|Year : 2014 | Volume
| Issue : 4 | Page : 539-544
Ultrasound-guided transversus abdominis plane block for radical cystectomy with and without dexamethasone: a prospective, double-blinded controlled trial
Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||04-Jan-2014|
|Date of Acceptance||03-Aug-2014|
|Date of Web Publication||28-Nov-2014|
20 Taksem Al-Awkaf, Presidential Palace Street, Al-Sawah, Cairo
Source of Support: None, Conflict of Interest: None
Poor control of pain after major abdominal surgeries is associated with a variety of unwanted consequences. The transversus abdominis plane (TAP) block provides analgesia to the parietal peritoneum and to the skin and muscles of the anterior abdominal wall. Different adjuvants including dexamethasone have been used to intensify the quality and increase the duration of local anesthetics. The aim of the study was to assess the efficacy of TAP block and to measure the effect of adding dexamethasone to bupivacaine on the quality of TAP block.
Patients and methods
Ninety ASA I-III patients, scheduled for radical cystectomy under general anesthesia, were enrolled in the study and were divided into three groups: group I was given TAP block with 20 ml 0.25% bupivacaine + 2 ml dexamethasone (8 mg)/side (n = 30); group II was given TAP block with 20 ml of 0.25% bupivacaine + 2 ml saline 0.9%/side (n = 30); and group III was given general anesthesia without TAP block (n = 30). The primary outcome was postoperative pain evaluated using the visual analogue scale (VAS) score for pain at 2, 4, 6, 12, and 24 h postoperatively, whereas the secondary outcome was the time to first analgesia (TFA), morphine consumption, and incidence of nausea or sedation.
Adding dexamethasone to bupivacaine compared with bupivacaine alone resulted in a reduction in the postoperative VAS for pain score, a longer TFA (220.5 ± 25.02 vs. 140.54 ± 15.12 min, P < 0.001), and lesser 24-h morphine consumption (5.11 ± 3.01 vs. 17.20 ± 7.75 mg, P < 0.001). The bupivacaine TAP group compared with the control group showed a significant reduction of the VAS pain score, a longer TFA (140.54 ± 15.12 vs. 35.055 ± 4.15 min, P = 0.01), and lesser 24-h morphine requirement (17.20 ± 7.75 vs. 27.58 ± 8.41 mg, P < 0.001). Both TAP block groups compared with the control group showed a significant reduction of nausea and a lower incidence of sedation.
TAP block with bupivacaine provided better analgesia with fewer side effects compared with conventional systemic analgesia. Adding dexamethasone to bupivacaine in TAP block added better analgesic effect.
Keywords: bupivacaine, dexamethasone, radical cystectomy, transversus abdominis plane block
|How to cite this article:|
Abdalla W. Ultrasound-guided transversus abdominis plane block for radical cystectomy with and without dexamethasone: a prospective, double-blinded controlled trial. Ain-Shams J Anaesthesiol 2014;7:539-44
|How to cite this URL:|
Abdalla W. Ultrasound-guided transversus abdominis plane block for radical cystectomy with and without dexamethasone: a prospective, double-blinded controlled trial. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2017 Jun 24];7:539-44. Available from: http://www.asja.eg.net/text.asp?2014/7/4/539/145709
| Background|| |
Poor control of pain after major abdominal surgeries is associated with a variety of unwanted consequences such as respiratory complications, cardiac troubles, patient's discomfort, and a prolonged hospital stay . Pain after abdominal surgery is mainly due to the incision made in the abdominal wall with the remaining part resulting from internal visceral trauma . Different methods to provide analgesia for abdominal surgeries have been used, including administration of systemic drugs such as opioids, paracetamol, and NSAIDs, infiltration of local anesthetics in the skin around the surgical wound, or insertion of an epidural catheter [3,4]. Peripheral nerve blockade is an alternative method of analgesia. The transversus abdominis plane (TAP) block provides analgesia to the parietal peritoneum in addition to the skin and muscles of the anterior abdominal wall. Different adjuvants have been used to intensify the quality and increase the duration of local anesthetics . Adding methyl prednisolone to local anesthetics has increased the duration of brachial plexus block . In addition, dexamethasone has been shown to have anti-inflammatory action . The aim of the present study was to assess the efficacy of TAP block as a part of multimodal analgesia in major abdominal surgeries in addition to measuring the effect of adding dexamethasone to bupivacaine on the intensity and the duration of TAP block.
| Patients and methods|| |
After obtaining approval of the Ain Shams University Hospital ethics committee, 90 ASA physical status I-III patients, scheduled for radical cystectomy with exploratory lower midline incision, were enrolled in a prospective, double-blinded controlled trial. The patients, their anesthesiologists, and the medical staff who provide postoperative care were blinded to group assignment; the anesthesiologist who performed the block was blinded to the given mixture of drugs. Exclusion criteria included patients unable or unwilling to give informed consent, those who had a history of relevant drug allergy, patients currently using analgesics or who had current acute or chronic pain or were receiving medical therapies considered to result in tolerance to opioids, and blood coagulation pathologies.
Informed written consents were obtained from all patients, and the technique of regional anesthesia was explained. General anesthesia was standardized in all groups using propofol (1-2 mg/kg) and fentanyl (2 μg/kg). Tracheal intubation was facilitated using rocuronium (0.6 mg/kg); maintenance of anesthesia was with 50 : 50% O 2 and air with sevoflurane, rocuronium, and fentanyl (1 μg/kg/h). The TAP block was performed at the end of the surgery and before extubation by the researcher anesthesiologist under ultrasound guidance using a 38-mm broadband linear ultrasound probe GE Healthcare, LOGIQ C3 Premium (Wauwatosa, Wisconsin, USA). Patients were randomized and divided into three groups, each containing 30 patients.
Group I received TAP block with 20 ml of 0.25% bupivacaine + 2 ml dexamethasone (8 mg)/side (n = 30); group II received TAP block with 20 ml of 0.25% bupivacaine + 2 ml saline 0.9%/side (n = 30); and group III underwent the standard general anesthesia technique without TAP block (n = 30). Randomization of patients was performed using the sealed-envelope design.
In all groups, the mode of postoperative analgesia was as follows: intravenous paracetamol (1 g) every 6 h was started on admission to the postanesthesia care unit and patient-controlled intravenous morphine analgesia (bolus dose 1 mg, lockout interval 10 min, 4 h maximum dose 20 mg) was started on demand after the time to first analgesic (TFA) request and continued on the patient's need. The technique of the block was the posterior approach. The anesthesiologist who performed the TAP block was scrubbed and gowned; the patient was placed in the supine position, the puncture area was sterilized, and the ultrasound probe was prepared in an aseptic manner and placed in the mid-axillary line transverse to the abdominal wall superior to the iliac crest and below the costal margin. The image produced showed (from superficial to deep) skin and subcutaneous tissue, fat, external oblique, internal oblique, and transversus abdominis muscles, and lastly the peritoneum and bowel may be seen deep to the muscles ([Figure 1]). After identifying the abdominal layers, the TAP was reached using the Pajunk SonoTAP cannula (Geisingen, Germany) for single-shot techniques size (22 G × 80 mm); the needle was advanced using the in-plane technique; once the tip of the needle was visualized to be in plane between the internal oblique and the transversus abdominis muscle, and after negative pressure aspiration, in group I, 20 ml 0.25% bupivacaine + 2 ml dexamethasone (8 mg) was administered incrementally in the TAP (hydrodissection) by the needle. The contralateral block was performed in a similar manner, whereas in group II, the same volume was injected using 20 ml bupivacaine 0.25% + 2 ml saline 0.9%. When the local anesthetic was deposited, it was seen as a hypoechoic shadow pushing the two layers of the muscle aponeurosis apart. Visualization of the hypoechoic spread, with the fascial layer above and the muscle layer below, was considered a sure sign of proper deposition ([Figure 2]).
|Figure 1: Image showing transversus abdominis plane layers from superfi cial to deep. EO, external oblique; IO, internal oblique; TA, transv ersus abdominis.|
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|Figure 2: Image showing transversus abdominis plane needle and local an esthetic spread.|
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Pain scores were observed and recorded using the visual analogue scale (VAS) (0 = no pain, 100 = worst imaginable pain), both at rest and on coughing. The sedation score was measured using a categorical scoring system (0 = awake and alert, 1 = quietly awake, 2 = asleep but easily roused, 3 = deep sleep). Nausea was also measured using a categorical system (0 = none, 1 = mild, 2 = moderate, 3 = severe). The recovery staff in the postanesthesia care unit recorded pain, sedation, and nausea scores on arrival and at 1 h postoperatively. The acute pain service team recorded the scores in the ward or in the ICU at 2, 4, 6, 12, and 24 h after TAP blockade. The main goal of the study was to compare the three groups with regards to the VAS pain scores, whereas secondary outcome measures included the time to first request for morphine (which was defined as the time elapsed between the injection of the local anesthetic and the first time for the patient to request for analgesia), 24-h morphine consumption, and side effects associated with morphine (sedation and nausea).
All data were collected by a nurse who was blinded to the anesthetic technique.
Before the study, a power analysis was performed to determine the minimal acceptable number of patients in each group on the basis of the VAS score. The minimal sample number was 28 patients for each group with type I α-error of 0.05 and type II β-error of 0.1, with the power of the test at 90%; hence, we set the group number at 30 for compensation of any possible dropouts. IBM Corp. 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. was used for data analysis. Data were expressed as mean ± SD for continuous variables, tested by analysis of variance and Tukey's test, or as the median and the interquartile range for nonparametric variables, tested by the Kruskal - Wallis test and the Mann - Whitney U-test. The probability of error at 0.05 was considered significant, whereas at 0.01 and 0.001 was highly significant.
| Results|| |
All groups were comparable with regard to the personal data and operative characteristics ([Table 1]). Adding dexamethasone to bupivacaine in TAP block (group I), compared with bupivacaine alone (group II), resulted in significant reduction in the postoperative VAS for pain score, a longer TFA (220.5 ± 25.02 vs. 140.54 ± 15.12 min, P < 0.001) ([Table 2]), and less morphine consumption through the first postoperative 24 h (5.11 ± 3.01 vs. 17.20 ± 7.75 mg, P < 0.001) ([Table 3]), whereas both TAP groups were comparable with regards to nausea or sedation ([Table 4]). The bupivacaine TAP group (group II) compared with the control group (group III) showed a significant reduction of the VAS pain score, prolongation of TFA (140.54 ± 15.12 vs. 35.055 ± 4.15 min, P = 0.01) ([Table 2]), and lesser morphine requirement during the postoperative 24 h (17.20 ± 7.75 vs. 27.58 ± 8.41 mg, P < 0.001) ([Table 3]). Both TAP block groups compared with the control group showed a significant reduction of nausea and a lower incidence of sedation ([Table 4]). No adverse effects related to the block technique were recorded.
|Table 2 The postoperative pain score (visual analogue scale) and the time to fi rst analgesic request|
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| Discussion|| |
TAP block as a regional analgesic technique for postoperative analgesia is gaining popularity; it may play a role in major abdominal surgeries. Many adjuvants have been used to intensify the quality and increase the duration of local anesthetics in different regional block techniques and peripheral nerve blocks. The current study focuses on combining dexamethasone with bupivacaine, assessing its effect on the quality and the duration of the TAP block in patients undergoing radical cystectomy.
The current study showed that the bupivacaine TAP group had a significant reduction in the postoperative VAS score for pain compared with the control group. It also showed that the dexamethasone/bupivacaine group had a significantly lower postoperative VAS score for pain compared with both the bupivacaine group and the control group over the first postoperative 24 h. Also, the TFA was significantly longer in the dexamethasone/bupivacaine group compared with the other two groups; it also showed that the incidence of complications related to morphine consumption (nausea or sedation) was significantly lower in patients who received TAP block compared with the control group. In a study by Carney et al.  comparing TAP block with TAP placebo block after elective total abdominal hysterectomy, their results showed that TAP block with ropivacaine reduced postoperative pain scores compared with the placebo block. Total morphine requirements in the first 48 postoperative hours were also reduced (55 ± 17 vs. 27 ± 20 mg). The incidence of sedation was reduced in patients undergoing TAP blockade, and there were no complications related to the block.
Another study showed that ultrasound-guided technique enables exact placement of the local anesthetic for TAP blocks. In patients undergoing laparoscopic cholecystectomy under standard general anesthesia, ultrasound-guided TAP block with 15 ml bupivacaine 5 mg/ml on each side reduced the postoperative morphine consumption [10.5 (7.7) vs. 22.8 (4.3) mg, P < 0.05] . In a randomized controlled trial, the analgesic efficacy of TAP block after abdominal surgery was studied, and the results showed that TAP block reduced pain scores on emergence (1 ± 1.4 vs. 6.6 ± 2.8, P < 0.05), and at all postoperative time points, including at 24 h (1.7 ± 1.7 vs. 3.1 ± 1.5, P < 0.05). Morphine requirements in the first 24 postoperative hours were also reduced (21.9 ± 8.9 vs. 80.4 ± 19.2 mg, P < 0.05) and there were no complications attributable to the TAP block. All TAP patients reported high levels of satisfaction with their postoperative analgesic regimen . Griffiths et al.  demonstrated that TAP blockade provided no benefit in addition to multimodal analgesia in women undergoing major gynecological cancer surgery, with inadequate analgesia either at rest (39 vs. 22%, P = 0.13) or with coughing (61 vs. 53%, P = 0.54) at 2 h. They found no significant difference in the postoperative morphine consumption between the placebo and the treatment groups at 2 h (13.5 vs. 11.87 mg, P = 0.53) or 24 h (34.0 vs. 36.1 mg, P = 0.76). They also found no significant differences in the incidence of opioid side effects or patient satisfaction.
In a study by Movafegh et al.  to evaluate the effect of dexamethasone added to lidocaine on the onset and the duration of axillary brachial plexus block, they found that it resulted in a longer sensory (the sensory blockade duration was 242 ± 76 vs. 98 ± 33 min for the control) and motor block (the motor blockade duration was 310 ± 81 vs. 130 ± 31 min for the control). In another study adding 8 mg of dexamethasone to a mixture of lidocaine and bupivacaine for supraclavicular brachial plexus block, there was a significantly faster onset of action and prolonged duration of analgesia in the dexamethasone group than in the control group with no reported complications . In another study, Parrington et al.  added 8 mg of dexamethasone to mepivacaine during supraclavicular brachial plexus blockade. The dexamethasone group showed a longer duration of analgesia of 332 versus 228 min in the control group, whereas the onset times were similar in both groups for sensory and motor blockade. Cummings et al.  studied the effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Dexamethasone significantly prolonged the duration of analgesia of both ropivacaine [11.8 (9.7-13.8) vs. 22.2 (18.0-28.6) h] and bupivacaine [14.8 (11.8-18.1) vs. 22.4 (20.5-29.3) h]. Dexamethasone prolonged analgesia more with ropivacaine than with bupivacaine, whereas the block duration was more prolonged with bupivacaine than with ropivacaine.
| Conclusion|| |
TAP block as a part of a multimodal analgesia regimen provided better analgesia after radical cystectomy operation with lesser incidence of opioid-related side effects (sedation or nausea) compared with systemic analgesia with morphine due to the lower dose of morphine. Adding dexamethasone to bupivacaine in TAP block added better analgesic effect compared with bupivacaine alone.
| Acknowledgements|| |
| References|| |
Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg 2007; 106:205-221.
Wall PD, Melzack R. Pain measurements in persons in pain. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. 409-426.
Kehlet H, Dahl JB. The value of 'multimodal' or 'balanced analgesia' in postoperative pain treatment. Anesth Analg 1993; 77:1048-1056.
Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001; 87:62-72.
Popping DM, Elia N, Marret E, Wenk M, Tramer MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 2009; 111:406-415.
Mirazi H, Tekin I, Alincak H. Perioperative use of corticosteroid and bupivacaine combination in lumbar disc surgery: a randomized controlled trial. Spine 2002; 27:343-346.
Skjelbred P, Lokken P. Postoperative pain and inflammatory reaction reduced by injection of corticosteroid. Eur J Clin Pharmacol 1982; 21: 391-396.
Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008; 107:2056-2060.
El-Dawlatly AA, Turkistani A, Kettner SC, Machata A-M, Delvi MB, Thallaj A, et al.
Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth 2009; 102:763-767.
McDonnell JG, O'Donnell B, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007; 104:193-197.
Griffiths J, Middle JV, Barron FA, Grant SJ, Popham PA, Royse CF. Transversus abdominis plane block does not provide additional benefit to multimodal analgesia in gynecological cancer surgery. Anesth Analg 2010; 111:797-801.
Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006; 102:263-267.
Shreshta BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone. A comparative study. Kathmandu Univ Med J 2003; 3:158-160.
Parrington SJ, O'Donnell D, Chan VW, Brown-Shreves D, Subramanyam R, Qu M, et al.
Dexamethasone added to mebivacaine prolongs the duration of analgesia of after supraclavicular brachial plexus blockade. Reg Anesth Pain Med 2010; 35:422-426.
Cummings KC III, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, et al.
Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011; 107:446-453.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]