|Year : 2015 | Volume
| Issue : 3 | Page : 382-387
Preemptive analgesia of ultrasound-guided transversus abdominis plane block compared with deep wound infiltration in patients undergoing urological surgery
Hoda Shokri PhD, MD 1, Karim O Elsaeed2
1 Department of Anesthesiology, Ain Shams University, Cairo, Egypt
2 Department of Urology, Ain Shams University, Cairo, Egypt
|Date of Submission||19-Nov-2014|
|Date of Acceptance||12-Apr-2015|
|Date of Web Publication||29-Jul-2015|
Department of Anesthesiology, Ain Shams University, Cairo 1156
Source of Support: None, Conflict of Interest: None
Transversus abdominis plane (TAP) block is suitable for unilateral urologic surgeries. Blind TAP block has many complications and uncertainty regarding its effects. Use of ultrasonography increases the safety and efficacy. This study was conducted to evaluate the analgesic efficacy of ultrasound-guided TAP block compared with wound infiltration with bupivacaine (0.25%) in patients undergoing urologic surgeries.
Patients and methods
In a prospective study, 30 patients undergoing elective unilateral urological surgeries such as nephrolithotomy were allocated into two groups: the TAP group and the infiltration group. The TAP group (n = 15) received TAP block with 0.25% bupivacaine (50 ml), and in the infiltration group (n = 15) the skin and subcutaneous tissues of the surgical incision and deep muscle layers were infiltrated with 0.25% bupivacaine (50 ml). Pethidine 1 mg/kg was given as rescue analgesic at visual analog scale (VAS) more than 3 at rest and on movement.
The total dose of pethidine, VAS at rest and on movement, and sedation scores were recorded.
Patients of the TAP group had significantly lower VAS score and lower pethidine consumption, and there was a nonsignificant difference between study groups as regards sedation score.
The ultrasound-guided TAP block is easy to perform and more effective as a postoperative analgesic regimen in urologic surgeries with opioid-sparing effects.
Keywords: block, bupivacaine, infiltration, pethidine, transversus, urology, visual analog scale
|How to cite this article:|
Shokri H, Elsaeed KO. Preemptive analgesia of ultrasound-guided transversus abdominis plane block compared with deep wound infiltration in patients undergoing urological surgery. Ain-Shams J Anaesthesiol 2015;8:382-7
|How to cite this URL:|
Shokri H, Elsaeed KO. Preemptive analgesia of ultrasound-guided transversus abdominis plane block compared with deep wound infiltration in patients undergoing urological surgery. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Feb 17];8:382-7. Available from: http://www.asja.eg.net/text.asp?2015/8/3/382/161714
| Introduction|| |
Pain after urologic surgeries is common and expected and hence should be treated adequately to avoid postoperative complications and the development of chronic pain  .
The most common approach to postoperative pain relief in urologic surgeries is multimodal, using NSAIDs, opioids, and local infiltration of anesthetics. Opioids are effective for treatment of postoperative pain but can cause adverse effects such as nausea, vomiting, decreased gastrointestinal motility, respiratory depression, and sedation, which further increase the morbidity of the patients. Local infiltration does not relieve deep muscular pain, and NSAIDs are nephrotoxic  .
In 2001, a novel approach to block the abdominal wall neural afferents through the lumbar triangle of petit was described by Rafi  , which is known as the transversus abdominis plane (TAP) block.
However, this landmark technique is associated with difficulties like anatomical variation of the triangle of petit  , difficulty in palpation of angle in obese patients, and complications like liver injury, nerve injury, and unpredictable spread of the local anesthetic  .
Hebbard and colleagues have subsequently described an ultrasound-guided approach to the TAP block , .
Real-time ultrasound provides reliable imaging of the muscular layers of the anterolateral abdominal wall and assessment of correct needle placement and local anesthetic injection, thus increasing the success and safety of the TAP block  .
The aim of our study was to evaluate the analgesic efficacy of ultrasound-guided TAP block by comparing it with bupivacaine deep wound infiltration in patients undergoing urologic surgeries.
| Patients and methods|| |
Following approval from the medical ethics committee of Ain Shams University, 30 patients of American Society of Anaesthesiologists (ASA) physical status I-II who were scheduled for elective urologic surgeries through abdominal wall incision under general anesthesia were included in this prospective randomized study. All patients provided written informed consent.
The trial was carried out between May 2013 and June 2014 at the Department of Urology, Ain Shams University Hospitals.
Patients with known allergy to any of the study medications, who were receiving medical therapies producing tolerance to opioids, had coagulopathy, and had psychiatric problems were excluded.
A preoperative evaluation was performed the day before surgery. Patients were randomly divided into two groups by allocation concealment: the TAP group (n = 15) and the infiltration group (n = 15). The TAP group received TAP block with 0.25% bupivacaine (50 ml), and in the infiltration group the skin and subcutaneous tissues of the surgical incision and deep muscle layers were infiltrated with 0.25% bupivacaine (50 ml).
In the induction room, intravenous access was established and an infusion of Ringer acetate was started. Patients were monitored with ECG, for noninvasive arterial blood pressure, arterial oxygen saturation, and for end-tidal carbon dioxide.
All patients underwent standardized general anesthesia with induction by intravenous fentanyl (1.5 µg/kg), thiopental Na (3-5 mg/kg), and rocuronium (0.25 mg/kg). Anesthesia was maintained with 100% oxygen and 1.2% isoflurane, and patients were mechanically ventilated to maintain the end expiratory carbon dioxide between 34 and 36 mmHg.
In the TAP group, patients were positioned in the supine position. The TAP block was performed under ultrasound guidance with a Logiq-e Ultrasound (General Electric Medical Systems, Milwaukee, Wisconsin, USA) and a linear 7-11 MHz ultrasound transducer on the same side of surgery. Once the external oblique abdominis muscle, the internal oblique abdominis muscle, and the transversus abdominis muscles were visualized at the level of the anterior axillary line between the 12th rib and the iliac crest, the puncture area and the ultrasound probe were prepared in a sterile manner. Thereafter, the neurofascial plane between the internal oblique abdominis muscle and the transversus abdominis muscle was identified.
In a sterile manner the block was performed with a 20-G, 100 mm Facette tip needle (B. Braun Stimuplex, Melsungen, Germany) following an inplane technique. Once the needle was placed in the space between the internal oblique abdominis muscle and transversus abdominis muscle, 50 ml bupivacaine (0.25%) was injected after negative aspiration. The drug was seen spreading in the TAP as a dark oval shape.
In the infiltration group, the borders of the surgical wounds were infiltrated with 10 ml of 0.25% bupivacaine before incision, and the surgeon infiltrated the muscle and subcutaneous layers of the wound with 40 ml of 0.25% bupivacaine during stages of closure.
Surgical relaxation was maintained with rocuronium at 0.1 mg/kg increments. At the end of surgery, isoflurane was discontinued, residual neuromuscular blockade was antagonized, and the trachea was extubated.
An injection of diclofenac sodium 1.5 mg/kg, intramuscular, was given to every patient in both groups before extubation as a standard analgesic regimen.
After recovery, patients were shifted to the postanesthetic care unit for 2 h and then to the ward.
The primary outcomes included cumulative consumption of pethidine over 24 h postoperatively.
The secondary outcome measures included both visual analog scale (VAS) at rest and on movement using a 10 cm VAS, where 0 = no pain and 10 = worst imaginable pain  , and postoperative sedation as part of secondary outcome measures was rated using the Ramsay sedation score (1 = awake and alert; 2 = quietly awake; 3 = asleep but easily aroused; 4 = brisk response to loud auditory stimulus; 5 = sluggish response to loud auditory stimulus; and 6 = deep sleep)  .
The sample size was calculated on the basis of 24-h VAS scores of patients undergoing urologic surgeries. The mean and SD of both groups was 1.00 ± 0.37 and 0.78 ± 0.2, respectively. On the basis of this, a sample size of 15 patients was needed per group for type I error 5% and type II error 10%, with power of test 90%.
Statistical analysis was performed using statistical package for the social sciences (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA) software. P values less than 0.05 were considered statistically significant.
Demographic data, the total dose of postoperative analgesics, and type of surgical procedures were compared between groups using the t-test and the χ2 -test; P values less than or equal to 0.05 were considered significant.
Variables such as age, BMI, and dosage of postoperative analgesics were shown as mean ± SD or range, and variables such as sex and type of surgical procedures were shown as percentage.
VAS at rest, VAS at movement, and sedation score were presented as range or median (interquartile range). They were compared between groups by means of the Mann-Whitney U-test for pairwise comparisons and P values less than 0.05 were considered significant.
| Results|| |
All 30 patients scheduled for urologic surgeries completed the study.
The demographic data and surgical factors are presented in [Table 1], with nonsignificant difference between the two groups.
As shown in [Table 2], the 24-h total dose of rescue analgesic (pethidine) was significantly less in the TAP group compared with the infiltration group.
The TAP group had significantly lower pain scores at rest compared with the infiltration group at 2, 6, 10, 12, and 18 h postoperatively, as shown in [Table 3] and [Figure 1].
|Table 2: Comparison of the dose of rescue opioids between the study groups|
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|Table 3: Comparison of visual analog scale at rest between the study groups|
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The TAP group had significantly lower pain scores on movement compared with the infiltration group at 2, 6, 10, and 12 h postoperatively, as shown in [Table 4] and [Figure 2].
|Table 4: Comparison of visual analog scale at movement between the study groups|
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Regarding sedation scores, there was a nonsignificant difference between the two groups at all time points postoperatively, as shown in [Table 5] and [Figure 3].
| Discussion|| |
In this prospective randomized clinical trial, patients who received a unilateral TAP block had significantly less pain and reduced pethidine requirements compared with wound infiltration with bupivacaine; hence, the TAP block proved to be a more effective method.
There was difference in timing between the two techniques: local wound infiltration was performed by the surgeon without the use of an ultrasound probe. After a review of the literature some investigators believed that better pain relief could be achieved when the local anesthetic was infiltrated during wound closure as pain stemmed from trauma to the abdominal muscles. In contrast, preemptive TAP was easier under ultrasound guidance before skin incision and proved to be more effective as it can potentially reduce the metabolic responses during surgery and avoid central desensitization  .
There are many studies showing the efficacy of TAP blocks in different patient populations. However, Griffiths et al.  reported that TAP block was not effective in reducing postoperative pain after gynecological cancer surgery.
Carney et al.  compared TAP block with placebo and demonstrated that TAP block provided effective analgesia and reduced postoperative morphine requirements in patients undergoing total abdominal hysterectomy (TAH). It also reduced sedation in these patients, which was not similar to the results of our study.
Our study showed that there was insignificant difference between the study groups regarding sedation scores.
Parikh et al.  assumed that the TAP block as a part of a multimodal analgesic regimen would result in improved analgesia in the first 24 h and in decreased opioid consumption after retroperitoneoscopic donor nephrectomy.
We compared TAP block with incisional local anesthetic technique and found that TAP block was effective against both rest and movement pain for longer duration and significantly reduced postoperative opioid requirements.
Yu et al.  reported that there were significantly lower pain scores in the TAP group at 24 h postoperatively, whereas local anesthetic infiltration was limited to a short period of pain control, which reached a peak at 1 h postoperatively and a minimum by 8 h and was negligible at 16 h; however, the data analyzed in their study demonstrated that TAP block did not significantly reduce morphine requirements.
On the contrary, our study showed that TAP block significantly reduced postoperative opioid requirements.
Petersen et al.  showed that pain scores at 6 h were significantly lower in the infiltration group than in the TAP group (10 vs. 25 mm at rest, P < 0.001; 17 vs. 40 mm while coughing, P < 0.001). In their study ultrasound-guided TAP block did not reduce postoperative pain after inguinal hernia repair, which disagreed with the findings of our study.
The principle behind preemptive TAP blocking is that the local anesthetic is injected into the neurofascial plane where it may act on the afferent sensory nerves of the lower six thoracic and upper lumbar nerves as they course through the plane before they pierce the musculature to innervate the abdominal wall. This plane is poorly vascularized and thus it has been suggested that prolonged analgesic effect can be observed in TAP blocking due to slow drug clearance  .
The ultrasound-guided sensory block of the anterior abdominal wall with local anesthesia for postoperative pain relief has been shown to be a promising and successful technique for providing analgesia after surgery involving the anterior abdominal wall. Hebbard et al.  described a new technique called subcostal injection technique in which a local anaesthetic is delivered in the same plane with insertion of the needle at the xiphoid and the needle passes to the costal margin.
| Conclusion|| |
In this study ultrasound-guided TAP block reduced postoperative rest and movement pain, as well as analgesic requirement, after urologic surgeries and was more effective than deep wound infiltration.
| Acknowledgements|| |
This work was supported by the Department of Urology and the Department of Anesthesiology at Ain Shams University (Cairo, Egypt).
The authors thank assistant lecturer of anesthesia Mahmoud Saad who helped in the clinical work, as well as residents of urology who helped us collect the data.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]