Efficacy of Bilateral Transversus Abdominis Plane and Ilioinguinal-Iliohypogastric Nerve Blocks for Postcaesarean Delivery Pain Relief under Spinal Anesthesia

Classical TAP vs. I TAP Using the Same Dose of Local Anesthetic in Elective Cesarean Section: A Randomized Controlled Trial

INTRODUCTION

The effectiveness of postoperative pain control following a Cesarean section influences mother-child attachment, improves early healing, and undoubtedly hastens discharge. Transverse abdominis plane (TAP) and ilioinguinal iliohypogastric (ILIH) blocks have been used to minimize postoperative opioid intake, although their relative effectiveness is unknown. The study aims to determine which procedure was more effective at reducing the need for postoperative rescue analgesics after lower segment Cesarean section (LSCS). TAP block or I TAP (TAP block plus ilioinguinal iliohypogastric nerve block). Both procedures used the same amount of local anesthetic.

METHODS

A sealed envelope technique was used to randomly assign 210 patients who received LSCS into two equal groups to receive either ultrasound (US)-guided TAP block or US-guided ILIH nerve block with US-guided TAP block at the conclusion of the procedure. As per the study protocol, the charge nurse in the postoperative ward gave rescue analgesics to patients who complained of discomfort. At hours 0, 2, 4, 6, 8, 10, and 24 following surgeries, a blinded observer checked on the patient and noted the effectiveness of pain management, the quantity of rescue analgesics used, and patient satisfaction.

RESULTS

While there was a substantial decrease in pain score while resting at 2, 3, 4, 8, 12, 16, 20, and 24 postoperative hours in the ITAP group, there was not a significant change in visual analogue scale (VAS) score at the first postoperative hour. However, there was a large delay in the first request for analgesia in the ITAP group (13.15 ± 1.85) as opposed to the TAP group (10.06 ± 1.61) and there was a significant decline in nalbuphine use as well as a higher satisfaction score in the ITAP group.

CONCLUSIONS

Following LSCS, ITAP block offered better postoperative analgesia than TAP block in terms of quality.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

The comparison of postoperative analgesic efficacy of three-in-one-block versus fascia-iliaca blocks following femoral fracture orthopedics surgical procedures under spinal anesthesia, Gondar, Ethiopia, 2021: A prospective cohort study

INTRODUCTION

Femoral bone fracture is the predominant, lower limb orthopedic surgery that is associated with severe acute and persistent chronic pain that needs better postoperative pain management. Untreated postoperative pain results inability to do physiotherapy resulting in stiffens of joints and immobility. This study aimed to compare the postoperative analgesic efficacy of three-in-one-block versus fascia iliaca block in patients who underwent surgically treated femoral fractured patients under spinal anesthesia.

METHODS

A prospective cohort study was conducted on 110 elective surgically treated femoral fractured orthopedic patients from January to October 2021. Data were entered into epi-data 4.4.2 and imported into a statistical package of social science version 22 for analysis. Shapiro-Wilk normality test was used to check the normality of the data and normally distributed data were analyzed using Student's independent t-test, whereas non-normally distributed variables were analyzed with Mann-Whitney U-test. The comparisons of categorical parameters were analyzed using the chi-square test and Fisher's exact test. Finally p-value < 0.05 was declared to be statistically significant.

RESULT

The median and interquartile range of the postoperative numerical rating scale at rest and on movement was significantly less in three-in-one-block (3IN1B) as compared with fascia-iliaca block (FICB). But at 30 min no significantly different between the two pain management modalities. Moreover, the meantime to seek the first request of analgesia was significantly prolonged in 3IN1B compared with FICB. Regarding the total analgesic consumption, the mean total tramadol consumption was 97. 27 ± 53. 07 and 180 ± 72.96 (p < 0.001) and Diclofenac 53.18 ± 29.28 and 72 ± 43.54 (p < 0. 001) in 3IN1 and FICB, respectively.

CONCLUSION

The present study concludes that three-in-one-block provides more effective analgesia, reduced postoperative analgesic requirements, and prolonged first analgesics requests compared with fascia iliaca block, and Landmark technique fascia-iliaca block (FICB) is an alternative pain management modality in a resource-limited setting.

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.

The efficacy of TAP block versus ilioinguinal block for post-cesarean section pain management: A systematic review and meta-analysis

Background

Controversy still exists regarding the analgesic efficacy of transverse abdominis plane (TAP) block versus ilioinguinal or iliohypogastric (IL/IH) nerve block for postoperative pain management following cesarean section. This meta-analysis aimed to perform relatively credible pooled results on the efficacy of the TAP versus IL/IH nerve block for postoperative pain management after cesarean section.

Methods

Databases such as: PubMed/MEDLINE, Google scholar, and google were systematically searched. studies compared the analgesic efficacy of TAP versus IL/IH nerve block for postoperative pain management following cesarean section were included. Data were extracted by three reviewers independently by using Microsoft Excel and then exported to STATA™ 16 version statistical software for analysis. We used a random-effects model meta-analysis and the mean difference of analgesic efficacy with a 95 ​% confidence interval was reported based on Preferred Reporting Items for systematic reviews and meta-analysis (PRISMA).

Results

Five studies with a total of 390 (196 in TAP and 194 in IL/IH) study participants were included in this meta-analysis. No statistically significant difference was observed between the TAP and IL/IH groups in time to first rescue analgesic request, total postoperative analgesic consumption in milligrams of intravenous tramadol equivalence, and post pain severity score at different points of time both rest and movement.

Conclusion

This meta-analysis revealed that both approaches have similar postoperative analgesic efficacy following cesarean section. we recommend that the clinician may consider either approach for post-cesarean section pain management.

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.

[Peripheral truncal blocks-Overview and assessment]

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.