|Year : 2017 | Volume
| Issue : 1 | Page : 38-42
Transversus abdominis plane block: A multimodal analgesia technique – Our experience
Deepak Dwivedi, Vidhu Bhatnagar, Harindra Kumar Goje, Arijit Ray, Pawan Kumar
Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS Asvini, Mumbai, Maharashtra, India
|Date of Web Publication||17-Aug-2017|
Lt Col Deepak Dwivedi
Department of Anaesthesiology and Critical Care, Institute of Naval Medicine, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: A retrospective observational study conducted to assess transversus abdominis plane (TAP) block as a tool for providing multimodal analgesia postoperatively for abdominal surgeries. Aims: The aim is to compare the visual analog scale (VAS) of pain and the requirement of rescue analgesia postoperatively in patients undergoing various abdominal surgeries (open and laparoscopic) where TAP block was given for postoperative analgesia and was compared with patients who received pain relief according to the institutional protocol. Settings and Design: Retrospective observational study conducted in a tertiary care hospital. Subjects and Methods: Retrospective data from anesthesia records of patients, who underwent abdominal surgeries from January 2016 to December 2016, were analyzed and were divided into two groups. Group A (n = 250) consisted of patients who received the conventional standard postoperative analgesia protocol of the department of anesthesia. Group B (n = 136) consisted of patients who were administered TAP block postsurgery for the postoperative analgesia by the trained anesthesiologist. Primary outcome considered was (i) average VAS at 02, 06, 12, and 24 h and (ii) average opioid/nonsteroidal anti-inflammatory drug consumption at 24 h postoperatively. Secondary outcome considered was time to first rescue analgesia. Statistical Analysis: All parametric data were analyzed using unpaired t-test. Data are expressed as the mean ± standard deviation. A SPSS version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Results: Average pain scores (VAS) were lower in Group B as compared to Group A in all subcategories of surgery postoperatively. Patients given TAP block (Group B) required less rescue analgesia in the postoperative period with time to first rescue analgesia being prolonged. Conclusions: On the basis of our retrospective study, we suggest that TAP block can be utilized as a part of multimodal analgesia regimen for abdominal surgeries, laparoscopic as well as open. Tap block has demonstrated a good safety profile in experienced hands; it is easy to perform and has displayed consistent analgesia over a prolonged period. It reduces postoperative morbidity and supports early ambulation.
Keywords: Analgesia, minimal invasive surgeries, nerve block, regional anesthesia, ropivacaine, transversus abdominis plane block
|How to cite this article:|
Dwivedi D, Bhatnagar V, Goje HK, Ray A, Kumar P. Transversus abdominis plane block: A multimodal analgesia technique – Our experience. J Mar Med Soc 2017;19:38-42
| Introduction|| |
Some regional blocks for analgesia are difficult when given blind. With the advent of technology of ultrasonography (USG), regional blocks such as transversus abdominis plane (TAP) blocks have found a new life as the landmarks are easily delineated and needle track seen clearly. Moreover, the drug deposition in the TAP block could be clearly visualized [Figure 1].
|Figure 1: Ultrasound image of abdominal wall. EO: External oblique, IO: Internal oblique, TA: Transversus abdominis.|
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The TAP block is achieved by depositing the local anesthetic drug between the fascial plane of the internal oblique and transversus abdominis muscle under vision using USG or blindly by two pops technique thereby blocking the dermatomal afferents from intercostal nerves (T7–T11), subcostal nerves (T12), and ilioinguinal and iliohypogastric nerves (L1).
Inadequate management of acute pain in immediate postoperative period may predispose the patient to develop various chronic regional pain syndromes. Tackling acute pain requires a multimodal strategy, and regional analgesia plays an important role in this multimodal analgesia regimen.
This has led to a surge in interest in abdominal blocks to provide adequate analgesia in abdominal surgical procedures as a technique to provide analgesia for parietal pain along with multimodal analgesia for visceral pain.,
We, in our institution, have been using USG-guided TAP block depending on the choice and skills of the anesthesiologist and departmental standard postoperative pain control protocol utilizing intravenous (IV)/intramuscular (IM) analgesics, postabdominal surgeries for the postoperative analgesia. This retrospective study was conducted to ascertain the TAP block as an effective mode of multimodal analgesia technique for providing lasting analgesia and its role in the consumption of the nonsteroidal anti-inflammatory drug (NSAIDs)/opioids in the postoperative period.
| Subjects and Methods|| |
This retrospective observational study was conducted in the department of anesthesia from January 2016 to December 2016, on patients who underwent abdominal surgeries under general anesthesia (GA) after taking clearance from the institutional review board. Participants were divided into two groups. Group A participants received the conventional standard postoperative analgesia protocol of the department of anesthesia. The protocol includes injection tramadol 2 mg/kg IV slow 8 h and injection diclofenac sodium 75 mg/50 mg IM 12 h.
Group B included patients who received USG-guided posterior TAP block by a trained anesthesiologist postsurgery using linear high frequency (5–13 MHZ) probe (Sonosite, Micromaxx). Drug used was 0.2% ropivacaine (maximum 3 mg/kg). Volume of the drug used was 20 ml for a unilateral procedure and 40 ml for bilateral procedure as per our institutional protocol. Surgeries such as inguinal hernias required TAP block unilaterally, i.e., the drug deposited between internal oblique and transversus abdominis muscle plane, only to the ipsilateral side of the incision; whereas, surgeries involving midline abdominal incisions as well as the laparoscopic surgeries required bilateral TAP blocks.
Inclusion criteria included patients who underwent abdominal surgery under GA, American Society of Anesthesiologists (ASA) Physical Status I and II, age more than 18 years and <65 years. Whereas, patients in ASA Physical Status III and above, patients refusing the intervention, below 18 or above 65 years of age, patients allergic to local anesthetic drugs were excluded from the study.
All patients received the standard of care in the operation theater (OT). On shifting in the OT, patients were connected to the standard monitors (noninvasive blood pressure, capnogram, electrocardiogram, pulse oximetry). They were premedicated with injection midazolam 1 mg IV, injection fentanyl 1.5 μg/kg IV, and induction done with injection propofol 2 mg/kg IV. Airway was secured with appropriate size endotracheal tube after the administration of the injection atracurium 0.5 mg/kg IV, and anesthesia was maintained with oxygen, air, and sevoflurane (1%–2%). Intraoperative analgesia was augmented with injection paracetamol 1 g IV in all the patients. Antiemetic injection ondansetron 4 mg IV was administered to all the patients.
Postsurgery, in Group B, USG-guided TAP block was administered by a trained anesthesiologist as per the protocol. All patients were then reversed with injection neostigmine 50 μg/kg and injection glycopyrrolate 10 μg/kg IV.
All patients undergoing anesthesia with or without regional block in our institute are being followed up in the postoperative period with the standard monitoring except capnogram. The visual analog scale (VAS) which is a horizontal line of 10 cm with marking on the left side as 0 denoting no pain whereas, extreme right end marking of 10 denoting worst possible pain. The intensity of the pain was marked in each case, and the scores were noted at 2, 6, 12, and 24 h and entered in the OT central registry by the duty anesthesia resident. According to departmental postoperative pain protocol rescue analgesia was administered when VAS score was more than four. Rescue analgesia consisted of Tramadol 50 mg slow I.V infusion and/or inj Diclofenac sodium 75mg/50mg I.M. Time to rescue analgesia in minutes and the mean dose of the injection tramadol as well as diclofenac sodium in first 24 h was calculated in both groups.
All parametric data were analyzed using unpaired t-test. The nonparametric data analyzed using Fisher's exact test. Data are expressed as the mean ± standard deviation. A SPSS version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Software and P < 0.05 was considered statistically significant.
| Results|| |
Out of 386 patients, Group A had a total of 250 patients who underwent abdominal (general surgery and gynecological) surgeries both open and laparoscopic and were provided analgesia in accordance with the anesthesia departmental protocol. Group B had a total of 136 patients (general surgery and gynecological) who were given TAP block postsurgery by the trained anesthesiologist.
Demographic data (age, body weight, ASA Class I and II, sex ratio) in the two groups showed variation with majority of participants in both groups being females (Group A - 81% and Group B - 70%). ASA physical status classification showed that majority of patients was in ASA Class II (Group A - 60%, Group B - 68%) [Table 1].
Types of surgery performed in both groups showed laparoscopic surgeries are the most commonly performed [Figure 2]. Surgery-wise comparison of the average VAS score between the two groups at all times was lower in the Group B [Table 2]. However, the average VAS score was higher in open surgery category (general and gynecological) in both groups with Group B having lower VAS score at 24 h.
|Figure 2: Type of surgery. Lap: Laparoscopic, Gen: General, Gynec: Gynecologic.|
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Mean time to first rescue analgesia when compared between Group A and Group B showed significant results (P< 0.05) in all subcategories of surgery with delayed requirement of the rescue analgesia in Group B [Table 3].
Average dose of the tramadol/diclofenac sodium consumed on being compared between the two groups revealed lower consumption of both the drugs in all subcategories of surgery in Group B [Table 4].
|Table 4: Average dose of Tramadol/Diclofenac sodium (NSAID) consumed at 24h|
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| Discussion|| |
The International Association for Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Adequate postoperative analgesia translates into a favorable outcome by limiting the cardiopulmonary morbidity and speeding up the recovery with early ambulation.
Many studies have shown efficacy of TAP block for the postoperative pain relief following abdominal surgeries.,,,,, TAP block has evolved over the last decade beginning from TAP block given in the triangle of Petit using single-shot double loss of resistance technique as described by Rafi  to Hebbard et al. who described the block under the USG guidance in the posterior triangle of Petit. Jankovic et al. found that all the nerves of interest traversed the TAP at the midaxillary line. The oblique subcostal and the lateral approach to TAP blocks came into existence producing good analgesia both above and below the umbilicus. The four-point single-shot technique combining bilateral oblique subcostal and posterior TAP block to provide bilateral analgesia was described by Børglum et al.
TAP block is said to provide analgesia by blocking somatic component of pain thereby sparing the visceral component. Therefore, this limitation postmajor abdominal surgeries was thought to be overcome by supplementing with NSAIDs, paracetamol, tramadol, gabapentin, N methyl D- aspartic acid. antagonist. Patients undergoing extensive surgeries such as exploratory laparotomy and total abdominal hysterectomy, where there is large amount of tissue dissection and organ handling, the requirement for rescue analgesia despite TAP block was high. This also has been observed in our study as depicted in [Table 2] and [Table 4]. Whereas, requirement for rescue analgesia in the first 12 h postminimal access laparoscopic surgeries where the visceral component of pain is greatly reduced was comparatively lower. Abdallah et al. demonstrated that using posterior approach of TAP block; the analgesia could be achieved for a prolonged duration which seems to be associated with retrograde spread of the drug resulting in additional visceral block along the sympathetic chain located at thoracolumbar region.
The similar technique of TAP block was adopted in our practice leading to the better VAS scores despite the open abdominal surgeries. The mean dose requirement of the tramadol and diclofenac sodium at 24 h in Group B patients with TAP block when compared with the Group A patients, showed lower VAS scores with lower mean dose requirement of the standard rescue analgesia when compared in both laparoscopic and open abdominal surgeries as shown in [Table 4].
TAP block is considered highly efficacious in providing quality postoperative analgesia with lower VAS scores up to 24 h which has been confirmed by various studies., The opioids sparing effect has been documented by Niraj et al. in their study with TAP block; the similar result of reduced opioids consumption had been observed in our retrospective analysi's of the data of TAP block post both open and laparoscopic surgery, thereby reducing the incidence of the opioids-related side effects.
Time to rescue analgesia was prolonged in our study in all the subcategories of surgeries where TAP block was administered which was in accordance with the study of McDonnell et al. and Carney et al.
Since, this is a retrospective, observational study the limitations are non randomization and non comparable sample size. Selection bias may have acted as a confounding factor. Limitations for the intervention (TAP block) are greater skills required for the anesthesiologist, the possibility of delay in patient turnover as extra time is required to administer the block, and advanced equipment (ultrasound) is required. Administration of TAP block is an additional intervention for the patient. Keeping in view these limitations, prospective studies for various subgroups for the assessment of TAP block efficacy for postoperative analgesia have been designed and are currently undergoing in our department.
USG-guided TAP block is a safe, feasible, and easily reproducible block which can be included successfully in the protocol for postoperative multimodal analgesia regimen with reduction in the opioids consumption and the side effects associated with them.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]