Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 346-349

Efficacy of transversus abdominis plane block with ketamine for inguinal hernioplasty: A controlled study


1 Department of Anesthesia and Intensive Care, College of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Surgery, College of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission21-May-2014
Date of Acceptance25-Jun-2014
Date of Web Publication27-Aug-2014

Correspondence Address:
Doaa G Diab
Department of Anesthesia and Intensive Care, College of Medicine, Mansoura University, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.139564

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  Abstract 

Background
Addition of ketamine to bupivacaine would improve the duration of analgesia after transversus abdominis plane (TAP) block for inguinal hernioplasty.
Materials and Methods
After ethical approval, 28 patients scheduled for elective unilateral inguinal hernioplasty under sevoflurane-fentanyl-rocuronium anesthesia were randomly allocated to receive ipsilateral TAP block to the side of surgery with either bupivacaine 0.5% or bupivacaine 0.5% with 0.5 mg/kg ketamine (n = 14 for each). Postoperative 24 h cumulative morphine consumption, first request for morphine, pain scores at rest, sedation, nausea and vomiting scores, and complications were recorded.
Results
Patients who received TAP bupivacaine-ketamine had comparable postoperative 24 h cumulative morphine consumption, first request for morphine, pain and sedation scores, and postoperative nausea and vomiting. No patient reported postoperative complications related to ketamine.
Conclusion
The author is able to reject with confidence the hypothesis that the addition of ketamine to bupivacaine for TAP block has any major analgesic effect after inguinal hernioplasty.

Keywords: analgesia, inguinal hernioplasty, ketamine, transversus abdominis plane block


How to cite this article:
Diab DG, Roshdy H. Efficacy of transversus abdominis plane block with ketamine for inguinal hernioplasty: A controlled study. Ain-Shams J Anaesthesiol 2014;7:346-9

How to cite this URL:
Diab DG, Roshdy H. Efficacy of transversus abdominis plane block with ketamine for inguinal hernioplasty: A controlled study. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Dec 1];7:346-9. Available from: http://www.asja.eg.net/text.asp?2014/7/3/346/139564


  Introduction Top


Surgical incisions involving the abdominal wall could be a significant source of pain after surgery [1]. The transversus abdominis plane (TAP) block is described as peripheral block involving the nerves of the anterior abdominal wall to provide effective analgesia after lower abdominal surgery [2].

There are encouraging studies demonstrating clinically significant reductions of postoperative opioid requirements and pain, as well as some effects on opioid-related side effects such as postoperative sedation, nausea, and vomiting (PONV) [3]. Unfortunately, these benefits may be short-lived secondary to the short duration of local anesthetics action.

Although an older study suggested that addition of ketamine (N-methyl-d-aspartate receptors antagonist) 30 mg to ropivacaine in the brachial plexus block did not improve the onset or duration of sensory block [4], a case series demonstrated that perineural addition of ketamine 0.5 mg/kg to the sympathetic blocks in three patients who suffered from gunshot wounds and developed characteristic features of complex regional pain syndrome Type II resulted in marked relief in the allodynia [5]. Thus, human studies show effective analgesia after subcutaneous administration of ketamine [6]. This could be investigated to prolong the duration of analgesia after TAP block.

The investigator hypothesized that addition of ketamine to bupivacaine would improve the duration of analgesia after TAP block for lower abdominal surgery.

This study aimed to compare the duration and efficacy of analgesia and analgesic consumption after TAP block with bupivacaine and bupivacaine-ketamine after unilateral inguinal hernioplasty under general anesthesia.


  Materials and Methods Top


Following institutional ethical approval, 28 patients aged 18-65 years (American Society of Anesthiologists class of I-III) scheduled for elective unilateral inguinal hernioplasty under general anesthesia at Mansoura Main University Hospital were included in this controlled randomized prospective double-blind study after obtaining informed written consent.

Patients with history of cardiopulmonary, renal, hepatic, neuropsychiatric, and endocrinal diseases, seizures, hypertension, tachyarrhythmia, communication problems, drug dependence, or those receiving antipsychotic, anticonvulsants, opioids or other analgesics during the last 7 days were excluded from the study.

The studied patients were randomly assigned into two groups (n = 14 in each) using computer-generated randomization codes included in sealed closed opaque envelopes. In the control group, TAP block was performed using a mixture of 20 ml of bupivacaine 0.5% and 0.01 ml/kg of normal saline. In the ketamine group, TAP block was performed using 20 ml of bupivacaine 0.5% with 0.01 ml/kg of ketamine 5% (0.5 mg/kg).

All patients were familiarized with a 10 cm visual analog scale (VAS) (0 = no pain; 10 = worst imaginable) to assess the intensity of pain.

All operations were performed by the same surgeons. The anesthesiologists who gave the anesthetics and performed the TAP block were unaware of the used medication for TAP block and were not involved in the patients' assessments. All staffs in the operating room were unaware of the patient randomization code.

Anesthesia technique was standardized in all patients. Patient's monitoring included noninvasive blood pressure, ECG, and pulse oximetry. After obtaining an intravenous access, 10 ml/kg of lactated Ringer's solution was infused before induction of anesthesia followed by 5 ml/kg/h throughout the procedure. General anesthesia was induced with propofol 1.5-2.5 mg/kg, and fentanyl 1-2 μg/kg and rocuronium 0.6 mg/kg were given to facilitate tracheal intubation. Anesthesia was maintained with a 2-2.5% end-tidal concentration of sevoflurane vaporized in oxygen of 40% in air and fentany l 0.5 μg/kg increments to maintain the heart rate and mean arterial blood pressure values within 15% of the baseline values. Patient's lungs were ventilated using a volume-controlled ventilation.

Before skin incision, TAP block was performed on the side of surgery by the assigned anesthesiologist using the double loss-of-resistance (2-pop) technique through the Triangle of Petit (bordered posteriorly by the latissimus dorsi muscle, anteriorly by the external oblique muscle, and inferiorly by the iliac crest), as described by McDonnell et al. [1]. After placement of the needle in the transversus abdominis fascial plane, careful aspiration was performed to exclude vascular puncture, and needle tip placement was confirmed within the fascial plane. After this, the study solution was injected through the needle while observing closely for signs of toxicity.

Surgical relaxation was maintained with rocuronium 0.1 mg/kg increments. All patients received intravenous granisetron 1 mg after induction of anesthesia. At the end of surgery, sevoflurane was discontinued, residual neuromuscular blockade was antagonized, and the trachea was extubated.

A standard postoperative analgesic regimen was used in all patients, consisting of 12 hourly intramuscular diclofenac 50 mg, 6 hourly intravenous paracetamol 1 g, and intravenous morphine 0.05 mg/kg when VAS at rest was greater than 4 or if the patient requested analgesic. If the patient had persistent PONV, metoclopramide 10 mg was administered intravenously when needed.

A blinded investigator to the patient's randomization and who was not involved in the patient's care assessed the patient. The primary outcome included the cumulative consumption of morphine during the first 24 postoperative hours. The secondary outcomes included the first request for morphine, VAS pain scores at rest, postoperative sedation (0: no sedation, 1: mild sedation, 2: deep sedation), and PONV scores (0: no nausea or vomiting, 1: nausea, 2: nausea and vomiting) at 2, 4, 6, 12, and 24 h after surgery. Therefore, postoperative complications such as delayed awakening, hallucination, nightmares, insomnia, diplopia, nystagmus, tachycardia, hypertension, seizures, or tremors were recorded.

Sample size calculation

On the basis of our pilot study, the mean and SD values of 24 h consumption of morphine after TAP block with bupivacaine 0.5% were 10.5 and 1.5 mg, respectively. A priori power analysis indicated that 12 patients in each group was sufficient to detect a 20% reduction in the 24 h cumulative morphine consumption, which was considered to be of clinical validity, with a type-I error of 0.05 and a power of 90%. We added 10% extra patients to compensate for possible dropouts.

Statistical analysis

Data were tested for normality using the Kolmogorov-Smirnov test. Repeated measure analysis of variances was performed. Unpaired Student's t-test was used to compare the parametric values in the two groups. The Mann-Whitney U-test was performed to compare the nonparametric values of the two groups. The χ2 -test was used for categorical data. Data were expressed as frequency, mean ± SD, or median (range). A value of P less than 0.05 was considered to represent statistical significance.


  Results Top


All 28 patients scheduled for inguinal hernioplasty completed the study. Patients' age, sex, weight, and durations of surgery and anesthesia are presented in [Table 1], with no significant difference between the two groups.
Table 1 Patients characteristics

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The groups also did not differ significantly in terms of perioperative heart rate and mean arterial blood pressure (P < 0.05) [Figure 1].
Figure 1: Postoperative heart rate (bpm) and mean arterial blood pressure (MAP) (mmHg). Data are presented in mean ± SD. bpm, beats/min.

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As shown in [Table 2], the addition of ketamine to bupivacaine for TAP block for inguinal hernioplasty resulted in comparable 24 h cumulative morphine consumption, first request for rescue morphine, pain and sedation scores at all observation times, and PONV to the use of TAP block with bupivacaine.
Table 2 Outcomes data

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No patient reported postoperative delayed awakening, hallucination, nightmares, insomnia, diplopia, nystagmus, tachycardia, hypertension, seizures, or tremors.


  Discussion Top


TAP block has been justified as an option for postoperative analgesia after inguinal hernioplasty [7]. Petersen et al. [8] found that ultrasound-guided TAP block did not reduce postoperative pain after inguinal hernia repair; however, the study was nonblinded and included fewer patients.

The present study showed that, compared with the use of TAP block with bupivacaine, the addition of ketamine to bupivacaine during TAP block resulted in comparable 24 h morphine consumption, pain scores, and hemodynamic values in patients undergoing inguinal hernioplasty under sevoflurane anesthesia, receiving a basic analgesic regimen of paracetamol and diclofenac. No patient developed unwanted effects to ketamine.

To the authors' knowledge, this study is the first to assess the effects of addition of ketamine to bupivacaine during TAP block on the duration and quality of postoperative analgesia.

A previous study showed that addition of S (+)-ketamine 0.5 mg/kg allows a lower concentration of levobupivacaine and improves the effectiveness of postoperative analgesia during caudal anesthesia for lower abdominal and urological surgery without loss of clinical effectiveness [9]. Other investigators found that the addition of 0.5 mg/kg of ketamine to bupivacaine-lidocaine mixture for stellate ganglion block was associated with significant pain relief that lasted for longer duration [10]. The author expected to demonstrate a similar long-lasting effect of addition of ketamine for TAP block by the Triangle of Petit after inguinal hernioplasty that might lead to a paravertebral spread of local anesthetic [11]. These studies, however, investigated the analgesic efficacy of the addition of ketamine during caudal anesthesia [9] and stellate ganglion block [10], with possible considerable central spread of ketamine after the TAP block. Therefore, the use of catheter technique for TAP block would provide longer duration of analgesia with the privilege of addition of ketamine to local anesthetics.

We did not encounter any complications with the addition of ketamine to bupivacaine for TAP block, but our study is underpowered to detect complications.

Further multicenter studies are needed to address the clinical importance of the addition of ketamine to local anesthetic during the TAP block, especially with the use of catheter technique.

The present study has many limitations. First, a real-time ultrasound-guided TAP block was not present in this study because of the current unavailability at the author's center; however, it is still unclear whether both techniques really result in equivalent results [12]. Thus, we reported no differences in pain scores or opioid consumption, which might not affect the reliability of our results. Second, we used bupivacaine for TAP block, although most practitioners are using ropivacaine for TAP blocks [7-10]; this medication was not available at the authors' center during the performance of this study. Therefore, other studies used bupivacaine for TAP block for pain control after minimally invasive esophegectomy and nephrectomy [13,14].

In conclusion, the author is able to reject with confidence the hypothesis that the addition of ketamine to bupivacaine for TAP block has any major analgesic effect after inguinal hernioplasty.


  Acknowledgements Top


 
  References Top

1.McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008; 106:186-191.  Back to cited text no. 1
    
2. Fujita Y, Horiguchi Y, Nakamura K, et al. Effect of postoperative analgesia by repeated transversus abdominis plane blocks via a placed catheter in patients undergoing ovarian cystectomy. Masui 2012; 61:155-158.  Back to cited text no. 2
    
3. Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review. Acta Anaesthesiol Scand 2010; 54:529-535.  Back to cited text no. 3
    
4. Lee IO, Kim WK, Kong MH, et al. No enhancement of sensory and motor blockade by ketamine added to ropivacaineinterscalene brachial plexus blockade. Acta Anaesthesiol Scand 2002; 46:821-826.  Back to cited text no. 4
    
5. Sunder RA, Toshniwal G, Dureja GP. Ketamine as an adjuvant in sympathetic blocks for management of central sensitization following peripheral nerve injury. J Brachial Plex Peripher Nerve Inj 2008; 3:22.  Back to cited text no. 5
    
6. Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kissin I. Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study in postoperative patients. Neurosci Lett 1996; 215:5-8.  Back to cited text no. 6
    
7. Aveline C, Le Hetet H, Le Roux A, et al. Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair. Br J Anaesth 2011; 106:380-386.  Back to cited text no. 7
    
8. Petersen PL, Mathiesen O, Stjernholm P, et al. The effect of transversus abdominis plane block or local anaesthetic infiltration in inguinal hernia repair: a randomised clinical trial. Eur J Anaesthesiol 2013; 30:415-421.  Back to cited text no. 8
[PUBMED]    
9. Locatelli BG, Frawley G, Spotti A, et al. Analgesic effectiveness of caudal levobupivacaine and ketamine. Br J Anaesth 2008; 100:701-706.  Back to cited text no. 9
    
10.Kulkarni KR, Kadam AI, Namazi IJ. Efficacy of stellate ganglion block with an adjuvant ketamine for peripheral vascular disease of the upper limbs. Indian J Anaesth 2010; 54:546-551.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Carney J, Finnerty O, Rauf J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011; 66:1023-1030.  Back to cited text no. 11
    
12.Jöhr M. Practical pediatric regional anesthesia. Curr Opin Anaesthesiol 2013; 26:327-332.  Back to cited text no. 12
    
13.Li NL, Liu CC, Cheng SH, et al. Feasibility of combined paravertebral block and subcostal transversus abdominis plane block in postoperative pain control after minimally invasive esophagectomy. Acta Anaesthesiol Taiwan 2013; 51:103-107.  Back to cited text no. 13
    
14.Parikh BK, Waghmare VT, Shah VR, et al. The analgesic efficacy of ultrasound-guided transversus abdominis plane block for retroperitoneoscopic donor nephrectomy: a randomized controlled study. Saudi J Anaesth 2013; 7:43-47.  Back to cited text no. 14
[PUBMED]  Medknow Journal  


    Figures

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    Tables

  [Table 1], [Table 2]


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