Transversus Abdominis Block: Clinical Uses,Side Effects,and Future Perspectives

Poorly controlled acute pain during the postoperative setting after abdominal surgery can be detrimental to the patient. Current pain management practices for the postoperative abdominal surgery patient rely heavily on opioids, which are associated with many unwanted side effects. Recently, interest surrounding regional anesthesia has been growing owing to its demonstrated efficacy and safety outcomes. More specifically, the transversus abdominis plane (TAP) block procedure has attracted attention owing to its ability to successfully block peripheral pain signaling in the abdomen, its ease of use, few complications, and its greater acceptability. A majority of the studies published has demonstrated the successful reduction in pain in many abdominal surgical procedures using local anesthetics during the TAP block. However, the short duration of the pain block causes the patient to still rely on other analgesics throughout the additional postoperative days. Preliminary studies using continuous infusion catheters placed in the TAP has been one of the ways to prolong the nerve block in the abdomen; however, technical and operational issues currently limit the widespread adoption of this method. In this review, current studies will be presented and summarized to update the field on the potential benefits of the TAP block procedure, in addition to providing insight into the future direction of the drugs that could be used for TAP block.     

Chronic Cancer-Related Pain: Continuous Perineural Infusion of Local Anesthetics as Alternative to Systemic Analgesic Drugs

Pain is a major concern for patients suffering from cancer. Although opioid drugs remain the gold standard for treatment of pain, little is known about the interest of continuous analgesia techniques as alternative. The aim of the present article is to detail the feasibility and to present the diversity of continuous perineural infusion of local anesthetic. A series of five patients suffering from different cancer-related pain is presented. A continuous perineural block was proposed to patients presenting with unbearable pain in an area innervated by a plexus or a nerve despite parenteral analgesic pharmacotherapy. All blocks were performed in a surgical theatre under sterile conditions. An initial bolus dose with 3.75 mg/mL ropivacaine was injected followed by a continuous infusion of 2 mg/mL of ropivacaine. Patient-controlled perineural analgesia was started at home by a nursing network. The technique, the efficacy, and the side effects were reported. Complete pain relief was noted 15 minutes after local anesthetic injection in the five cases, and efficacy was maintained during the following days at home, with no other analgesic treatment required. One patient restarted working a few weeks after catheter insertion. The catheter duration lasted for 12 to 110 days. One catheter was removed because of local anesthetic leak at the puncture point. Some paresthesia was noted in one patient. No other side effect was noted. No infection was reported. In selected patients, continuous perineural infusion of local anesthetics appears to be an attractive alternative to parenteral opioids for cancer-related pain. Further investigation is warranted to better define the place of these techniques in the armamentarium of cancer-related pain treatment.     

Ultrasound‐Guided Continuous Superficial Peroneal Nerve Block below the Knee for the Treatment of Nerve Injury

(CRPS) describes a constellation of symptoms including pain, trophic changes, hyperesthesia, allodynia, and dysregulation of local blood flow often following trauma. It is often confined to the extremities. Treatment of this disorder consists of a variety of modalities including systemic pharmacotherapy, local anesthetic injections or infusions, psychological nonpharmacotherapy, physical rehabilitation, and surgical intervention. Chronic pain not related to CRPS can also be treated with similar interventions. Despite the array of available therapies, it can still be difficult to manage. We report a case of a 19‐year‐old patient diagnosed by her surgeon as having CRPS Type II, secondary to foot trauma, which was treated with a continuous infusion of local anesthetic at the superficial peroneal nerve (SPN). While placement of peripheral nerve block catheters to augment chronic pain therapy is not novel, the application of a perineural catheter at the SPN has not been previously described.     

Ultrasound‐Guided Transversus Abdominis Plane Block for Spinal Infusion and Neurostimulation Implantation in Two Patients with Chronic Pain

Objective: This case report describes an ultrasound approach to the transversus abdominis plane (TAP) local anesthetic block. This block induces sensory blockade in the lower half of the abdomen where the pulse generator or the infusion pump is to be housed in a subcutaneous pocket, and therefore provides an alternate to general anesthesia or administration of high‐dose local anesthetics. Case Report: We report two cases of neuromodulation procedures—implantation of an internal morphine pump for severe somatic pain refractory to other therapies and placement of a double‐stimulator generator for dorsal column stimulation in a patient diagnosed with postoperative failed‐back syndrome. We successfully used ultrasound‐guided TAP block to achieve ipsilateral sensory block of dermatomes T9‐L1 in the context of a monitored anesthesia care multimodal approach. Conclusion: TAP block can be a potentially useful substitute to general anesthesia or local anesthesia for the pocket formation in neuromodulation techniques, and it provides adequate anesthesia of the abdominal wall. This block is potentially an important addition to the monitored anesthesia care protocol.     

Continuous peripheral nerve blocks

A continuous peripheral nerve block—also termed “perineural local anesthetic infusion”—involves the percutaneous insertion of a catheter adjacent to a peripheral nerve, followed by local anesthetic administration via the catheter, providing anesthesia/analgesia for a prolonged period of time. The most-common indication for continuous peripheral nerve blocks is analgesia following painful surgical procedures; but, they are also used for inducing a sympathectomy and vasodilation following digit transfer/replantation, a vascular accident, limb salvage, or peripheral embolism; treating intractable hiccups; alleviating the vasospasm of Raynaud’s disease; and treating chronic pain such as phantom limb pain, cancer-induced pain, complex regional pain syndrome, and trigeminal neuralgia. Continuous peripheral nerve blocks may also provide pain control during medical transport, or awaiting surgical correction. The most common catheter insertion techniques include electrical stimulation and ultrasound-guidance. Long-acting local anesthetic is usually the sole infusate, and is optimally delivered with a continuous basal infusion with available patient-controlled bolus doses. Benefits are dependent upon analgesia improvement, and include decreasing pain, supplemental analgesic consumption, opioid-related side effects, sleep disturbances, patient dissatisfaction, time until discharge readiness, and actual hospitalization duration. Additional possible benefits include improvements in ambulation/functioning and an accelerated resumption of passive joint range-of-motion. Most benefits occur during the infusion itself, but a few studies suggest prolonged benefits following catheter removal in some cases. Minor complications occur at approximately the incidence as for single-injection peripheral nerve blocks; but, major risks including nerve injury are extraordinary uncommon.     

Labor analgesia

Regional analgesia has become the most common method of pain relief used during labor in the United States. Epidural and spinal analgesia are two types of regional analgesia. With epidural analgesia, an indwelling catheter is directed into the epidural space, and the patient receives a continuous infusion or multiple injections of local anesthetic. Spinal injections are usually single injections into the intrathecal space. A combination of epidural and spinal analgesia, known as a walking epidural, also is available. This technique combines the rapid pain relief from the spinal regional block with the constant and consistent effects from the epidural block. It allows sufficient motor function for patients to ambulate. Complications with regional analgesia are uncommon, but may include postdural puncture headache. Rare serious complications include neurologic injury, epidural hematoma, or deep epidural infection. Regional analgesia increases the risk of instrument-assisted vaginal delivery, and family physicians should understand the contraindications and risks of complications. Continuous labor support (e.g., doula), systemic opioid analgesia, pudendal blocks, water immersion, sterile water injections into the lumbosacral spine, self-taught hypnosis, and acupuncture are other options for pain management during labor.     

神经刺激器引导用于臂丛神经阻滞及术后镇痛研究

目的 观察神经刺激器定位下经斜角肌间沟留置导管用于持续臂丛神经阻滞及术后镇痛的临床效果和可行性。方法 ASAⅠ～Ⅱ级上肢手术患者60例。随机分为套管针组（A组）和留置导管组（B组），每组30例。A组患者用20G静脉穿刺套管针行常规方法臂丛神经阻滞留置，B组患者在周围神经刺激器引导下穿刺置入专用的柔软导管，手术结束后两组患者均连接一电子镇痛泵行持续术后臂丛神经阻滞镇痛。结果 术中需辅助用药患者两组无统计学差异（P〉0．05）。A组患者术后镇痛失败率达23．3％，B组无镇痛失败患者，两组比较差异有显著性（P〈0．05）。剔除A组镇痛失败患者后，两组患者术后48h内的VAS评分、Ramsay评分和PCA按压次数无统计学差异（P〉0．05）。结论 周围神经刺激器精确引导下经斜角肌间沟留置导管行臂丛神经阻滞和持续术后镇痛是一种可行性好、镇痛效果确切、不良反应少的方法。     

Continuous peripheral nerve blocks in acute pain management

Continuous peripheral nerve block techniques offer many benefits for the surgical patient in terms of target-specific pain control and avoidance of opioid-related side effects. There are many acceptable techniques for perineural catheter placement and infusion management, and practitioners are encouraged to obtain specialized training to develop a consistent practice and ensure patient safety. Emerging technology in ultrasound guidance may offer advantages in perineural catheter insertion accuracy and procedural efficiency. Various infusion devices are available that permit delivery of a basal rate and patient-controlled bolus for use in the event of breakthrough pain. A successful outpatient continuous peripheral nerve block program should include thorough patient education, detailed written instructions, daily telephone follow-up, and contact information for a healthcare provider familiar with these techniques who can answer questions and intervene when necessary.     

Ultrasound‐Guided Paravertebral Neurolytic Block: A Report of Two Cases

Paravertebral block is commonly used in the treatment for acute and chronic pain. The duration of paravertebral block could theoretically be prolonged with neurolytic agents. We report two cases of ultrasound‐guided neurolytic paravertebral blocks in patients suffering from intense cancer‐related thoracic pain. Ultrasound was used to identify the space and plane of injection at the mid‐thoracic level. Absolute alcohol was used to block the nerves at different segments. The two patients had great pain relief. Neurolytic paravertebral block can be a useful technique in patients with intractable cancer pain. Because of the risk of complication, it is recommended that this technique should be limited to relief of intractable pain in cancer patients with a poor prognosis.     

Long-term pain control in trigeminal neuralgia with local anesthetics using an indwelling catheter in the mandibular nerve

OBJECTIVE: The authors sought to determine the usefulness of long-term continuous trigeminal nerve block with local anesthetics using an indwelling catheter in a patient with trigeminal neuralgia. DESIGN: The study design included pain control in a patient with trigeminal neuralgia until the time of neurosurgical operation. SETTING: The study was conducted in the Dental Hospital of Tokyo Medical and Dental University. PATIENT: The patient was a 78-year-old woman with trigeminal neuralgia in the right maxillary region. Her pain could not be controlled by carbamazepine and was unbearable. INTERVENTION: The authors estimated the patient's pain intensity, quality, and locality using a visual analog scale to determine the effectiveness of continuous nerve block. OUTCOME MEASURES: Visual analog scores were measured during treatment. The treatment term was divided into three periods according to the difference of the catheter location and injection protocol (premandibular nerve block, infuser injection, and patient-controlled analgesia [PCA] pump injection). The authors also examined the patient's general condition and blood concentration of drugs. RESULTS: The visual analog values were 44.8 +/- 3.6, 26.7 +/- 3.5, and 11.9 +/- 3.1 mm in each period, respectively. The value in the PCA pump infusion period was significantly lower than that in the other periods. No side effects of the local anesthetics were observed on the patient's systemic condition. CONCLUSIONS: The authors controlled trigeminal neuralgia pain by blocking the mandibular nerve with local anesthetics administered through an indwelling catheter. Because the continuous nerve block with local anesthetics is reversible and only mildly toxic, this method is beneficial for pain control in patients with trigeminal neuralgia scheduled to undergo microvascular decompression.     

Increasing the efficacy of a celiac plexus block in patients with severe pancreatic cancer pain.

The purpose of this study was to evaluate the technical possibilities of placing a catheter near the celiac plexus for performance of a celiac plexus block, and to study the efficacy of repeated neurolytic celiac plexus blocks with alcohol in patients with advanced pancreatic cancer pain resistant to opioid treatment. In 12 patients, a neurolytic celiac plexus block with alcohol, administered via an indwelling celiac catheter, was performed. To evaluate the efficacy, visual analog scale scores were recorded every day. Quality of life scores were registered before and 4 weeks following the procedure. Alterations in opioid consumption, and the time between the diagnosis of pancreatic cancer and the performance of the block, were registered. All patients were followed until they died. Two patients remained without pain after the first neurolytic celiac plexus block. In all other patients a second block was administered which provided only temporary relief. Additional intermittent administration of bupivacaine through the catheter was necessary to provide adequate pain relief in these patients. Quality of life increased significantly during the treatment. Opioid consumption decreased significantly in all patients. Our study indicates that a neurolytic celiac plexus blockade with alcohol results in a significant but short-lasting analgesic effect. The use of a celiac catheter improves the long-term management of pancreatic cancer pain.     

Transversus Abdominis Plane Blocks: An Overview of Indication and Nursing Care

Transversus abdominis plane (TAP) blocks are an evolving regional anesthesia technique used as part of postoperative pain management regimens after major abdominal surgery. This article reviews TAP block insertion techniques, commonly used local anesthetics, and recommends nursing care related to TAP blocks.     

Bilateral brachial plexus home going catheters after digital amputation for patient with upper extremity digital gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay. KEYWORDS: Brachial plexus; Home going catheters; Post-operative pain.     

Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option

We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPG) block was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome.     

Treatment of meralgia paresthetica with ultrasound-guided pulsed radiofrequency ablation of the lateral femoral cutaneous nerve

Abstract: A 23‐year‐old female with an 18‐month history of left anterolateral thigh paresthesias and burning pain consistent with meralgia paresthetica was referred to our clinic after failing trials of physical therapy, nonsteroidal anti‐inflammatories, gabapentin, and amitriptyline. We performed 3 lateral femoral cutaneous nerve blocks with corticosteroid over a 4‐month period; however, each block provided only temporary relief. As this pain was limiting the patient’s ability to perform her functions as an active duty service member, we elected to perform a pulsed radiofrequency treatment of the lateral femoral cutaneous nerve with ultrasound guidance and nerve stimulation. After locating the lateral femoral cutaneous nerve with ultrasound and reproducing the patient’s dysthesia with stimulation, pulsed radiofrequency treatment was performed at 42°C for 120 seconds. The needle was then rotated 180° and an additional cycle of pulsed radiofrequency treatment was performed followed by injection of 0.25% ropivacaine with 4 mg of dexamethasone. At 1.5 and 3 month follow‐up visits, the patient reported excellent pain relief with activity and improved ability to perform her duties as an active duty service member. ?     

Continuous peripheral nerve block for ambulatory surgery. (Duke University, Durham, NC) Reg Anesth Pain Med 2001;26:209–214.

In this study data was prospectively gathered for 1 year from 228 patients in an ambulatory surgery center. All continuous peripheral nerve blocks (CPNB) were performed using the Contiplex system to provide anesthesia and postoperative analgesia. CPNB were performed using 5 upper and lower extremity techniques. Postsurgery local anesthetic was infused and at 24 hours, a rebolus of local anesthetic was performed. The CPNB catheter was removed and patients were examined for a loss of sensation. Patients were then discharged. The initial peripheral block was successful in 94% of the patients. Failed nerve block requiring general anesthesia occurred in 6%. The catheter was patent and functional in 90% of the patients at 24 hours, and 8% of the patients required more than 10 mg of intravenous morphine by 24 hours postsurgery. In the postanesthesia care unit, only 4 patients (1.7%) required treatment for nausea. At 24 hours and 7 days postsurgery, no patient reported a dysesthesia. Conclude that CPNB using the insulated Tuohy catheter system offered acceptable anesthesia and prolonged pain relief postsurgery. There were few side effects. Comment by Alan David Kaye, M.D., Ph.D., Erin Bayer, M.D. This study demonstrates the efficacy of the Contiplex system (CPNB) in providing surgical anesthesia and postoperative analgesia through CPNB. Despite the efficacy of CPNB, which could provide longer duration of postoperative analgesia than single injection block, it is not widely used due to lack of available equipment. Contiplex system utilizes a connector for a nerve stimulator attached to a 18‐gauge Tuohy needle. It allows for aspiration of blood, injection of local anesthesia and passage of a peripheral nerve catheter. This study demonstrated in an ambulatory surgery center with 228 patients, CPNB was used for 27 different types of surgical procedures which involved 5 different block sites. Success rates were 94% for initial peripheral block while 6% required general anesthesia. Patients required less postoperative analgesia. The incidence of postoperative side effects such as nausea and vomiting were minimal. Not a single patient reported dissatisfied with a 7‐day telephone follow‐up. A disadvantage of this technique is the use of an 18‐gauge needle and potential for vascular and/or nerve injuries, which did not occur in this study. Though previous studies have demonstrated the efficacy of the CPNB in inpatients, this is an important study focused on outpatients. A larger study group will be valuable in future studies.     

Opioid‐Free Perioperative Analgesia for Hemicolectomy in a Patient With Opioid‐Induced Delirium: A Case Report and Review of the Analgesic Efficacy of the Alpha‐2 Agonist Agents

Abstract: Surgical pain in patients with documented opioid‐induced delirium can be difficult to treat. We present a case of a patient undergoing laparoscopic hemicolectomy effectively treated with an opioid‐free, alpha‐2 adrenoreceptor agonist analgesic regimen. Case report: A 21‐year‐old woman with persistent abdominal pain presented to the operating room for laparoscopic hemicolectomy for redundant right colon. Her medical history included a recently diagnosed postoperative opioid‐induced delirium. Epidural infusion with local anesthetic offered partial pain relief with sensory levels of T9‐L2. With the addition of dexmedetomidine infusion in the immediate postoperative period, the patient was comfortable with pain scores of 1 to 2/10 on Numerical Rating Scale (NRS). On postoperative day 1, the infusion was discontinued and the clonidine, 12 μg/hours was added to the epidural bupivacaine. With increased sedation 48 hours later, neuraxial clonidine was discontinued in favor to transdermal clonidine 0.1 mg/week, which was maintained until hospital discharge. Pain scores were maintained at 2 to 3/10 on NRS for the next 3 days when increased abdominal distention because of abscess formation rendered a new surgical intervention. The analgesia for the exploratory laparoscopy was maintained using epidural clonidine and bupivacaine infusion as well as intravenous dexmedetomidine, which were maintained another 2 days. Pain scores remained minimal until discharged home 3 day later. Discussion: Nonopioid analgesic regimens are beneficial in patients at risk of postoperative cognitive dysfunction attributable to opioids. Successful postoperative analgesia was achieved in our patient by alternating various routes of administration of alpha‐2 adrenoreceptor agonists.     

Anesthesia (7)

Extended “three‐in‐one” block after total knee arthroplasty: continuous versus patient‐controlled techniques. (St. Luc Hospital, Brussels, Belgium) Anesth Analg 2000;91:176–180. This prospective, randomized, doubled‐blinded study assessed the efficacy of patient‐controlled analgesia (PCA) techniques for an extended “3‐in‐1” block after total knee arthroplasty. A total of 45 patients were divided into 3 groups of 15. Over 48 h, all patients received 0.125% bupivacaine with 1 μg/mL clonidine via a femoral nerve sheath catheter in the following manner: as a continuous infusion at 10 mL/h in Group 1; as a continuous infusion at 5 mL/h plus PCA boluses (2.5 mL/30 min) in Group 2; or as PCA boluses only (10 mL/60 min) in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. Pain scores and supplemental analgesia were comparable in the three groups. Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.01), and in Group 3 than in Group 2 (P < 0.01). Side effects and satisfaction were comparable in the 3 groups. Conclude that extended “3‐in‐1” block provides efficient pain relief after total knee arthroplasty and that, compared with a continuous infusion, PCA techniques reduce the total anesthetic consumption without compromise in patient satisfaction or visual analog scale scores. Of the 2 PCA techniques tested, PCA boluses (10‐mL lockout; time 60 min) of 0.125% bupivacaine with 1 μg/mL clonidine was associated with the smallest local anesthetic consumption, and is, therefore, the recommended extended “3‐in‐1” block technique. Comment by Octavio Calvillo, MD, PhD. In a prospective, randomized, double‐blinded study, the authors studied the efficacy of the 3 in 1 block in a group of patients that had undergone total knee arthroplasty. Patients were allocated to 3 groups; all patients had a catheter implanted in the femoral sheath. Over 48 h all patients received 0.125% bupivacaine with 1 μg/mL clonidine. Group 1 received the mixture as a continuous infusion at 10 mL/h. Group 2 received a continuous infusion at 5 mL/h plus PCA boluses (2.5 mL/30 min). Group 3 received 10 mL of solution per 60 min. Pain scores, supplemental analgesia side effects, and patient satisfaction were comparable in all groups. Bupivacaine consumption was significantly lower in Group 2 and Group 3 as compared to Group 1 (P < 0.01). Of the PCA techniques studied, the regimen involving 10 mL per h was associated with the lowest local anesthesia consumption and is, therefore, the recommended technique for extended 3 in 1 block.