|Year : 2015 | Volume
| Issue : 3 | Page : 355-359
Bupivacaine in transverses abdominis plane block for postcesarean section either blindly or ultrasound guided
Mayar H El Sersi MD 1, Ahmed K Makled2
1 Department of Anesthesia and Intensive Care Medicine, Ain Shams University, Cairo, Egypt
2 Department of Obstetric and Gynecology, Ain Shams University, Cairo, Egypt
|Date of Submission||31-Jan-2014|
|Date of Acceptance||22-Feb-2014|
|Date of Web Publication||29-Jul-2015|
Mayar H El Sersi
Department of Anesthesia and Intensive Care Medicine, Ain Shams University, 12 Ahmed Ali st., Cairo
Source of Support: None, Conflict of Interest: None
To compare the effectiveness of blind transverses abdominis plane (TAP) block versus ultrasound-guided TAP block for pain relief after a cesarean section.
For decades, postoperative analgesia for cesarean deliveries was either systemic drugs, with their adverse effects such as nausea, or epidural analgesia, which would hinder ambulation. The TAP block was introduced by Rafi. It is a novel technique in which blockade of the sensory nerves to the anterior abdominal wall is performed by a regional anesthetic. This is a regional analgesic technique that blocks T6-L1 nerve branches and is increasingly playing a role in postoperative analgesia for lower abdominal surgeries.
Patients and methods
Sixty American Society of Anesthesiology I and II multiparous pregnant women aged 25 and 30 years old with BMI between 20 and 25 kg/m 2 planned for elective cesarean section (CS) at 38 weeks were allocated randomly to two groups of 30 patients each. Group B received bupivacaine 2 mg/kg of 0.375% solution per side to a maximum dose of 150 mg landmark guided. Group U received bupivacaine 2 mg/kg of 0.375% solution per side to a maximum dose of 150 mg ultrasound guided. Postoperatively, women were asked to document the degree of pain they experienced at 30 min, 1-, 4-, 6-, and 12-h periods. Printed copies of the visual analogue scale (VAS) between 'no pain' (0) and 'very severe pain' (100 mm) were given to patients and they were taught how to fill them. We assessed the patient clinically for pain and prescribed pethidine 100 mg intramuscularly if the patient complained of severe pain (VAS<60 mm). The time of analgesia was documented in the patient's form. Any local complications of the TAP block were also recorded.
Keywords: bupivacaine, cesarean section, postoperative analgesia, transverses abdominis plane block, ultrasound-guided block
|How to cite this article:|
El Sersi MH, Makled AK. Bupivacaine in transverses abdominis plane block for postcesarean section either blindly or ultrasound guided. Ain-Shams J Anaesthesiol 2015;8:355-9
|How to cite this URL:|
El Sersi MH, Makled AK. Bupivacaine in transverses abdominis plane block for postcesarean section either blindly or ultrasound guided. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Apr 1];8:355-9. Available from: http://www.asja.eg.net/text.asp?2015/8/3/355/161699
| Introduction|| |
The transverses abdominis plane (TAP) block blocks T6-L1 nerve branches and is increasingly playing a role in postoperative analgesia for lower abdominal surgeries ,, .
This alternative analgesia is becoming widely acknowledged by patients and surgeons. It decreases opioid consumption with the benefits of reducing opioid side effects specially nausea and vomiting. Also earlier ambulation and less hospital admission  .
A landmark-based 'double-pop' technique through the lumbar triangle of Petit is a blind technique that contacts the nerves as they course through the fascial plane between the internal oblique and the transverses abdominis muscles. It has been shown to be an effective analgesic adjuvant for lower abdominal surgery. It is a simple and safe technique and is a potential alternative to spinal opioid for analgesia after a cesarean section, whether guided by traditional anatomic landmarks or ultrasound (US)  .
The possibility for damage to nearby structures from blind placement of the needle is also a major concern. Few but bothersome injuries have been reported as there have been case reports of colonic puncture in the pediatric population following an ilioinguinal nerve block , . Liver injury and intraperitoneal injection were also reported following blind TAP blocks , .
An US-guided approach to the TAP block has been described to have the advantage of direct imagining of the needle and injection of the local anesthetic, which improves safety and efficacy  .
To compare the effectiveness and safety of a blind TAP block versus a US-guided TAP block for pain relief after a cesarean section.
| Patients and methods|| |
This is a comparative randomized, double-blind trial. It was conducted in Ain Shams Maternity Hospital after approval of the hospital ethics committee. The study followed the ethical principles for medical research involving human participants (Declaration of Helsinki).
Multiparous pregnant women aged between 25 and 30 years old who were pregnant with BMI between 20 and 25 kg/m 2 were studied. We included American Society of Anesthesiology I and II patients who were planned for elective CS at 38 weeks.
Patients known to have hepatic or renal dysfunction, infection at the proposed site of injection, coagulation disorders, or known allergy to local anesthetics were excluded.
Patients who fulfilled the study criteria were recruited from the antenatal care clinic and those who were willing to participate in the study provided written consent to participate in the study; they were allocated to a random number that would determine the method of TAP Block to be used. Patients were divided into two groups; group B received landmark-guided bupivacaine 2 mg/kg of a 0.375% solution per side to a maximum dose of 150 mg. Group U received US-guided bupivacaine 2 mg/kg of a 0.375% solution per side to a maximum dose of 150 mg. The key for randomization was with one pharmacist, who prepared the injection without informing other care givers or the patient herself about her group allocation.
All patients underwent standard monitoring and intravenous induction of general anesthesia (because of patient refusal of spinal anesthesia). All cesarean sections were performed by a single consultant obstetrician. A Pfannenstiel incision was performed in all patients and the skin was closed by polyglactin (Vicryl; Ethicon) number 3-0. The duration of operation was documented. Patients received bilateral TAP blocks in the operating theater immediately after completion of surgery.
Before placement of the block, the area was prepared with chlorhexidine. TAP blocks were performed bilaterally using a blunt regional anesthesia needle (22 G, 2″BA, Plexufix; B. Braun, Melsungen AG, Germany). In patients receiving the TAP block by the blind technique, we used a 'double-pop' landmark technique (mid-point of the iliac crest and the costal margin in the midaxillary line). In patients receiving a US-guided TAP block, an US scan of the area was performed using a SonoAce R5 (Medison). Views were considered satisfactory, if subcutaneous fat, external oblique muscle, internal oblique muscle, transverses abdominis muscle, peritoneum, and intraperitoneal structures were recognized.
A single consultant anesthetist performed bilateral TAP blockade either blindly or US guided.
Postoperatively, women were asked to document the degree of pain they experienced at 30 min, 1-, 4-, 6-, and 12-h periods. Printed copies of the visual analogue scale (VAS) between 'no pain' (0) and 'very severe pain' (100 mm) were provided to patients and they were taught how to fill them.
We assessed the patients clinically for pain and prescribed pethidine 100 mg intramuscularly if patients complained of severe pain (VAS<60 mm). The time and amount of analgesia required was documented in patients' forms. Any local complications of the TAP block were also recorded.
Statistical data analysis
We calculated the sample size on the basis of a previous audit of morphine use after cesarean delivery; it was determined that a study with 25 participants in each of the two arms would have a 90% power and a significance level at 95% to detect a reduction in VAS of 30 mm with an SD of 30 mm. We included 30 patients in each arm of the study to have a narrower confidence interval and to allow for any dropouts without affecting the results.
The statistical analysis was carried out using the SPSS software (19.0 version; SPSS Inc., Chicago, Illinois, USA). Normal distribution of the data was assessed using the Kolmogorov-Smirnov test. The nonparametric Mann-Whitney U-test was used to compare values. Categorical data were expressed as percentages and compared using the χ2 -test.
| Results|| |
For demographic data, there were no statistically significant differences between group B and group U [Table 1]. The median age was 26.75 years in group B and 26.25 years in group U. The median number of previous CS was 2 in both groups. The median weight was 74 kg in group B and 69.5 kg in group U. The median height was 1.65 m in group B and 1.63 in group U. BMI was 27.9 kg/m 2 in group B and 26.82 kg/m 2 in group U [Table 1].
There were no statistically significant differences between both groups in intraoperative data [Table 2] or intra-abdominal adhesions [Table 3].
|Table 3: Comparison between both groups in visual analogue scale after CS|
Click here to view
At 30 min and 1 h, both groups showed low VAS; group U (US-guided TAP block) produced lower VAS than blind technique group B. Nevertheless, the difference was not statistically significant. However, at 30 min, it was close to significance. At 2, 4, 6, and 12 h, group U reported less VAS than group B and the differences were statistically significant.
Group B needed more frequent injections of pethidine than group U. Group B needed earlier injections of analgesia than group U [Table 4].
There was less need for analgesia in group U than in group B, and the difference was statistically significant [Table 5]
|Table 5: Comparison between both groups in the number of pethidine doses|
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Group B developed more adverse effects than grou U, and the difference was statistically significant [Table 6]. Sixteen patients in group B had no adverse effects whereas 26 patients in group U had no adverse effects. Ten patients in group B had nausea; however, only three patients from group U had nausea. Three patients in group B had drowsiness in comparison with only one in group U. Only one patient from group B complained of itching whereas no patients in group U had itching.
In our study, there was no trauma in either the blind TAP block or the US-guided TAP block.
| Discussion|| |
The landmark-based regional anesthetic technique has been used for a long time, but there are always two main concerns: the first is the accuracy of placement of the needle and thus the local anesthetic and eventually the efficacy in a 'blind' technique and the second is the possibility for damage to nearby structures from blind placement of the needle. An inadvertent liver puncture in a patient postcesarean section has been reported after a landmark-based approach to the TAP block. In our study, there was no trauma during the TAP block. The injection blindly using the landmark technique and US-guided injection did not cause any trauma. This is in with agreement with one case series (>200 patients)  using a landmark-based technique, and reported no complications because of TAP block.
In our study, there were no statistically significant differences between both groups in demographic data or intraoperative findings.
Our study showed that an US-guided TAP block with bupivacaine (group U) produced less pain (lower VAS) in women who had cesarean deliveries in comparison with landmark-guided TAP block (group B). However, only at 30 min and 1 h postoperatively, there was low VAS in both groups. This short duration of analgesia in group B may be as attributed to the relatively large volume of local anesthetic used for TAP blocks (typically ≥20 ml); thus, it is possible that the local anesthetic could diffuse from a nearby plane to block the neural afferents in the TAP, resulting in an analgesic effect, but not as efficiently as direct visualization of local anesthetic placement as in group U.
In contrast to our study, McDonnell et al.  reported, in a study carried out on 32 adults who underwent large bowel resection by a midline abdominal incision and received a landmark-guided TAP block, highly effective postoperative analgesia in the first 24 postoperative hours.
Also, McDonnell et al.  reported a greater reduction in morphine consumption: a reduction of 70% in the active group compared with that in the placebo group over 24 h. This is in contrast to Belavy et al.  , who reported only a 43% reduction in morphine consumption.
In contrast with epidural, where loss of resistance is chiefly felt but can also be valued visually, there is no definite objective visual endpoint for the trainer with a blind TAP technique in the absence of US. A learning curve for a TAP block has not been defined in the literature to date. Quality assurance and performance assessment are progressively growing in importance in the practice of medicine. It is questionable how manual skills for a blind procedure can possibly be developed efficiently  .
In agreement with our study, McDermott et al.  established that positioning of the needle tip and local anesthetic using the standard landmark-based approach to the TAP block is imprecise, and the frequency of peritoneal placement is high.
Carney et al. reported that an US-guided TAP block using 20 ml of 0.5% levopubivacaine provided effective analgesia during the 12 postoperative hours after an open appendectomy  .
In our study, the median time to request for additional analgesia was 75 min in group B and 317 min in group U. In another double-blinded randomized study, women who received subarachnoid morphine were compared with those who had a TAP block (TAP group). The median time in which patients in the TAP group requested for analgesia was 4 h compared with 8 h in the subarachnoid morphine group  .
Our study showed that Group B developed more adverse effects than Group U, and the difference was statistically significant. However, Muhammed Rafay et al.  reported no significant differences in postoperative nausea between the TAP block groups and the non-TAP block patients. In contrast, a meta-analysis carried out by Sara and Rajiv  found that a common theme in the studies was that patients receiving TAP blocks seemed to have less nausea. This is very useful as nausea can hinder patients' mobilization and breast feeding of their baby. It may also postpone hospital discharge  .
| Conclusion|| |
The TAP block reduces the requirement of postoperative opioid use, provides more effective pain relief, and reduces opioid-associated side effects. The US-guided TAP block is more effective with a longer duration of analgesia, fewer postoperative analgesic requirements, and fewer adverse effects compared with the Blind TAP block. The visualization of the needle tip and more accurate injections result in better pain control.
| Acknowledgements|| |
Conflicts of interest
| References|| |
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]