A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery

Background

Optimal analgesia following laparoscopic colorectal resection is yet to be determined; however, recent studies have questioned the role of postoperative epidural anaesthesia, suggesting other analgesic modalities may be preferable. The aim of this randomised controlled trial was to assess the effect of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resection.

Methods

After appropriate trial registration (www.clinicaltrials.gov NCT 00830089) and local medical ethics review board approval (REC 09/H0407/10), all adult patients who were to undergo laparoscopic colorectal surgery at a single centre were randomised into the intervention group receiving bilateral TAP blocks or the control group (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist otherwise uninvolved with the case. The patient, theatre anaesthetist, surgeon, and ward staff were blinded to treatment allocation. All patients received postoperative analgesia of paracetamol and morphine as a patient-controlled analgesia (PCA). Cumulative opioid consumption and pain scores were recorded at 2, 4, 6, and 24 h postoperatively and compared between the groups as were clinical outcomes and length of stay.

Results

The intervention (TAP block) group (n = 33) and the control group (n = 35) were comparable with respect to characteristics, specimen pathology, and type of procedure. The TAP block group’s median cumulative morphine usage (40 mg [IQR = 25–63]) was significantly less than that of the control group (60 mg [IQR = 39–81]). Pain scores and median length of stay (LOS) were similar between the two groups.

Conclusion

Preoperative TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use in the first postoperative day in this study.     

The analgesic efficacy of transversus abdominis plane (TAP) block

The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. It was described for the first time in 2007 by McDonnell et al. We applied the technique after the original methodology of the authors. We evaluated its analgesic efficacy first 24 postoperative hours of patients, undergoing to surgical and urological interventions. After induction of anesthesia, 20 ml of 0.375% levobupivacaine was deposited into the transversus abdominis neuro-fascial plane via the bilateral lumbar triangles of Petit. Each patient was evaluated by VAS in the postanesthesia care unit at the 2, 4, 6, 12 and 24 h postoperatively. Despite the results were more unsatisfactory than those of McDonnel, they were good. Our first impression is that the TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery.     

连续与单次腹横肌平面阻滞用于腹腔镜胆囊切除术后镇痛的效果比较

目的比较连续腹横肌平面阻滞(CTAPB)与单次腹横肌平面阻滞(STAPB)用于腹腔镜下胆囊切除术(LC)的术后镇痛效果。方法纳入拟行LC患者90例,分成对照组、S组和C组,每组30例,S组和C组患者气管插管后分别行STAPB和CTAPB,术毕三组患者均行患者自控静脉镇痛(PCIA),记录三组患者术后1,6,12,24,48,72 h切口部位及腹部深处疼痛视觉模拟(VAS)评分,术后72 h内PCIA镇痛泵按压次数,术后麻醉不良反应发生情况和术后镇痛的满意度。结果 S组和C组患者术后1、6和12 h切口部位和腹部深处VAS评分均显著低于对照组患者(P0.05),S组和对照组患者术后24、48和72 h切口部位和腹部深处VAS评分差异无统计学意义(P0.05),C组患者术后24、48和72 h切口部位和腹部深处VAS评分显著低于S组和对照组患者(P0.05)。术后72 h内S组和C组患者PCIA按压次数均显著少于对照组患者(P0.05),C组患者术后PCIA镇痛泵按压次数显著少于S组患者(P0.05)。S组和C组患者术后恶心发生率均低于对照组患者(P0.05)。术后S组和C组患者满意度均高于对照组患者(P0.05),C组患者满意度高于S组患者(P0.05)。结论超声引导下CTAPB可有效增强LC术后患者的镇痛效果,减少患者阿片类药物使用,降低阿片类药物不良反应发生率,提高患者术后满意度,可作为LC术后较为理想的镇痛方式。     

Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery

Subcostal transversus abdominis plane (TAP) catheters have been reported to be an effective method of providing analgesia after upper abdominal surgery. We compared their analgesic efficacy with that of epidural analgesia after major upper abdominal surgery in a randomised controlled trial. Adult patients undergoing elective open hepatobiliary or renal surgery were randomly allocated to receive subcostal TAP catheters (n=29) or epidural analgesia (n=33), in addition to a standard postoperative analgesic regimen comprising of regular paracetamol and tramadol as required. The TAP group patients received bilateral subcostal TAP catheters and 1 mg.kg(-1) bupivacaine 0.375% bilaterally every 8 h. The epidural group patients received an infusion of bupivacaine 0.125% with fentanyl 2 μg.ml(-1) . The primary outcome measure was visual analogue pain scores during coughing at 8, 24, 48 and 72 h after surgery. We found no significant differences in median (IQR [range]) visual analogue scores during coughing at 8 h between the TAP group (4.0 (2.3-6.0 [0-7.5])) and epidural group (4.0 (2.5-5.3) [0-8.5])) and at 72 h (2.0 (0.8-4.0 [0-5]) and 2.5 (1.0-5.0 [0-6]), respectively). Tramadol consumption was significantly greater in the TAP group (p=0.002). Subcostal TAP catheter boluses may be an effective alternative to epidural infusions for providing postoperative analgesia after upper abdominal surgery.     

A randomised controlled trial of ultrasound‐guided transversus abdominis plane block for renal transplantation

We conducted this study to evaluate the efficacy of a transversus abdominis plane block in reducing morphine requirements in the first 24 h after renal transplant surgery. We performed transversus abdominis plane injections under ultrasound guidance in 54 patients with either 20 ml levobupivacaine 0.5% (n = 27) or 20 ml saline 0.9% (n = 27). All patients received regular paracetamol and patient‐controlled analgesia postoperatively. Three participants were not studied owing to protocol violations. In the remaining 51 patients, median (IQR [range]) morphine consumption in the first 24 h was similar in both the transversus abdominis plane group (19.4 (11.7?28.6 [0.5?49.8]) mg) and the control group (16.4 (12.0?31.0 [0.0?61.7]) mg), p = 0.94. We found that use of ultrasound‐guided transversus abdominis plane block for renal transplantation did not reduce 24‐h morphine requirements.     

Levobupivacaine – dextran mixture for transversus abdominis plane block and rectus sheath block in patients undergoing laparoscopic colectomy: a randomised controlled trial

We performed a randomised controlled double‐blinded study of patients having laparoscopic colectomy with bilateral transversus abdominis plane block plus rectus sheath block, comparing a control group receiving 80 ml levobupivacaine 0.2% in saline with a dextran group receiving 80 ml levobupivacaine 0.2% in 8% low‐molecular weight dextran. Twenty‐seven patients were studied in each group. The mean (SD) maximum plasma concentration of levobupivacaine in the control group (1410 (322) ng.ml^?1) was higher than the dextran group (1141 (287) ng.ml^?1; p = 0.004), and was reached more quickly (50.6 (30.2) min vs 73.2 (24.6) min; p = 0.006). The area under the plasma concentration–time curve from 0 min to 240 min in the control group (229,124 (87,254) ng.min.ml^?1) was larger than in the dextran group (172,484 (50,502) ng.min.ml^?1; p = 0.007). The median (IQR [range]) of the summated numerical pain rating score at rest during the first postoperative 24 h in the control group (16 (9–20 [3–31]) was higher than in the dextran group (8 (2–11 [0–18]); p = 0.0001). In this study, adding dextran to levobupivacaine decreased the risk of levobupivacaine toxicity while providing better analgesia.     

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。     

A triple‐blind,placebo‐controlled randomised trial of the ilioinguinal‐transversus abdominis plane (I‐TAP) nerve block for elective caesarean section

This study investigated the efficacy of a new ilioinguinal‐transversus abdominis plane block when used as a component of multimodal analgesia. We conducted a prospective, triple‐blind, placebo‐controlled randomised study of 100 women undergoing elective caesarean section. All women had spinal anaesthesia with hyperbaric bupivacaine, 15 μg fentanyl and 150 μg morphine, as well as 100 mg diclofenac and 1.5 g paracetamol rectally. Women were randomly allocated to receive the ilioinguinal‐transversus abdominis plane block or a sham block at the end of surgery. The primary outcome was the difference in fentanyl patient‐controlled analgesia dose at 24 h. Secondary outcomes included postoperative pain scores, adverse effects and maternal satisfaction. The cumulative mean (95%CI) fentanyl dose at 24 h was 71.9 (55.6–92.7) μg in the ilioinguinal‐transversus abdominis group compared with 179.1 (138.5–231.4) μg in the control group (p < 0.001). Visual analogue scale pain scores averaged across time‐points were 1.9 (1.5–2.3) mm vs. 5.0 (4.3–5.9) mm (p = 0.006) at rest, and 4.7 (4.1–5.5) mm vs. 11.3 (9.9–13.0) mm (p = 0.001) on movement, respectively. Post‐hoc analysis showed that the ilioinguinal‐transversus abdominis group was less likely to use ≥ 1000 μg fentanyl compared with the control group (2% vs. 16%; p = 0.016). There were no differences in opioid‐related side‐effects or maternal satisfaction with analgesia. The addition of the ilioinguinal‐transversus abdominis plane block provides superior analgesia to our usual multimodal analgesic regimen.     

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.

     

腹横肌平面阻滞联合氢吗啡酮对腹腔镜结直肠癌手术患者应激反应及术后镇痛的影响

目的 探讨腹横肌平面阻滞(TAPB)联合氢吗啡酮静脉用药对腹腔镜结直肠癌根治术患者应激反应及术后镇痛的影响。方法 选择择期全身麻醉下行腹腔镜结直肠癌根治术的患者119例,男43例,女76例,年龄40～64岁,BMI<28 kg/m²,ASAⅡ或Ⅲ级。采用随机数字表法将患者分为四组：TAPB组(T组,n=29)、氢吗啡酮静脉用药组(H组,n=31)、TAPB联合氢吗啡酮静脉用药组(TH组,n=30)和对照组(C组,n=29)。记录诱导前10 min和拔管后5 min的血浆肾上腺素(E)和去甲肾上腺素(NE)浓度。记录术中丙泊酚、瑞芬太尼、阿托品、去氧肾上腺素、艾司洛尔、乌拉地尔的使用情况。记录拔管后5 min、1、6、12 h的VAS疼痛评分和Ricker镇静-躁动评分(SAS)。记录术后24 h内镇痛泵有效按压次数、舒芬太尼用量、补救镇痛例数。记录拔管后24 h内恶心呕吐、低血压、呼吸抑制、皮肤瘙痒等不良反应的发生情况。结果 与诱导前10 min比较,拔管后5 min四组血浆E和NE浓度明显升高(P<0.05)。与C组比较,拔管后5 min, T组、H...