Subcostal transversus abdominis plane block for postoperative analgesia in liver transplant recipients

Background

Postoperative pain treatment in orthotopic liver transplant (OLT) patients is a challenge. We performed a pilot study on ultrasound-guided transversus abdominis plane (TAP) block in OLT patients. To test the efficacy of this technique, which is noveI to OLT patients, we compared morphine consumption, pain scores, and time to extubation with a matching control group.

Methods

Seventeen patients who underwent OLT underwent bilateral ultrasound-guided TAP block using a subcostal approach with levobupivacaine (0.5%; 20 mL each) followed by postoperative morphine patient-controlled analgesia (PCA). The control group of 17 patients had only morphine PCA. We recorded the total morphine consumption, postoperative pain, and time to extubation.

Results

The total amount of morphine consumption over 24 hours was 45.9 ± 33.9 mg in the TAP group and 71.8 ± 39.9 mg in the control group (P < .005). Median pain scores were 1 in the TAP group and 2 in the control group (not significant [NS]). Median time to extubation was 60 minutes in the TAP group and 97 minutes in the control group (P = NS).

Conclusion

Initial evaluation of subcostal TAP block after OLT showed significant reduction in postoperative morphine consumption.     

A randomized controlled trial comparing intrathecal morphine with transversus abdominis plane block for post-cesarean delivery analgesia

BackgroundIntrathecal morphine is an effective analgesic post-cesarean delivery; however, it may be contraindicated or unsuitable in some patients. We compared the efficacy and side effects of intrathecal morphine with an ultrasound-guided transversus abdominis plane (TAP) block in a randomized, controlled, double-blinded trial. The primary outcome was the morphine equivalents dose used in the first 24 h post-surgery. Secondary outcomes were pain scores and side effects, including pruritus, sedation, nausea and vomiting.MethodsPlanned recruitment was for 90 women; however, the study was terminated early. Sixty-nine women undergoing elective cesarean delivery under spinal anesthesia were enrolled. They were randomized to receive either intrathecal morphine 100 μg plus a sham TAP block or a TAP block with 0.5% ropivacaine 1.5 mg/kg, to each side to a maximum of 20 mL. Women were assessed at 2, 6, 10, 24 h and 3 months post-spinal.ResultsSixty-six women completed the trial. The morphine equivalents dose used in the TAP block group was greater at 24 h compared with the intrathecal morphine group (7.5 mg (95% CI 4.8–10.2) vs. 2.7 mg (95% CI 1.0–4.3), F [1, 64] = 9.62, P = 0.003). There was no difference at 2, 6, or 10 h. Pain scores on rest and movement were higher in the TAP block group at all times although this only reached statistical significance at 10 h (P = 0.001). Nausea and vomiting (P = 0.02) and pruritus (P = 0.007) were lower in the TAP block group.ConclusionsIn this trial, the TAP block was associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine but fewer opioid-related side effects. The TAP block may be a reasonable alternative when intrathecal morphine is contraindicated or not appropriate.     

腹横肌平面阻滞在腹部手术术后镇痛中的应用

背景 腹横肌平面（transversus abdominis plane block,TAP）阻滞技术是一项近几十年发展起来的新型的局部神经阻滞技术,它可以减少术后镇痛阿片类药物的用量,继而减少其相关副作用,提高患者总的满意度. 目的 介绍TAP阻滞技术,探讨其在腹部手术术后镇痛中的应用. 内容 就TAP阻滞的解剖基础、操作方法、临床效果、并发症及尚待解决的问题等方面进行综述,为临床研究及应用提供参考. 趋向 TAP阻滞技术,被证实在很多手术的术后镇痛应用中是安全、有效的,有着广阔的应用前景.     

Improved analgesia with the ilioinguinal block compared to the transversus abdominis plane block after pediatric inguinal surgery: a prospective randomized trial

Background: Ultrasound‐guided transversus abdominis plane (TAP) block has shown promise for analgesia after pediatric inguinal surgery. This prospective, randomized study tested the hypothesis that the TAP block would provide comparable analgesia after pediatric inguinal surgery compared with a conventional ultrasound‐guided ilioinguinal block. Methods: After induction of general anesthesia , infants and children presenting for elective inguinal surgery were randomly assigned to receive an ultrasound‐guided TAP block (needle cephalad of the iliac crest at the anterior axillary line) (n = 20) or ilioinguinal block (needle immediately anteromedial to the anterior superior iliac spine) (n = 21). Supplemental analgesia consisted of as‐required intraoperative fentanyl, regular acetaminophen, as‐required ibuprofen, and rescue morphine. Patients were assessed in the recovery room, the day‐stay unit (30 min to 2 h after surgery) and at 24 h for age appropriate numerical pain score, analgesic consumption, and parental satisfaction. Results: In the day‐stay unit, pain was more frequent (76% vs 45%, P = 0.040), and ibuprofen use was higher (62% vs 30%, P = 0.037) in the TAP group. Recovery room pain, morphine consumption and postdischarge ibuprofen use, comfort and satisfaction scores were similar between groups. Ultrasound image quality was poorer, and needle time under the skin was longer (median [interquartile range] 81 [66–120] vs 46 [40–51], P < 0.001) for the ilioinguinal group. Conclusions: Following pediatric inguinal surgery, ilioinguinal block provides more effective analgesia than the TAP block.     

腹横肌平面阻滞用于剖宫产术后镇痛的效果评价:Meta分析

目的 采用Meta分析的方法评价腹横肌平面阻滞(transversus abdominis plane block,TAPB)在剖宫产术后镇痛的安全性及有效性. 方法 检索PubMed 、OVID、EMBASE、Cochrane图书馆,检索时间从建库至2015年3月.收集剖宫产术后镇痛使用TAPB的随机对照临床试验.采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan5.2软件进行Meta分析. 结果 共纳入12项研究,包括663例患者,其中TAPB组342例,对照组321例.与对照组比较,TAPB组患者术后12h活动时VAS评分明显降低[加权均数差(weighted mean difference,WMD)=-0.61,95％置信区间(confidence interval,CI):-1.13～-0.09,P＜0.05]、术后24 h吗啡累积消耗量减少(WMD=-22.78,95％CI:-24.49～-21.07,P＜0.05)以及TAPB组患者需首次给予补救镇痛的时间延长(WMD=148.22,95％CI:86.57～209.86,P＜0.05),并且TAPB组患者恶心呕吐[比值比(OR)=0.23,95％CI:0.12～0.44,P＜0.05]及过度镇静(OR=0.29,95％CI:0.12～0.67,P＜0.05)的发生率较低. 结论 TAPB可能是剖宫产患者术后镇痛的一种较好的选择.     

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study

Purpose

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors.

Methods

Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade.

Results

Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24–48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02).

Conclusions

In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

     

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: A randomized,placebo-controlled trial

Study objectiveThe aim of this study was to evaluate the effect of ultrasound-guided erector spinae plane (ESP) block on postoperative pain in radical prostatectomy, which leads to both visceral and somatic pain.DesignProspective, randomized, placebo controlled, double-blinded.SettingUniversity hospital.PatientsA total of ASA I-III, 50 patients aged 18–65 who were scheduled for elective open radical prostatectomy surgery.InterventionsPatients were randomly allocated to receive an ultrasound-guided ESP block, with either local anesthetic (10 mL of 1% lidocaine +10 mL of 0.5% bupivacaine) or placebo bilaterally.MeasurementsThe primary outcome was morphine consumption in the first 24 h after surgery. The secondary outcomes were NRS pain scores at rest and coughing, intraoperative remifentanil consumption and need for rescue analgesic during the first 24 h after surgery.Main resultsBoth NRS scores for post-anesthesia care unit and NRS_rest scores for 1st hours were lower in Group ESPB (p < 0.001 and p = 0.033, respectively). Cumulative morphine consumption at 24 h post-surgery was similar between the groups (p = 0.447). Rescue analgesic requirement was higher in the placebo injection group than in the ESPB group at the 1st postoperative hour (p = 0.002).ConclusionsIn open radical prostatectomies, except for the first hour, ESP block is ineffective for pain scores and on morphine consumption compared to the placebo injection group in the postoperative period.     

超声引导下腹横肌平面阻滞与髂腹股沟及髂腹下神经阻滞在小儿腹股沟区手术应用的比较

目的 比较超声引导下腹横肌平面阻滞(transversus abdominis plane block,TAPB)与髂腹股沟及髂腹下神经阻滞(ilioinguinal/iliohypogastric nerve block,IINB)在小儿腹股沟区手术术中及术后早期的应用效果. 方法 选择择期进行单侧腹股沟区手术的患儿80例,年龄2～4岁,ASA分级Ⅰ级.按随机数余数法分为TAPB组和IINB组,每组40例.两组患儿均于全身麻醉下行超声引导下TAPB或超声引导下IINB.分别观察与记录患儿的入室基础情绪,入室(T1)、切皮(T2)、缝皮(T3)时的HR、BP,手术时间、苏醒时间、PACU留观时间,改良加拿大东安大略儿童医院疼痛评分量表(modified children's hospital of eastern ontario pain scale,m-CHEOPS)评分、儿童麻醉后躁动评分(pediatric anesthesia emergence delirium,PAED)、PACU给药人数、术后恶心呕吐人数及患儿家长满意度. 结果 超声引导下TAPB组与IINB组在一般情况、基础情绪、局部麻醉药用量及入室的HR、BP方面差异无统计学意义(P＞0.05).IINB组患儿在PACU首次、10、20、30 min的m-CHEOPS评分都低于TAPB组,差异有统计学意义(P＜0.05),并且PACU给药人数IINB组也低于TAPB组[IINB组6人(15％),TAPB组15人(39％)],差异有统计学意义(P＜0.05);两组躁动发生率比较,差异没有统计学意义(P＞0.05),但IINB组的PAED评分明显低于TAPB组{IINB组PAED评分[中位数(四份位数间距)]3(0～14),TAPB组PAED评分6(0～16)},差异有统计学意义(P＜0.05);IINB组在术后恶心呕吐的发生率及家长满意度均低于TAPB组,但差异无统计学意义(P＞0.05). 结论 超声引导下,相比于TAPB,IINB能为腹股沟区术后的小儿提供更为安全、高效的镇痛,是小儿腹股沟区手术术后镇痛的较佳选择.     

Evaluation of ultrasound-guided transversalis fascia plane block for postoperative analgesia in cesarean section: A prospective,randomized, controlled clinical trial

Study objectiveCesarean Delivery (CD) is a commonly performed obstetric procedure. Adding a regional anesthesia technique to multimodal analgesia in CD, may improve the quality of postoperative analgesia. In this study we evaluated the efficacy of Transversalis Fascia Plane Block (TFPB) for postoperative analgesia management in CD.DesignBlinded, prospective, randomized study.SettingPostoperative recovery room & ward, tertiary university hospital, Istanbul, Turkey,PatientsSeventy-five patients (ASA II-III) scheduled to undergo Cesarean delivery were recruited. Following exclusion, 70 patients were randomized into two equal groups (block and control group).InterventionsStandard multimodal analgesia (routine paracetamol and tramadol PCA in addition to diclophenac sodium as rescue analgesia) was performed in Group C while TFPB block was also performed in the intervention (TFPB) group.MeasurementsThe primary outcome was tramadol consumption within the first 24 h. The secondary outcome was Numeric Rating Scale (NRS) scores during rest and movement/coughing.Main resultsTramadol consumption in the first 24 h was 175 ± 72.32 mg in the control and 101.42 ± 51.45 mg in the TFPB group (p < 0.05). NRS was lower in Group TFPB during the first 3 h and at the 12th hour. There was no difference in NRS scores at other hours.ConclusionBilateral ultrasound guided TFPB leads to effective analgesia and a decrease in analgesia requirement in first 24 h in patients undergoing CD.     

Posteromedial quadratus lumborum block versus transversus abdominal plane block for postoperative analgesia following laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveOur hypothesis was that a pre-operative posteromedial quadratus lumborum (QL) block would reduce postoperative morphine consumption and provide superior analgesia in the setting of multimodal analgesia compared with a lateral transversus abdominis plane (TAP) block for laparoscopic colorectal surgery.DesignA randomized controlled study.SettingA single tertiary hospital. March to August 2018.Patients80 ASA I–II colorectal cancer patients undergoing laparoscopic radical resection were enrolled. 77 patients (group QL 38, group TAP 39) were included in the analysis.InterventionPre-operatively, patients were randomized to receive either a QL or TAP block (0.375% ropivacaine 20 ml bilaterally for each group).MeasurementsThe primary outcome was cumulative morphine consumption 24 h postoperatively. Secondary outcomes included postoperative pain scores, clinical recovery, and side-effect profiles of the blocks.Main resultsFor the primary outcome measure, morphine consumption 24 h postoperatively was significantly lower in the QL group than in the TAP group (estimated median difference −8 mg, adjusted 95% confidential interval −12 to −6 mg, P < 0.001). The pain visual analogue scores at rest and during movement were found to be statistically significantly lower in the QL group than in the TAP group 8, 12, and 24 h postoperatively (P < 0.006). The QL group reported higher overall satisfaction scores regarding postoperative analgesia than the TAP group (P = 0.014). One patient in the QL group experienced moderate back pain close to the needle entry site postoperatively. There was no statistically significant difference in postoperative nausea and vomiting, bowel recovery or length of hospital stay between the groups.ConclusionsThe pre-operative bilateral, ultrasound-guided posteromedial QL block reduces morphine consumption and improves analgesia in the setting of multimodal analgesia compared with the lateral TAP block after laparoscopic colorectal surgery.     

腰方肌阻滞与腹横肌平面阻滞用于成人腹部手术术后镇痛效果的Meta分析

目的评价超声引导下腰方肌阻滞(QLB)与腹横肌平面阻滞(TAPB)在成人腹部手术术后镇痛的效果。方法检索Cochrane、Pubmed、Embase、中国知网、万方和维普数据库,纳入腰方肌阻滞(QLB组)与腹横肌平面阻滞(TAP组)在成人腹部手术后镇痛比较的随机对照试验(RCT)。主要结局指标为术后VAS疼痛评分,次要结局指标包括术后24 h内补救性镇痛率及术后不良反应发生率。采用RevMan 5.3进行Meta分析。结果最终纳入19项RCTs,共1412例患者。与TAP组比较,QLB组术后8 h静息(MD=-0.29, 95%CI-0.52～-0.06,P0.05)及运动状态(MD=-0.47, 95%CI-0.80～-0.14,P0.05)和12h静息(MD=-0.30,95%CI-0.48～-0.13,P0.05)及运动状态(MD=-0.68, 95%CI-1.03～-0.33,P0.05)时VAS评分均明显降低。QLB组术后24 h内补救性镇痛率明显低于TAP组(RR=0.27, 95%CI 0.17～0.42,P0.05),同时恶心呕吐、眩晕的发生率明显低于TAP组(RR=0.37, 95%CI 0.24～0.56,P0.05; RR=0.29, 95%CI 0.14～0.57,P0.05)。结论腰方肌阻滞用于成人腹部手术术后镇痛效果优于腹横肌平面阻滞,且不良反应更少。     

Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach

Background: We describe a new ultrasound‐guided bilateral dual transversus abdominis plane block. Our hypothesis was that we could anaesthetize both the upper (Th6–Th9) and the lower (Th10–Th12) abdominal wall bilaterally using a four‐point single‐shot technique to provide effective post‐operative analgesia. Methods: A prospective cohort of 25 recovery room patients was included. They had undergone major open or laparoscopic abdominal surgery under general anaesthesia and had severe post‐operative pain. The blocks were conducted using a high‐frequency linear transducer and a 22 G, 80‐mm‐long needle. The needle was inserted in‐plane from medial to lateral for each injection. Fifteen millilitres of bupivacaine 2.5 mg/ml was injected at each of the four sites. Results: Block performance took on average 16 min (range 10–20 min). The 25 patients reported a reduction of their maximum pain (visual analogue scale 0–10) from a mean of 8.2 to a mean of 2.2 10 min after block performance (P<0.001). They were discharged from the post‐anaesthesia care unit after an average of 34 min. Twenty‐one patients (84%) did not require any i.v. opioids in the following 6 h. Sixteen patients (64%) were mobilized within 6 h after the block. Data were similar irrespective of open or laparoscopic surgery (P=0.68). Conclusion: This new four‐point single‐shot technique was effective in decreasing severe pain after a major abdominal surgery. The block, although short‐lived, facilitated discharge from the post‐anaesthesia care unit, few patients required opioids on the day of surgery and mobilization was improved.     

超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果

目的 评价超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果.方法 择期在椎管内麻醉下行单侧腹股沟疝成形术病人40例,年龄18 ～ 79岁,BMI＜ 30 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将病人分为2组(n=20):生理盐水对照组(C组)和超声引导下腹横肌平面阻滞组(B组),B组术毕在超声引导下行腹横肌平面阻滞,注入0.375％罗哌卡因20 ml,C组给予等容量生理盐水.术后当视觉模拟评分(VAS评分)≥4分时静脉注射曲马多,分别于术后4、6、24、48 h时记录静态和动态VAS评分,分别于术后24、48 h时测定阻滞侧温觉阻滞平面,记录术后病人镇痛总体满意度评分和排气时间,记录腹横肌平面阻滞相关不良反应的发生情况.结果 C组有4例病人使用曲马多镇痛,B组无一例病人需补救镇痛;与C组比较,B组术后VAS评分降低,镇痛总体满意度评分升高(P＜ 0.05或0.01),排气时间差异无统计学意义(P＞0.05);B组术后24 h时阻滞侧温觉平面阻滞率为80％,术后48 h时阻滞侧无一例病人存在温觉阻滞平面;C组术后24、48 h时无一例病人存在温觉阻滞平面.B组未见腹横肌平面阻滞相关不良反应.结论 超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果较好,且安全性较高.