Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 653-657

Efficacy of ultrasound-guided transversus abdominis plane block versus epidural analgesia in pain management following lower abdominal surgery


Anesthesia and Intensive Care Department, Al-Azhar faculty of Medicine, Egypt

Date of Submission26-Jun-2014
Date of Acceptance29-Dec-2014
Date of Web Publication29-Dec-2015

Correspondence Address:
Yousry Kandi
Anesthesia and Intensive Care Department, Al-Azhar faculty of Medicine
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.172762

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  Abstract 

Objective
Transversus abdominis plane (TAP) block is a new, rapidly expanding technique. This study was designed to evaluate the efficacy of ultrasound-guided TAP block in comparison with epidural analgesia in pain management following lower abdominal surgery.
Setting and duration
The present study was conducted on 60 patients aged 20-75 years, who were admitted at Al-Azhar University Hospitals from February 2013 to March 2014.
Patients and methods
These patients were allocated to either group I (TAP, 30 cases) or group II (epidural block, 30 cases) using a randomized central computer-generated sequence held by an investigator not involved with the clinical management or data collection. The primary outcome was the proportion of participants who used more than 200 mg/kg of morphine in the first 24 h on arrival at the recovery ward. Secondary outcomes included the following: morphine consumption 24 h after operation; pain measured using the visual analog score in the recovery ward and at 2, 6, 10, 14, 18, and 24 h after operation; and postoperative nausea and vomiting measured with the total number of vomits during the first 24 h.
Results
The most important finding in our study was that TAP block provided highly effective postoperative analgesia in the first 24 h, especially in the neurofascial plane in the muscles and the skin but not the visceral pain, and that the TAP block reduced the mean intravenous morphine requirements by more than 70%. This reduction in opioid requirement resulted in fewer opioid side effects. In the present study, there was no significant difference between the studied groups as regards time spent in the recovery room, need for paracetamol during the first 8 h after surgical intervention, postoperative nausea and vomiting, and duration of hospital stay. In contrast, the total morphine consumption during the first 8 h was significantly less in group I than in group II, and the time to first analgesic request was significantly longer in group I than in group II. Finally, the number of cases that required more than 200 mg of morphine during the first 24 h was significantly less in group I than in group II.
Conclusion
Ultrasound-guided TAP block is an effective alternative for providing postoperative analgesia after lower abdominal surgery in comparison with epidural analgesia, but further studies in larger population are necessary.

Keywords: epidural analgesia, transversus abdominis plane block, ultrasound guided


How to cite this article:
Kandi Y. Efficacy of ultrasound-guided transversus abdominis plane block versus epidural analgesia in pain management following lower abdominal surgery. Ain-Shams J Anaesthesiol 2015;8:653-7

How to cite this URL:
Kandi Y. Efficacy of ultrasound-guided transversus abdominis plane block versus epidural analgesia in pain management following lower abdominal surgery. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jun 25];8:653-7. Available from: http://www.asja.eg.net/text.asp?2015/8/4/653/172762


  Introduction Top


As a regional anesthetic technique, transversus abdominis plane (TAP) block is a new, rapidly expanding technique. It is relatively simple and efficacious. It has been reported to significantly reduce pain associated with lower abdominal surgery, regardless of whether it is used as the primary anesthetic or for pain control after general or spinal anesthesia [1] . Ultrasound-guided TAP block has been described with promises of better localization and deposition of the local anesthetic with improved accuracy [2] . The aim of a TAP block is to deposit local anesthetic in the plane between the internal oblique and transversus abdominis muscles, targeting the spinal nerves in this plane [3] . It has been used for adults undergoing colonic resection surgery, cesarean delivery, and total abdominal hysterectomy [4] . In addition, TAP had been demonstrated to provide excellent analgesia to the skin and musculature of the anterior abdominal wall following appendectomy, inguinal hernia repair, and radical prostatectomy [3],[5],[6] . There have been no reported complications with the ultrasound-guided technique. A few complications have been reported with blind TAP block; the most significant of which was a case report of intrahepatic injection [7] . Other complications include intraperitoneal injection, bowel hematoma, and transient femoral nerve palsy. Local anesthetic toxicity could also occur because of the large volumes required to perform this block, especially if performed bilaterally [3] . To increase the efficacy (success rate) and accuracy of TAP and prevent potential complications, ultrasound was used [8] .

Epidural analgesia is a popular analgesic technique for abdominal surgery, with high efficacy and safety. However, the debate on whether epidural analgesia improves outcome has not been settled. It had no effect on hospital stay in colorectal surgery, although it decreased postoperative pain and ileus rate [9] .

Over TAP block, epidural analgesia has the advantage of providing analgesia for visceral and somatic pain [8] ; to the best of our knowledge, clinical trials comparing different aspects of efficacy and safety between ultrasound-guided TAP and epidural analgesia are few. Thus, the present study was designed to investigate both the efficacy and safety of TAP versus epidural analgesia in lower abdominal surgery.


  Patients and methods Top


After approval from the hospital ethics committee, the study was conducted on 60 patients aged 20-75 years, who were admitted to Al-Azhar University Hospitals from February 2013 to March 2014. Patients were allocated to either group I (ultrasound-guided TAP, 30 cases) or group II (epidural block, 30 cases) using a randomized central computer-generated sequence held by an investigator not involved with the clinical management or data collection. All patients received a standard general anesthetic involving induction with propofol (1 mg/kg for geriatric patients; 1.5-2 mg/kg for young patients) and succinylcholine (1.5-2 mg/kg) and continued paralysis with atracurium 0.5 mg/kg; anesthesia was maintained with sevoflurane on MAC 2. All cases received intravenous fentanyl at 1 mg/kg. Standard monitoring maintained throughout the procedure included ECG (3-leads), noninvasive arterial blood pressure, oxygen saturation, and capnometry.

Exclusion criteria

Exclusion criteria were as follows: patients aged less than 20 years; presence of absolute contraindications to TAP blocks, including patient refusal, soft-tissue infection of the abdominal wall and skin; patients requiring urgent surgery; those requiring postoperative mechanical ventilation; presence of communicative or cognitive limitations interfering with pain measurements; and patients suffering from coagulopathy.

Technique for ultrasound-guided TAP block

The ultrasound probe (7-10 MHz linear array ultrasound transducer) was placed in a plane transverse to the lateral abdominal wall in the midaxillary line, between the lower costal margin and the iliac crest. The needle was introduced under aseptic conditions in the plane of the ultrasound probe directly under the probe and advanced until it reached the plane between the internal oblique and transversus abdominis muscles (the TAP). Upon reaching the plane, 2 ml of saline was injected to confirm correct needle position, after which 20 ml of local anesthetic solution (bupivacaine 0.5 ml/kg of 0.125%) was injected. The TAP was visualized expanding with the injection (appears as a hypoechoic space). The use of ultrasound allows for accurate deposition of the local anesthetic in the correct neurovascular plane [Figure 1].
Figure 1: Ultrasound image showing local anesthetic splitting transversus abdominal plane. EO, external oblique; IO, internal oblique; TA, transversus abdo minis

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Epidural technique

Unless contraindicated, epidural analgesia was offered before induction of general anesthesia between lumbar vertebrae 3-4 to all patients undergoing open abdominal surgery. Patients with epidural analgesia received bupivacaine 0.125% at 4-8 ml/h. In case of inadequate pain reduction [visual analog scale (VAS) score>4], the epidural catheter was tested with a bolus dose of 5 ml lidocaine 1% and the maintenance dose was increased by 2 ml/h. In general, the epidural catheter was removed on the second postoperative day; however, if required, the treatment was continued until the patient was pain free.

Concentration was adjusted on the basis of intraoperative hemodynamics to maintain an end-tidal concentration of 1.5-2%. All patients had a urethral Foley catheter inserted before the incision. Lactated Ringer's solution was used as the maintenance fluid and intraoperative losses were adequately replaced.

Outcome measures

The primary outcome was the proportion of participants who used more than 200 mg/kg of morphine during the first 24 h on arrival at the recovery ward. Secondary outcomes included the following: morphine consumption of 0.1-0.2 mg/kg 24 h after operation; pain measured with 0-10 self-assessment VAS in the recovery ward and at 2, 6, 10, 14, 18, and 24 h after operation (if the patient was asleep, the VAS was recorded as zero); postoperative nausea and vomiting (PONV) measured with the total number of vomits during the first 24 h; and time to hospital discharge, adverse effects of TAP blocks, including bleeding, swelling, or bruising at the injection site were recorded.

Statistical analysis of data

The data of the present work were coded, tabulated, and statistically analyzed using a personal computer with IBM-SPSS statistics computer package, version 18 (IBM Corp., Armonk, New York, USA). Normally distributed numerical data are presented as mean and SD. Qualitative data are presented as relative frequency and percentage distribution. For normally distributed numerical data, the independent samples Student's (t) test was used to compare the difference in the means between the two studied groups. The Pearson c2 -test was used for comparison of the two groups as regards differences in categorical data. Fisher's exact test was applied in place of the c2 -test (if 20% of the cells in any contingency table had an expected count of less than 5). All P values are two sided, and P values less than or equal to 0.05 were considered statistically significant.


  Results Top


In the present study, there was no significant difference between the studied groups as regards the ASA classification (76.7% of group I were ASA I compared with 73.3% of group II), sex distribution (men represent 76.7 and 60.0% of groups I and II, respectively), and age (the mean ± SD age was 40.73 ± 1.43 and 42.16 ± 4.29 of groups I and II, respectively). In addition, there was no significant difference between groups as regards time at recovery room, need for paracetamol during the first 8 h after surgical intervention, PONV, and duration of hospital stay (2.13 ± 0.57 days in group I and 2.06 ± 0.44 days in group II). In contrast, there was significant increase in intervention duration in group I in comparison with group II (103.16 ± 11.17 vs. 93.43 ± 6.22 min, respectively). In addition, there was significant decrease in total morphine required during the first 8 h in group I in comparison with group II (69.0 ± 12.95 vs. 80.0 ± 11.52, respectively), and there was significant increase in the time interval to when the first dose of morphine or first dose of paracetamol was needed in group I (TAP) compared with group II. Finally, there was significant decrease in cases that needed more than 200 mg of morphine during the first 24 h in the TAP group compared with the epidural group (43.3 vs. 73.3%, respectively) [Table 1].
Table 1 Characteristics of patients in both groups

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As regards the VAS, it was found that, there was statistically significant decrease in VAS in group I compared with group II at 2, 6, 10, 14, and 18 h postoperatively. At 24 h, there was no significant difference between the two groups as regards VAS [Table 2].
Table 2 Visual analog score at different postoperative time in the two groups

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  Discussion Top


Poorly controlled acute pain after abdominal surgery is associated with a variety of unwanted postoperative consequences, including patient suffering from distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, and an increased likelihood of chronic pain. A major contributor to the pain experienced after abdominal surgery is pain from the incision made in the abdominal wall, with the remainder resulting from internal visceral trauma. Traditionally, analgesia for abdominal surgery is provided either by means of systemic drugs such as opioids, ketamine, NSAIDs, a2 agonists, and paracetamol or by means of epidural anesthesia [10] .

Peripheral nerve blockade is an alternative means of providing analgesia by anesthetizing the sensory nerves conveying pain impulses from the incision site to the spinal cord and brain [10] .

The TAP block is a peripheral nerve block that anesthetizes the abdominal wall. Although this technique was first described in 2004, variations have been used by anesthetists for decades, without becoming widely adopted [11] .

The advent of ultrasound as a means of localizing the nerves for block placement provides excellent results for survivors of this technique. Supporters of this technique suggest that analgesia provided by the TAP block is equal or superior to that provided by systemic opioids such as morphine. It has also been claimed that postoperative opioid consumption and opioid-derived adverse effects can be reduced [12],[13] . Furthermore, the TAP block may have a lower risk of complications and greater acceptability in patients compared with epidural analgesia [10] .

There have been no reports evaluating the efficacy of the TAP block in comparison with epidural block for pain relief after lower abdominal surgery. Thus, the present study was designed to give the author's experience with both techniques.

The results of the present study showed that there was significant increase in all intervention time in the ultrasound-guided TAP group compared with the epidural group, which means that the TAP procedure requires more time. In contrast, ultrasound-guided TAP is associated with decreased scores on the VAS and with reduced need for analgesics postoperatively. Further, the time interval to when these analgesics are requested is longer in the TAP procedure compared with epidural block. Finally, there was significant decrease in cases that needed more than 200 mg of morphine during the first 24 h in the ultrasound-guided TAP group compared with the epidural group (43.3 vs. 73.3%, respectively).

The results are consistent with those of previous studies that reported analgesic benefits of TAP block in abdominal surgeries [10] . In addition, McDonnell et al. [11] reported statistically significant reduction in morphine requirements after large bowel resection in patients receiving TAP block with 20 ml of 0.375% bupivacaine (P < 0.05). Moreover, Hebbard [14] reported that subcostal TAP block provided postoperative analgesia after upper abdominal surgery in a series of 20 patients.

In addition, Carney et al. [15] reported that TAP block provides highly effective postoperative analgesia during the first 24-48 h. Overall, during the first 24 postoperative hours, the TAP block reduced the mean intraveneous morphine requirements by more than 70%. This reduction in opioid requirement resulted in fewer opioid-mediated side effects. The incidence of PONV was reduced by more than half in the TAP block group. These results are supported by the present work.

Epidural analgesia can provide optimal analgesia for abdominal wall structures as well as for deep visceral pain; however, it is unquestionably contraindicated in sepsis, hemodynamic instability, or anticoagulant medications, which necessitate the importance of another safe and reliable technique. In the present study, all cases were elective and the decision for the course of epidural analgesia was predicted to be safe [14] .

In the literature, there are few studies comparing both techniques. For example, Niraj et al. [16] reported that rescue analgesia with tramadol was significantly higher in the TAP block (400 mg) group than in the epidural group (200 mg) (P = 0.002), which is inconsistent with the result of the present study of low morphine consumption in the TAP group. This can be attributed to different protocols used in their study. In addition, the values of VAS scores in their groups were statistically insignificant.


  Conclusion Top


We found significant advantage of ultrasound-guided TAP over epidural analgesia in terms of efficacy of postoperative analgesia and time of need and quantity of postoperative analgesics. Thus, ultrasound-guided TAP may be an effective alternative for providing postoperative analgesia after lower abdominal surgery.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Jankovic Z. Transversus abdominis plane block: the Holy Grail of anesthesia for (lower) abdominal surgery. Period boil 2009; 111:203-208.  Back to cited text no. 1
    
2.
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007; 35:616-617.  Back to cited text no. 2
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3.
Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesthia 2009; 102:143-144.  Back to cited text no. 3
    
4.
McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, Laffey JG. 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. 4
    
5.
O'Donnell BD. The transversus abdominis plane (TAP) block in open retropubic prostatectomy [Letter to the Editor]. Reg Anesth Pain Med 2006; 31:91.  Back to cited text no. 5
    
6.
French JL, McCullough J, Bachra P, Bedforth NM. Transversus abdominis plane block for analgesia after caesarean section in a patient with an intracranial lesion. Int J Obstet Anesth 2009; 18:52-54.  Back to cited text no. 6
    
7.
Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med 2008; 33:274-275.  Back to cited text no. 7
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8.
Jankovic Z, Ahmadn R, Ravishankar NA. Transversus abdominis plane block: how safe is it? Anesth Analg 2008; 107:1758-1759.  Back to cited text no. 8
    
9.
Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 2007; 94: 665-673.  Back to cited text no. 9
    
10.
Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev 2010; 67:124-127.  Back to cited text no. 10
    
11.
McDonnell JG, O'Donnell BD, Tuite D, Farrell T, Power C. The regional abdominal field infiltration (RAFI) technique: computerised tomographic and anatomical identification of a novel approach to the transversus abdominis neuro-vascular fascial plane. Anesthesiology 2004; 101:A899.  Back to cited text no. 11
    
12.
McDonnell JG, O'Donnell B, Curley G, 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.  Back to cited text no. 12
    
13.
Randall IM, Costello J, Carvalho JC. Transversus abdominis plane block in a patient with debilitating pain from an abdominal wall hematoma following cesarean delivery. Anesth Analg 2008; 106:1928.  Back to cited text no. 13
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14.
Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008; 106:674-675 author reply 675.  Back to cited text no. 14
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15.
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.  Back to cited text no. 15
    
16.
Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011; 66:465-471.  Back to cited text no. 16
    


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