Ultrasound‐Guided Transversus Abdominis Plane Catheter for Chronic Abdominal Pain

Abstract Background and Objectives: Neural blockade of the thoracolumbar nerves supplying the anterior abdominal wall through transversus abdominis plane (TAP) has been investigated for different applications mainly for the acute pain management following abdominal surgical procedures. The role of this block for chronic pain syndromes is still to be discovered, and its value in chronic abdominal pain needs to be studied. We are presenting new application of the TAP technique for management of chronic abdominal pain syndrome using the continuous infusion. Case report: We present a case of an 18‐year‐old girl who underwent an uneventful laparoscopic cholecystectomy. Postoperatively, patient complained of chronic pain at the site of the surgery. All diagnostic and imaging studies were negative for a surgical or a medical cause. Multiple interventions including epidural blocks, transcutaneous electrical neural stimulation, and celiac plexus blocks had failed to relieve the pain. After discussion with the patient about the diagnostic nature of the procedure and the likelihood of recurrence of pain, TAP block was performed on the right side with significant improvement of pain for about 24 hours. The degree of pain relief experienced by the patient was very dramatic, which encouraged us to proceed with an indwelling TAP catheter to allow for continuous infusion of a local anesthetic. The patient was sent home with the continuous infusion through a TAP catheter for 2 weeks. From the day of catheter insertion and up to 9 months of follow‐up, patient had marked improvement of her pain level as well as her functional status and ability to perform her daily activities, after which our acute pain team stopped following the patient. Conclusion: A successful TAP block confirmed the peripheral (somatic) source of the abdominal pain and provided temporary analgesia after which an indwelling catheter was inserted, which provided prolonged pain relief.     

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.     

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.     

急诊阑尾切除术中超声引导腹横肌平面阻滞的镇痛效果

目的：探讨全麻急诊阑尾切除术中超声引导腹横肌平面阻滞的镇痛效果。方法全麻下接受急诊开腹阑尾切除术患者50例,采用计算机排序分为A、B组各25例,分别予以超声引导腹横肌平面阻滞和常规麻醉。观察并记录48 h内各随访时点运动与静息时的数字评分（ NRS）,使用镇痛药物辅助的病例数,患者对术后疼痛缓解自我评分以及镇痛相关并发症。结果在12 h内各时点静息与运动时的NRS评分,A组明显低于B组（ P＜0.05）,24～48 h各时点两组间比较差异无统计学意义（P ＞0.05）。 A组患者术后疼痛缓解自我评分明显高于B组（P＜0.05）。术后第一日和第二日辅助镇痛药使用率A组低于B组（ P＜0.05）。结论超声引导下腹横肌平面阻滞可以产生良好12小时左右的术后镇痛。在多模式镇痛中可能更占优势。     

Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen

Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after “minor” surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.     

腹部术后患者疼痛知识、态度及行为的现状调查

目的了解腹部术后患者疼痛知识、信念及行为的现状,为制定疼痛健康教育对策提供参考。方法采用方便抽样法,选取江苏省某三级甲等医院2011年11月至2012年3月行腹部手术的患者116名进行问卷调查,调查内容包括患者一般人口学资料、既往手术史和疼痛教育史及术后疼痛知识、信念、行为等。结果患者术后疼痛知识问卷得分为（63．03±2．68）分,处于较低的水平;有无手术史或疼痛教育史患者的知识得分差异有统计学意义（P〈O．05）;信念问卷5个维度中“行为改变的障碍”维度的4个项目得分最低,分别为（2．974±0．639）、（2．991±0．582）、（2．491±0．502）及（2．241±0．430）分;行为问卷的各条目得分为（i．517±0．502）至（3．448±0．499）分。结论患者对术后疼痛知识了解较少,对疼痛和止痛药的使用存在错误的观念,对术后疼痛控制的参与度不够。应选择适宜的健康教育方式,改善患者对术后疼痛相关知识的掌握,坚定其术后镇痛的信念,加强其术后自我镇痛管理行为,从而提高疼痛控制的效果。     

Transversus abdominis plane block: A new method in renal colic pain management

In recent decades, regional plane blocks via ultrasonography have become very popular in regional anesthesia and are more commonly used in pain management. The transversus abdominis plane (TAP) block is a procedure where local anesthetics are applied to block the anterior divisions of the tenth thoracic intercostal through the first lumbar nerves (T10–L1) into the anatomic space formed amidst the internal oblique and transversus abdominis muscles located in the antero-lateral part of the abdomen wall. The most important advantage of this block method is that ultrasonographic identification is easier and its complications are fewer compared with central neuroaxial or paravertebral blocks. Here, we describe three cases where pain management in renal colic was treated with the TAP block.     

Delayed distal pancreatectomy for isolated complete pancreatic disruption secondary to “trivial” blunt abdominal injury: A case report and literature review

Pancreatic injury is a formidable diagnostic and therapeutic challenge owing to its relative rarity. Most injuries are from motor vehicle related injuries in blunt trauma patients. We present a 22‐year‐old male patient presented after sustaining a kick to the abdomen. He developed progressive abdominal pain with vomiting with delayed generalization of the pain and involuntary guarding. On initial exploratory laparotomy, suction drainage was inserted, and patient underwent delayed spleen sparing distal pancreatectomy on the 25th post‐admission day. Patient had smooth postoperative course and was discharged on the 7th postoperative day.     

针刺第二掌骨侧穴位对丙泊酚无痛人流的临床效果观察

目的:观察针刺第二掌骨侧缘的下腹穴区对丙泊酚用于人工流产术的麻醉效果以及术后下腹痛等并发症的影响.方法:80例早孕妇,随机分为对照组和针刺组,全部病人予以丙泊酚静脉全麻.针刺组病人针刺其两侧第二掌骨内侧缘凹沟中的下腹穴区,以快速和慢速捻转手法持续刺激并留针,对照组不予针刺.结果:针刺组较对照组更易扩张宫颈(P＜0.05).两组病人丙泊酚诱导用量无显著性差异(P＞0.05),但需追加用药病人例数针刺组明显少于对照组(P＜0.05).麻醉效果针刺组优于对照组(P＜0.05).病人术后下腹痛的发生率及程度针刺组明显低于对照组(P＜0.05),围术期恶心和唾液增多的发生率针刺组也明显减少(P＜0.05).结论:针刺第二掌骨侧下腹穴位,可改善丙泊酚用于人工流产术的麻醉效果,减轻术后下腹痛等并发症.     

CT-guided percutaneous neurolytic celiac plexus block technique

Up to now, the studies in the world have demonstrated that CT-guided percutaneous neurolytic celiac plexus block (PNCPB) is an invaluable therapeutic modality in the treatment of refractory abdominal pain caused by cancer. Its efficacy of pain relief varied in reported studies. The main technical considerations which would affect the analgesic effects on abdominal pain included the patients’ cooperation, needle entry approaches, combined use of blocking approaches, localization of the target area, dosage of the blocker, and so on. A success of PNCPB depends greatly on close cooperation with patients. The patient should be educated about the purpose and steps of the procedure, and trained of breathing in and breathing hold. The needle entry can be divided into the posterior approach and the anterior approach. The former one is the most commonly used in clinical practice, but the latter one is rarely used except in the cases that the posterior approach becomes technically difficult. Bilateral multiple blocking of celiac plexus and splanchnic nerves is often required to achieve optimal analgesia. The needle entry site, insertion course, and depth should be preselected and simulated on CT monitor prior to the procedure in order to ensure an accurate and safe celiac plexus block. The magnitude of analgesic effect is closely related to the degree of degeneration and necrosis of the celiac plexus. Maximally filling with blocker in the retropancreatic space is an indication of sufficient blocking. We also provided an overview of indications and contraindications, preoperative preparations, complications and its treatment of PNCPB.     

Abdominal surgery, pain and anxiety: preoperative nursing intervention

AIM: This paper reports a study examining the effects of preoperative nursing intervention for pain on abdominal surgery preoperative anxiety and attitude to pain, and postoperative pain. METHOD: In a randomized controlled study conducted between January and August 2001, patients undergoing abdominal surgery in a medical center in southern Taiwan were randomly assigned to an experimental (n = 32) or control group (n = 30). The experimental group received routine care and preoperative nursing intervention for pain, while the control group received routine care only. A structured questionnaire including an anxiety scale, pain attitude scale, and Brief Pain Inventory was used to assess the results. RESULTS: Participants in the experimental group experienced a significant decrease in preoperative anxiety and a significant improvement in preoperative pain attitude. They also had statistically significantly lower postoperative pain intensity for 4 hours after surgery and lower highest pain intensity within the first 24 hours after surgery. Perceived pain interference during position changes, deep breathing/coughing, and moments of emotion in the experimental group was statistically significantly lower than that of the control group in the same situations. The experimental group also started out-of-bed activities 1.5 days earlier. CONCLUSION: Preoperative nursing intervention for pain has positive effects for patients undergoing abdominal surgery. The intervention used in this study could serve as a guide for nurses to improve the pain care of these patients.     

Omental Infarction: Case Series and Review of the Literature

Background: Omental infarction is a rare disease entity that can cause acute or subacute abdominal pain. In the past, it was thought that omental infarction mainly occurred on the right side because it was detected when surgery was performed on patients who complained of abdominal pain on the right side. Objective: We present this case to demonstrate that omental infarction can occur at any site, including the epigastric area and the lower abdomen, and even on the left side where the greater omentum is located. Case Report: Four patients with omental infarction presented to the Emergency Department with various clinical symptoms. All of them were diagnosed by computed tomography scan. Omental infarction occurred on the right side in 2 patients, at the epigastric area in 1 patient, and on the left side in 1 patient. Three were improved with supportive care. Laparoscopy was performed in 1 patient because his abdominal pain persisted despite conservative treatment. Conclusion: Omental infarction should be included in the differential diagnosis list of acute abdominal pain because it can occur at any site. In addition, because this disease runs a self-limited course, conservative care is recommended. Thus, unnecessary operations can be avoided in cases where omental infarction is diagnosed by imaging studies.     

Combined fascia iliaca compartment block and monitored anesthesia care for geriatric patients with hip fracture: Two case reports

BACKGROUNDMajor hip surgery usually requires neuraxial or general anesthesia with tracheal intubation and may be supplemented with a nerve block to provide intraoperative and postoperative pain relief.CASE SUMMARYThis report established that hip surgical procedures can be performed with a fascia iliaca compartment block (FICB) and monitored anesthesia care (MAC) while avoiding neuraxial or general anesthesia. This was a preliminary experience with two geriatric patients with hip fracture, American Society of Anesthesiologists status III, and with many comorbidities. Neither patient could be operated on within 48 h after admission. Both general anesthesia and neuraxial anesthesia were high-risk procedures and had contraindications. Hence, we chose nerve block combined with a small amount of sedation. Intraoperative analgesia was provided by single-injection ultrasound-guided FICB. Light intravenous sedation was added. Surgical exposure was satisfactory, and neither patient complained of any symptoms during the procedure.CONCLUSIONThis report showed that hip surgery for geriatric patients can be performed with FICB and MAC, although complications and contraindications are common. The anesthetic program was accompanied by stable respiratory and circulatory system responses and satisfactory analgesia while avoiding the adverse effects and problems associated with either neuraxial or general anesthesia.     

Patients with Chronic Pain After Abdominal Surgery Show Less Preoperative Endogenous Pain Inhibition and More Postoperative Hyperalgesia: A Pilot Study

ABSTRACT

Chronic pain is common and undesirable after surgery. Progression from acute to chronic pain involves altered pain processing. The authors studied relationships between presence of chronic pain versus preoperative descending pain control (diffuse noxious inhibitory controls; DNICs) and postoperative persistence and spread of skin and deep tissue hyperalgesia (change in electric/pressure pain tolerance thresholds; ePTT/pPTT) up to 6 months postoperatively. In 20 patients undergoing elective major abdominal surgery under standardized anesthesia, we determined ePTT/pPTT (close to [abdomen] and distant from [leg] incision), eDNIC/pDNIC (change in ePTT/pPTT with cold pressor pain task; only preoperatively), and a 100 mm long pain visual analogue scale (VAS) (0 mm = no pain, 100 mm = worst pain imaginable), both at rest and on movement preoperatively, and 1 day and 1, 3, and 6 months postoperatively. Patients reporting chronic pain 6 months postoperatively had more abdominal and leg skin hyperalgesia over the postoperative period. More inhibitory preoperative eDNIC was associated with less late postoperative pain, without affecting skin hyperalgesia. More inhibitory pDNIC was linked to less postoperative leg deep tissue hyperalgesia, without affecting pain VAS. This pilot study for the first time links chronic pain after surgery, poorer preoperative inhibitory pain modulation (DNIC), and greater postoperative degree, persistence, and spread of hyperalgesia. If confirmed, these results support the potential clinical utility of perioperative pain processing testing.     

腹部手术患者术后镇痛自我管理行为现状及影响因素分析

目的调查腹部手术患者术后镇痛自我管理行为现状,并探讨其影响因素。方法采用腹部手术患者术后镇痛自我管理行为问卷、手术疼痛认知量表、医学应对问卷和社会支持评定量表对行腹部手术的116例患者进行问卷调查。结果腹部手术患者术后镇痛自我管理行为得分为（26．11±1．74）分,处于较低水平;手术病史、面对的应对方式及手术疼痛认知是影响患者术后镇痛自我管理行为的主要因素。结论患者术后镇痛自我管理行为的现状不理想,建议根据影响患者术后镇痛自我管理行为的因素,制订针对性的措施。     

Acute pain teams and the management of postoperative pain: a systematic review and meta-analysis

BACKGROUND: The introduction of acute pain teams (APTs) in every hospital performing surgery in the UK has been recommended in order to reduce postoperative pain. However, recent evidence suggests that many APTs are under-resourced. Purchasers may be more prepared to invest in these services if they are persuaded that they result in measurable improvements in patient outcomes. AIM: A systematic review of the literature and meta-analysis were performed to determine the effectiveness of APTs in improving the quality of analgesia and other postoperative outcomes of adult patients undergoing surgery. METHODS: A broad search strategy using the terms 'pain team' and 'pain service' was adapted for a variety of databases. Key journals were hand-searched and reference lists of selected reports were reviewed. Subject experts and study authors were contacted. Studies describing the impact of the APT/acute pain service (APS) on postoperative pain relief, other postoperative outcomes or the processes of postoperative pain were included. Study quality was assessed using a multidimensional instrument. A broad qualitative overview of the included studies was conducted. Continuous outcome data for pain in the first 24 hours postoperatively (in one case worst pain at 24-48 hours) were pooled. RESULTS: Fifteen studies were included in the review. There were considerable differences in study design and quality, the nature of the APT and the outcomes measured. Of the nine studies measuring pain, it was possible to present data as Standardized Mean Differences for only four studies. Quantitative synthesis indicates a statistically significant overall estimate of effect using a fixed effects model only. LIMITATIONS: Only published studies in English were included. Study inclusion decisions and data extraction were performed by one reviewer only. CONCLUSION: There is insufficient robust research to assess the impact of APTs on postoperative outcomes of adult patients or on the processes of postoperative pain relief.     

A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study. (University of Michigan Medical Center, Ann Arbor, MI) Anesth Analg 2000;91:781–786.

Carotid endarterectomy may be preformed by using cervical plexus blockade with local anesthetic supplementation by the surgeon during surgery. Most practitioners use either a superficial cervical plexus block or a combined (superficial and deep) block, but it is unclear which offers the best operative conditions or greatest patient satisfaction. This study compared the 2 techniques in 40 patients undergoing carotid endarterectomy. The patient randomly received either a superficial or a combined cervical plexus block. Bupivacaine 0.375% to a total dose of 1.4 mg/kg was used. The main outcome measure was the amount of supplemental lidocaine 1% used by the surgeon. Subsidiary outcome measures were postoperative pain score, sedative and analgesic requirements before and during surgery, and postoperative analgesic requirements. Median supplemental lidocaine requirements were 100 mg in the superficial block group and 115 mg in the combined block group. These differences were not statistically significant. There was no significant difference in the number of patients needing postoperative analgesia between the groups in the 24 h after surgery. The median time to first analgesia in the superficial block group was 150 min. more than in the combined block group, but this difference, although large, was not statistically significant. No significant differences were found between the anesthetic techniques studied. Comment by Alan Kaye, M.D. Carotid endarterectomy surgery can be performed with regional or general anesthesia. It is probable that a substantial majority of CEAs performed in North America are performed under general anesthesia. Debate over choice of regional versus general anesthesia persists because of various studies of risks and benefits. Each type of anesthesia has its own advantages and disadvantages, which must be considered when choosing the optimal anesthetic for patients. Regional anesthetic techniques available include local infiltration, superficial and deep cervical plexus block, a combination of these with or without contralateral superficial plexus, and cervical epidural anesthesia. This prospective, randomized, double‐blinded study compared superficial versus combined (superficial and deep) cervical plexus block in 40 patients. Outcomes were measured by supplemental local anesthetic used by the surgeon, postoperative pain scores, and sedative and analgesic requirements before, during, and postoperatively. The results showed no significant difference in either study group. Therefore, this small study suggests that superficial block should be preferred in as much that it is relatively easy to do and the potential side‐effects are far less than deep cervical block. Larger studies are warranted in this difficult population of patients.     

Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Hip arthroscopy is a minimally invasive alternative to open hip surgery. Despite its minimally invasive nature, there can still be significant reported pain following these procedures. The impact of combined sciatic and lumbar plexus nerve blocks on postoperative pain scores and opioid consumption in patients undergoing hip arthroscopy was investigated. A retrospective analysis of 176 patients revealed that compared with patients with no preoperative peripheral nerve block, significant reductions in pain scores to 24 hours were reported and decreased opioid consumption during the post anesthesia care unit (PACU) stay was recorded; no significant differences in opioid consumption out to 24 hours were discovered. A subgroup analysis comparing two approaches to the sciatic nerve block in patients receiving the additional lumbar plexus nerve block failed to reveal a significant difference for this patient population. We conclude that peripheral nerve blockade can be a useful analgesic modality for patients undergoing hip arthroscopy.     

腰-硬联合麻醉剖宫产术后超声引导双侧TAP阻滞的镇痛优势分析

目的：探究超声引导双侧腹横肌平面（TAP）阻滞在腰硬联合麻醉剖宫产术后的镇痛效果。方法：本次研究为前瞻性研究,选取2018年5月-2020年5月在我院行剖宫产手术产妇共计200例为研究对象,采取奇偶数分组法,奇数100例为对照组,偶数100例为观察组,两组产妇均给予腰硬联合麻醉,术后对照组给予静脉自控镇痛,观察组给予静脉自控镇痛联合超声引导双侧TAP阻滞。对两组产妇的术后疼痛程度、舒适度、血清因子、镇痛泵按压次数、并发症及不良反应发生率进行比较。结果：观察组产妇各时点VAS疼痛评分均显著低于对照组（P<0.05）;各时点BCS评分均显著高于对照组（P<0.05）;术后24h,两组产妇血糖、皮质醇、IL-6水平均高于术前,但观察组显著低于对照组（P<0.05）;术后72h后,观察组产妇镇痛泵按压次数、不良反应发生率均低于对照组（P<0.05）。结论：腰硬联合麻醉剖宫产术后采用静脉自控镇痛联合超声引导双侧腹横肌平面阻滞镇痛效果良好,安全性较高,值得推广应用。