The efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing hysterectomy

The study objective of this prospective, double-blind randomised controlled study was to evaluate the efficacy of ultrasound guided transversus abdominis plane (TAP) block and bupivacaine infiltration of the skin and subcutaneous tissue of the wound in patients undergoing hysterectomy. Patients were randomly allocated to three groups: a control group (n = 18) and TAP block group (n = 18) received bilateral TAP blocks with saline and bupivacaine respectively, and an infiltration group (n = 19) received skin and subcutaneous wound tissue infiltration with bupivacaine at the end of surgery. After surgery patients received patient-controlled intravenous tramadol and were assessed for pain and tramadol consumption at 1, 2, 4, 6 and 24 hours. Both the TAP and infiltration groups had lower movement and rest pain scores than the control group, with lower scores in the TAP group than the infiltration group at 6 and 24 hours. Total tramadol consumption was significantly lower in the TAP group than in the other groups at all time points. We concluded that ultrasound-guided TAP block reduced rest and movement pain after total abdominal hysterectomy and was more effective than superficial wound infiltration for postoperative pain management.     

Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study

Ultrasound-guided transversus abdominis plane (TAP) block can be performed using a subcostal technique. This technique was simulated using dye injection in cadavers in order to determine segmental nerve involvement and spread of injectate using either single or multiple-injection techniques. Dye most commonly spread to affect T9 and T10 nerves with the single injection technique and T9, T10 and T11 with multiple injections. The median (IQR [range]) spread of dye was 60 (36–63 [32–78]) cm² using the single-injection technique and 90 (85–96 [72–136]) cm², in the multiple-injection technique, and this difference was statistically significant (p = 0.003). These results indicate that ultrasound-guided subcostal TAP block will involve nerve roots T9, T10 and T11 and that a multiple-injection technique may block more segmental nerves and increase spread of injectate.     

Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study

Background: The transversus abdominis plane (TAP) block is a new regionalanaesthesia technique that provides analgesia after abdominalsurgery. It involves injection of local anaesthetic into theplane between the transversus abdominis and the internal obliquemuscles. The TAP block can be performed using a landmark techniquethrough the lumbar triangle or with ultrasound guidance. Thegoal of this anatomical study with dye injection into the TAPand subsequent cadaver dissections was to establish the likelyspread of local anaesthesia in vivo and the segmental nerveinvolvement resulting from ultrasound-guided TAP block. Methods: An ultrasound-guided injection of aniline dye into the TAP wasperformed for each hemi-abdominal wall of 10 unembalmed humancadavers and this was followed by dissection to determine theextent of dye spread and nerve involvement in the dye injection. Results: After excluding one pilot specimen and one with advanced tissuedecomposition, 16 hemi-abdominal walls were successfully injectedand dissected. The lower thoracic nerves (T10–T12) andfirst lumbar nerve (L1) were found emerging from posterior toanterior between the costal margin and the iliac crest. Segmentalnerves T10, T11, T12, and L1 were involved in the dye in 50%,100%, 100%, and 93% of cases, respectively. Conclusions: This anatomical study shows that an ultrasound-guided TAP injectioncephalad to the iliac crest is likely to involve the T10–L1nerve roots, and implies that the technique may be limited touse in lower abdominal surgery.     

Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia

BackgroundTransversus abdominis plane block is an effective method of post-cesarean analgesia. There are no data available about plasma bupivacaine levels after this block in adults. This study aimed to assess bupivacaine pharmacokinetic parameters after ultrasound-guided transversus abdominis plane blocks following cesarean delivery under spinal anesthesia.MethodsA prospective observational study in parturients undergoing elective cesarean delivery under hyperbaric bupivacaine spinal anesthesia was conducted. After surgery, patients received bilateral transversus abdominis plane block (50 mg bupivacaine each side). Venous blood samples were collected immediately before performing the block and at 10, 20, 30, 45, 60, 90, 120, 180, 240, 720 and 1440 minutes. High performance liquid chromatography was used to measure total plasma bupivacaine concentrations. Mean bupivacaine area under the curve (AUC) was calculated from 0 to 24 hours.ResultsData were collected from 17 parturients. Mean age and body mass index were 31 ± 6 y and 30 ± 4 kg/m² respectively. Mean plasma bupivacaine concentration before the block was 171 ng/mL. Mean peak concentration was 802.36 ng/mL (range 231.8 to 3504.5 ng/mL). Mean time to peak concentration was 30 min and mean area-under-the-curve (0–24 h) was 4505.4 h.ng/mL. Mean elimination half-life was 8.75 h. Three subjects had concentrations above the quoted toxic threshold and mild symptoms suggestive of neurotoxicity were reported by two subjects, but no treatment was required.ConclusionSingle-dose bilateral transversus abdominis plane block using 100 mg of bupivacaine, after spinal anesthesia for cesarean delivery, can result in toxic plasma bupivacaine concentrations.     

超声引导下腹横肌平面阻滞用于剖宫产患者超前镇痛的效果

目的 评价超声引导下腹横肌平面(transversus abdominis plane,TAP)阻滞用于剖宫产患者超前镇痛的效果.方法 采用前瞻性、随机对照研究设计.择期行剖宫产患者90例,年龄20～39岁,体重50～80 kg,ASA分级Ⅰ、Ⅱ级,采用随机数字表法分为3组(每组30例):对照组(Ⅰ组)、术前TAP阻滞组(Ⅱ组)、术后TAP阻滞组(Ⅲ组).Ⅰ组不实施TAP阻滞,Ⅱ组和Ⅲ组分别于麻醉诱导前即刻和手术结束时即刻在超声引导下行双侧TAP阻滞.记录术后2、4、12、24 h和48 h时点3组产妇静息状态下的VAS评分,术后24 h内舒芬太尼累积消耗量、镇痛补救率、镇痛泵按压次数,术后24 h内副作用发生情况.结果 Ⅱ组患者术后2、4h和12 h VAS评分[(2.3±0.4)、(2.4±0.4)、(2.2±0.4)分]与Ⅲ组[(3.2±0.8)、(34±0.3)、(3.1±0.5)分]比较,明显降低(P＜0.05);Ⅱ组患者术后24 h内舒芬太尼累积消耗量、镇痛补救率及镇痛泵按压次数[(40±5)μg、10％、(5.8±1.4)次]与Ⅲ组[(53±7)μg、20％、(10.3±2.6)次]比较,明显降低(P＜0.05);Ⅱ组患者术后24h内恶心呕吐发生率与Ⅲ组比较,明显降低(P＜0.05). 结论 术前超声引导下TAP阻滞对剖宫产患者具有良好的超前镇痛效应,且安全性较高.     

Audit of initial use of the ultrasound-guided transversus abdominis plane block in children

The extent of dermatomal block post transversus abdominis plane block is described in adults as T7-L1; other authors argue extent above T10 is infrequent (supra-iliac 20 ml injection). A paediatric guideline recommends this block for upper and lower abdominal surgery using 0.2 ml/kg. We aimed (through prospective audit) to document the multi-level block achieved with ultrasound-guided transversus abdominis plane block in children having abdominal surgery, during a departmental training period. Data included patient, anaesthetic and surgical details, transversus abdominis plane block characteristics (anterior supra-iliac injections) and dermatomal blockade to ice. Twenty-seven children received 38 blocks performed by 58% consultant and 42% trainee operators (90% novices): 16 unilateral/11 bilateral for umbilical (1), inguinal (13), laparoscopic (8) and laparotomy (5) surgery. Dermatomal assessment for 35 blocks (mean local anaesthetic volume 0.4 ml/kg [SD 0.2]) revealed the median blockade achieved was 3 dermatomes (interquartile range 3 to 4) involving T10 to L1 in 75% of patients. Eight blocks (six patients) also involved T8 and T9, following 0.31 to 0.81 ml/kg. One patient (3% of assessed blocks) had no block to ice at 60 minutes, but required no postoperative analgesia. Ultrasound-guided transversus abdominis plane blocks performed by supra-iliac approach and novice operators produced lower abdominal sensory blockade in children of usually 3 to 4 dermatomes, and should be offered for lower abdominal surgery only, as only 25% had upper abdominal block extension. The optimal local anaesthetic dose/volume, duration of effect and utility for these blocks in relation to peripheral and neuraxial blockade needs clarification.     

超声引导下腹横筋膜平面阻滞与腹横肌平面阻滞在剖宫产术后镇痛中的效果比较

目的 比较超声引导下腹横筋膜平面(TFP)阻滞与腹横肌平面(TAP)阻滞在剖宫产术后镇痛中的效果。
方法 择期蛛网膜下腔阻滞下行剖宫产术产妇60例,年龄20～35岁,体重50～75 kg,ASA Ⅰ或Ⅱ级,采用随机数字表法分为两组：腹横筋膜平面阻滞组（TFP组）和腹横肌平面阻滞组（TAP组）,每组29例。术毕TFP组行超声引导下双侧腹横筋膜平面阻滞,TAP组行超声引导下双侧腹横肌平面阻滞,两组均每侧注射0.375%罗哌卡因1.25 mg/kg。术后均行曲马多PCIA,若VAS疼痛评分≥4分,肌肉注射曲马多100 mg行补救镇痛。记录术后6、12、24、36、48 h PCIA中曲马多累积用量;记录术后48 h内曲马多补救镇痛情况;记录镇痛期间恶心呕吐、局麻药中毒、呼吸抑制、穿刺部位血肿、穿刺部位感染、腹膜刺穿造成腹腔内注射等不良反应的发生情况。
结果 与TAP组比较,TFP组术后6、12、24、36、48 h PCIA中曲马多累积用量明显减少 （P＜0.05）,术后48 h内曲马多补救镇痛率明显降低 （P＜0.05）。两组镇痛期间恶心呕吐发生率差异统计学意义。两组均无其他不良反应发生。
结论 与超声引导下腹横肌平面阻滞比较,腹横筋膜平面阻滞可减少剖宫产术后阿片类药物用量,镇痛效果更佳。     

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.     

Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block for open retropubic prostatectomy

Purpose

Ropivacaine-induced vasoconstriction may affect the early absorption speed of ropivacaine; however, the effects of dose on pharmacokinetics following transversus abdominis plane (TAP) block have not been studied. In this study, we have examined plasma ropivacaine concentrations following TAP block with various ropivacaine concentrations (0.25, 0.5, and 0.75 %).

Methods

With the approval of our University ethics committee and informed consent, 39 adult patients undergoing open retropubic prostatectomy were enrolled. Patients were randomly assigned to three groups (n = 13 each) receiving TAP block with 20 ml (10 ml each side) of different concentrations of ropivacaine. To determine plasma concentrations, blood samples were drawn before and 15, 30, 45, 60, 90, 120, and 180 min after completion of bilateral TAP blocks. Plasma ropivacaine concentrations were analyzed by gas chromatography with mass spectrometry.

Results

We found that the peak plasma concentrations (C _max) increased dose dependently (0.41 ± 0.14, 0.89 ± 0.55, and 1.56 ± 0.50 µg/ml), but the times to C _max (23.0 ± 15.8, 23.1 ± 14.5, and 20.8 ± 11.5 min) were not different between 0.25, 0.5, and 0.75 % ropivacaine doses, respectively. Terminal elimination half-life (t _1/2), total body clearance (CL), and distribution volume (V _d) were also not different among the three groups.

Conclusion

Ropivacaine concentration did not alter pharmacokinetic profile following TAP blocks.     

Bilateral ultrasound-guided transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block for cesarean delivery anesthesia

The ultrasound-guided transversus abdominis plane block and ilioinguinal-iliohypogastric nerve block have been shown to provide pain relief after abdominal surgery. A combination of the 2 blocks may provide acceptable surgical anesthesia for cesarean delivery. We describe 4 women who had contraindications to neuraxial anesthesia, who underwent cesarean delivery with ultrasound-guided bilateral transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block using 40 mL 0.5% ropivacaine. Breakthrough pain during the delivery of the fetus was treated with small doses of IV ketamine and propofol. We suggest that this technique may be an alternative to local anesthesia for cesarean delivery in clinical practice.     

超声引导下腹横肌平面阻滞用于老年患者腹股沟疝修补术的临床研究

目的 探讨超声引导下腹横肌平面(transversus abdominis plane,TAP)阻滞用于老年患者腹股沟疝修补术的安全性和有效性. 方法 选择择期行腹股沟疝修补术65岁以上老年患者60例,ASA分级Ⅰ～Ⅲ级,采用随机数字表法分为TAP阻滞组(A组)和局部浸润麻醉组(B组),每组30例.记录麻醉前(T0)、手术开始(T1)、手术开始后15 min(T2)、手术开始后30 min(T3)及手术结束(T4)时的MAP和HR;记录术后4、8、12、24h的VAS评分,追加镇痛药的例数;记录麻醉相关并发症;于术后48 h行患者麻醉满意度评价. 结果 A组术后4、8、12 h VAS评分[2(1～2)、2(1～2)、1(0～1)]均低于同时点B组[3(2～3)、3(2～3)、1(0～1)],差异有统计学意义(P＜0.05).术后镇痛药追加例数A组为0例,B组为20例(66.7％),差异有统计学意义(P＜0.05).A组总体满意度(93％)明显高于B组(73％),差异有统计学意义(P＜0.05). 结论 超声引导下TAP阻滞用于老年患者腹股沟疝修补术效果确切,对血流动力学影响小,可减少术后镇痛药用量,且患者的总体满意度高.     

超声引导下腹横肌平面阻滞用于下腹部手术术后镇痛的效果

目的观察超声引导下腹横肌平面(TAP)阻滞用于下腹部手术术后镇痛的临床效果。方法选择下腹部手术患者90例,年龄25~55岁,随机分为三组,每组30例。A组行超声引导下单侧TAP阻滞;B组行舒芬太尼PCIA;C组行舒芬太尼+罗哌卡因PCEA。所有患者均在腰-硬联合麻醉下完成手术。观察并记录术后2、4、8、16、24h的VAS疼痛评分,及术后镇痛相关的不良反应。结果与A组比较,B组在术后2、4、8、16h的VAS疼痛评分明显升高(P0.05);C组在术后24h的VAS疼痛评分明显降低(P0.05)。与A组比较,B组恶心呕吐、皮肤瘙痒、嗜睡明显增多(P0.05);C组恶心呕吐、下肢感觉及运动异常、尿潴留明显增多(P0.05)。结论超声引导下腹横肌平面阻滞可有效缓解下腹部手术后24h内的疼痛,且无明显不良反应。     

Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double-blind randomized controlled trial

Background

Although laparoscopic colorectal surgery decreases postoperative pain and facilitates a speedier recovery compared with laparotomy, postoperative pain at trocar insertion sites remains a clinical concern. The objective of this study was to assess the effects of a preoperative ultrasound-guided transversus abdominis plane (TAP) block on pain after laparoscopic surgery for colorectal cancer.

Methods

In total, 58 patients scheduled to undergo laparoscopic surgery following a diagnosis of colorectal cancer were included in this study. The patients were randomized into TAP and control groups; the TAP group patients received a preoperative ultrasound-guided bilateral TAP block with 0.5 mL/kg of 0.25 % bupivacaine, while the control patients received the block with an equal amount of saline. Pain on coughing and at rest was assessed during postanesthetic recovery (PAR; 1 h after surgery) and on postoperative days (PODs) 1 (24 h), 2 (48 h), and 3 (72 h) by an investigator blinded to group allocations using the numeric rating scale (NRS). The primary outcome was pain on coughing on postoperative day (POD) 1.

Results

Fifty-five patients were included in the final analysis, including 28 in the TAP and 27 in the control groups. The pain intensity on coughing and at rest during PAR and on PODs 1, 2, and 3 showed no significant differences between groups. Furthermore, there was no significant difference in postoperative opioid consumption, sedation scores, nausea scores at the four time points, complication rates, and length of hospital stay between groups.

Conclusions

In colorectal cancer patients undergoing laparoscopic colorectal surgery, a TAP block did not offer enough benefit for clinical efficacy in terms of postoperative pain or analgesic consumption.

     

超声引导下腹横肌平面阻滞技术对腹部手术后镇痛的效果

目的观察超声引导下腹横肌平面阻滞技术对腹部手术后镇痛的效果。方法选择64例开腹手术患者,按照随机数字表法分为观察组和对照组,各32例。观察组采用腹横肌平面阻滞(TAPB)+自控静脉镇痛(PCIA)镇痛,对照组行单纯PCIA镇痛。记录2组患者术后清醒拔管即刻(T_0)、2 h(T_1)、6 h(T_2)、12 h(T_3)、24 h(T_4)各时间点的Prince-Henry评分及Ramsay镇静评分。记录穿刺相关并发症及术后各时段镇痛装置按压次数。记录患者满意度及不良反应。结果观察组T_0、T_1、T_2时点Prince-Henry评分明显小于对照组(P0.05)。2组患者不同时间点的Ramsay镇静评分差异均无统计学意义(P0.05)。观察组未发生穿刺相关并发症,术后6 h内镇痛泵按压次数明显少于对照组(P0.05),呕吐发生率明显低于对照组(P0.05),镇痛满意度高于对照组(P0.05),差异均有统计学意义。结论超声引导下腹横肌平面阻滞技术可降低腹部手术后6 h内Prince-Henry评分,减少术后镇痛药物的用量及并发症,术后镇痛满意度高。     

吗啡联合布比卡因腹横肌平面阻滞在腹式全子宫切除术术后镇痛中的应用和讨论

目的探讨吗啡联合布比卡因腹横肌平面阻滞(TAPB)在腹式全子宫切除术术后镇痛中的应用效果。方法本研究采用前瞻性方法,选取拟行腹式全子宫切除术患者94例,分成对照组和观察组,每组47例。患者全身麻醉后手术开始前15分钟左右行TAPB,对照组患者TAPB麻醉药物为0.5%盐酸布比卡因20 mL+生理盐水20 mL,共40 mL,观察组患者TAPB麻醉药物为0.5%盐酸布比卡因20 mL+吗啡10 mg+生理盐水20 mL,共40 mL。双侧TAPB分别注入20 mL麻醉药物混合液。结果观察组患者术后2、4、8、12、18和24 h静息疼痛评分和活动疼痛评分均显著低于对照组患者(P0.05)。观察组患者术后24 h内需要使用吗啡静脉患者自控镇痛(IV-PCA)的人数和吗啡IV-PCA总使用量均显著低于对照组患者(P0.05)。观察组患者术后首次使用吗啡IV-PCA时间显著高于对照组患者(P0.05)。观察组术后恶心和呕吐的发生率显著低于对照组患者(P0.05)。结论吗啡联合布比卡因TAPB较单纯布比卡因TAPB可显著降低腹式全子宫切除术术后患者24 h内疼痛评分、阿片类药物用量及其不良反应发生率,延长术后首次需要镇痛时间。