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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 134-140

Transversus abdominis plane block for postoperative analgesia after abdominal surgeries in morbidly obese


Department of Anesthesia and Intensive Care, Al-Azhar University, Cairo, Egypt

Date of Submission20-Apr-2018
Date of Acceptance08-Jul-2018
Date of Web Publication27-Feb-2019

Correspondence Address:
Mofeed A Abdelmaboud
Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine, Al-Azhar University, Cairo 12992
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_30_18

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  Abstract 

Background Pain is a significant problem for many patients after major surgery. The transversus abdominis plane (TAP) block is a new technique that provides analgesia following abdominal surgery. TAP block can be done blindly or by using ultrasound that include posterior and subcostal approach.
Aim The primary aim was to study the clinical utility of TAP block as analgesia after lower abdominal surgeries in morbidly obese. The secondary aim was to assess the advantages and disadvantages of the same.
Patients and methods A total of 60 patients fulfilling inclusion criteria who were undergoing elective lower abdominal surgeries were divided into two equal groups. Group T (TAP group), which received bilateral ultrasound-guided subcostal TAP block at the end of the surgery before emergence, and group C (control group) that received general anesthesia, with no further narcotic administration. Postoperative mean arterial pressure, heart rate, respiratory rate, visual analog scale, and visual analog scale on cough, PaCO2, time to first request of analgesia, average frequency of analgesia, average total analgesics consumption, average total local anesthetic (bupivacaine) consumption, postoperative complications, and frequency of antiemetic were recorded. Bromage score was assessed at 20 min postoperatively.
Results There were significant decrease in mean arterial pressure, heart rate, respiratory rate, visual analog scale, and visual analog scale on cough in group T than group C at 10, 20 min. There wasa high significant decrease in peak expiratory flow rate and significant increase in PaCO2 in group C than group T at 2, 6 h postoperatively. There was a high significant increase in the time to first request of analgesia, and a high significant decrease of both frequency of analgesia and average total consumption of analgesia. A high significant increase was observed in local anesthetic consumption in the first 24 h postoperatively in group T than group C. There were significant differences in nausea, vomiting, and frequency of antiemetic, whereas they did not occur in group T. There were no significant differences in the grade of motor block between two groups at 20 min or any other time.
Conclusion TAP block was safe, and easy to perform, and more effective in the early postoperative period with significant reductions in opioid requirement, pain score, and complications, and did not produce motor block.

Keywords: abdominal surgeries, morbidly obese, postoperative analgesia, transversus abdominis plane block


How to cite this article:
Abdelmaboud MA. Transversus abdominis plane block for postoperative analgesia after abdominal surgeries in morbidly obese. Al-Azhar Assiut Med J 2018;16:134-40

How to cite this URL:
Abdelmaboud MA. Transversus abdominis plane block for postoperative analgesia after abdominal surgeries in morbidly obese. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:134-40. Available from: http://www.azmj.eg.net/text.asp?2018/16/2/134/253086


  Introduction Top


Pain is a significant problem for many patients after major surgery [1].

The transversus abdominis plane (TAP) block is a new technique that provides analgesia following abdominal surgery.

TAP block can be done blindly or by using ultrasound that include posterior and subcostal approach. Ultrasound-guided subcostal approach was chosen in this study.

Ultrasound-guided subcostal approach

This should be performed if analgesia of the abdominal wall above the umbilicus is required [2].

The ultrasound transducer should be placed under the costal margin close to the midline, and the upper portion of the rectus muscle should be identified where the transversus abdominis muscle can be seen deep to the rectus abdominis muscle [3].

When the tip of the needle is positioned between the superficial border of transversus abdominis and posterior rectus sheath, a small amount of local anesthetic is injected (after aspiration) [2].

Further needle advancement and injection must continue following along an oblique line extending from the xiphoid process to the anterior part of the iliac crest. On approaching the iliac crest, you reach the lateral border of rectus abdominis. The transversus abdominis muscle become deep to the internal oblique muscle ([Figure 2]) [3].

For filling the TAP along this oblique subcostal line, about 20 ml of local anesthetic may be needed [4].


  Patients and methods Top


This study was carried out at Al-Azhar University Hospitals in the period from June 2015 to May 2017. This study was approved by Anesthesia Department Scientific and Ethical committee. Written informed consent was obtained from all the patients.

A total of 60 patients, American Society of Anesthesiologists physical status II, aged above 18 years up to 60 years of both sex, and morbidly obese with BMI greater than or equal to 40 kg/m2, who were undergoing elective abdominal surgeries with abdominal sensory level at or above T 10 were included in this study.

Exclusion criteria included age below 18 or above 60 years. The American Society of Anesthesiologists physical status more than II, patients with musculoskeletal disorders, patients with hypersensitivity to local anesthetics, complicated diabetes mellitus, uncontrolled hypertension or ischemic heart disease, and patients with contraindication to neuroaxial block.

Patients passing inclusion criteria were further evaluated by medical history, physical examination, and laboratory test (complete blood picture, kidney function tests, liver function tests, international normalized ratio, prothrombintime, partial thromboplastin time, and chest radiography). ECG was done for patients above 40 years old. All doses of the drugs were based on ideal body weight.

All patients were premedicated after insertion of intravenous cannula with midazolam (0.05 mg/kg intravenously), ranitidine (50 mg intravenously), and metocloropramide (10 mg intravenously).

In the operating room, after routine monitoring (ECG, noninvasive blood pressure, pulse oximetry, and end tidal CO2), baseline vital signs were taken and general anesthesia was induced after preoxygenation for 4 min by fentanyl (2 μg/kg intravenously), propofol (2 mg/kg intravenously), and cis-atracurium (0.15 mg/kg intravenously), and then the insertion of appropriate size endotrachial tube was carried out.

Anesthesia was maintained by volume-controlled ventilation (maintained end tidal CO2 around 35–38 mmHg), isoflurane (1.15%), and cis-atracurium (0.05 mg/kg intravenously) every 20 min.

At the end of surgery, bilateral TAP block was performed using ultrasound-guided subcostal approach to all patients of group B in the supine position before emergence, using a traumatic echogenic 20 G needle with injection port attached to a flexible tubing system, which was further attached to a syringe filled with the local anesthetic (using 30 ml of isobaric bupivacaine 0.25% on each side with a maximum dose of 3 mg/kg, and the same procedure was repeated on the contralateral side). Injection was administered after careful aspiration.

At the end of opertation, isoflurane was discontinued and muscle relaxant was reversed by mixture of neostigmine (0.04 mg/kg) and atropine (0.01 mg/kg), and then the patients were extubated after taking good regular tidal volume.

Mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) were assessed in two groups at 0, 10, 20, 40, and 60 min postemergence, then at 2, 6, 12, and 24 h postoperatively (P0, P1, P2, P3, P4, P5, P6, P7, P8, respectively). Partial arterial carbon dioxide tension (PaCO2) was assessed at 2, 6, 12, and 24 h postoperatively (T1, T2, T3, T4, respectively). Peak expiratory flow rate (PEFR) was assessed preoperatively, then at 2 and 6 h postoperatively (F0, F1, F2, respectively). Visual analog scale (VAS) and visual analog scale on cough (VASOC) for pain were assessed at 0, 10, 20, and 60 min, then at 6, 12, and 24 h postoperatively (V0, V1, V2, V3, V4, V5, V6, respectively). Time to first request of analgesia, average frequency of analgesia, average total analgesics consumption in the first 24 h, and average total local anesthetic (bupivacaine) consumption in the first 24 h postoperatively were recorded. Postoperative complications (pruritus, nausea, and vomiting) and average frequency of antiemetic (metoclopramide) were recorded. Bromage score was assessed at 20 min postoperatively.

Postoperative nausea and vomiting is defined as any nausea, retching, or vomiting occurring during the first 24–48 h after surgery. Vomiting was treated by intravenous injection of 10 mg metoclopramide.

Pruritis was treated by oral administration of 10 mg loratadine tablets, once.

Visual analog scale

VAS uses 10 cm line with one end defined as ‘no pain’ and the other end being ‘unbearable pain’. The patient is asked to place mark on the line to describe the amount of the current pain. The distance between the end labeled ‘no pain’ and the mark is measured and rounded to the nearest centimeter. To assist in describing the intensity of pain, words can be placed along the scale, such as mild, moderate, and severe. Assessment of dynamic pain (VASOC) is more important than pain at rest, as relief of dynamic pain facilitates mobilization and therefore may improve long-term outcome after surgery [5].

Analgesic regimens

For all patients of the two groups, rescue analgesia was given postoperatively for VAS greater than or equal to 4 by ketorolac (30 mg intravenous infusion) first, then VAS was reassessed 10 min later, pethidine (1 mg/kg intravenously) was given if VAS greater than or equal to 4 after giving ketorolac. VAS was reassessed 10 min later for any rescue analgesic injection.

Group T (TAP group)

Patients of this group received bilateral ultrasound subcostal TAP block at the end of the surgery before emergence (using 30 ml of isobaric bupivacaine 0.25% on each side) with a maximum dose of 3 mg/kg.

Group C (control group)

Patients of this group received general anesthesia as mentioned above, with no further administration of narcotics.

Bromage score

All patients were examined by Bromage score for any motor blockade that occurred as a side effect of the local anesthetic used during the TAP block ([Table 1]).
Table 1 Description of the Bromage score

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Statistical analysis

SPSS version 17 program (SPSS Inc., Chicago, Illinois, USA), were used to enter data and statistical analysis. Data were presented as mean±SD, number, and percentage. Comparison between the two groups was performed using unpaired Student t-tests for parametric data and χ2 for number. P value less than 0.05 was considered as statistically significant.


  Aim Top


The primary aim of the work was to study the clinical utility of TAP block as analgesia for patient undergoing lower abdominal surgeries in morbidly obese. The secondary aim was to assess the advantages and disadvantage of the same.


  Results Top


There were no statistically significant differences between the study groups with respect to age, sex, BMI, and duration of the surgery ([Table 2]).
Table 2 Demographic data

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The two groups were comparable with respect to the baseline hemodynamics ([Table 3]).
Table 3 Baseline parameters

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With respect to MAP, HR, RR, VAS, and VASOC, there were no significant differences between two groups except at 10, 20 min, where they were significantly lower in group T than group C ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]).
Figure 1 Picture showing the ultrasound transducer position and in-plane needle technique for the oblique subcostal transversus abdominis plane block on the left side of the patient.

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Figure 2 Ultrasound image of rectus abdominis and transversus abdominis muscles immediately adjacent to the midline. Dotted white line indicates the desired needle position [3].

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Figure 3 Postoperative mean arterial blood pressure.

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Figure 4 Postoperative heart rate.

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Figure 5 Postoperative respiratory rate.

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Figure 6 Visual analog scale.

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Figure 7 Visual analog scale on cough.

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There was nosignificant difference in the baseline PEFR between two groups, but there were high significant decrease in PEFR in group C than group T at 2, 6 h postoperatively ([Figure 8]).
Figure 8 Peak expiratory flow rate changes.

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With respect to PaCO2, there were significant increase in group C than group T at 2, 6 h, but there were no significant differences between two groups at 12, 24 h ([Figure 9]).
Figure 9 Postoperative partial arterial carbon dioxide tension.

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There was a high significant increase in the time to first request of analgesia in group T than group C, but a high significant decrease of both frequency of analgesia and its average total consumption in the first 24 h postoperatively in group T than group C ([Table 4]).
Table 4 Time to the irst request of analgesia, frequency of analgesia, and average consumption of analgesia

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There was a high significant increase in local anesthetic consumption in group T compared to group C, whereas no local anesthetic was given to group C ([Table 5]).
Table 5 Total bupivacaine consumption

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With respect to postoperative complication in the first 24 h, there was no significant difference in pruritis between two groups but there were significant differences in other complications, they did not occur in groups T ([Table 6]).
Table 6 Complications

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With respect to assessment of Bromage scale at 20 min postoperatively, the number of patients who showed grade I were 30 in both groups, whereas the number of patients who showed grade II, III, IV Bromage scale were 0 in both group T, C with no significant differences, and also, none of the patients in the two groups showed any grade of motor block at any other time with no significant differences ([Table 7]).
Table 7 Degree of motor block at 20 min postoperatively

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  Discussion Top


The current study demonstrated that there were significant decrease in MAP, HR, RR, VAS, and VASOC at 10, 20 min in TAP group than control group (mostly due to the rapid onset of action of the bupivacaine used in TAP block and thus reducing postoperative pain and producing cardiovascular stability) but there were no differences between the two groups at other times. There were high significant decrease in PEFR in control group than TAP group at 2, 6 h. There were high significant increase in the time to first request of analgesia in TAP group than control group, but high significant decrease of both frequency of analgesia and its average total consumption was observed in the first 24 h postoperatively in TAP group than control group. There was a high significant increase in local anesthetic consumption in TAP group than control group, where no local anesthetic was given in control group. There was no significant difference in pruritis between two groups but there were high incidence of other complications in control group due to increased opioid requirement, they mainly depend on the systemic opioids for rescue analgesia. There were no significant differences in the grade of motor block at 20 min or at any other time.

Bhanulakshmi et al. [7], compared ultrasound-guided TAP block versus intravenous diclofenac for postoperative analgesia in elective lower segment ceserean section (LSCS). They concluded that TAP block can be easily and safely performed and more effective with significant decrease in opioid requirement and pain score.

Erbabacan et al. [8], compared TAP block and IV patient-controlled analgesia (PCA) after lower abdominal surgery, and concluded that TAP block was preferable to IV-PCA, as the analgesic effect starts earlier and decreases the systemic effect of the morphine used in PCA.

Ghisi et al. [9], did comparative study between TAP block and morphine patient-controlled analgesia for postoperative analgesia in patients undergoing total laparoscopic hysterectomy. They found that TAP block neither reduced morphine consumption nor the incidence of postoperative nausea and vomiting.

Chen et al. [10] observed no difference in analgesic efficacy between oblique subcostal TAP block (OSTAP) block and intravenous morphine during the postoperative period and did not reduce the incidence of nausea and vomiting.

Carrie and Biais [11], reported that after laparoscopic cholecystectomy, OSTAP block can provide significant improvement in respiratory function and better pain relief with lower opioid requirement.

Sharma et al. [12], reported that the TAP block provided highly effective postoperative analgesia in the first 24 h after major abdominal surgery with no complications.

Recommendations

Further studies are needed to evaluate the beneficial effects of insertion of TAP catheter for continuous infusion or titration of local anesthetic, and may eliminate the need for any intravenous analgesia.

Limitations

This study had the following limitations: first, the frequency of the study assessments was limited to the immediate postoperative period and at 24 h after surgery; second, the dose of the local anesthetic bupivacaine (3 mg/kg) used in this study, which may be considered high, is still within the recommended safe dose range.


  Conclusion Top


TAP block was safe, easy to perform, and more effective in the early postoperative period with significant reduction in opioid requirement, pain score, and complications, and did not produce motor block.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology 2011; 115:181–188.  Back to cited text no. 1
    
2.
Hebbard P, Barrington MJ, Vasey C. Ultrasound-guided oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Reg Anesth Pain Med 2010; 35:436–441.  Back to cited text no. 2
    
3.
Paul T, James F. (2011) Transversus abdominis plane block, anaesthesia tutorial of The Week 239, 5 Septemeber; pp. 1–12.  Back to cited text no. 3
    
4.
Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (tap) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev 2010; 8:CD007705.  Back to cited text no. 4
    
5.
Maximilian WB, David GS. Applying parametric tests to visual analogue scores. Anesth Analg 2000; 91:248–249.  Back to cited text no. 5
    
6.
Bromage PR. A comparison of the hydrochloride and carbon dioxide salt of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand 1965; Suppl. XVI:55–69.  Back to cited text no. 6
    
7.
Bhanulakshmi M, Chander DS, Raj GV. Comparative study between ultrasound guided transversus abdominis plane (TAP) block vs. intravenous diclofenac for post-operative analgesia in elective LSCS. J Evidence Based Med Hlthcare 2015; 2:5911–5918.  Back to cited text no. 7
    
8.
Erbabacan E, Kendigelen P, Koksal GM, Tutuncu C, Ekici BB, Şeker TB et al. Comparison of transversus abdominis plane block and iv patient-controlled analgesia after lower abdominal surgery. Turk J Anaesthesiol Reanim 2015; 43:24–28.  Back to cited text no. 8
    
9.
Ghisi D, Fanelli A, Vianello F, Gardini M, Mensi G, La Colla L, Danelli G. Transversus abdominis plane block for postoperative analgesia in patients undergoing total laparoscopic hysterectomy: a randomized, controlled, observer-blinded trial. Anesth Analg 2016; 123:488–492.  Back to cited text no. 9
    
10.
Chen CK, Tan PC, Phui VE. A comparison of analgesic efficacy between oblique subcostal transversus abdominis plane block and intravenous morphine for laparascopic cholecystectomy. A prospective randomized controlled trial. Korean J Anesthesiol 2013; 64:511–516.  Back to cited text no. 10
    
11.
Carrie C, Biais M. Subcostal TAP block and postoperative respiratory function after abdominal surgery. Anaesthesia 2014; 69:1056–1057.  Back to cited text no. 11
    
12.
Sharma P, Chand T, Saxena A, Bansal R, Mittal A, Shrivastava U. Evaluation of postoperative analgesic efficacy of transversus abdominis plane block after abdominal surgery: a comparative study. J Nat Sc Biol Med 2013; 4:177–180.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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