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The efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing hysterectomy.

An important component of the pain experienced by patients after abdominal surgery comes from the abdominal wall incision (1). The abdominal wall sensory afferents course through the transversus abdominis plane superficial to the transversus abdominis muscle (2). Transversus abdominis plane (TAP) block was first described by Rafi in 2001 (3) and can be performed by a landmark technique or under ultrasound guidance. This block provides effective postoperative analgesia after colorectal surgery (4), caesarean delivery (5), inguinal herniography, open radical prostatectomy (6), laparoscopic cholecystectomy (7), open appendicectomy (8) and renal transplantation (9). Patients having total abdominal hysterectomy (TAH) are also likely to benefit from multimodal pain management.

Bonnet et al suggested that larger studies comparing the TAP block technique with alternatives such as wound catheters, neuraxial techniques and wound infiltration were needed to further define the role of TAP blocks in postoperative pain management (10). No study has compared ultrasound guided TAP block with bupivacaine infiltration of the wound (skin and subcutaneous tissue) for postoperative pain management. The aim of this study was to evaluate the analgesic efficacy of ultrasound-guided TAP block by comparing it with superficial bupivacaine wound infiltration in patients undergoing TAH.

METHODS

Following approval of the Institutional Review Board, 60 female patients (American Society of Anesthesiologists physical status score I to III) who were scheduled for elective TAH via Pfannenstiel abdominal wall incision under general anaesthesia were included in this prospective, double-blind randomised controlled study. All patients provided written informed consent. Patients with known allergy to any of the study medications, receiving medical therapies producing tolerance to opioids, with coagulopathy, psychiatric problems or inability to operate a patient-controlled analgesia device were excluded. Following enrolment, patients whose surgery did not proceed to TAH were also excluded from the study.

A preoperative evaluation was performed the day before surgery and patient-controlled analgesia technique and visual analog scale pain score were explained. Patients were randomised in equal numbers within blocks of 20 and allocation was by sealed envelope. Patients were divided into three groups: the TAP group (n=18) received bilateral TAP blocks with 0.25% bupivacaine (20 ml) each side, a control group (n=18) received sham bilateral TAP blocks with 20 ml 0.9% saline, and for the infiltration group (n=19) the skin and subcutaneous tissues of the surgical incision site were infiltrated with 0.25% bupivacaine (20 ml) at the end of the surgery. The patient, anaesthetists and the staff providing postoperative care were blinded to the group assignment.

Patients were monitored with electrocardiogram, arterial blood pressure, arterial oxygen saturation and end-tidal carbon dioxide monitoring. All had standardised general anaesthesia induced with intraveneous (IV) fentanyl (1.5 [micro]g/kg), propofol (2 mg/kg) and vecuronium (0.1 mg/kg). Anaesthesia was maintained with 50% nitrous oxide in oxygen and 1.5% sevoflurane and patients were mechanically ventilated to maintain the end-expiratory carbon dioxide (C[O.sub.2]) 34 to 36 mmHg. Diclofenac sodium 75 mg IV was given immediately before surgical incision and before closure of the surgical incision, 0.5 mg/kg IV tramadol was administered. Patients were connected to the IV patient-controlled analgesia device for 24 hours, receiving a tramadol 3 mg/ml 20 mg bolus with a lockout interval of 10 minutes and four hour maximum dose of 150 mg. Patients with a pain score [greater than or equal to] 4 were given 1 mg/kg pethidine intramuscularly as rescue analgesic.

Following induction, patients allocated to bilateral TAP blocks had these performed with a Logiq-e Ultrasound (General Electric Medical Systems, Milwaukee, Wisconsin, USA) and a linear 7-11 MHz ultrasound transducer. In a sterile manner, the block was performed with a 20 gauge, 100 mm Facette tip needle (B. Braun Stimuplex, Melsungen, Germany) using an 'in-plane' technique. Postoperative pain was evaluated at rest and on movement (hip joint flexion) using 0 to 10 cm visual analog scale scores. Postoperative haemodynamic variables, oxygen saturation, respiratory rate, pain scores and tramadol consumption were recorded postoperatively in the post-anaesthesia care unit at 1, 2, 4, 6 and 24 hours. All measurements were taken by the same anaesthetist who was blinded to the study group.

The presence and intensity of side-effects (e.g. nausea and vomiting) were assessed in the postanaesthesia care unit at 1, 2, 4, 6 and 24 hours after surgery. Nausea was measured using a categorical scoring system (none=0, mild=1, moderate=2, severe=3). Vomiting was noted and ondansetron 4 mg IV used for treatment. Sedation was rated on a categorical scale (awake and alert=0, quietly awake = 1, asleep but easily roused=2, deep sleep=3).

STATISTICAL ANALYSES

Statistical analyses were performed using SPSS for Windows V.15.0 (SPSS Inc., Chicago, IL, USA). The estimated sample size was calculated using the Power and Sample Size Calculator v.2.0.1. Our previous experience showed that the average total tramadol consumption was 260 mg (SD 65 mg). We assumed that with use of a TAP block, we could achieve 25% reduction in postoperative tramadol consumption. Our power analysis indicated that for 5% alpha error and 90% power, at least 17 patients were needed per group. Descriptive statistics in the tables are shown as median and data in the figures are presented as mean (standard error of mean). Kruskal Wallis tests were used to compare the three groups, and Bonferonni-corrected Mann-Whitney U tests used for pairwise comparisons. Chi square tests were used to compare percentages. A P value <0.05 was considered statistically significant.

RESULTS

Two patients from TAP group, two patients from the control group and one patient from infiltration group were excluded because the surgeons decided to perform vaginal hysterectomy. The groups were comparable for patient age and operative procedure performed. There were no differences between the groups for complications (Table 1) and patients receiving TAP blocks had no procedural complications. Comparison of the groups for rest and movement pain scores showed a statistically significant difference between the groups (Figures 1 and 2). The TAP group had lower rest pain scores than the control group at 1, 2, 4, 6 and 24 hours and lower movement-related pain scores than the control group at all time points. When the TAP and infiltration groups were compared, there were no significant differences in rest or movement-related pain scores at 1, 2 and 4 hours but significant lower scores at 6 and 24 hours in the TAP group (Table 2). Pain scores in the infiltration group were significantly lower than those of the control group at 1, 2 and 4 hours (Table 2).

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Total tramadol consumption is shown in Figure 3 and was significantly different between groups at 1, 2, 4, 6 and 24 hours (Figure 3). Consumption in the TAP group was lower than the control group at 1, 2, 4, 6 and 24 hours (Table 2). The infiltration group had lower consumption than the control group at 1 hour only. When the TAP and infiltration groups were compared, the TAP group used less tramadol than the infiltration group at all time points (Table 2).

In the control group, one patient did not require rescue analgesic but 12 and five patients respectively required one or two doses. In the TAP group, 14 patients did not require rescue analgesia, however three patients needed one, and one patient two, doses of pethidine. In the infiltration group, 13 patients did not received rescue analgesic and six patients received one dose of pethidine. The median (range) rescue analgesic requirement in the control, TAP and infiltration groups was 1.0 (0.0 to 2.0), 0.0 (0.0 to 2.0) and 0.0 (0.0 to 1.0) doses, respectively (P <0.001, control vs TAP groups).

[FIGURE 3 OMITTED]

DISCUSSION

In this randomised, double-blind clinical trial, patients who received bilateral TAP blocks had significantly less pain and reduced tramadol requirements compared with either sham TAP blocks or superficial wound infiltration with bupivacaine. Wound infiltration has been found to be effective in postoperative pain management following TAH, but in this study TAP block proved to be a more effective method. There are many other studies showing the efficacy of TAP blocks in different patient populations, although recently Griffiths et al reported that TAP block was not effective in reducing postoperative pain after gynaecological cancer surgery (11). In that study patients had a midline laparotomy incision.

Pain in the postoperative period impedes recovery from surgery and anaesthesia and after TAH through a Pfannenstiel incision, patients usually require strong analgesics for 24 to 48 hours. Potential analgesic methods include intraperitoneal, incisional or epidural injections of local anaesthetics (12). TAP block is another, now popular, method at the time of a number of abdominal surgical procedures (2,4,6,8). Carney et al compared TAP block with placebo after TAH and found it effective (2). We compared TAP block with incisional local anaesthetic, a technique which is controversial (12-14). Superficial infiltration was found to be effective in the short term (first four hours), primarily reducing rest pain, whereas TAP block was effective against both rest and movement pain for a longer duration, suggesting analgesia from skin and subcutaneous tissues and deeper structures such as muscle and abdominal fascia (12).

Pain from muscle and fascial tissues is more intense and difficult to manage1. Less pain observed during hip joint flexion suggests the potential for better patient movement and ambulation, which might limit postoperative complications. We observed only the first 24 postoperative hours so are unable to comment on times to mobilisation and study of this is needed.

Limitations of the study include the difference in timing of the interventions, with TAP block performed at the beginning of the surgery but wound infiltration performed at its end. Also, local anaesthetic infiltration was only along the incisional skin edges and analgesia may have been improved by deep wound infiltration.

All ultrasound-guided TAP blocks in out study appeared successful and no complications related to the procedure were observed. Recently, a subcostal injection technique was described by Hebbard et al, in which local anaesthetic is delivered in the same plane with the insertion of the needle at the xiphoid and the needle path parallel to the costal margin (15). Lee et al compared the extent of sensory block following posterior and subcostal approaches to ultrasound-guided TAP block and considered that the posterior approach was more appropriate for lower abdominal surgery and the subcostal approach for upper abdominal surgery (16). Further studies are needed to investigate the effect of combining rectus sheath block with posterior TAP block.

In conclusion, in this study ultrasound-guided TAP block reduced postoperative rest and movement pain and analgesic requirements after TAH and was more effective than superficial wound infiltration.

Accepted for publication on February 17, 2011.

REFERENCES

(1.) Tuncer S, Reisli R, Kececioglu M, Erol A. [The effects of intravenous dexketoprofen on postoperative analgesia and morphine consumption in patients undergoing abdominal hysterectomy]. Agri 2010; 22:98-102.

(2.) 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.

(3.) Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56:1024-1026.

(4.) 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.

(5.) Belavy D, Cowlishaw PJ, Howes M, Phillips F. Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery. Br J Anaesth 2009; 103:726-730.

(6.) O'Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med 2006; 31:91.

(7.) Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesth 2009; 102:143-144.

(8.) Niraj G, Searle A, Mathews M, Misra V, Baban M, Kiani S et al. Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing open appendicectomy. Br J Anaesth 2009; 103:601-605.

(9.) Jankovic ZB, Pollard SG, Nachiappan MM. Continuous transversus abdominis plane block for renal transplant recipients. Anesthesia Analgesia 2009; 109:1710-1711.

(10.) Bonnet F, Berger J, Aveline C. Transversus abdominis plane block: what is its role in postoperative analgesia? Br J Anaesth 2009; 103:468-470.

(11.) Griffiths JD, 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.

(12.) Ng A, Swami A, Smith G, Davidson AC, Emembolu J. The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy. Anesth Analg 2002; 95:158-162.

(13.) Klein JR, Heaton JP, Thompson JP, Cotton BR, Davidson AC, Smith G. Infiltration of the abdominal wall with local anesthetic after total abdominal hysterectomy has no opioid sparing effect. Br J Anaesth 2000; 84:248-249.

(14.) Moiniche S, Wettersley J, Dahl JB. A qualitative systematic review of incisional local anesthesia for postoperative pain relief after abdominal operations. Br J Anaesth 1998; 81:377-383.

(15.) Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008; 106:674-675.

(16.) Lee TH, Barrington MJ, Tran TM, Wong D, Hebbard PD. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesth Intensive Care 2010; 38:452-460.

A. ATIM*, F. BILGIN([dagger]), O. KILICKAYA*, T. PURTULOGLU*, I. ALANBAY*, M. E. ORHAN*, E. KURT([section])

Department of Anesthesiology, Gulhane Military Medical Academy, Ankara, Turkey

* M.D., Assistant Professor.

([dagger]) M.D., Anaesthetist.

([double dagger]) M.D., Associate Professor.

([section]) M.D., Professor.

Address for correspondence: Dr A. Atim, Gulhane Military Medical Academy, Department of Anesthesiology, Etlik, Ankara 06018, Turkey. Email: drkadiratim@yahoo.com
Table 1

Baseline patient characteristics

 Control (n=18) TAP (n=18)

Age, y 44 (30-63) 47 (31-63)
Weight, kg 67 (55-78) 71 (53-86)
ASA physical status I/II, n 8/10 9/9
Duration of operation, min 105.0 (55.0-165.0) 110.0 (60.0-205.0)
Complications, N (%) 3 (16.7) 1 (5.6)

 Infiltration (n=19) P

Age, y 40 (30-71) 0.22
Weight, kg 65 (58-81) 0.43
ASA physical status I/II, n 10/9 0.88
Duration of operation, min 90.0 (55.0-180.0) 0.26
Complications, N (%) 2 (10.5) 0.56

Age, weight and duration of operation are expressed as median (range).
TAP=transversus abdominis plane, ASA=American Society of
Anesthesiologists.

Table 2

Pair wise comparison of control, TAP and infiltration groups

Variable Control- Control- TAP-
 TAP infiltration infiltration

Duration of operation 1.00 0.117 0.042

Rescue analgesic <0.001 <0.001 1.00

Postoperative pain
scores at rest

1 h <0.001 <0.001 0.171
2 h <0.001 0.012 0.414
4 h <0.001 0.003 0.645
6 h <0.001 0.576 0.003
24 h 0.018 1.00 0.027

Postoperative pain
scores with movement

1 h <0.001 <0.001 0,132
2 h <0.001 0.006 0,576
4 h 0.003 0,003 0,852
6 h <0.001 0,378 0,033
24 h 0.018 1.00 0.009

Postoperative tramadol
consumption

1 h <0.001 0.015 0.003
2 h <0.001 0.201 0.030
4 h <0.001 0.396 0.009
6 h 0.012 1.00 0.042
24 h 0.003 1.00 0.018

TAP=transversus abdominis plane.
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Author:Atim, A.; Bilgin, F.; Kilickaya, O.; Purtuloglu, T.; Alanbay, I.; Orhan, M.E.; Kurt, E.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Date:Jul 1, 2011
Words:2583
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