Transversus Abdominis Plane Block Versus Caudal Epidural for Lower Abdominal Surgery in Children

Fascial plane blocks in children-Scientifically supported or not?

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta-analyses in children, there is still no clear-cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well-known analgesic and anti-inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi-modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor-moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block.

Erector spinae plane block versus caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair: a randomized controlled trial

BACKGROUND

Erector spinae plane block is a promising strategy for pain management in some settings. However, the effectiveness of erector spinae plane block versus caudal block in pediatric inguinal hernia repair has yet to be formally investigated.

METHODS

One hundred and two patients aged 2-5 years undergoing unilateral open inguinal hernia repair randomly received unilateral erector spinae plane block (0.2% ropivacaine 0.5 mL kg-1), caudal block (0.2% ropivacaine 1 mL kg-1), or no block. The primary outcome was time to the first rescue analgesia, defined as the interval from the end of surgery to the Face, Legs, Activity, Cry, and Consolability scale greater than three. Secondary outcomes included the number of patients requiring rescue analgesia, the area under the curve of pain scores over time, satisfaction of guardians, and adverse events.

RESULTS

The median time to the first rescue analgesia was longer in the erector spinae plane block group than in the caudal block group [10.0 h (interquartile range, 6.6-24.0 h) vs. 5.0 h (interquartile range, 2.9-7.3 h); p < .001]. The Cox regression model demonstrated that the risk of postoperative rescue analgesia requirement was 0.38 in children receiving erector spinae plane block compared with caudal block (95% confidence interval 0.23-0.64; p < .001). Additionally, the area under the curve of the pain scores over time was lower in the erector spinae plane block group than in the caudal block group (44.3 [36.6-50.7] vs. 59.0 [47.1-64.5]; p < .001).

CONCLUSIONS

Erector spinae plane block provided superior postoperative analgesia compared to caudal block in children undergoing inguinal hernia repair.Trial registration: Chinese Clinical Trial Registry; ChiCTR2100048303.

A Systematic Review and Meta-Analysis Comparing the Effectiveness of Transversus Abdominis Plane Block and Caudal Block for Relief of Postoperative Pain in Children Who Underwent Lower Abdominal Surgeries

Background and Objectives: Postoperative pain after lower abdominal surgery is typically severe. Traditionally, in pediatric anesthesia, a caudal block (CB) has been used for pain management in these cases. Nowadays, a transversus abdominis plane block (TAPB) seems to be an effective alternative. However, which technique for perioperative analgesia is better and more effective remains unclear in children who undergo abdominal surgeries. The aim of this study was to compare the efficacy and safety of a TAPB and CB for pain management in children after abdominal surgery by conducting a meta-analysis of published papers in this area. Methods: We conducted a thorough search of PubMed, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that compared a TAPB and CB for pain management in children who had abdominal surgery. Two researchers screened and assessed all the information with RevMan5.3 used for this meta-analysis. Pain scores, the total dose of rescue analgesic given, the mean duration of analgesia, the intraoperative and postoperative hemodynamic conditions 24 h after surgery, and adverse events were compared. Results: 15 RCTs that involved a total of 970 pediatric patients were included in this study. The results of this meta-analysis showed that there were no significant differences between the 2 groups in terms of postoperative pain scores at 1 h (SMD = 0.35; 95% CI = -0.54 to 1.24; p = 0.44, I2 = 94%), 6 h (SMD = -0.10; 95% CI = -0.44 to -0.23; p = 0.55, I2 = 69%), 12 h (SMD = -0.02; 95% CI = -0.45 to -0.40; p = 0.93, I2 = 80%), and 24 h (SMD = -0.66; 95% CI = -1.57 to -0.25; p = 0.15, I2 = 94%); additional analgesic requirement (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004, I2 = 72%); total dose of rescue analgesic given in 24 h (SMD = -0.37; 95% CI = -1.33 to -0.58; p = 0.44; I2 = 97%); mean duration of analgesia (SMD = 1.29; 95% CI = 0.01 to 2.57; p = 0.05, I2 = 98%); parents' satisfaction (SMD = 0.44; 95% CI = -0.12 to 1.0; p = 0.12; I2 = 80%); and intraoperative and postoperative hemodynamic conditions 24 h after the surgery and adverse events (SMD = 0.78; 95% CI = 0.22 to 2.82; p = 0.70; I2 = 62%). Compared to a CB, a TAPB resulted in a small but significant reduction in additional analgesic requirement after surgery (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004). Conclusions: TAPBs and CBs result in similar efficient early analgesia and safety profiles in children undergoing abdominal surgeries. Moreover, no disparities were observed for adverse effects between TAPBs and CBs.

Posterior transversus abdominis plane block versus lateral quadratus lumborum block in children undergoing open orchiopexy: a randomized clinical trial☆

BACKGROUND

Due to the complex innervation of the testicle and spermatic cord, analgesic management can be challenging in orchiopexy. We aimed to compare the effects of posterior Transversus Abdominis Plane (TAP) and lateral Quadratus Lumborum Block (QLB) on analgesic use, pain, and parent satisfaction in unilateral orchiopexy.

METHODS

ASA I-III, aged 6 months - 12 years children undergoing unilateral orchiopexy were included to this double-blinded randomized trial. Patients were randomized into two groups with the closed envelope method before the surgery. Lateral QLB or posterior TAP block was applied under ultrasonography with 0.4 mL.kg^-1 0.25% bupivacaine for both groups. The primary outcome was the assessment of additional analgesic usage in the peri-postoperative period. Evaluation of postoperative pain until 24 hours after surgery and parental satisfaction were also assessed as secondary outcomes.

RESULTS

A total of 90 patients were included in the analysis (45 patients in each group). The number of patients needing remifentanil was significantly higher in the TAP group (p < 0.001). The average FLACC (TAP: 2.74 ± 1.8, QLB: 0.7 ± 0.84) and Wong-Baker scores (TAP: 3.13 ± 2.42, QLB: 0.53 ± 1.12) were significantly higher for TAP (p < 0.001). Additional analgesic consumption at the 10^th, 20^th minutes, 6^th, 16^th, and 24^th hours, especially after the 6^th hour, were significantly higher for TAP. Parent satisfaction was significantly higher in the QLB group (p < 0.001).

CONCLUSION

Lateral QLB provided more effective analgesia than posterior TAP block in children undergoing elective open unilateral orchiopexy.

CLINICAL TRIALS REGISTRY

NCT03969316.

Dexmedetomidine as an Adjuvant in Peripheral Nerve Block

Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α₂-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.

Ultrasound-guided transversalis fascia plane block versus lateral quadratus lumborum plane block for analgesia after inguinal herniotomy in children: a randomized controlled non-inferiority study

BACKGROUND

Surgical repair of inguinal hernia is one of the most common day case surgeries in the pediatric population. This study compared the postoperative analgesic effects of transversalis fascia plane block (TFB) versus quadratus lumborum block (QLB) in children scheduled for open unilateral inguinal herniotomy.

METHODS

In this prospective, randomized, double-blind, controlled non-inferiority study, 76 eligible patients were recruited. Patients were randomly allocated to either the TFB or QLB group. The primary outcome measure was the proportion of patients who needed rescue analgesia during the first postoperative 12 h. The secondary outcomes were, the time needed to perform the block, the postoperative FLACC score, intraoperative heart rate (HR) and mean arterial pressure (MAP).

RESULTS

The proportion of patients who required a rescue analgesic was comparable (p = 1.000) between the TFB group (7/34, 20.5%) and the QLB group (6/34, 17.6%). The median [Q1-Q3] time needed to perform the block (min) was significantly longer (p < 0.001) in the QLB group (5[5]) compared with the TFB group. The postoperative FLACC pain scale was comparable between the two groups at all-time points of assessment. There is no difference regarding the heart rate and mean arterial blood pressure values at the time points that the values were recorded. (P > 0.005).

CONCLUSIONS

Both TFB and QLB similarly provide good postoperative analgesia by reducing the proportion of patients who required rescue analgesia, pain scores and analgesic consumption. Moreover, TFB is technically easier than QLB.

Transversus abdominis plane block with different bupivacaine concentrations in children undergoing unilateral inguinal hernia repair: a single-blind randomized clinical trial

BACKGROUND

Current knowledge on the ideal local anesthetic concentration for the ultrasound-guided transversus abdominis plane block (TAPB) in pediatrics is scarce. The purpose of this study is to compare the efficacy of US-guided TAPB at two different concentrations of bupivacaine in pediatrics undergoing unilateral inguinal hernia repair.

METHODS

After random allocation, 74 children aged 1-8 were randomized to receive US-guided TAPB by using 1 mg.kg^- 1 bupivacaine as either 0,25% (0,4 ml.kg^- 1) (Group 1) or 0,125% (0,8 ml.kg^- 1) (Group 2) concentration. All blocks were performed under general anesthesia, immediately after the induction, unilaterally with a lateral approach. All subjects received intravenous 15 mg/kg paracetamol 0.15 mg/kg dexamethasone and 0.1 mg/kg ondansetron intraoperatively. The primary outcome was the efficacy which is assessed by postoperative FLACC behavioral pain assessment score at 15', 30', 45', 1 h, 2 h, 6 h, and 24 h. The secondary outcomes were to assess the total dose of rescue analgesic consumption, length of hospital stay, the incidence of side effects, complications and satisfaction levels of the patients' parents and the surgeons.

RESULTS

Sixty-four children were recruited for the study. Postoperative pain scores were equal between the two groups. There was no need for a rescue analgesic in any group after the postoperative 6^thhour. No local or systemic complication or side effect related to anesthesia or surgery was reported.

CONCLUSION

TAPB using 1 mg.kg^- 1 bupivacaine administered as either high volume/low concentration or low volume/high concentration was providing both adequate analgesia and no side effects.

TRIAL REGISTRATION

This trial was retrospectively registered at Clinicaltrals.gov , NCT04202367 .

Effects of ultrasound guided caudal epidural and transversus abdominis plane block on postoperative analgesia in pediatric inguinal hernia repair surgeries

INTRODUCTION

Ultrasound guided caudal epidural block (CEB) and transversus abdominis plane block (TAPB) are two techniques which are used for pain management after inguinal hernia surgeries (IHR). CEB is accepted as gold standard for lower abdominal surgeries while TAPB is more popular.

OBJECTIVE

It is aimed to compare ultrasound guided CEB and TAPB for postoperative pain scores, additional analgesic requirement and chronic pain development in pediatric bilateral open IHR.

STUDY DESIGN

Seventy patients aged 1-7 years undergoing bilateral open IHR were included in this prospective, randomized, double-blinded study. Patients were randomized into group T (Bilateral TAPB) and group C (CEB). Postoperative FLACC (Face, Legs, Activity, Cry, Consolability) scores were evaluated for pain density. Additional analgesic requirement, length of hospital stay was also recorded. Chronic pain is evaluated within a subgroup by using "revised Bieri faces pain scale" in the postoperative second month.

RESULTS

Postoperative 15th, 30th, 45th min, first, second hour FLACC scores were similar in both groups (P > 0.05). In group C, FLACC scores at postoperative sixth and 24th were significantly higher than group T (1 (0-5) vs 0 (0-2); 1 (0-3) vs 0 (0-2), respectively; P < 0.001). Additional analgesic requirement in the postoperative 24 h was found to be statistically higher in Group C (56.7%) than in Group T (20%) (P < 0.01). Chronic pain development did not differ between the groups (P > 0.05). Length of hospital stay was found to be shorter in patients in Group T compared to patients in Group C [10 (5-14) vs 16 (5-18) hours, respectively; P < 0.01)].

DISCUSSION

Our results exhibited that TAPB and CEB for bilateral IHR have similar early analgesic efficacy in children. However; CEB patients experienced higher FLACC scores at the postoperative sixth and 24th hours, and the need for additional analgesics was higher and the length of hospital stay was longer comparing to TAPB. Of note, chronic pain was not observed in any of our subgroup patients (n = 21) who are older than four years.

CONCLUSION

For bilateral IHR, US-guided CEB and TAPB have similar analgesic efficacy in the first six hours, postoperatively, However, TAPB appears to be slightly superior than CEB in terms of subacute pain and length of stay which is still not clinically distinctive.

Evaluation of the Postoperative Analgesic Effect of 2 Different Blocks after Pediatric Circumcision Surgery

BACKGROUND

Circumcision is a painful day-case surgery. Regional anesthesia techniques are used effectively for anesthesia and postoperative analgesia after pediatric circumcision surgery.

OBJECTIVE

Our prospective observational study aimed to compare postoperative analgesic efficiency of a dorsal penile nerve (DPN) block with a transversus abdominis plane (TAP) block after male pediatric circumcision surgery and complications related to each block.

STUDY DESIGN

We enrolled 80 male children under the age of 10 years with American Society of Anesthesiologists I-II status scheduled for circumcision in this prospective observational study. A TAP or DPN block was performed after induction of general anesthesia before surgery with ultrasound (US) guidance. Postoperative pain was assessed with Faces Pain Scale-Revised and the Faces, Legs, Activity, Cry and Consolability scale.

RESULTS

There was no statistically significant difference between the groups regarding 30-min pain score levels (p > 0.05). But, the 1st hour, 2nd hour, 6th hour, 12th hour, and 24th-hour pain score levels in the TAP block group were statistically significantly higher than those of the DPN block group (p < 0.05). The 1st rescue analgesic requirement in the TAP block group was at the 6th hour postoperative. There was no need for rescue analgesia in the DPN block group during the postoperative 24-h follow-up.

DISCUSSION

A US-guided DPN block provided effective and long-lasting postoperative analgesia for circumcision surgery with statistically significantly lower pain score levels than a US-guided TAP block.

CONCLUSION

This study found that a TAP block alone was insufficient to provide adequate postoperative analgesia for circumcision surgery compared to DPN block.

Comparison of Analgesic Efficacy of Ultrasound-Guided Transversus Abdominus Plane Block and Caudal Block for Inguinal Hernia Repair in Pediatric Population: A Single-Blinded, Randomized Controlled Study

Background:

Caudal analgesia was a widely practiced regional anesthesia technique in pediatric population. Transversus abdominus plane block (TAP) block has recently emerged as a promising analgesic method in pediatric lower abdominal surgeries.

Aim:

This study aimed to compare the analgesic efficacy of ultrasound-guided TAP block and caudal block.

Setting:

This study was conducted in the department of anesthesiology of a tertiary care teaching hospital.

Design:

This was a prospective, single-blinded, randomized controlled study.

Materials and Methods:

Sixty-two children of American Society of Anesthesiologists Class I and II undergoing inguinal hernia repair received TAP block at a dose of 0.5 ml.kg^{− 1} of 0.25% bupivacaine (Group A) or caudal block at a dose of 1 ml.kg^{− 1} of 0.25% bupivacaine (Group B) after randomization. The children were analyzed by comparing the post operative pain scores and duration of analgesia. Statistical analysis was done with IBM SPSS software 23 version. Unpaired sample t-test and Mann–Whitney U-test were used to compare the means of continuous variables. Fisher's exact test/Chi-square test was used to find the association between categorical variables.

Results:

Both groups were comparable in terms of age, gender, weight, and surgery duration. Duration of analgesia was longer in TAP block group compared to that of caudal analgesia (12.93 ± 2.91 h vs. 6.52 ± 1.67 P < 0.001). The postoperative pain scores were comparable up to 6 h and at 24 h. Pain scores at 12 h and 18 h were significantly higher in caudal analgesia group compared to that of TAP block group.

Conclusion:

Children who received TAP block had prolonged duration of analgesia and lower pain scores compared to those who received caudal analgesia.

The Role of Interfascial Plane Blocks in Paediatric Regional Anaesthesia: A Narrative Review of Current Perspectives and Updates

Regional anaesthesia has been increasingly used for analgesia in the perioperative period in paediatric anaesthesia for better pain control and improved patient outcomes. Interfascial plane blocks are considered as a subgroup of peripheral nerve blocks. The advent of ultrasound in modern regional anaesthesia practice has led to the evolution of various interfascial plane blocks. The ease of their performance and the low complication rates, compared with neuraxial anaesthesia, have led to their increased use in the perioperative period. Interfascial plane blocks are often incorporated in the multimodal analgesia regimen in the early recovery and ambulation after surgery protocols for various chest wall and abdominal surgeries. This achieves better pain control and decreases the requirements of opioids in the perioperative period, thereby facilitating early mobilization and discharge. This narrative review focuses on the relevant anatomic considerations, technique for the performance of each block along with its current applications and limitations, and includes a review of the current literature on various interfascial plane blocks in paediatric regional anaesthesia.

Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis

Background

Caudal block is a well-established technique for providing perioperative analgesia in pediatric genitourinary surgery, but abdominal wall blocks such as ilioinguinal–iliohypogastric (II-IH) and transversus abdominis plane (TAP) block are increasingly being used.

Methods

Our protocol for this meta-analysis was registered on PROSPERO (CRD42020163497). Central, CINAHL, Embase, Global Health, LILACS, MEDLINE, Scopus and Web of Science were searched from inception to 11 December 2019 for randomized controlled trials that included pediatric patients having genitourinary surgery with II-IH or TAP block as the intervention and caudal analgesia as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenzel method.

Results

In all, 23 trials with 1399 patients were included. II-IH and TAP block were similar to caudal analgesia in the coprimary outcomes of the postoperative pain score at 0–2 hours (high-quality evidence) and the need for in-hospital rescue analgesia (moderate-quality evidence consequent to downgrading by publication bias). No subgroup differences in regard to the type of abdominal wall block or the method of block localization were demonstrated for these primary outcomes. Relative to caudal analgesia, II-IH and TAP block reduced the incidence of postoperative motor blockade and the time to micturition.

Conclusions

This meta-analysis was limited by unclear risk of selection and performance biases and significant heterogeneity. In summary, II-IH and TAP block are a non-invasive and reasonable alternative to caudal analgesia in pediatric genitourinary surgery.

Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing inguinal hernia surgery: A comparative study

BACKGROUND AND AIMS

Ultrasound-guided (USG) transversus abdominis plane (TAP) block has emerged as a safe and effective regional anesthesia technique as it provides adequate postoperative pain relief for lower abdominal surgeries. Caudal block is a gold standard technique in pediatric surgeries. Our aim was to compare the duration of postoperative analgesia between TAP block and caudal block in children undergoing inguinal hernia surgeries.

MATERIAL AND METHODS

In a prospective, randomized, controlled study, 112 children of age 2-8 years and ASA grade I and II, undergoing elective inguinal hernia surgery were randomly allocated into two groups: Group T (n = 56) received USG-guided TAP block with 0.5mL/kg of 0.2% ropivacaine and Group C (n = 56) received caudal block with 1mL/kg of 0.2% ropivacaine. The primary outcome variable was the duration of postoperative analgesia and the secondary outcome variables included variation in hemodynamic parameters and adverse effects, if any.

RESULTS

There was no significant difference in median of CHEOPS score till 5 postoperative hours, thereafter till 24 postoperative hours, significantly lower CHEOPS score were found in Group T. Mean duration of analgesia was 523.44 ± 61.30 min in Group T, whereas in Group C, it was 352.59 ± 32.54 min. No significant difference was observed in hemodynamic variations and adverse effects.

CONCLUSION

TAP block and caudal block both are effective in providing postoperative analgesia in children undergoing inguinal herniotomy. USG-guided TAP block was found to be superior as it provided longer duration of analgesia and reduced rescue analgesic dose without any significant adverse effects as compared with caudal block after inguinal herniotomy.

Comparison of quadratus lumborum block and caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries: a randomized controlled trial

Background and objectives

Caudal epidural anesthesia is a widely used popular technique for postoperative analgesia but it has potential side effects and duration of analgesia is short. Quadratus lumborum block (QLB) was found to be an effective method for postoperative analgesia in lower abdominal surgeries. In this double-blind prospective randomized trial, we aimed to compare the postoperative analgesic efficacies of QLB and the caudal block in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries under general anesthesia.

Materials and methods

After approval was obtained from the ethics committee, in this prospective randomized double-blind trial, 53 patients under general anesthesia undergoing inguinal hernia repair and orchiopexy surgeries randomly received caudal block or QLB. Demographic data, postoperative analgesic requirement, Face, Legs, Activity, Cry, and Consolability (FLACC) scores at 30 min, 1, 2, 4, 6, 12 and 24 hours, parent satisfaction scores and complications were recorded.

Results

The study included 52 patients, after excluding one patient because of a failed caudal block. There were no significant differences between the groups based on demographic data (p>0.05). The number of patients who required analgesics in the first 24 hours was significantly lower in QLB group (p=0.001). Postoperative 4, 6, 12 hours FLACC scores were significantly lower in the QLB group (p<0.001, p=0.001 and p<0.001, respectively). Parent satisfaction scores were higher in the QLB group (p=0.014).

Conclusion

According to the results of this study, QLB can provide much more effective analgesia than caudal block without adjuvants in multimodal analgesia management of children undergoing inguinal hernia repair and orchiopexy surgeries.

Trial registration number

NCT03294291.

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.

Epidemiology of regional anesthesia in children: Lessons learned from the European Multi-Institutional Study APRICOT

BACKGROUND

Recently, the European prospective observational multicenter cohort study, APRICOT, reported anesthesia techniques and complications in more than 31 000 pediatric procedures. The main objective of this study was to analyze the current practice in regional anesthesia in the 33 countries that participated to APRICOT.

METHODS

Data on regional anesthesia techniques were extracted from the database of APRICOT (261 centers across 33 European countries). All children, aged from birth to 16 years old, were eligible for inclusion during a 2-week period. Type of regional anesthesia, whether used awake or with sedation or general anesthesia, techniques of guidance, and the drugs administered were analyzed.

RESULTS

Regional anesthesia was used in 4377 pediatric surgical procedures. The large majority was performed under general anesthesia with central blocks and truncal blocks, representing, respectively, 42.6% and 41.8% of performed techniques. Caudal blocks represented 76.9% of all central blocks. The penile and ilioinguinal/iliohypogastric blocks were the most commonly performed truncal blocks. Anesthetists used mainly anatomical landmarks; ultrasound guidance was applied in only 23.8% of cases. A wide variability of practices was observed in terms of regional anesthesia techniques and local anesthetics among the participating European countries. No serious complications were reported.

CONCLUSION

These data show a large predominance of central and truncal blocks in APRICOT study. Ultrasound guidance was mainly used for peripheral nerve blocks while central blocks were performed using landmark techniques.

Ultrasound-guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex

BACKGROUND

Ultrasound-guided quadratus lumborum block is a regional anesthetic technique which can provide perioperative analgesia for all age groups, including pediatric patients undergoing abdominal surgery. We hypothesized that the quadratus lumborum block would be as efficacious as a caudal block, the gold standard of pediatric lower abdominal regional anesthesia, in providing pain control after ureteral reimplantation but also have a longer duration.

METHODS

Forty-seven pediatric patients between the ages of 1 and 17 years undergoing bilateral ureteral reimplantation surgery via a low transverse incision were enrolled and randomized into the quadratus lumborum block and caudal block groups. All blocks were performed preoperatively under general anesthesia. We analyzed the following outcomes: the requirement for narcotic analgesics, pain score, episodes of emesis, and complications at 0, 4, 24, and 48 hours postoperatively.

RESULTS

The study included 44 patients after excluding three who were ineligible. The fentanyl requirement for postoperative rescue analgesia during the first 24 hours was significantly lower in the quadratus lumborum block group than in the caudal block group (median [interquartile range]: 0 [0-1] vs 3 [0-5], P = 0.016, 95% confidence intervals: -4 to 0) but not at 30 minutes, 4, or 48 hours. No significant difference was observed in the pain scores or the incidence of interventions to treat nausea and vomiting during the entire period. No postoperative complication was observed.

CONCLUSION

The quadratus lumborum block was more effective in reducing the postoperative opioid requirement for rescue analgesia during the initial 24 hours than caudal ropivacaine/morphine.

The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children

BACKGROUND

The use of ultrasound guidance for regional anaesthesia has become popular over the past two decades. However, it is not recognized by all experts as an essential tool, perhaps because it is unclear whether ultrasound reduces the risk of severe neurological complications, and the cost of an ultrasound machine (USD 22,000) is substantially higher than the cost of other tools. This review was published in 2016 and updated in 2019.

OBJECTIVES

To determine whether ultrasound guidance offers any clinical advantage when neuraxial and peripheral nerve blocks are performed in children in terms of decreasing failure rate or the rate of complications.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registers up to March 2018 together with reference checking to identify additional studies and contacted study authors to obtain additional trial information.

SELECTION CRITERIA

We included all parallel randomized controlled trials that evaluated the effects of ultrasound guidance used when a regional blockade technique was performed in children. We included studies performed in children (≤ 18 years of age) undergoing any type of surgical procedure (open or laparoscopic), for which a neuraxial (spinal, epidural, caudal, or combined spinal and epidural) or peripheral nerve block (any peripheral nerve block including fascial (fascia iliaca, transversus abdominis plane, rectus sheath blocks) or perivascular blocks), for surgical anaesthesia (alone or in combination with general anaesthesia) or for postoperative analgesia, was performed with ultrasound guidance. We excluded studies in which regional blockade was used to treat chronic pain.We included studies in which ultrasound guidance was used to perform the technique in real time (in-plane or out-of-plane), as pre-scanning before the procedure or to evaluate the spread of the local anaesthetic so the position of the needle could be adjusted or the block complemented. For control groups, any other technique used to perform the block including landmarks, loss of resistance (air or fluid), click, paraesthesia, nerve stimulator, transarterial, or infiltration was accepted.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were failed blocks, pain scores at one hour after surgery, and block duration. Secondary outcomes included time to perform the block, number of needle passes, and minor and major complications. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included 33 trials with a total of 2293 participants from 0.9 to 12 (mean or median) years of age. Most trials were at low risk of selection, detection, attrition, and reporting bias, however the lack of blinding of participants and personnel caring for participants resulted in 25 trials being judged as at high or unclear risk of bias. We identified five ongoing trials.Ultrasound guidance probably reduces the risk of failed block (risk difference (RD) -0.16, 95% confidence interval (CI) -0.25 to -0.07; 22 trials; 1789 participants; moderate-quality evidence). When ultrasound guidance was used, there was a small to moderate reduction in pain one hour after surgery, equivalent to a reduction of 1.3 points on the revised Bieri FACES pain scale (scale; 0 = no pain, 10 = maximal pain) (standardized mean difference (SMD) -0.41, 95% CI -0.74 to -0.07 (medium effect size); 15 trials; 982 participants; moderate-quality evidence). Ultrasound guidance increases block duration by the equivalent of 42 minutes (SMD 1.24, 95% CI 0.72 to 1.75; 10 trials; 460 participants; high-quality evidence).There is probably little or no difference in the time taken to perform the block (SMD -0.46, 95% CI -1.06 to 0.13; 9 trials; 680 participants; moderate-quality evidence). It is uncertain whether the number of needle passes required is reduced with the use of ultrasound guidance (SMD -0.63, 95% CI -1.08 to -0.18; 3 trials; 256 participants; very low-quality evidence).There were no occurrences of major complications in either the intervention or control arms of the trials (cardiac arrest from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence); lasting neurological injury (19 trials; 1250 participants; low-quality evidence)).There may be little of no difference in the risk of bloody puncture (RD -0.02, 95% CI -0.05 to 0.00; 13 trials; 896 participants; low-quality evidence) or transient neurological injury (RD -0.00, 95% CI -0.01 to 0.01; 18 trials; 1230 participants; low-quality evidence). There were no occurrences of seizure from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence) or block infections without neurological injury (18 trials; 1238 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

Ultrasound guidance for regional blockade in children probably decreases the risk of failed block. It increases the duration of the block and probably decreases pain scores at one hour after surgery. There may be little or no difference in the risks of some minor complications. The five ongoing studies may alter the conclusions of the review once published and assessed.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Pain management in abdominal surgery

BACKGROUND

Abdominal surgery has undergone major changes during the last two decades with a general shift from open, invasive surgery to closed minimally invasive surgery. Accordingly, pain management strategies have also changed, especially with the introduction of ultrasound-guided abdominal wall blocks. Despite laparoscopic abdominal surgery classified as minimal, pain can be quite significant and needs to be addressed appropriately.

PURPOSE

This narrative review focuses on adequate pain strategies for various types of surgery. The respective techniques are described and examples of specific pain management strategies given. Advantages and disadvantages of techniques are discussed. This review can serve as a sort of empirical guideline and orientation for the reader to develop their own strategy as well as bringing surgeons up-to-date with the latest anesthetic techniques.

CONCLUSION

Pain is not less or less relevant in minimally invasive surgery. New hallmarks of a multimodal pain strategy are abdominal wall blocks, either as single shot or continuously. Minor open surgery is best performed under a combination of loco-regional blocks and continuous sedation. Abdominal wall blocks, NSAIDs, and short-acting opioids given by nurses or as PCA present the best multimodal pain strategy in abdominal surgery. Epidural analgesia and spinal anesthesia have become second-line options or are reserved for specific patient morbidities or surgical requirements.

Ultrasound guided transversus abdominis plane block. Postoperative analgesia in children with spinal dysraphism

Pediatric regional anesthesia is widely used to relieve postoperative pain after abdominal surgery. Commonly used techniques of regional anesthesia include lumbar epidural and caudal block. However, the use of central neuraxial blockade has limitations. It is contraindicated in patients with clotting abnormalities, spinal dysraphism with tethered cord syndrome, meningomyelocele, and following spinal surgery with instrumentation. Ultrasound guided transversus abdominis plane block is a new method of regional anesthesia that can be used in settings where central neuraxial blockade is contraindicated. In this study, we present 5 pediatric cases in which major abdominal surgery was performed but central neuraxial blockade could not be carried out due to spinal abnormalities.

The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: A systematic review with meta-analysis

BACKGROUND

The aim of the study was to compare the analgesic efficacy of epidural analgesia and transverse abdominis plane (TAP) block. TAP block has gained popularity to provide postoperative analgesia after abdominal surgery but its advantage over epidural analgesia is disputed.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Only trials comparing TAP block with epidural analgesia were included. The primary outcome was pain score at rest (analog scale, 0-10) on postoperative day 1 analyzed in subgroups according to the population (children and adults). Secondary outcomes included rate of hypotension, length of stay, and functional outcomes (time to first bowel sound, time to first flatus).

RESULTS

Ten controlled trials, including 505 patients (195 children and 310 adults), were identified. Pain scores at rest on postoperative day 1 were equivalent for TAP block and epidural analgesia groups in children (mean difference: 0.3; 95% confidence interval [CI]: -0.1 to 0.6; I = 0%; P = .15) and in adults (mean difference: 0.5; 95% CI: -0.1 to 1.0; I = 81%; P = .10). The quality of evidence for our primary outcome was moderate according to the GRADE system. The epidural analgesia group experienced a higher rate of hypotension (relative risk: 0.13; 95% CI: 0.04-0.38; I = 0%; P = .0002), while hospital length of stay was shorter in the TAP block group (mean difference: -0.6 days; 95% CI: -0.9 to -0.3 days; I = 0%; P < .0001), without impact on functional outcomes.

CONCLUSION

There is moderate evidence that TAP block and epidural analgesia are equally effective in treating postoperative pain in both pediatric and adult patients, while TAP block is associated with fewer episodes of hypotension and reduced length of stay.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

A Randomized Controlled Trial of Comparing Ultrasound-Guided Transversus Abdominis Plane Block with Local Anesthetic Infiltration in Peritoneal Dialysis Catheter Implantation

BACKGROUND

The ultrasound-guided transversus abdominis plane (TAP) block has been demonstrated as a useful analgesia technique in lower-abdomen surgeries. We hypothesized that it could be the principal anesthesia technique for end-stage renal disease (ESRD) patients undergoing peritoneal dialysis (PD) catheter (PDC) implantation using the open dissection method.

METHODS

This was a single-center, prospective, randomized, and double-blinded study. All eligible patients were randomized into 2 groups: the TAP block group (n = 20) and the local anesthetic infiltration (LAI) group (n = 20).

RESULTS

Compared with the LAI group, the TAP block group revealed a remarkably lower visual analogue score, lower switching rate into general anesthesia, higher satisfaction rate, and less rescuing analgesic consumption during operation (p < 0.05). Both PD- and anesthesia-related complications were rare in the 4-week follow-up.

CONCLUSIONS

The ultrasound-guided TAP block had better analgesic effect than LAI and can be used as a principal anesthesia technique for PDC implantation in ESRD patients without previous abdominal surgery.

Perioperative Care of Elderly Surgical Outpatients

The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.

Influence of caudal block on postoperative oliguria in infants undergoing bilateral ureteroneocystostomy: a retrospective analysis

BACKGROUND

Caudal block has been widely used in children undergoing genitourinary surgery. However, the influence of caudal block on postoperative oliguria is unclear.

AIM

The aim of this study was to assess the effect of caudal block on urinary flow through the reimplanted ureter after ureteroneocystostomy and the incidence of postoperative oliguria in infants.

METHODS

This retrospective study analyzed the medical records of 121 infants aged less than 12 months who underwent bilateral ureteroneocystostomy for vesicoureteral reflux at a tertiary medical center. In all study infants, a ureteral catheter was placed in one of the two ureters in order to relieve the clinical consequences of transient ureteral obstruction and a urethral catheter was placed at the end of the ureteroneocystostomy procedure. Urinary output was assessed separately for each catheter. Logistic regression analysis was performed to identify the risk factors for oliguria from the urethral catheter.

RESULTS

Among the 121 patients, 63 (52%) received caudal block (caudal block group) and 58 (48%) did not (no caudal block group). Patient characteristics, preoperative vesicoureteral reflux grade and renal function, and intraoperative profiles were comparable between the groups. The incidence of oliguria from the urethral catheter for 8 h after the surgery was significantly higher in the caudal block group than in the no caudal block group. However, the incidence of oliguria from the ureteral catheter was comparable between the groups. In multivariate analysis, oliguria from the urethral catheter was associated with caudal block, anesthesia duration, and intraoperative dexamethasone administration. The odds for oliguria was 3.069-fold greater in patients who received caudal block than in those who did not (95%CI, 1.303-7.228, P = 0.010). On the other hand, intraoperative dexamethasone reduced the risk of oliguria.

CONCLUSION

Caudal block may be associated with postoperative oliguria in infants undergoing ureteroneocystostomy.

Comparison of caudal ropivacaine-morphine and paravertebral catheter for major upper abdominal surgery in infants

BACKGROUND

The caudal epidural block is one of the most commonly used regional anesthetic techniques in children. Administration of morphine via caudal injection enables analgesia, even for upper abdominal surgery. The thoracic paravertebral block has also been successfully used to treat perioperative pain during upper abdominal procedures in pediatric patients.

AIM

In the current study, we compared the two regional techniques for upper abdominal surgery in infants to determine whether one of them was preferable to the other.

METHODS

Consecutive patients under 12 months of age who underwent upper abdominal surgery were retrospectively divided according to the chosen postoperative analgesia: Group C, caudal ropivacaine-morphine; Group P, paravertebral catheter. We analyzed the following outcomes: requirement for additional analgesics, pain scores, need for mechanical ventilation and oxygen dosage, postoperative blood pressure and heart rate, time to pass first stool, time until first full meal, and complications.

RESULTS

Twenty-one consecutive patients were included: 10 in Group C and 11 in Group P. Median age at surgery was 80 (47.5-270.0) and 84.5 (34.3-287.5) days, respectively. No difference was found between the two groups in requirement for additional analgesics at 24 h after surgery (median 1 in Group C vs 1 in Group P, P = 0.288, 95% CI: -2 to 1). BOPS pain scores were only lower in Group P when compared to Group C at 24 h after surgery (median 1 vs 2, P = 0.041, 95% CI: -2 to 0). None of the patients had perioperative complications.

CONCLUSIONS

In this small series, there was no significant difference between caudal ropivacaine-morphine and paravertebral catheter for postoperative care in infants undergoing upper abdominal surgery. Further prospective studies are needed to compare the efficacy and incidence of complications of caudal block and paravertebral catheter for postoperative analgesia.

An update on pain management for elderly patients undergoing ambulatory surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting.

RECENT FINDINGS

Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h.

SUMMARY

The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

Paediatric regional anaesthesia: a current perspective

PURPOSE OF REVIEW

Effective analgesia is necessary for optimal recovery after surgery, but children often do not attain adequate postoperative pain control. This review examines the current trends in paediatric regional anaesthesia.

RECENT FINDINGS

Better pain assessment and therapeutic regimens are needed for our patients. Trunk blocks such as paravertebral, transversus abdominis plane, rectus sheath and ilioinguinal/iliohypogastric are becoming a popular means of providing analgesia for thoracic and abdominal procedures. The introduction of ultrasound guidance improves accuracy, efficacy, and safety of regional anaesthesia, and also decreases the amount of local anaesthetic injected. Single injection nerve blocks have a limited duration and the patients can benefit from adding an adjunct to local anaesthetic or placing a catheter. The use of adjuncts is reasonable, but it is difficult to find a medication with both minimal side-effects and the ability to combat pain for extended periods of time. More peripheral nerve block catheters are used in the paediatric inpatient and outpatient settings and recent data support the feasibility and efficacy of ambulatory peripheral nerve catheters.

SUMMARY

By using a multimodal approach that includes regional anaesthesia, paediatric pain management should aim to reduce patients' pain to an acceptable level without compromising their degree of mobilization. Undoubtedly, peripheral nerve blocks improve analgesia, but future large prospective studies should be conducted to further delineate their effectiveness, duration and safety.