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Hughey S, Cole J, Drew B, Brust A, Stedjelarsen E. Regional anesthesia in resource-limited and disaster environments: a daring discourse. Reg Anesth Pain Med 2024:rapm-2024-105680. [PMID: 38942425 DOI: 10.1136/rapm-2024-105680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/12/2024] [Indexed: 06/30/2024]
Abstract
Regional anesthesia (RA) is commonly used in perioperative settings of developed and well-resourced environments. RA has significant potential benefits when used in resource-limited environments, including disaster, mass casualty, and wartime environments. RA offers benefits over general anesthesia and opioid-based analgesia, including decreased risk of complications, decreased reliance on mechanical ventilation, improved cost efficiency, and others. The decreasing cost of ultrasound matched with its smaller size and portability increases the availability of ultrasound in these environments, making ultrasound-guided RA more feasible. This daring discourse discusses some historical examples of RA in ultralow resource environments, both man-made disasters and natural disasters. Future investigations should increase the usefulness and availability of RA in resource-limited environments.
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Affiliation(s)
- Scott Hughey
- Anesthesiology and Pain Medicine, US Naval Hospital Okinawa, Okinawa, Japan
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Jacob Cole
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Benjamin Drew
- Naval Medical Center San Diego, San Diego, California, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Adam Brust
- Anesthesiology, US Naval Hospital Pensacola, Pensacola, Florida, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - Eric Stedjelarsen
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Naval Biotechnology Group, Portsmouth, Virginia, USA
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Tao S, Ning M, Lu Y, Hu C, Chen L, Yang Y. Transversus abdominis plane block improves postoperative recovery following cesarean delivery under general anesthesia: A propensity score matched retrospective cohort study. Int J Gynaecol Obstet 2024; 164:641-649. [PMID: 37492952 DOI: 10.1002/ijgo.15011] [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: 10/22/2022] [Revised: 06/04/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Abstract
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.
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Affiliation(s)
- Shengnan Tao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Meng Ning
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chengyang Hu
- Department of Humanistic Medicine, School of Humanistic Medicine, Anhui Medical University, Hefei, China
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Lijian Chen
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuanyuan Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Silverman M, Zwolinski N, Wang E, Lockwood N, Ancuta M, Jin E, Li J. Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients. J Pain Res 2023; 16:3807-3835. [PMID: 38026463 PMCID: PMC10644837 DOI: 10.2147/jpr.s428332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section. Methods A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate. Results In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population. Conclusion Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.
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Affiliation(s)
- Matthew Silverman
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Nicholas Zwolinski
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Ethan Wang
- Yale University School of Medicine, New Haven, CT, USA
| | - Nishita Lockwood
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Ancuta
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Evan Jin
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jinlei Li
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Peebles AF, Mouch A, Maxwell RA, Ruby T, Kindig MJ. Long-Acting Bupivacaine for Pain Control After Cesarean Birth. Nurs Womens Health 2023:S1751-4851(23)00124-1. [PMID: 37385592 DOI: 10.1016/j.nwh.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/07/2023] [Accepted: 05/23/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To evaluate women's postcesarean pain levels and total opioid use for standard opioid pain management compared with local anesthetic with patient-requested opioids. DESIGN Retrospective cohort study. SETTING/LOCAL PROBLEM Rural southeast Ohio. Ohio had a higher rate of opioid use disorder (1.4%) than both the regional average (0.8%) and the national average (0.7%). PARTICIPANTS We performed a retrospective study of 402 medical records of women who gave birth by caesarean. INTERVENTION Women were provided one of three types of perioperative anesthesia: routine spinal (standard of care group), wound infiltration with liposomal bupivacaine (LB INF), and transversus abdominis plane (TAP) block with liposomal bupivacaine (LB TAP).Data were collected on the amount of opioids taken postoperatively (measured as morphine milligram equivalents [MME]), pain scores, and history of opioid use. RESULTS The LB INF and LB TAP groups had significantly lower total and average MME per day than the standard of care group (p < .001). Pain scores for the LB INF group were lower on postoperative day (POD) 0 and POD1, whereas LB TAP pain scores were lower than standard of care pain scores on POD1 (p < .004). Women with a prior history of substance use disorders reported higher pain scores, took more total opioids. and stayed in the hospital longer regardless of type of anesthesia received (p < .001). CONCLUSION LB INF and LB TAP were associated with lower amounts of opioids used and with lower postcesarean pain scores compared with the standard of care.
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Yan ZR, Chen LJ, Zhang SJ, Zhang LX, Lu H, Zhang L, Liu M, Zhou M, Lin LH. The transversus abdominis plane block in conjunction with intrathecal morphine use after cesarean section in women with severe pre-eclampsia: a randomized controlled trial. BMC Anesthesiol 2023; 23:100. [PMID: 36997853 PMCID: PMC10061731 DOI: 10.1186/s12871-023-02061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Abstract
Background
The transversus abdominis plane (TAP) block in conjunction with intrathecal morphine has been demonstrated to provide more superior postcesarean analgesia to intrathecal morphine alone. However, the analgesia efficacy of their conjunction has not been demonstrated in patients with severe pre-eclampsia. The study aimed to compare the postcesarean analgesia of TAP block in conjunction with intrathecal morphine versus intrathecal morphine alone in women with severe pre-eclampsia.
Methods
Pregnant women with severe pre-eclampsia undergoing planned cesarean section were randomly allocated into 2 groups to receive TAP block with 20 ml of 0.35% Ropivacaine (TAP group) or with the same volume of 0.9% saline (Sham group) after undergoing elective cesarean section under spinal anaesthesia with 15 mg of 0.5% Ropivacaine plus 0.1 mg of morphine. The outcomes for this analysis include the visual analog scale (VAS) pain score at rest and with movement at 4,8,12,24 h after TAP block was performed, times of use of intravenous patient-controlled analgesia (PCA) within 12 h after anesthesia, the occurrence of maternal side effects, maternal satisfaction, and Apgar score at 1 and 5 min of newborns.
Results
119 subjects receive TAP block with 0.35% Ropivacaine (n = 59)or 0.9% saline (n = 60). At 4,8, 12 h after TAP block, the TAP group reported lower VAS score at rest [at 4 h: 1(0,1) vs. 1(1,2), P < 0.001; at 8 h:1(1,1) vs. 1(1.5,2),P < 0.001; at 12 h:1(1,2) vs. 2(1,2),P = 0.001] and higher satisfaction [53(89.9%) vs.45(75.0%), P < 0.05]. There were no differences between groups in VAS score at 24 h at rest and at all time points above with movement, times of use of PCA within 12 h after anesthesia, maternal side-effect, and Apgar score at 1 and 5 min of newborns.
Conclusions
In conclusion, The TAP block performed in conjunction with intrathecal morphine may not reduce opioid consumption, but it could reduce VAS scores at rest in the first 12 h after cesarean section in women with severe pre-eclampsia, and improve maternal satisfaction, which is worthy of clinical promotion.
Trial registration
Registered at Chinese Clinical Trial Registry(http://www.chictr.org.cn) on 13/12/2021: ChiCTR2100054293.
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Transversus Abdominis Plan Block and Visceral Analgesia. J Gastrointest Surg 2023; 27:464-465. [PMID: 36509897 DOI: 10.1007/s11605-022-05555-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022]
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Mo X, Zhao T, Chen J, Li X, Liu J, Xu C, Song X. Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for Uterine Contraction Pain Relief After Cesarean Section: A Randomized, Double-Blind Clinical Trial. Drug Des Devel Ther 2022; 16:999-1009. [PMID: 35400993 PMCID: PMC8985825 DOI: 10.2147/dddt.s350418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/23/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Programmed intermittent epidural bolus (PIEB) was reported to provide superior maintenance of labour analgesia with better pain relief and less motor block than continuous epidural infusion (CEI). Whether this is also evident for uterine contraction pain relief after cesarean section remains unknown. Patients and Methods Parturients scheduled for cesarean section were recruited for the study. At the end of the surgery, after a similar epidural loading dose given, patients received either PIEB (6 mL·h−1) or CEI (6 mL·h−1) of 0.1% ropivacaine. The primary outcome was the uterine contraction pain assessed with visual analog scale (VAS-U) at the postoperative 36 h. Secondary outcomes included incision pain at the rest (VAS-R) and in the movement-evoked (VAS-P), and lower extremity motor block (defined as Bromage score > 0). The whole profile of VAS scores between groups was analyzed using linear mixed model. When significant differences were found, the pairwise comparison was done with the Mann Whitney U-test followed by Bonferroni correction. Results One hundred and twenty parturients were studied (PIEB, 60; CEI, 60). VAS-U at the postoperative 36 h in the PIEB group was lower than in the CEI group (Bonferroni-adjusted P < 0.01). The linear mixed model indicated that VAS-U, VAS-R and VAS-P were lower in the PIEB group compared with the CEI group (all P < 0.01). Motor block was higher in the CEI group than in the PIEB group during the study period except 2 h (all P < 0.05). No differences of adverse events such as hypotension and urinary retention were observed between the two groups. Conclusion Programmed intermittent epidural bolus provides more effective uterine contraction and incision pain relief and less motor block after cesarean section than continuous epidural infusion without an increased risk of urinary retention and blood pressure instability.
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Affiliation(s)
- Xiaofei Mo
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Tianyun Zhao
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Jinghui Chen
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Xiang Li
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Jun Liu
- Department of Medical Records, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Cuiyi Xu
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
- Correspondence: Xingrong Song; Tianyun Zhao, Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jinsui Road, Tianhe District, Guangzhou, 510623, People’s Republic of China, Tel +86 13922416303; +86 18198907639, Fax +86 20 38076243, Email ;
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Gabriel RA, Burton BN, Curran BP, Urman RD. Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence. Curr Pain Headache Rep 2021; 25:28. [PMID: 33761010 DOI: 10.1007/s11916-021-00945-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD). RECENT FINDINGS Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA.
- Division of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA.
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Brian P Curran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Guay J. Is transversus abdominis plane block adding anything to intrathecal morphine for postoperative analgesia after cesarean section? Reg Anesth Pain Med 2020; 46:551-552. [PMID: 32699104 DOI: 10.1136/rapm-2020-101796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Joanne Guay
- Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Quebec City, Quebec, Canada .,Department of Anesthesiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada.,Department of Anesthesiology and Critical Care, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
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