcesarean section pain, opioid consumption, and related side effects.

DESIGN

Systematic review and meta-analysis.

METHODS

A search for evidence was conducted in PubMed, Google Scholar, CINAHL, Cochrane Collaboration Database, UpToDate, Health Source, and gray literature. Only randomized controlled trials (RCTs) were included in the study. The methodological quality of evidence assessment was conducted using the Risk of Bias and Grades of Recommendation, Assessment, Development, and Evaluation system. The meta-analysis used Review Manager (RevMan 5.4, The Cochrane Collaboration).

FINDINGS

A total of 11 RCTs involving 1,129 patients were analyzed. Compared to ITM, TAP has a similar effect on static (mean difference [MD]; 0.37; 95% confidence interval [CI], -0.04 to 0.79; P = .08) and dynamic pain scores (MD, 0.43; 95% CI, -0.06 to 0.92; P = .09) within the first 48 hours after surgery. Additionally, the TAP block had a lower incidence of postoperative nausea and vomiting (risk ratio, 0.45; 95% CI, 0.31 to 0.66; P < .0001) and increased opioid consumption (MD, 6.78; 95% CI, 3.79 to 9.77; P < .00001). Overall, TAP block and ITM did not differ in the time to first to rescue analgesia, incidence of sedation, and pruritus.

CONCLUSIONS

Evidence suggests that TAP blocks are equivalent to ITM in pain scores and more effective at lowering the incidence of postoperative nausea and vomiting, yet ITM has been shown to be more effective in reducing postoperative opioid consumption.

Comparison of Spinal Morphine and Transversus Abdominis Plane Block on Opioid Requirements After Caesarean Section: An Observational Study

Objective

Acute postoperative pain is one of the major clinical problems that occurs in patients undergoing cesarean section with a prevalence of 89.8%. Postoperative pain causes discomfort and various complications for the mother. In addition, postoperative pain that is not handled properly can increase the risk of becoming chronic pain by 2.5 times. One of the methods recommended in the Enhanced Recovery After Caesarean Section (ERACS) protocol to prevent acute postoperative pain is the use of intrathecal long-acting opioids, with intrathecal morphine as the gold standard and Transversus Abdominis Plane (TAP) block. This study aims to assess the comparison of opioid needs as analgesic rescue between the administration of 0.1mg spinal morphine and TAP block with bupivacaine 0.2% 10mg in patients undergoing cesarean section.

Methods

This study is an observational study in a single Tertiary Hospital in West Java - Indonesia. Patients were given patient-controlled anesthesia (PCA) with fentanyl as analgesic rescue. Statistical analysis of the numerical data used the unpaired t-test and Chi-Square test for categorical data.

Results

In the group that was given spinal morphine, the duration of additional opioids was longer (p < 0.05), and the total dose of additional opioids was less than the TAP block group (p < 0.05).

Conclusion

The spinal morphine requires fewer additional opioids than the TAP block.

Postoperative pain control and opioid use with transversus abdominis plane block and scheduled multimodal pain management in patients undergoing cesarean section

OBJECTIVE

The impact of a transversus abdominis plane (TAP) block in patients undergoing cesarean section requires further evaluation. The aim of this study was to compare postoperative pain scores and opioid use in cesarean surgery patients undergoing either a TAP block and scheduled multimodal pain management (SMPM) or SMPM alone.

METHODS

In this retrospective, dual cohort study, cesarean surgery patients underwent neuraxial anesthesia and a TAP block (SMPM/TAP) or SMPM; the TAP block incorporated ropivacaine (20-30 mL) administered bilaterally. The group analyses involved a comparison of postoperative pain scores using the visual analog scale and opioid consumption at 24 and 24-48 h.

RESULTS

There were 94 (52.8%) patients in the SMPM/TAP group and 84 (47.2%) subjects in the SMPM alone group. At 24 h postoperatively, the SMPM/TAP group exhibited significantly lower pain scores (4.07 vs 4.54) than the SMPM group (P < 0.001) and reduced opioid consumption (2.29 vs 3.28 mg; P < 0.001). However, at 24-48 h, the SMPM group demonstrated lower pain scores (5.46 vs 5.98) compared to the SMPM/TAP group (P < 0.001) and reduced opioid consumption (8.75 vs 10.21 mg; P < 0.001); overall opioid consumption was higher (12.50 vs 12.02 mg) in the SMPM/TAP group (P < 0.001).

CONCLUSION

The TAP block improved cesarean surgery patients' pain scores and reduced opioid consumption at 24 h postoperatively but the effect of the TAP block was ephemeral as the SMPM/TAP group exhibited inferior pain scores and greater opioid consumption compared to the SMPM group at 24-48 h postoperatively.

Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.

Randomized Clinical Trial Comparing Quadratus Lumborum Block and Intrathecal Morphine for Postcesarean Analgesia

OBJECTIVE

 To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia.

METHODS

 Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded.

RESULTS

 Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group.

CONCLUSION

 Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.

Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Analgesic Efficacy of Spinal Morphine in Comparison With Transversus Abdominis Plane Block for Postoperative Pain Management in Patients Undergoing Cesarean Section Under Spinal Anesthesia: A Randomized Controlled Trial

Background

Cesarean section (CS) has been one of the most frequently performed major surgical interventions and causes severe postoperative pain. Spinal opioid and abdominal field block have been investigated as effective analgesia for postoperative pain and reduce the need for systemic medications and associated side effects. The aim of the current study is to compare spinal morphine (SM) and bilateral landmark oriented transversus abdominis plane (TAP) block for postoperative pain management.

Method

In this randomized controlled trial, 114 pregnant mothers scheduled for CS under spinal anesthesia were allocated randomly to receive either SM 0.1 mg (group SM; n = 56) or bilateral landmark-oriented TAP block with 20 ml of 0.25% of bupivacaine (group TAP; n = 52). A comparison of numerical variables between study groups was done using unpaired student t-test and Mann–Whitney test for symmetric and asymmetric data, respectively. Time to event variable was analyzed by using Kaplan–Meir's survival function. A p-value of < 0.05 was considered statistically significant.

Result

A total of 114 patients were recruited and randomly assigned and received interventions. Among them, 108 patients completed this study. Time to first analgesic request was significantly shorter in the TAP block compared to SM. Twenty-four-hour median morphine consumption was reduced in the SM group compared to the TAP block (p < 0.001). Median postoperative pain score during movement and rest shows statistically significant differences between groups (p < 0.001).

Conclusion

The addition of preservative-free 100 μg SM provides prolonged postoperative analgesia time, superior postoperative analgesia, and less postoperative opioid consumption compared to the TAP block.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

Impact of Transversus Abdominis Plane Block With Bupivacaine or Ropivacaine Versus Intrathecal Morphine on Opioid-related Side Effects After Cesarean Delivery: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Intrathecal morphine (ITM) is frequently associated with side effects such as postoperative nausea and vomiting (PONV) and pruritus. The aim of this meta-analysis was to compare the impact of transversus abdominis plane (TAP) block versus ITM on side effects following cesarean delivery.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and CENTRAL were searched for randomized controlled trials that compared TAP with ITM for cesarean delivery. The primary outcomes were opioid-related side effects. The secondary outcomes included pain scores, opioid consumption, patient satisfaction, and time to the first analgesia request.

RESULTS

Seven studies involving 660 patients were included. TAP blocks were performed with bupivacaine or ropivacaine. There was less PONV with TAP versus ITM (risk ratio [RR]=0.45, 95% confidence interval [CI]: 0.33-0.63, P<0.001; I2=0%), but no significant difference in pruritus (RR=0.76, 95% CI: 0.49-1.18, P=0.22; I2=78%) and sedation (RR=0.44, 95% CI: 0.19-1.00, P=0.05; I2=0%). TAP had a greater morphine consumption in 24 hours (mean difference: 5.80 mg; 95% CI: 1.38-10.22 mg, P=0.01; I2=89%) and higher pain score at rest at 6 hours (mean difference: 0.70, 95% CI: 0.39-1.02, P<0.001; I2=56%), but similar pain at rest at 24 hours and on movement compared with ITM. No differences were found in time to first analgesia and patient satisfaction.

DISCUSSION

Compared with ITM, TAP block is associated with less PONV but inferior early analgesia after cesarean delivery. However, the heterogeneity among the studies highlights the need for more well-designed studies to obtain more robust conclusions.

Comparative Study of the Analgesic Efficacy of Intrathecal Fentanyl with Ultrasound-Guided Transversus Abdominis Plane Block after Lower Segment Cesarean Section

Background:

This study was conducted to compare the analgesic efficacy of intrathecal fentanyl with ultrasound-guided transversus abdominis plane (TAP) block after lower segment cesarean section. The objectives of the study were to compare the effects of subarachnoid fentanyl versus TAP block with respect to duration of postoperative analgesia, time for first analgesic request, total analgesic consumption in 24 h, time to first breastfeed and Apgar score at 1 and 5 min.

Materials and Methods:

Sixty-two patients undergoing elective or emergency cesarean delivery were recruited for the study in a prospective, randomized, single-blind manner. The patients were randomly allocated to either intrathecal fentanyl group (Group F) or TAP block group (Group T) after determining the eligibility criteria. Group F patients received subarachnoid block with 10 mg of 0.5% bupivacaine heavy with 25 mcg of fentanyl. Group T patients received subarachnoid block with 10 mg of 0.5% bupivacaine heavy prior to surgery and at the end of surgery, they received TAP block with 0.25% bupivacaine 20 mL on each side.

Results:

Group T had significantly longer time for the first analgesic request (7.65 ± 1.23 h) than group F (4.10 ± 0.32 h). The total analgesic consumption in 24 h was significantly less in Group T (1.0 ± 0) than Group F (2.13 ± 0.34). The Visual Analogue Scale scores at rest and on movement were significantly less in Group T than Group F at all-time points. The Apgar score at 1 and 5 min and time to first breast feed were comparable between the two groups. The incidence of side effects was less in Group T.

Conclusion:

This study indicated that ultrasound-guided TAP block has a better analgesic as well as safety profile compared to intrathecal fentanyl for cesarean delivery.

Quadratus lumborum or transversus abdominis plane block for postoperative analgesia after cesarean: a double-blinded randomized trial

Background

Multimodal analgesia (MMA) is the current standard practice to provide post-cesarean analgesia. The aim of this study was to compare the analgesic efficacy of quadratus lumborum (QL) block and transversus abdominis plane (TAP) block as an adjunct to MMA.

Methods

Eighty mothers undergoing cesarean delivery under spinal anesthesia were randomized to receive either TAP or transmuscular QL block (QLB) with 20 mL 0.375% ropivacaine on each side. Postoperatively, all the subjects were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcomes were the pain scores during rest and movement, number of doses of tramadol, postoperative nausea-vomiting, sedation, and mother’s satisfaction with the pain management.

Results

The median (IQR) time to first analgesic request was 12 (9.25, 13) hours in the QL group and 9 (8.25, 11.37) hours in the TAP group (p = 0.0008). Patients in QL group consumed less doses of tramadol than those in TAP group (p < 0.0001). Pain scores were significantly lower in the QL group at all time points (p < 0.0001) except at 8^th hour when at rest, p = 0.0024, and on movement, p = 0.0028. The maternal satisfaction was significantly higher in the QL group (p = 0.0017).

Conclusion

Our study showed the significant delay in time to first analgesic request in QL group patients. Patients in the QL group had lower pain scores, required fewer analgesic supplements, and had more satisfaction. Nausea-vomiting and sedation were comparable.

The Effectiveness of Transversus Abdominis Plane and Quadratus Lumborum Blocks in Acute Postoperative Pain Following Cesarean Section-A Randomized, Single-Blind, Controlled Trial

Acute pain intensity related to cesarean section (CS) may be extensive and is often underestimated. This may influence mothers’ quality of life and their children’s development. Regional analgesia techniques that include transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have proven their efficacy in the postoperative period after CS. Although several randomized controlled studies and one meta-analysis have investigated the utility of TAPB and QLB in the reduction of acute and chronic pain after CS, only one study directly compared both types of regional blocks and revealed superiority of QLB over TAPB. Our study aimed to reevaluate the effectiveness of transversus TAPB and QLB in controlling acute postoperative pain after CS. We recruited 197 women with singleton pregnancies undergoing CS under spinal anesthesia. The patients were randomized to receive either TAPB or QLB after CS. The acute postoperative pain was evaluated using the visual analog scale (VAS) at 2, 4, 8, 12 and 24 h after the operation. No significant difference in acute postoperative pain intensity between the groups was found. The patients who received TAPB had a higher demand for supplemental morphine injections (p < 0.039). In our study, none of the evaluated regional blocks demonstrated an advantage over the other regarding acute postoperative pain management.

Intrathecal morphine versus transversus abdominis plane block for caesarean delivery: a systematic review and meta-analysis

Background

The number of caesarean deliveries has been increasing. Although intrathecal morphine (ITM) can relieve pain and is widely applied in caesarean deliveries, it is associated with many side effects. Transversus abdominis plane block (TAPB), a new analgesic technology, has also began playing a certain role after caesarean delivery, with fewer adverse effects. This study mainly compares the analgesic and adverse effects of ITM and TAPB in caesarean delivery.

Methods

We systematically searched PubMed, Cochrane Library, EMBASE, and Web of Science, for randomised controlled trials (RCTs) published before 9 October, 2020 to compare the effects of ITM and TAPB. Primary outcome of the study was the pain score at rest 24 h after caesarean delivery, whereas the secondary outcomes were the pain score at movement 24 h after operation, postoperative nausea and vomiting (PONV), itching, and morphine consumption. For the outcome assessment, we conducted a sensitivity analysis.

Result

Six RCTs involving 563 patients and meeting the study inclusion criteria were included in this study. Results indicated no significant difference in the pain score between ITM and TAPB at 24 h of rest or movement. The sensitivity analysis results indicated that the resting pain score (95% CI = − 1.27 to − 0.28; P = 0.002) and 24-h moving pain score (95% CI = − 1.8 to − 0.07; P = 0.03) of the ITM group were lower than those of the TAPB group. The consumption of morphine in the ITM group was lower than in the TAPB group (95% CI = 1.92 to 4.87; P < 0.00001); however, in terms of adverse reactions, the incidence of pruritus (95% CI = 1.17 to 8.26; P = 0.02) and PONV (95% CI = 1.92 to 4.87, P < 0.00001) in the ITM group was higher than in the TAPB group.

Conclusion

Parturients in the ITM and TAPB groups exhibited similar analgesic effects. However, in the sensitivity analysis performed by eliminating the studies causing heterogeneity, the ITM group was found to have superior analgesic effects compared with the TAPB group, with less morphine consumption. Differently, the TAPB group displayed less side effects such as PONV. Therefore, TAPB is still a valuable analgesia option for patients who cannot use ITM for analgesia after caesarean delivery or those having a high risk of PONV.

Trial registration

Registration number: Registered on Prospero with the registration number of CRD42020210135.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01392-9.

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.

The analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) block combined with oral multimodal analgesia in comparison with oral multimodal analgesia after caesarean delivery: a randomized controlled trial

Background

The transversus abdominis plane (TAP) block is used increasingly in parturients after caesarean delivery. This is a randomized controlled trial to evaluate the effectiveness of bilateral single-shot of TAP blocks in patients who received multimodal oral analgesia for postoperative pain relief.

Methods

Parturients who were scheduled for elective caesarean delivery under spinal anaesthesia were recruited and randomized to receive bilateral single-shot of TAP blocks or placebo in addition to multimodal oral analgesia which consisted of regular tramadol, celecoxib and paracetamol, with oral oxycodone used as a rescue for breakthrough pain. Only parturients in the TAP group would receive the TAP blocks with an injection of 15 ml (0.25%) ropivacaine on each side under aseptic techniques. All the parturients were evaluated for pain or related complications in the first 24 h after surgery. The primary outcome is the percentage of parturients who required oxycodone as a rescue analgesia.

Results

Eighty and 79 parturients were allocated to the TAP and placebo group respectively. Nine out of 79 (11.4%) parturients in the TAP group and 15 out of 73 (20.5%) parturients in the placebo group required oxycodone for breakthrough pain, P = 0.122.

Conclusions

Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anaesthesia.

Trial registration

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-INR-16010130, retrospectively registered on Dec 12, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-020-01223-3.

The use of bilateral transversus abdominis plane blocks with liposomal bupivacaine on postoperative cesarean delivery patients during COVID-19 pandemic is associated with reduced narcotics use and reduced length of stay

Background:

The use of transversus abdominis plane blocks has been previously shown in both large-scale studies and our own institution to significantly reduce postoperative pain and opioid use. In addition, the use of bilateral transversus abdominis plane blocks using liposomal bupivacaine in combination with neuraxial morphine significantly reduced post-cesarean-delivery pain and opioid use. During the COVID-19 crisis, our anesthesia department in a collaborative effort with our obstetric colleagues thought that the use of bilateral transversus abdominis plane blocks with liposomal bupivacaine could reduce the use of opioids to treat postoperative pain and might result in decreased length of stay.

Methods:

After institutional review board approval, a retrospective study of 288 patients who underwent cesarean delivery under spinal or epidural (neuraxial) anesthesia at Maimonides Medical Center in Brooklyn, NY was conducted. Historical controls were from 142 consecutive patients from 1 January 2012 through 12 May 2012. An additional set of controls consisted of 30 consecutive patients from 10 March 2020 through 13 April 2020. The primary outcome data analyzed were the use of opioids and length of stay.

Results:

Post cesarean delivery, patients who received both bilateral transversus abdominis plane blocks with liposomal bupivacaine and neuraxial morphine was associated with a significant decrease in the number of patients using post operative opioids, 54%–60% decreased to 18% (p < 0.001), and a decreased length of stay; 3.1 days was reduced to 2.39 (p < 0.001).

Conclusion:

Neuraxial opioids combined with liposomal bupivacaine transversus abdominis plane blocks provided significant pain relief for patients post cesarean delivery, required less post operative opioids, and facilitated earlier discharge that may aid in reducing patient exposure and hospital burden secondary to COVID-19.

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia 2020;76:393-403. [PMID: 32621529 DOI: 10.1111/anae.15160]

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.

Comparison of efficacy of thoracic paravertebral block with oblique subcostal transversus abdominis plane block in open cholecystectomy

BACKGROUND AND AIMS

Sensory afferent nerve branches of lower six thoracic and upper lumbar nerves innervate the anterior abdominal wall and are the therapeutic focus of local anesthetics to provide analgesia for the abdominal surgical incision. Central neuraxial and regional analgesia can provide better control of pain due to right subcostal incision used in open cholecystectomy and attenuate the need for opioids. The earlier studies which showed the benefit of the thoracic paravertebral block (TPVB) for analgesia after upper abdominal surgeries did not compare TPVB with oblique subcostal transversus abdominis plane (OSTAP) block. Therefore, the current study compares the analgesic efficacy of TPVB and OSTAP block in open cholecystectomy.

MATERIAL AND METHODS

Seventy consenting adults scheduled for open cholecystectomy were allocated to one of the two groups: ultrasound-guided TPVB (Group I) and ultrasound-guided OSTAP block (Group II). The primary objective of this study is to assess and compare tramadol consumption in 48 h in both the groups along with VAS in post anesthesia care unit, and then at 2, 4, 6, 8, 12, 24, and 48 h. The secondary objective of the study is to assess the incidence of PONV.

RESULTS

The number of doses of rescue analgesia required was less in Group I when compared with Group II (P < 0.001). Patients in Group I had significantly lower pain scores than Group II. Although in the initial 8 h, both groups had comparable pain scores, after 8 h, these scores were significantly lower in patients in Group I. Less postoperative nausea and vomiting was seen in Group I patients (11.7%) in comparison to Group II (18.1%).

CONCLUSION

Ultrasound-guided TPVB is superior to OSTAP block because of its association with decreased postoperative opioid consumption, lower VAS score, and reduction in opioid-related side effects. Thus, it should be strongly considered as a part of multimodal analgesia regimen in upper abdominal surgeries.

The impact of a transversus abdominis plane block including clonidine vs. intrathecal morphine on nausea and vomiting after caesarean section: A randomised controlled trial

BACKGROUND

Intrathecal morphine (ITM) is a widely used technique for postcaesarean section analgesia but entails a high risk of postoperative nausea and vomiting (PONV). The transversus abdominis plane (TAP) block is an alternative.

OBJECTIVE

We tested the hypothesis that a TAP block including clonidine reduces the incidence of PONV after caesarean section when compared with ITM.

DESIGN

A randomised, controlled, double-blinded study.

SETTING

Geneva University Hospitals, Switzerland, from October 2013 to February 2017.

PATIENTS

A total of 182 patients undergoing elective caesarean section were studied. Reasons for noninclusion were complicated pregnancy, contraindication to spinal anaesthesia or TAP block, extreme weight or height, allergy to any medication or previous median abdominal incision.

INTERVENTIONS

Patients were allocated randomly to one of two groups (quadruple blinded): 100 μg of morphine added to the spinal local anaesthetic or a bilateral TAP block with 20 ml of ropivacaine 0.375% + 75 μg of clonidine on each side.

MAIN OUTCOME MEASURES

The primary outcome measure was the total number of patients presenting with PONV at 24 h. Secondary aims were to compare other adverse effects (pruritus, respiratory depression, hypotension, bradycardia, sedation), analgesic efficacy and the quality of postoperative recovery.

RESULTS

At 24 h, there was no significant difference between ITM and TAP groups in the total number of patients presenting with PONV: 17/92 patients (18.5%, 95% confidence interval 11.1 to 27.9) and 27/88 patients (30.7%, 95% confidence interval 21.3 to 41.4) in TAP and ITM groups, respectively (P = 0.065). Pain scores at 6 h and cumulative morphine consumption at 24 h were lower in the ITM group (P < 0.0001 for morphine consumption at 24 h). The incidence of hypotension was higher in the TAP group (54.3 vs. 29.2%, P = 0.0006). Maternal satisfaction was high and not different between groups.

CONCLUSION

A TAP block with clonidine and local anaesthetic does not reduce significantly the incidence of PONV compared with ITM. We confirm the superiority of ITM on acute postcaesarean section analgesia compared with a TAP block, even with clonidine as an adjunct.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01931215.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial

Background and Aims:

Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures.

Methods:

The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 μg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software.

Results:

Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000).

Conclusion:

ITM 5 μg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

Comparison of Analgesic Effect Between Erector Spinae Plane Block and Transversus Abdominis Plane Block After Elective Cesarean Section: A Prospective Randomized Single-Blind Controlled Study

Background

This study compared the analgesic efficacy of a bilateral erector spinae plane (ESP) block with that of a bilateral transversus abdominis plane (TAP) block after elective cesarean delivery.

Methods

Sixty mothers scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either ESP block or TAP block. The ESP group received ESP block at the level of the ninth thoracic transverse process with 20 mL of 0.25% bupivacaine at the end of surgery. The TAP group received an ultrasound-guided TAP block with 20 mL of 0.25% bupivacaine on completion of delivery. The primary outcome was the duration of analgesia achieved by each block. Secondary outcome measures were the postoperative pain severity, total tramadol consumption, patient satisfaction.

Results

The median (interquartile range) duration of block was longer in the ESP group than in the TAP group (12 hours [10, 14] vs 8 hours [8, 8], p<0.0001). In the first 24 hours, the mean visual analog pain score at rest was lower by 0.32 units in the ESP group. The median tramadol consumption in the first 24 hours was significantly higher in the TAP group than in the ESP group (125 mg [100, 150] vs 100 mg [75, 100, p=0.003]).

Conclusion

Compared with the TAP block, the ESP block provides more effective pain relief, has a longer duration of analgesic action, prolongs time to first analgesic requirement, is associated with less tramadol consumption, and can be used in multimodal analgesia and opioid-sparing regimens after cesarean section.

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.

Transversus abdominis plane block and intrathecal morphine use in cesarean section: a retrospective review

OBJECTIVES

Cesarean delivery is an extremely common surgical procedure practiced worldwide. It is an open abdominal surgery, and is associated with significant postoperative pain. One modality that helps alleviate this pain is the transversus abdominis plane (TAP) block. This analysis sought to evaluate postoperative pain when this block was used in conjunction with intrathecal morphine.

METHODS

A retrospective review was performed of 142 patients who underwent cesarean section at our institution. Of those, 43 patients had a TAP block performed. The primary outcome for this analysis was the time to first opioid administration following discharge from the operating room. Secondary outcomes included differences in postoperative pain scores, and overall opioid consumption.

RESULTS

The average time to first opioid use postoperatively decreased in the TAP group when compared with the No-TAP group, 23.3 versus 12.1, respectively (difference of 48.2% (95% CI 74.0% to 24.3%); p<0.001) and opioid consumption was significantly decreased within the first 24 hours following surgery from 4.55 intravenous morphine equivalents (IVME) to 2.67 IVME, respectively (difference of 107.1% (95% CI 145.1% to 69.2%); p=0.006). Visual analog pain scores were significantly decreased in the TAP group versus the No-TAP group up to 36 hours postoperatively.

CONCLUSIONS

TAP blocks performed in conjunction with intrathecal morphine may decrease opioid use in the first 24 hours and improve pain scores for at least 36 hours following cesarean section. Because of the favorable safety profile, TAP blocks may contribute meaningfully to multimodal anesthesia for cesarean sections.

Randomized clinical trial of liposomal bupivacaine transverse abdominis plane block versus intrathecal analgesia in colorectal surgery

Background

Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT.

Methods

Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia.

Results

In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes.

Conclusion

IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).

The efficacy of transversus abdominis plane block for post-operative analgesia after the cesarean section performed under general anesthesia

OBJECTIVE:

Several methods are used to control the pain after cesarean operations. Recently, the transverse abdominis plane block (TAP) has been proposed to compensate for the problems developed by preexisting methods. In the present study, we compared the analgesic efficacy of the TAP block after caesarean section in a prospective, randomized, double-blinded controlled trial.

METHODS:

In this study, thirty patients undergoing cesarean sections under general anesthesia were divided into two groups. Patients in Group T (n=15) on whom TAP Block with USG guidance was performed using 0.25% bupivacaine totally 60 ml. The patients in Group C were administered (n=15), 0.9% NaCl totally 60 ml (30 ml at each side) with USG guidance. Post-operative demand of meperidine using a patient-controlled analgesia device was recorded.

RESULTS:

First time on the need for analgesia were significantly higher in the control group (Group C). The total dose of meperidine, tenoxicam, paracetamol used for analgesia was significantly higher in the Group C. The outset times of breastfeeding and mobilization did not change between the groups.

CONCLUSION:

The USG-TAP block with 0.25% bupivacaine 60 ml (30 ml on each side) significantly reduced post-operative pain in patients undergoing the cesarean section. We think that TAP block is a comfortable and feasible method which reduces post-operative analgesia need and does not lead any serious complications.

Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial

Background

Adequate pain control after cesarean section (CS) is crucial for mothers caring for newborns, and early ambulation to avoid thromboembolism and chronic abdominal and pelvic pain. This randomized controlled trial compared the efficacy of quadratus lumborum block (QLB) and intrathecal morphine (ITM) for analgesia after CS.

Methods

Ninety women at ≥ 37 weeks pregnancy scheduled for elective CS were enrolled. All patients received spinal anesthesia and post-operative QLB. They were randomly allocated to Control (anesthesia: 0.1 ml saline, QLB: 24 ml saline), ITM (anesthesia: 0.1 mg morphine, QLB: 24 ml saline), or QLB groups (anesthesia: 0.1 ml saline, QLB: 24 ml 0.375% ropivacaine). Integrated analgesia score (IAS) and numerical rating scale (NRS) scores at rest and during movement, morphine requirements in the first 48 h, time to first morphine dose and morphine-related side effects were recorded.

Results

IASs and NRS scores at rest and during movement were significantly lower in QLB and ITM group than in Control group. Moreover, IASs and NRS scores at rest and during movement were lower in QLB group than in ITM group. Time to first morphine dose was significantly longer in QLB group than in ITM and Control group. Furthermore, morphine requirements in the first 48 h were significantly lower in QLB group than ITM and Control group. Incidence of morphine-related side effects was significantly higher in ITM group than in QLB and Control group.

Conclusions

QLB and ITM are effective analgesic regimens after CS. However, QLB provides better long-lasting analgesia and reduced total postoperative morphine consumption.

The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

Laparoscopic-guided transversus abdominis plane block versus trocar site local anesthetic infiltration in gynecologic laparoscopy

Background

Relieving postoperative pain and prompt resumption of physical activity are of the utmost importance for the patients and surgeons. Infiltration of local anesthetic is frequently used methods of pain control postoperatively. Laparoscopically delivered transversus abdominis plane block is a new modification of ultrasound-guided transversus abdominis plane block.

This study was conducted to compare the efficacy of laparoscopic-guided transversus abdominis plane block with trocar site local anesthetic infiltration for pain control after gynecologic laparoscopy.

Results

No statistically significant difference between the two groups in mean visual analogue scale at 1, 18, and 24 h (P = 0.34, P = 0.41, and P = 0.61, respectively), while the mean visual analogue scale was significantly lower in the laparoscopic-guided transversus abdominis plane block group than in the trocar site local anesthetic infiltration group at 3, 6, and 12 h (P = 0.049, P = 0.011, and P = 0.042, respectively). No statistically significant difference was observed in the cumulative narcotics consumed at 3 h (P = 0.52); however, women with transversus abdominis plane block have consumed significantly less amount of narcotics than women with trocar site infiltration at 6, 12, and 24 h (P = 0.04, P = 0.038, and P = 0.031 respectively). Patient satisfaction was significantly higher in the laparoscopic-guided transversus abdominis plane block group (P = 0.035).

Conclusion

Laparoscopic-guided transversus abdominis plane block is more effective in reduction of both pain scores in the early postoperative period and the cumulative narcotics consumption than trocar site local anesthetic infiltration in gynecologic laparoscopy.

Trial registration

Clinical Trials.gov NCT02973451

Clinical analgesic efficacy of dexamethasone as a local anesthetic adjuvant for transversus abdominis plane (TAP) block: A meta-analysis

BACKGROUND

Perineural dexamethasone has been shown to prolong the duration of local anesthetic (LA) effect in regional anesthesia; however, the use of perineural dexamethasone as an adjuvant to to the transversus abdominis plane (TAP) block remains controversial. This meta-analysis sought to assess the efficacy of dexamethasone in prolonging the TAP block and enhancing recovery after abdominal surgery.

METHODS

We identified and analyzed 9 RCTs published on or before September 30, 2017, regardless of the original language, after searching the following 6 bibliographic databases: PubMed, EMBASE, Medline, Springer, Ovid, and the Cochrane Library. databases. These studies compared the effects of perineural dexamethasone mixed with local anesthetic versus local anesthetic alone in the TAP block. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate the methodological quality of each RCT. The primary outcomes were the time until the first request for postoperative analgesics and the analog pain scores at 2, 6, 12, and 24 h after surgery. The secondary outcomes were the analgesic consumption and the incidence of nausea and vomiting on the first day after surgery. We used Trial Sequential Analysis (TSA) to control for random errors.

RESULTS

Perineural dexamethasone prolonged the duration of LA effect in the TAP block [mean difference (MD): 2.98 h; 95% confidence interval (CI): 2.19 to 3.78] and reduced analog pain scores at 2 h [MD: -1.15; 95% CI: -2.14 to -0.16], 6 h [MD: -0.97; 95% CI: -1.51 to -0.44], and 12 h [MD: -0.93; 95% CI: -1.14 to -0.72] postoperatively. Furthermore, the use of perineural dexamethasone was associated with less analgesic consumption [standard mean difference: -1.29; 95% CI: -1.88 to -0.70] and a lower incidence of nausea and vomiting [odds ratio: 0.28; 95% CI: 0.16 to 0.49] on the first day after surgery.

CONCLUSION

Dexamethasone prolongs the LA effect when used as an adjuvant in the TAP block and improves the analgesic effects of the block.

Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study

Background

While opioids are the mainstay for post-operative analgesia after lower segment caesarean section, they are associated with various untoward effects. Ultrasound guided transversus abdominis plane (TAP) block has been postulated to provide effective analgesia for caesarean section. We evaluated the analgesic efficacy of this block for post caesarean analgesia in a randomised controlled trial.

Methods

One hundred thirty-nine mothers undergoing caesarean delivery were randomised to receive TAP block with either 20 ml 0.375% ropivacaine or 20 ml saline after obtaining informed consent. All the subjects received a standard spinal anaesthetic and diclofenac was administered for post-operative pain. Breakthrough pain was treated with tramadol. Post-operatively, all the subjects were assessed at 0, 2, 4, 6, 8, 10, 12, 18 & 24 h. The primary outcome was the time to first analgesic request. The secondary measures of outcome were pain, nausea, sedation, number of doses of tramadol administered and satisfaction with the pain management.

Results

The median (interquartile range) time to first analgesic request was prolonged in the TAP group compared to the control group (p < 0.0001); 11 h (8,12) and 4 h (2.5,6) respectively. The median (interquartile range) number of doses of tramadol consumed in the TAP group was 0 (0,1) compared to 2 (1,2) in the control group (p < 0.0001). At all points in the study, pain scores both at rest and on movement were lower in the study group (p < 0.0001). Maternal satisfaction with pain relief was also higher in the study group (p 0.0002). One subject in the TAP group had convulsions following injection of local anaesthetic solution. She was managed conservatively with supportive treatment following which she recovered.

Conclusion

TAP block reduces pain, prolongs the duration of analgesia and decreases supplemental opioid consumption when used for multimodal analgesia for pain relief after caesarean section. However, the risk of local anaesthetic systemic toxicity remains unknown with this block. Hence larger safety trials and measures to limit this complication need to be ascertained.

Trial registration

The trial was registered with the Clinical Trial Registry of India (CTRI/2017/03/008194) on 23/03/2017 (trial registered retrospectively).

Peripartum Management of Obstructive Sleep Apnea

The prevalence of obstructive sleep apnea is unknown during pregnancy, but the syndrome is likely underdiagnosed and rising in frequency along with the obesity epidemic. Obstructive sleep apnea is associated with adverse outcomes, including hypertensive disorders of pregnancy, gestational diabetes, preterm, and cesarean delivery. Obese pregnant women should be screened and referred to a sleep medicine specialist for evaluation. Continuous positive airway pressure is the treatment of choice with demonstrated safety and compliance in pregnancy. Early anesthesia consultation allows for preparation and implementation of a peripartum plan that includes early labor analgesia, avoidance of respiratory depressants, and closer monitoring of oxygenation.

A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery

OBJECTIVES

Our aim was to apply the principles of enhanced recovery in renal transplant recipients and to assess the changes in the quality of patient care and patient satisfaction.

MATERIALS AND METHODS

Our study included 286 consecutive renal transplant patients. Of these, 135 patients went through the enhanced recovery program and 151 patients had traditional recovery. Patient education and discharge planning were commenced on admission. For enhanced recovery, prolonged preoperative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia. Patients started oral intake a few hours postoperatively. The urinary catheter was removed 2 to 4 days after transplant.

RESULTS

The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < 0.001). The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P < 0.001) with enhanced recovery versus recipients who had traditional recovery. Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant. In the enhanced recovery group, readmission within 10 days after transplant was 5%.

CONCLUSIONS

Our service evaluation demonstrated that enhanced recovery benefits both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay.

A Comparative Study of Analgesic Efficacy of Intrathecal Buprenorphine with Ultrasound-Guided Transversus Abdominis Plane Block for Postcesarean Delivery Analgesia

BACKGROUND

Women undergoing cesarean (CS) delivery present a unique set of challenges to the anesthetist in terms of postoperative pain management. This study was conducted to compare the analgesic efficacy of intrathecal buprenorphine (ITB) with ultrasound-guided transversus abdominis plane (TAP) block in post-CS delivery pain.

METHODOLOGY

A prospective randomized comparative study of sixty American Society of Anesthesiologists physical status I and II pregnant patients divided into two groups of thirty each as ITB group and TAP block group after satisfying the inclusion criteria.

RESULTS

In the present study, demographic data were comparable between both groups. The time to first analgesic request was significantly longer in ITB group (389.67 ± 90.78 min) compared to TAP group (669.17 ± 140.65 min) and was statistically significant, P < 0.001. The mean paracetamol consumption in the first 24 h was higher in the TAP group (3.5 g) compared to the ITB group (1.13 g) and was statistically significant, P < 0.0001, and the mean tramadol consumed in first 24 h was higher in the TAP (46.66 mg) group as compared to the ITB group (16.66 mg) and was statistically significant, P < 0.001. The mean visual analog scale scores assessed at 4, 6, 12, and 24 h was higher in the TAP group and was statistically significant, P < 0.001.

CONCLUSIONS

Our study showed that patients receiving ITB for post-CS pain management reported longer duration of analgesia, lower pain scores, and lower analgesic consumption during the first 24 h. The benefits of neuraxial opiates are significant and far outweigh the side effects.