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Audit of initial use of the ultrasound-guided transversus abdominis plane block in children.

Transversus abdominis plane (TAP) block is described in adults for lower abdominal surgery including radical prostatectomy (1), midline lower abdominal bowel surgery (2,3), appendicectomy (3,4), caesarean section (3,5-7), total abdominal hysterectomy (8), laparoscopic gynaecological surgery (9), inguinal hernia repair (10), for caesarean wound haematoma pain (11) and for laparoscopic cholecystectomy (with infraumbilical ports) (12). The techniques described are a lateral supra-iliac (Triangle of Petit) blind approach (1,5,8,13) versus the anterior supra-iliac (3,9,12) and sub-costal6 approaches with ultrasound guidance.

Various local anaesthetic (LA) agents have been used at different concentrations and volumes. There is debate about the height of the dermatomal block achievable. One group stated that T7-L1 coverage occurs (n=6)13. Others argue that, as a mean height of T10 is achieved with 20 ml (n=12 (6) and 26 (9)), the suprailiac TAP block should be reserved for lower abdominal surgery. This is also supported by a recent cadaver ultrasound-guided (UG)-TAP study (14) where, following 20 ml supra-iliac injections (n=16), dye involved 50% of T10 and 0% of T9 segmental nerves.

Small paediatric case series are reported of neonates post laparotomy (n=4) (15), children having inguinal hernia repair (n=8) (16) and adolescents having laparoscopic appendectomy (n=4) (10) using 0.3 ml/kg of 0.5% lignocaine and 0.5% ropivacaine with 1/200,000 adrenaline (15,16) and 20 ml of 0.25% levobupivacaine (10). A guideline article (17) describes an UG-TAP technique (recommending 0.2 ml/kg to a maximum of 20 ml per side with bupivacaine, limited to a total dose of 3 mg/kg in children and 4 mg/kg in adolescents) listing multiple indications for paediatric TAP blocks, including upper abdominal surgery. These paediatric articles do not report dermatomal block extent. We consequently performed a prospective audit (prior to any paediatric publication being available) of our department's initial use during an ultrasound-training period to establish the extent of dermatomal block following the supra-iliac UG-TAP block in children.


The Ethics and Human Research Committee Chairman of the Royal Children's Hospital (RCH) approved a prospective audit. RCH is a tertiary paediatric centre with 16,000 operations performed annually: 3750 for general, urological and gynaecological surgery. Patients audited received an UG-TAP block as part of multimodal analgesia for surgery via anterior abdominal wall incisions (and no LA infiltration or other nerve or field block). Blocks were performed via the anterior supra-iliac approach (4,17) after induction of general anaesthesia. The LOGIQ e US machine (GE Healthcare, General Electric Company, UK, 2007) with the 12 MHz linear or 6 to 10 MHz 'hockey stick' probe (in younger children) and the 'nerve block' preset function were used. The US probe was placed on the abdominal wall transversely, in the midline inferior to the umbilicus, to identify the rectus aponeurosis (figure of 8 pattern) and the overlying fat layer. It was then moved laterally over the rectus abdominus muscle and beyond to image initially the transversus abdominus, then the internal oblique, between which the TAP lies. Proceeding further laterally, the outer-most muscle of the three lateral abdominal wall muscle layers is now seen (the external oblique). We believe this technique (which is standard for the subcostal TAP approach) is superior to placing the probe immediately on the lateral aspect of the abdomen, for the supra-iliac approach, as the fat layer (which has variable echogenicity, pattern and outline) is not misidentified as the external oblique muscle layer.

After anterior identification of the TAP, the probe is moved posterolaterally to lie transversely at the mid-axillary line between the iliac crest and the lower costal margin. The depth of view is adjusted to include visualisation of the three muscles, peritoneum and part-view of bowel below. The needle is introduced via the anterior abdominal wall one patient's fingerbreadth medial to the probe (above and medial to the anterior superior iliac spine) and directed posteriorly. The skin can be indented by the probe to flatten the muscles (Figure 1 and 2A). The endpoint for advancement of the needle tip is to lie within the fascial plane, in between the internal oblique and TA muscle bellies (the TAP plane). Needle shaft/tip passage is observed real-time ('in plane' to the probe), along with the distension by LA (post negative aspiration test) (Figure 2B). As TAP block volume data in children were unavailable at the time of the audit, anaesthetists were instructed to administer a minimum of 0.2 ml/kg LA, remaining below a maximum dose of 2.5 mg/kg bupivacaine or 3 mg/kg ropivacaine. The needle type was not prespecified; the choice of gauge and length was left to the anaesthetist's discretion as paediatric patient size varies. The relative echogenicity of the needles used was documented by the auditor (author VL).



Data collection and handling

Information collected included patient demographics, surgical procedure and features of the UG-TAP block/s performed, and anaesthetic details. When the patient was awake and co-operative (score 0 or 1 on the University of Michigan Sedation Scale--the sedation tool used routinely by RCH's recovery and ward nurses18), a single investigator (who was present during but did not perform the blocks--VL) was paged to assess the dermatomal blockade using response to ice according to the institution's dermatomal map (where T5 is nipple level, T10 is peri-umbilical and L2 is mid-thigh). The ice was placed on an area anticipated to be insensate (T11) and moved rostrally then caudally from there asking the patients to report when they could feel cold. If patients were non-verbal, then a change in facial expression or flinch was used to demarcate the level (a technique used and taught by our institution's pain service). A pain score was recorded at the same time using one of three tools that are employed by the pain service depending upon patient age and verbal capability. For those patients who were non-verbal or aged less than five years, the observer-rated Faces, Legs, Activity, Cry and Consolability Scale (19) was used. For older children, self-reporting was used with the Wong-Baker Faces pain scale (20) for patients between five and seven years old and the verbal numeric pain rating scale (0 to 10) for those over seven years old (21).

Data were entered using EpiData 3.1 (the EpiData Association, Denmark, 2003 to 2004) and analysed using Stata version 10.0 (Stata Statistical Software, StataCorp LP, Texas, USA). Data are presented as frequency or as mean and standard deviation (SD) when normally distributed and as median and inter-quartile range (IQR) when non-normally distributed. The maximum dose of LA and full range for dermatomal levels and time of assessment is also presented. Patients were divided into two groups based on surgical invasiveness--minimally invasive (limited to abdominal wall and extraperitoneal surgery) and invasive (involving intra-abdominal/ intraperitoneal [+ or -] visceral surgery) to tabulate their perioperative analgesic requirement.

Dermatomal block spread was plotted against each LA dose (mg per kg patient body weight), volume and concentration for the most frequently used local anaesthetic agent, which was levobupivacaine plain (i.e. without adrenaline). Associations were summarised using the Spearman's correlation coefficient. P values less than 0.05 were considered statistically significant.


The audit was performed over two training periods involving different anaesthetic consultants and trainees from September to November 2007 and February to April 2008 (4.5 months total). Twenty-seven patients received a total of 38 TAP blocks: 16 unilateral, 11 bilateral. These were performed by consultants (58%), 5th (24%) to 3rd (18%) year trainees (90% for the first time) and 82% with a single needle pass. Table 1 lists patient age, weight, gender, premedication and intraoperative opioid, sorted according to surgery type and invasiveness.

Figure 2 demonstrates the typical US view obtained with the TA neurofascial plane, represented by the hyper-echoic (white) line running between the internal oblique and TA muscles [2A] and the lens shape of LA depot post-injection [2B]. A mean LA volume of 0.4 ml/kg (SD 0.2) or 10.8 ml (SD 4.2) was injected per block.

The LA agents used were 0.25 or 0.5% levobupivacaine (69%: 13% with adrenaline) or bupivacaine (8%: 3% with adrenaline), or 0.25% combined with 2% lignocaine (10%) or 0.25 to 0.75% ropivacaine (13%). The dose administered of levo or racemic bupivacaine per block was a mean of 1.4 (SD 0.6) mg/kg (maximum 2.5 mg/kg) and for ropivacaine was 1.4 (SD 0.3) mg/kg (maximum 1.7 mg/kg). The maximum volume injected was 20 ml. The needle types used included 22 g St Vincent's[R] needles (Portland Medical, Portland, Victoria, Australia: 67%), 23 g Terumo[R] (Terumo Medical Products, Tokyo, Japan: 24%) or 20 to 22 g Stimuplex[R] (B.Braun, Sydney, NSW: 9%). The St Vincent's and Stimuplex were more hyper-echoic than the slimmer Terumo needles. No peritoneal puncture or haemorrhage was observed and no complications were experienced relating to UG-TAP block insertion.

The dermatomal extent of sensory blockade was assessed at a median of 135 minutes (IQR 75 to 172.5, range 40 to 365) after LA injection for 35 TAP blocks in 25 patients. Of those not assessed, one was autistic and not approachable and for the second, the auditor was not available afterhours. One 12-year-old patient, who had scrotal exploration via an inguinal approach, had no block to ice assessed 60 minutes post-injection of 10 ml 0.5% levobupivacaine (0.24 ml/kg). He had intraoperative fentanyl (1.2 [micro]g/kg), a postoperative verbal numeric pain rating scale of 0 and required no postoperative analgesia. The remaining 24 patients had median upper and lower dermatomal levels of sensory block to ice of T10 and L1 (range T8 to L2) with a median number of dermatomes covered of 3 (IQR 3 to 4). Three patients (four blocks) had loss of sensation to T8 following 0.29 to 0.57 ml/kg and three patients (four blocks) had loss of sensation to T9 following 0.31 to 0.81 ml/kg. Five of these high blocks involved L2 as their lowest dermatome (to mid-thigh) and a sixth patient had a block from T10 to L2 with 0.5 ml/kg. Figure 3 shows the relationship of total number of dermatomes blocked to ice with the dose (mg/kg patient body weight; 3A), volume (ml/kg patient body weight; 3B), and two concentrations (3C) used of plain levobupivacaine (n=19). The Spearman correlation coefficients are 0.31 for both dose and volume (per kg patient body weight) suggesting possible association with block spread, with non-significant P values of 0.19 and 0.20 respectively. For concentration and block spread the coefficient is 0.05 and P=0.86, suggesting no association.

The patients' postoperative pain scores were recorded at the time of block assessment at a median of 50 (IQR 30 to 82.5) minutes following surgery completion. These are amalgamated across the tool type used (all 0 to 10 scale) and presented according to surgery type in Figure 4. The overall postoperative pain score was low: median 1/10 (IQR 0 to 2). Only 'invasive surgery' patients reported pain scores of more than 3/10. All invasive surgery patients required additional postoperative analgesia (Table 1), while half of the minimally invasive surgery patients required no postoperative analgesia.




This prospective audit of a small cohort is the first to document the multi-level dermatomal blockade achieved following UG-TAP blocks in children. The anterior supra-iliac ultrasound guided approach performed by multiple novice operators reliably produced lower abdominal sensory blockade of usually three and sometimes four dermatomes. We affirm extension of the recommendation to reserve the supra-iliac TAP block approach for lower abdominal surgery in adults (6,9) to children. We do not support listing upper abdominal surgery (such as pyloromyotomy and Nissen fundoplication) as an indication using 0.2 ml/kg via this approach (as suggested by Suresh and Chan (17)), as only 25% of this audit's assessed blocks involved upper abdominal dermatomes, requiring injected volumes greater than 0.3 ml/kg.

The prior adult patient studies report a range of injected LA concentrations and volumes: levo- and racemic bupivacaine 0.25 to 0.5% 15 to 40 ml (1,2,10-12) and ropivacaine 0.5 to 0.75% 20 ml (3,8). The cadaver studies used 20 ml injectate (13,14). The volunteer series (13) reported wide dermatomal block with 20 ml supra-iliac injection of low concentration and dose (0.5% lignocaine or 0.1% levobupivacaine in six adults) maximal 90 minutes post-injection with one volunteer having altered sensation to T4. Only a few publications (2,5,8,12) report patient weight (mean 66 to 80 kg) equating to LA volumes used of 0.18 to 0.3 ml/kg. In this paediatric audit, the LA agent, doses, concentrations and volumes administered also varied. The volumes used were mostly larger than used in adults and larger than the since published reports in children of dosing with 0.2 (17) and 0.3 ml/kg (16). Plotting the weight-based doses and volumes for plain levobupivacaine administered against dermatomal spread demonstrates variation in the extent of dermatomal block achieved. The Spearman correlation coefficients suggest a positive association that may become statistically significant with a larger sample size. A greater number of data points would also better define the type of relationship (i.e. whether it is linear or sigmoidal). The clinical translatability is also limited as the block heights were assessed at convenient and not fixed times. The time at which maximum block spread or peak effect occurs is also not established. Reported dermatomal assessment in adults has occurred at variable times post-block insertion from 30 (9) and 60 minutes (13) to four13 and more (6,13) hours later. The small volunteer study (with low LA concentration/dose) (13) suggested peak effect at 90 minutes with recession at four hours. The majority of dermatomal blocks to ice in this paediatric audit were assessed within one to three hours. Serial measurements following clinically employed doses in a larger case series are required, including determination of whether adrenaline (as used by Frederickson (15,16)) has an additive effect. Opioid-sparing efficacy (up to 48 hours) is established in adults (2,5,8,12) but duration of block is uncertain (12 (10) to 24 (3) hours have been suggested). Although the pain scores were low, this audit cannot address efficacy as the patient age, pain assessment tools used, surgery types performed and rescue analgesia used were heterogeneous. The optimal dose and volume for UG-TAP in both adults and children requires further clarification. Our current recommendation following this audit is for a minimum volume of 0.3 ml/kg. As has been found for ultrasound guided ilio-inguinal/ilio-hypogastric blocks (22), we acknowledge that lower volumes (such as recommended by Suresh and Chan (17)) are likely adequate but we will refine our departmental guidelines once more information of duration of effect is known.

The TAP block can be considered an addition to the available analgesic armamentarium. No comparative trials with regional or other peripheral techniques exist to date. The TAP block (single-shot or catheter technique) is a consideration when the motor block of caudal or epidural local anaesthetic infusion is undesirable, these techniques fail or are contraindicated, or sympathetic or visceral block is not desirable. As the L1 segmental nerve may exit the muscle layer more anteriorly (14), TAP blocks may be inferior to ilio-hypogastric/ilio-inguinal blocks for inguinal surgery in a percentage of patients. The patient in this series with no demonstrable block to ice had an adequate volume injected (per Suresh and Chan's guidelines). With the 0.5% concentration used and assessment at 60 minutes, a degree of demonstrable block would be expected in the lower thoracic dermatomes and thus the aforementioned L1 anatomical variation is not an explanation. A later dermatomal assessment in this patient would have helped clarify this, in light of his lack of pain and analgesic requirement, but was not performed. The lower extent of a percentage of blocks to involve the mid-thigh usually attributed to the 'L2 dermatome' is most likely explained by anatomical variation, with the L1 segmental nerve skin supply extending more caudal than usual.

Similar to previous TAP block literature, this paediatric audit has low patient numbers limiting the level of conclusions that can be drawn. The low number of UG-TAP blocks performed during the audited months was a consequence of various factors. The portable US machine was a new departmental acquisition; two anaesthetists received US training to then educate the rest of the department. Block frequency was influenced by availability of the trained anaesthetists, the US machine (used also for vascular access), appropriate patients and time. Additionally, the audit occurred across two trainee rotations requiring repeat staff education sessions and regeneration of enthusiasm. Patient numbers to date are inadequate in this and previous reports (totalling 140 adults and 40 children) to draw conclusions regarding safety and rare but serious outcomes, although where the block is performed using real-time imaging, the risk is likely to be reduced.

The preliminary data provided by this small-scale prospective audit is positive. It suggests that the UG-TAP block via the supra-iliac approach in the hands of novice operators reliably achieves dermatomal block and spread that is adequate for paediatric patients having lower abdominal surgery. Specifically designed studies are required to establish the optimal LA type and dosing regimes and whether the addition of adrenaline affects dermatomal block spread or duration. A larger series will affirm the type and significance of association between dose and volume used and extent of block. It is likely that the TAP block has clinical utility as part of multimodal analgesia but it remains to be determined if this block is superior to alternative peripheral or regional nerve blocks that also produce sensory blockade of the abdominal wall.


The Department of Human Services (Melbourne, Victoria) provided funding for the purchase of the LOGIC e Ultrasound machine. We would also like to acknowledge Dr Peter Hebbard for presenting his data and demonstrating his technique at a RCH anaesthetic department meeting.


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G. M. PALMER *, V. H. Y. LUK ([dagger]), K. R. SMITH ([double dagger]), E. K. PRENTICE ([section]) Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia

* F.F.P.M.A.N.Z.C.A., F.A.N.Z.C.A., M.B., B.S., Clin. Assoc. Prof., Paediatric Anaesthetist, Pain Management Specialist and Deputy Head, Children's Pain Management Service, Department of Anaesthesia and Pain Management, Royal Children's Hospital, Murdoch Childrens Research Institute and University of Melbourne.

([dagger]) B.Med.Sci., Medical Student, Department of Paediatrics, University of Melbourne.

([double dagger]) B.Sc. (Hons), Statistician, Murdoch Childrens Research Institute.

([section]) M.B., B.S., F.A.N.Z.C.A., Consultant Anaesthetist, Department of Paediatric Anaesthesia and Pain Management.

Address for correspondence: Dr G. Palmer, C/O Department of Anaesthesia and Pain Management, Royal Children's Hospital, Flemington Rd, Parkville, Vic. 3052.

Accepted for publication on November 2, 2010.
Patient demographics, surgery types, premedication, intraoperative and
postoperative analgesic details

 Minimally invasive, n=15

 Age, y, median (IQR) 5.7 (2.3-7.3)
 Male gender, n (%) 12 (80)
 Weight, kg, median (IQR) 21 (14-27)
Surgery types, n (%)
 Umbilical hernia repair 2 (13)
 Inguinal herniotomy for hernia repair 13 (87)
 (10), scrotal exploration (1),
 hydrocoele repair (1), orchidopexy (1)
 Laparotomy --
 Laparoscopy --
Premedication, n (%)
 None 3 (20)
 Paracetamol 7 (47)
 Paracetamol and other 1 (7) + ibuprofen
 Oral midazolam with paracetamol 4 (27)
Intraoperative analgesia, n (%)
 None 8 (53)
 Fentanyl--mean dose 0.78 6 (40)
 [micro]g.[kg.sup.-1] (SD 0.3)
 Morphine, mean dose 0.1 mg.[kg.sup.-1] 0
 (SD 0.03) and ketorolac (1), IV
 paracetamol * (3), ketamine (3) or
 tramadol * (2)
 Tramadol - 1 (7) + IV paracetamol *
 IV paracetamol * 0
Postoperative analgesia, type n (%)
 None 8 (53)
 Codeine 3 (20)
 Ibuprofen 2 (13)
 Tramadol oral 2 (13)
 Tramadol/paracetamol IV/ibuprofen 0
 Morphine/paracetamol IV 0
 Morphine/tramadol/paracetamol IV 0
Time to first rescue analgesia, minutes, 65 (40-75)
 median (IQR)

 Invasive, n=13

 Age, y, median (IQR) 7.5 (3.4-11.5)
 Male gender, n (%) 7 (54)
 Weight, kg, median (IQR) 30 (17.5-44)
Surgery types, n (%)
 Umbilical hernia repair --
 Inguinal herniotomy for hernia repair --
 (10), scrotal exploration (1),
 hydrocoele repair (1), orchidopexy (1)
 Laparotomy 4 (31)
 Laparoscopy 9 (69)
Premedication, n (%)
 None 7 (54)
 Paracetamol 4 (31)
 Paracetamol and other 1 (8) + codeine
 Oral midazolam with paracetamol 1 (8)
Intraoperative analgesia, n (%)
 None 0
 Fentanyl--mean dose 0.78 0
 [micro]g.[kg.sup.-1] (SD 0.3)
 Morphine, mean dose 0.1 mg.[kg.sup.-1] 11 (84)
 (SD 0.03) and ketorolac (1), IV
 paracetamol * (3), ketamine (3) or
 tramadol * (2)
 Tramadol - 1 (8)
 IV paracetamol * 1 (8)
Postoperative analgesia, type n (%)
 None 0
 Codeine 0
 Ibuprofen 0
 Tramadol oral 0
 Tramadol/paracetamol IV/ibuprofen 1 (8)
 Morphine/paracetamol IV 5 (38)
 Morphine/tramadol/paracetamol IV 7 (54)
Time to first rescue analgesia, minutes, 50 (40-125)
 median (IQR)

 All patients, n=28

 Age, y, median (IQR) 5.7 (3.1-9.9)
 Male gender, n (%) 19 (68)
 Weight, kg, median (IQR) 21.5 (15.8-35.2)
Surgery types, n (%)
 Umbilical hernia repair 2 (7)
 Inguinal herniotomy for hernia repair 13 (47)
 (10), scrotal exploration (1),
 hydrocoele repair (1), orchidopexy (1)
 Laparotomy 4 (14)
 Laparoscopy 9 (32)
Premedication, n (%)
 None 10 (36)
 Paracetamol 11 (39)
 Paracetamol and other 2 (7)
 Oral midazolam with paracetamol 5 (18)
Intraoperative analgesia, n (%)
 None 8 (29)
 Fentanyl--mean dose 0.78 6 (21)
 [micro]g.[kg.sup.-1] (SD 0.3)
 Morphine, mean dose 0.1 mg.[kg.sup.-1] 11 (39)
 (SD 0.03) and ketorolac (1), IV
 paracetamol * (3), ketamine (3) or
 tramadol * (2)
 Tramadol - 2 (7)
 IV paracetamol * 1 (4)
Postoperative analgesia, type n (%)
 None 8 (19)
 Codeine 3 (11)
 Ibuprofen 2 (7)
 Tramadol oral 2 (5)
 Tramadol/paracetamol IV/ibuprofen 1 (2)
 Morphine/paracetamol IV 5 (18)
 Morphine/tramadol/paracetamol IV 7 (25)
Time to first rescue analgesia, minutes, 57.5 (40-100)
 median (IQR)

IQR=interquartile range, IV=intravenous. * IV paracetamol mean dose
16.7 mg.[kg.sup.-1] (SD 2.0). (#) Tramadol mean dose 2.7
mg.[kg.sup.-1] (SD 1.1)
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Author:Palmer, G.M.; Luk, V.H.Y.; Smith, K.R.; Prentice, E.K.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2011
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