Clinical effectiveness of transversus abdominis plane (TAP) blocks for pain relief after caesarean section: a meta-analysis

Postoperative pain control and opioid use with transversus abdominis plane block and scheduled multimodal pain management in patients undergoing cesarean section

OBJECTIVE

The impact of a transversus abdominis plane (TAP) block in patients undergoing cesarean section requires further evaluation. The aim of this study was to compare postoperative pain scores and opioid use in cesarean surgery patients undergoing either a TAP block and scheduled multimodal pain management (SMPM) or SMPM alone.

METHODS

In this retrospective, dual cohort study, cesarean surgery patients underwent neuraxial anesthesia and a TAP block (SMPM/TAP) or SMPM; the TAP block incorporated ropivacaine (20-30 mL) administered bilaterally. The group analyses involved a comparison of postoperative pain scores using the visual analog scale and opioid consumption at 24 and 24-48 h.

RESULTS

There were 94 (52.8%) patients in the SMPM/TAP group and 84 (47.2%) subjects in the SMPM alone group. At 24 h postoperatively, the SMPM/TAP group exhibited significantly lower pain scores (4.07 vs 4.54) than the SMPM group (P < 0.001) and reduced opioid consumption (2.29 vs 3.28 mg; P < 0.001). However, at 24-48 h, the SMPM group demonstrated lower pain scores (5.46 vs 5.98) compared to the SMPM/TAP group (P < 0.001) and reduced opioid consumption (8.75 vs 10.21 mg; P < 0.001); overall opioid consumption was higher (12.50 vs 12.02 mg) in the SMPM/TAP group (P < 0.001).

CONCLUSION

The TAP block improved cesarean surgery patients' pain scores and reduced opioid consumption at 24 h postoperatively but the effect of the TAP block was ephemeral as the SMPM/TAP group exhibited inferior pain scores and greater opioid consumption compared to the SMPM group at 24-48 h postoperatively.

Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study

Background

The role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery.

Methods

After institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0-100%), and continuous wound infusion catheter-related complications.

Results

All women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5-61.9] mg morphine equivalents vs control group 30.0 [11.3-48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1-3] vs 1.5 [0-3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91-100%] vs 90% [86-100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm.

Conclusions

The addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.

[Old and New Regional Anesthesia Procedures Under Review - Abdomen to Toe]

Ultrasound (US) technology has significantly expanded the spectrum of regional anesthesiological procedures in recent years. Abdominal wall blocks are becoming an increasingly integral part of a multimodal postoperative pain concept after abdominal surgery, gynecological or urological interventions. Thoracic epidural analgesia remains the gold standard for extensive surgery. The requirement for rapid postoperative mobilization and discharge after lower extremity surgery has led to the abandonment of neuroaxial or plexus blocks in favor of selective, peripheral blocks such as the PENG block or adductor canal block. The following article is intended to show the reader the change in the use of regional anesthesiological procedures for abdominal wall and lower extremity blocks using selected blockages.

Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial

BACKGROUND

Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown.

OBJECTIVE

This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine.

STUDY DESIGN

This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test.

RESULTS

Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar.

CONCLUSION

Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients

Introduction

With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section.

Methods

A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate.

Results

In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population.

Conclusion

Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.

The effects of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) on clinical efficacy of the patients undergoing abdominal surgery

Background

Although opioids provide effective analgesia for abdominal surgery, they also present serious unwanted side effects. Ultrasound-guild quadratus lumborum block (QLB) and transversus abdominis plane block (TAPB) have been proven to offer long-lasting and efficient analgesia during abdominal surgery. However, the clinical efficacy of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) in abdominal surgery remains unclear.

Objective

This study aimed to investigate the impact of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) on the clinical efficacy of abdominal surgery.

Methods

A total of 122 patients scheduled for abdominal surgery at People's Hospital of Wanning between March 2021 and April 2022 were enrolled in this study. Participants were randomly divided into two groups: the experimental group (QLB/TAPB + OFA, 62 patients) and the control group (opioid anesthesia, 60 patients). The clinical efficacy of the QLB/TAPB combined with OFA technique was evaluated by analyzing patients' vital signs, postoperative consciousness recovery time, numeric rating scale (NRS) score, and immune function in both groups.

Results

We observed that systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in experimental group were significantly higher than those in control group after induction (p < 0.05). Heart rate (HR) in experimental group was significantly lower than in the control group at intraoperative 1h (p < 0.05). Additionally, bispectral index (BIS), state entropy (SE), and response entropy (RE) levels in the experimental group were significantly higher than those in the control group (p < 0.05). Furthermore, extubation and awakening time were significantly shorter in the experimental group compared to the control group (p < 0.05). The NRS scores in the experimental group were markedly lower than those in the control group. Moreover, IL-6 and CRP levels in the experimental group were obviously lower than in the control group after postoperative 1d (p < 0.05). Interestingly, IL-6 (p < 0.001), CRP (p < 0.001), and PCT (p = 0.037) levels in female patients of the experimental group were all significantly lower than those in the control group after postoperative 1d.

Conclusions

Ultrasound-guided QLB and TAPB combined with OFA technique can reduce pain intensity and enhance the patients' immune function in abdominal surgery.

Comparison of ultrasound-guided transversalis fascia and posterior transversus abdominis plane block for postoperative analgesia following caesarean delivery: A double-blinded randomised controlled trial

Background and Aims

Posterior-transversus abdominus plane (TAP) block and transversalis fascia plane (TFP) block have been used for postoperative analgesia following caesarean delivery. We compared the analgesic efficacy of the TAP vs TFP plane blocks in patients undergoing elective caesarean delivery.

Methods

We randomised 90 women undergoing caesarean delivery under spinal anaesthesia to receive either a posterior-TAP (Group-TAP), TFP (Group-TFP) or no block (Group-C) postoperatively. The primary objective was the postoperative analgesic requirements. Secondary objectives were duration of analgesia, pain scores and infra-umbilical sensory loss, which were recorded at specific intervals for 24 h. Statistical analysis was carried out using Statistical Package for Social Sciences version 16.0 software.

Results

The patients requiring one, two or nil rescue analgesics were comparable between the interventions and the control (P = 0.32). The duration of analgesia was longer in Group-TAP when compared to Group-C, 4.76 (1.2) vs. 6.89 (2.4); P < 0.001, whereas Group-TFP, 5.64 (2.1) h, was not significantly different from Group-C. The static pain score in Group-TAP was significantly less than that in Group-C at 4 h and beyond 12 h (P < 0.001), whereas Group-TFP was comparable with Group-C at all time points except at 4 h and 24 h (P = 0.002). Only Group-TAP demonstrated midline infraumbilical sensory loss.

Conclusion

TAP and TFP blocks did not decrease the rescue analgesic requirement compared with the control group. The posterior-TAP block prolonged the duration of analgesia by 2 h, maintained the median static pain score at 0 beyond 12 h, and demonstrated sensory loss at the infraumbilical dermatomes.

Long-Acting Bupivacaine for Pain Control After Cesarean Birth

OBJECTIVE

To evaluate women's postcesarean pain levels and total opioid use for standard opioid pain management compared with local anesthetic with patient-requested opioids.

DESIGN

Retrospective cohort study.

SETTING/LOCAL PROBLEM

Rural southeast Ohio. Ohio had a higher rate of opioid use disorder (1.4%) than both the regional average (0.8%) and the national average (0.7%).

PARTICIPANTS

We performed a retrospective study of 402 medical records of women who gave birth by caesarean.

INTERVENTION

Women were provided one of three types of perioperative anesthesia: routine spinal (standard of care group), wound infiltration with liposomal bupivacaine (LB INF), and transversus abdominis plane (TAP) block with liposomal bupivacaine (LB TAP).Data were collected on the amount of opioids taken postoperatively (measured as morphine milligram equivalents [MME]), pain scores, and history of opioid use.

RESULTS

The LB INF and LB TAP groups had significantly lower total and average MME per day than the standard of care group (p < .001). Pain scores for the LB INF group were lower on postoperative day (POD) 0 and POD1, whereas LB TAP pain scores were lower than standard of care pain scores on POD1 (p < .004). Women with a prior history of substance use disorders reported higher pain scores, took more total opioids. and stayed in the hospital longer regardless of type of anesthesia received (p < .001).

CONCLUSION

LB INF and LB TAP were associated with lower amounts of opioids used and with lower postcesarean pain scores compared with the standard of care.

Transversus Abdominis Plane Block for Anterior Lumbar Interbody Fusion: a randomized controlled trial

BACKGROUND CONTEXT

ALIF (Anterior Lumbar Interbody Fusion) is a lumbar arthrodesis technique via an anterior approach that is less invasive than the posterior approaches. However, it is associated with specific pain in the abdominal wall.

PURPOSE

The objective of this study was to determine whether performing a bilateral ultrasound-guided TAP (Transversus Abdominis Plane) block allows a reduction in morphine consumption in the first 24 hours after surgery.

STUDY DESIGN

This study is a prospective single-centre, randomized, double-blind study.

PATIENT SAMPLE

Patients undergoing ALIF surgery were included and randomized into two groups. Both groups received a TAP block performed at the end of surgery with either ropivacaine or placebo.

OUTCOME MEASURES

The primary outcome measure was morphine consumption in the first 24 hours. The main secondary outcomes were immediate postoperative pain and opioid-related side effects METHODS: Intra- and postoperative anaesthesia and analgesia protocols where standardized. A bilateral ultrasound-guided TAP block was performed with 75 mg (in 15 ml) of ropivacaine per side or isotonic saline serum depending on their assignment group.

RESULTS

Forty-two patients were included in the study (21 per group). Morphine consumption at 24 hours (28 mg [18 - 35] in the ropivacaine group vs 25 mg [19 - 37] in the placebo group (p=0.503)) were not significantly different between the 2 groups.

CONCLUSION

TAP block with ropivacaine or placebo provided a similar postoperative analgesia when associated with a multimodal analgesia protocol for ALIF.

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Pentazocine with rectal diclofenac versus pentazocine alone for pain relief following caesarean delivery in Enugu, Nigeria: A randomized controlled trial

Objective

To measure postoperative pain relief following the use of rectal diclofenac combined with intramuscular pentazocine compared with intramuscular pentazocine alone in patients undergoing a caesarean delivery.

Methods

This single-blind randomized controlled trial enrolled pregnant women that had a caesarean section at the Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria. Study participants were randomized to receive either 100 mg of rectal diclofenac given every 12 h plus 30 mg of intramuscular pentazocine given every 6 h (group A) or 60 mg of intramuscular pentazocine given every 6 h (group B). The primary outcome was the level of pain as measured using a visual analogue scale. The secondary outcomes were the level of satisfaction with pain relief and need for rescue analgesia.

Results

A total of 200 participants were randomized equally into the two groups. Participants in group A had significantly better pain control and satisfaction over the 48 h after surgery compared with group B. Significantly more of group B required rescue analgesia for breakthrough pain compared with group A.

Conclusion

Rectal diclofenac combined with intramuscular pentazocine was significantly better at controlling pain compared with pentazocine alone in the first 48 h following caesarean section.

Trial registration number: PACTR202107706925314 at www.pactr.org on 28 July 2021.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

Impact of Transversus Abdominis Plane Block With Bupivacaine or Ropivacaine Versus Intrathecal Morphine on Opioid-related Side Effects After Cesarean Delivery: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Intrathecal morphine (ITM) is frequently associated with side effects such as postoperative nausea and vomiting (PONV) and pruritus. The aim of this meta-analysis was to compare the impact of transversus abdominis plane (TAP) block versus ITM on side effects following cesarean delivery.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and CENTRAL were searched for randomized controlled trials that compared TAP with ITM for cesarean delivery. The primary outcomes were opioid-related side effects. The secondary outcomes included pain scores, opioid consumption, patient satisfaction, and time to the first analgesia request.

RESULTS

Seven studies involving 660 patients were included. TAP blocks were performed with bupivacaine or ropivacaine. There was less PONV with TAP versus ITM (risk ratio [RR]=0.45, 95% confidence interval [CI]: 0.33-0.63, P<0.001; I2=0%), but no significant difference in pruritus (RR=0.76, 95% CI: 0.49-1.18, P=0.22; I2=78%) and sedation (RR=0.44, 95% CI: 0.19-1.00, P=0.05; I2=0%). TAP had a greater morphine consumption in 24 hours (mean difference: 5.80 mg; 95% CI: 1.38-10.22 mg, P=0.01; I2=89%) and higher pain score at rest at 6 hours (mean difference: 0.70, 95% CI: 0.39-1.02, P<0.001; I2=56%), but similar pain at rest at 24 hours and on movement compared with ITM. No differences were found in time to first analgesia and patient satisfaction.

DISCUSSION

Compared with ITM, TAP block is associated with less PONV but inferior early analgesia after cesarean delivery. However, the heterogeneity among the studies highlights the need for more well-designed studies to obtain more robust conclusions.

Caring for Parturients with Substance Use Disorders

Parturients with substance use disorder require expertise to manage the complexity of intoxication, withdrawal, and chronic use as well as ensure adequate analgesia throughout labor. Opioid use disorder in pregnancy has increased more than 4-fold in the past decade, with a 50-fold geographic variability that now dwarfs other substance use in this population. Understanding not only the medical but also the public health and criminal justice implications of substance use disorder is essential to providing optimal care to this at-risk population.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

The analgesic effectiveness of ilioinguinal-iliohypogastric block for caesarean delivery: A meta-analysis and trial sequential analysis

BACKGROUND

An effective analgesia strategy following caesarean delivery should be designed to improve fetomaternal outcomes. Much recent research has focused on the efficacy of ilioinguinal-iliohypogastric (II-IH) block for providing such analgesia.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVES

To investigate the effectiveness of II-IH block in patients undergoing caesarean delivery. The primary outcome was the cumulative parenteral morphine equivalents at 24 h. Pain scores at 4 to 6 and 24 h postsurgery, time to first rescue analgesia and adverse effects were the secondary outcomes analysed.

DATA SOURCES

Two reviewers searched independently PubMed, Embase, Google Scholar and the Cochrane central registers of a controlled trial from their inception until June 2020.

METHODOLOGY

Prospective randomised control trials comparing II-IH block with either systemic analgesia alone or a placebo block (non-active controls) were eligible for inclusion. Only trials that reported their methods comprehensibly and transparently were included. Cochrane methodology was used to assess the risk of bias. Data are presented as mean difference with 95% confidence interval (CI).

RESULTS

Thirteen trials comprising a total of 858 patients were included. Opioid (intravenous morphine equivalents) consumption was reduced by 15.57 mg (95% CI -19.87 to -11.28; P < 0.00001; I2 = 95%) during the first 24 h in patients receiving II-IH block when compared with placebo or no block. Patients receiving general anaesthesia showed a greater reduction in morphine requirement at 24 h than those receiving neuraxial anaesthesia. Adequate 'information size' for the above outcome was confirmed with trial sequential analysis to rule out the possibility of a false-positive result. II-IH also significantly reduced pain scores at rest more so at 4 to 6 h than at 24 h.

CONCLUSIONS

Our study suggests that the use of II-IH blocks is associated with a lower 24 h requirement for intravenous morphine equivalents in patients undergoing caesarean delivery. However, given the methodological limitations, data should be interpreted with caution until more studies are available.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Transversus abdominis plane block in urological procedures: A systematic review and meta-analysis

BACKGROUND

Transversus abdominis plane (TAP) blocks have been shown to successfully reduce pain and opioid consumption after general and gynaecological surgery.

OBJECTIVE

To evaluate whether TAP blocks alleviate pain and opioid consumption after urological procedures.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and CENTRAL.

ELIGIBILITY CRITERIA

Without language restriction, randomised controlled trials (RCTs) that compared the effects of TAP blocks with placebo or no treatment in urological surgery.

MAIN OUTCOME MEASURES

Primary outcomes were pain intensities at rest and movement at 6, 12 and 24 h after surgery. Secondary outcomes were postoperative opioid consumption in the first 24 h after surgery and postoperative nausea and vomiting. We performed meta-analyses using random effects models. Effect sizes were expressed as mean differences for continuous variables. We used the Cochrane risk of bias tool (RoB 2.0) to assess risk of bias.

RESULTS

We analysed 20 RCTs comprising a total of 1239 patients. The risk of bias of the studies was relatively high. TAP blocks significantly reduced postoperative pain at all time points compared with placebo or no treatment. Mean differences on an 11-point pain intensity scale were between 0.55 (95% CI: -0.90, to -0.21; P = 0.002; I2 = 94%) to 1.13 (95% CI: -1.62 to -0.65; P < 0.001; I2 = 95%) less at rest and 0.74 (95% CI: -1.25 to -0.23; P = 0.005; I2 = 79%) to 1.32 (95% CI: -1.83 to -0.81; P < 0.001; I2 = 68%) less on movements. TAP blocks also reduced opioid consumption in the first 24 h after surgery significantly by 12.25 mg (95% CI: -17.99 to -6.52 mg; P < 0.001; I2 = 99%) morphine equivalents. Possibly, this had no influence on postoperative nausea and vomiting (risk ratio: 0.98; 95% CI: 0.66 to 1.45; P = 0.91; I2 = 30%).

CONCLUSION

TAP blocks seem to offer improved analgesia when used after urological surgery. However, due to the large heterogeneity between and the considerable risk of bias within the included studies results should be viewed with caution.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42018112737.

The Effectiveness of Transversus Abdominis Plane and Quadratus Lumborum Blocks in Acute Postoperative Pain Following Cesarean Section-A Randomized, Single-Blind, Controlled Trial

Acute pain intensity related to cesarean section (CS) may be extensive and is often underestimated. This may influence mothers’ quality of life and their children’s development. Regional analgesia techniques that include transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have proven their efficacy in the postoperative period after CS. Although several randomized controlled studies and one meta-analysis have investigated the utility of TAPB and QLB in the reduction of acute and chronic pain after CS, only one study directly compared both types of regional blocks and revealed superiority of QLB over TAPB. Our study aimed to reevaluate the effectiveness of transversus TAPB and QLB in controlling acute postoperative pain after CS. We recruited 197 women with singleton pregnancies undergoing CS under spinal anesthesia. The patients were randomized to receive either TAPB or QLB after CS. The acute postoperative pain was evaluated using the visual analog scale (VAS) at 2, 4, 8, 12 and 24 h after the operation. No significant difference in acute postoperative pain intensity between the groups was found. The patients who received TAPB had a higher demand for supplemental morphine injections (p < 0.039). In our study, none of the evaluated regional blocks demonstrated an advantage over the other regarding acute postoperative pain management.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block after cesarean delivery: A systematic review and meta-analysis

PURPOSE

The meta-analysis is aimed to further access the analgesic efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block after cesarean section (CS).

METHODS

Electronic databases were searched for eligible studies. Primary objectives were pain-related outcomes. Weighted mean differences (WMDs) or standardized mean differences (SMDs), as well as risk ratios (RRs) with 95% confidence intervals (CIs), were used to calculate estimates. Subgroup analyses were done based on whether USG-TAP blocks were performed with long-acting intrathecal opioids (ITO).

RESULTS

A total of 17 studies were included. When compared with control groups (placebo or no blocks), USG-TAP block resulted in lower cumulative opioid consumption at 6 h (WMD: -8.32; 95% CI: -14.86, -1.79), 12 h (WMD: -10.75; 95% CI: -20.93, -0.57), and 24 h (WMD: -12.71, 95% CI: -21.28, -4.14). No significant differences were demonstrated among dynamic or resting pain scores. Patients in USG-TAP groups needed longer time to request first analgesic (WMD: 3.56; 95% CI: 1.43, 5.68) and showed a lower requirement of opioid rescue analgesia for breakthrough severe pain during 24 h (RR: 0.40; 95% CI: 0.18, 0.86). Subgroup analyses showed USG-TAP blocks did not afford additional benefit in the presence of intrathecal morphine. Also, reduced need for antiemetics after CS and higher maternal satisfaction were provided by USG-TAP blocks.

CONCLUSION

USG-TAP block can provide significantly effective analgesia for patients who underwent CS in the absence of long-acting ITO and therefore are worth promoting in the setting of long-acting ITO being unfeasible.

Comparison of ropivacaine plasma concentration after posterior Quadratus Lumborum Block in Cesarean Section with ropivacaine with epinephrine vs plane

BACKGROUND

The posterior Quadratus Lumborum Block (pQLB) has been used in postoperative pain management after Cesarean Section (CS). However, clinicians have no data about pQLB safety in pregnants, at increased risk of local anesthetic systemic toxicity (LAST). The purpose of the present study was to explore the efficacy and the safety of adding epinephrine to ropivacaine for bilateral pQLB vs. bilateral pQLB performed with ropivacaine alone in CS.

METHODS

in this prospective trial 52 pregnants, ASA 2 physiological status, were consecutively allocated to one of 2 groups, e-pQLB and pQLB; e-pQLB group received 0.375% ropivacaine+100 mcg epinephrine, 20 ml each side; pQLB received 0.375% ropivacaine alone, 20 ml each side. The primary and secondary outcomes were to evaluate if the adjunct of epinephrine to ropivacaine increases efficacy and safety of pQLB, respectively.

RESULTS

Authors found in e-pQLB group vs. p-QLB group: a total mean morphine consumption statistically lower during the first 24 postoperative hours (5.08±3.12, vs 9.11±4.67 SD mg, p=0.0002); NRS values statistically lower at 6 hours from block, both at rest (1,73±1,88 SD vs. 2,88±2,53, p=0.03) and with movement (3,03±1,98 SD vs. 4,23±2,87, p=0.04); a longer time between block and the first opioid request (5.92±2.48 vs 3.78±2.68 SD hrs, p< 0.003); venous ropivacaine concentrations significantly lower at any time of samples but at 120 minutes.

CONCLUSIONS

Adding epinephrine to ropivacaine increases efficacy and duration of pQLB. Moreover it increases block safety, reducing peak and mean venous ropivacaine concentration.

Quadratus Lumborum and Transversus Abdominis Plane Blocks and Their Impact on Acute and Chronic Pain in Patients after Cesarean Section: A Randomized Controlled Study

BACKGROUND

Severe postoperative pain is a significant problem after cesarean sections.

METHODS

This study was a randomized, controlled trial of 105 patients conducted in two hospitals. All patients were anesthetized spinally for elective cesarean section. Each participant was randomly allocated to one of three study groups: the quadratus lumborum block (QLB) group, the transversus abdominis plane block (TAPB) group, or the control (CON) group. The primary outcome of this study determined acute pain intensity on the visual analog scale (VAS). The secondary outcomes determined morphine consumption and chronic pain evaluation according to the Neuropathic Pain Symptom Inventory (NPSI) after hospital discharge.

RESULTS

At rest, the pain intensity was significantly higher in the CON group than in the QLB and TAPB groups at hours two and eight. Upon activity, the pain in the control subjects was more severe than in the QLB and TAPB groups in three and two of five measurements, respectively. Moreover, morphine consumption was significantly lower in the QLB (9 (5-10)) and TAPB (10 (6-14)) groups than in the CON (16 (11-19)) group. Persistent postoperative pain was significantly lower in the QLB group than in the CON group at months one and six following hospital discharge.

CONCLUSIONS

Both the QLB and TAPB can improve pain management after cesarean delivery. Moreover, the QLB might reduce the severity of persistent postoperative pain months after cesarean section.

Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

The analgesic efficacy of quadratus lumborum block in caesarean delivery: a meta-analysis and trial sequential analysis

PURPOSE

Quadratus lumborum block (QLB) has recently gained popularity for postoperative analgesia after cesarean delivery (CD) as it provides both visceral and somato-sensory blockade of the abdomen. Aim of this meta-analysis was to evaluate the analgesic potential of QLB after CD.

METHODS

Electronic database from inception to December 2019 was searched systematically for randomized-controlled trials comparing QLB with injection of inactive solution in women undergoing CD. Primary outcome was consumption of morphine at 24 h. Morphine consumption at 48 h, dynamic and static pain scores at various time intervals were the secondary outcomes studied.

RESULTS

Seven trials met the inclusion criteria. Morphine consumption was reduced significantly with QLB in comparison to sham or no block at 24 h (mean difference [MD] - 9.84 mg; 95% confidence interval [CI] - 18.16, - 0.50; p = 0.04; I² = zero). Adequate "information size" for above outcome was confirmed with trial sequential analysis, ruling out any possibility of a false-positive result. QLB significantly reduced pain scores at rest (MD - 1.13; 95% CI - 1.75, - 0.56; p = 0.00) and on movement (MD - 1.48; 95% CI - 2.5, - 0.46; p = 0.01) at 6 h. However, statistically significant difference in pain scores persisted only for dynamic pain at 24 h (MD - 0.55; 95% CI - 1.04, - 0.06; p = 0.03). QLB does not provide any additional analgesic benefit to the parturient receiving intrathecal morphine.

CONCLUSION

QLB significantly reduces opioid requirements in CD and may have analgesic effects lasting 24 h.

[Peripheral truncal blocks-Overview and assessment]

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia 2020;76:393-403. [PMID: 32621529 DOI: 10.1111/anae.15160]

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.

The impact of a transversus abdominis plane block including clonidine vs. intrathecal morphine on nausea and vomiting after caesarean section: A randomised controlled trial

BACKGROUND

Intrathecal morphine (ITM) is a widely used technique for postcaesarean section analgesia but entails a high risk of postoperative nausea and vomiting (PONV). The transversus abdominis plane (TAP) block is an alternative.

OBJECTIVE

We tested the hypothesis that a TAP block including clonidine reduces the incidence of PONV after caesarean section when compared with ITM.

DESIGN

A randomised, controlled, double-blinded study.

SETTING

Geneva University Hospitals, Switzerland, from October 2013 to February 2017.

PATIENTS

A total of 182 patients undergoing elective caesarean section were studied. Reasons for noninclusion were complicated pregnancy, contraindication to spinal anaesthesia or TAP block, extreme weight or height, allergy to any medication or previous median abdominal incision.

INTERVENTIONS

Patients were allocated randomly to one of two groups (quadruple blinded): 100 μg of morphine added to the spinal local anaesthetic or a bilateral TAP block with 20 ml of ropivacaine 0.375% + 75 μg of clonidine on each side.

MAIN OUTCOME MEASURES

The primary outcome measure was the total number of patients presenting with PONV at 24 h. Secondary aims were to compare other adverse effects (pruritus, respiratory depression, hypotension, bradycardia, sedation), analgesic efficacy and the quality of postoperative recovery.

RESULTS

At 24 h, there was no significant difference between ITM and TAP groups in the total number of patients presenting with PONV: 17/92 patients (18.5%, 95% confidence interval 11.1 to 27.9) and 27/88 patients (30.7%, 95% confidence interval 21.3 to 41.4) in TAP and ITM groups, respectively (P = 0.065). Pain scores at 6 h and cumulative morphine consumption at 24 h were lower in the ITM group (P < 0.0001 for morphine consumption at 24 h). The incidence of hypotension was higher in the TAP group (54.3 vs. 29.2%, P = 0.0006). Maternal satisfaction was high and not different between groups.

CONCLUSION

A TAP block with clonidine and local anaesthetic does not reduce significantly the incidence of PONV compared with ITM. We confirm the superiority of ITM on acute postcaesarean section analgesia compared with a TAP block, even with clonidine as an adjunct.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01931215.

Comparison of Analgesic Effect Between Erector Spinae Plane Block and Transversus Abdominis Plane Block After Elective Cesarean Section: A Prospective Randomized Single-Blind Controlled Study

Background

This study compared the analgesic efficacy of a bilateral erector spinae plane (ESP) block with that of a bilateral transversus abdominis plane (TAP) block after elective cesarean delivery.

Methods

Sixty mothers scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either ESP block or TAP block. The ESP group received ESP block at the level of the ninth thoracic transverse process with 20 mL of 0.25% bupivacaine at the end of surgery. The TAP group received an ultrasound-guided TAP block with 20 mL of 0.25% bupivacaine on completion of delivery. The primary outcome was the duration of analgesia achieved by each block. Secondary outcome measures were the postoperative pain severity, total tramadol consumption, patient satisfaction.

Results

The median (interquartile range) duration of block was longer in the ESP group than in the TAP group (12 hours [10, 14] vs 8 hours [8, 8], p<0.0001). In the first 24 hours, the mean visual analog pain score at rest was lower by 0.32 units in the ESP group. The median tramadol consumption in the first 24 hours was significantly higher in the TAP group than in the ESP group (125 mg [100, 150] vs 100 mg [75, 100, p=0.003]).

Conclusion

Compared with the TAP block, the ESP block provides more effective pain relief, has a longer duration of analgesic action, prolongs time to first analgesic requirement, is associated with less tramadol consumption, and can be used in multimodal analgesia and opioid-sparing regimens after cesarean section.

Anesthesia for Urgent Cesarean Section

Cesarean section (CS) is a common surgical procedure worldwide. The anesthesiologist is responsible, together with obstetrician and neonatologist, for safe perioperative management. A continuum of risk exists for urgent CS. The decision-to-delivery interval is an important audit tool, to ensure international standards are upheld and good outcomes for mother and neonate are achieved. Urgent CS may be performed under either GA or RA, with benefits and risks attributable to each. Specific clinical scenarios require an individualized approach to anesthesia, including hemorrhage, hypertensive disorders, cardiac disease, the difficult airway and fetal compromise. Ongoing training is integral to the provision of safe anesthesia.

Transversus Abdominis Plane Block

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.

Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.

Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.

Ultrasound and Plastic Surgery: Clinical Applications of the Newest Technology

BACKGROUND

Color Doppler ultrasound (CDUS) has not been routinely used in plastic and reconstructive surgery. Barriers to use have included large, cumbersome equipment, low-definition images, cost, and availability. In addition, programs in plastic surgery have not included training with ultrasound (US); thus, many current-day practitioners are unfamiliar with and reluctant to use this technology. Nevertheless, recent studies have demonstrated the utility of US in surgical planning. With the miniaturization, clearer imaging, and decreased costs of the latest US technology, previous barriers to use have largely been eliminated.

METHODS

Fifty-six patients scheduled for either reconstructive or aesthetic surgery were evaluated preoperatively and/or intraoperatively by a single surgeon with the linear 12-4 probe of a Philips Lumify CDUS device (Philips, Reedsville, Penn). For patients undergoing flap reconstruction, potential donor sites were imaged in order to locate the largest perforator. For patients undergoing abdominal procedures, intraoperative visualization of the abdominal muscular layers was used for the delivery of anesthesia during transversus abdominis plane block. Lastly, the superficial fascial system (SFS) was subjectively evaluated in all preoperative patients.

RESULTS

For flap reconstruction, 11 patients were preoperatively examined with CDUS in order to locate the largest perforators prior to perforator flap reconstruction. Flaps studied included the deep inferior epigastric perforator, anterolateral thigh, tensor fascia lata, thoracodorsal artery perforator, superior gluteal artery perforator, and the gracilis musculocutaneous. Color Doppler ultrasound findings were confirmed intraoperatively for all cases (100%). In 2 (18.2%) of 11 cases, CDUS identified perforators not detected by computed tomography angiography. Twenty-five patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction had successful intraoperative visualization of the abdominal wall muscular layers, thus allowing administration of transversus abdominis plane blocks by the operating surgeon. Twenty patients undergoing body contouring surgery had preoperative visualization of the SFS. The SFS was found to be varied not only among different patients but also within individual patients.

CONCLUSIONS

The newest, miniaturized CDUS technology has a variety of applications that may improve patient outcomes and experience in plastic surgery. Our observations require further investigation to quantify the perceived benefits of this new technology.

A review of peripheral nerve blocks for cesarean delivery analgesia

Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.

Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section: a randomized controlled trial

Purpose

Quadratus lumborum block (QLB) is shown to be effective on analgesia following cesarean section. This study aimed to compare the effects of three practical QLB approaches and classic epidural analgesia (EA) for cesarean section under spinal anesthesia.

Patients and methods

Parturients undergoing elective cesarean section were randomized as group 1 (QLB type 2), group 2 (QLB type 3), group 3 (QLB type 2+3) and group 4 (EA). The block was performed at the end of the operation, and the epidural group was given a single epidural bolus. All subjects were provided with intravenous patient-controlled analgesia under identical settings. In addition, the postoperative pain severity was assessed by the VAS, which together with the morphine consumption at specific time intervals, was recorded within 48 hrs after surgery. Data were collected from December 2017 to June 2018.

Results

A total of 94 parturients had completed the study. At almost all postoperative time points, the VAS scores at rest and with movement in QLB type 2+3 group were lower than those in QLB type 2 or 3 group. The mean additional morphine consumption in QLB type 2+3 group (2.7 mg) was lower than that in QLB type 2 or 3 group (6.1 mg and 5.7 mg, respectively) within 48 h after surgery (P<0.001). Besides, the total morphine consumption in EA group (1.3 mg) was lower than that in any other QLB group (P<0.001).

Conclusions

The analgesic effect of QLB is highly dependent on the injection position of local anesthetic. Besides, the ultrasound-guided QLB type 2+3 can provide superior analgesic effect following cesarean section to that of QLB type 2 or 3 block. However, it remains to be further validated about whether the combination of QLB type 2 and 3 is the best approach.

Comparison of ultrasound-guided iliohypogastric/ilioinguinal nerve block and transversus abdominis plane block for analgesia after cesarean section: A retrospective propensity match study

Effective and adequate post-operative analgesia for cesarean section is in demand due to increasing rates of cesarean deliveries, and may help promote recovery, ambulation and breastfeeding. Local nerve block has been applied as post-operative analgesia for maternal patients receiving cesarean section; specifically, lateral abdominal transversus abdominis plane block (TAPB) and iliohypogastric/ilioinguinal nerve block (IHINB) under ultrasound guidance have been proven to be effective. The present study aimed to compare the analgesic effect of TAPB and IHINB in maternal females undergoing cesarean section. Propensity-matched females who received cesarean section (n=124) were retrospectively enrolled and divided into the TAPB group (n=62) and the IHINB group (n=62) according to their post-operative analgesia treatment. All of the patients have been given spinal-epidural anesthesia during the operation, while they received either TAPB or IHINB for post-operative analgesia. Demographic and clinical data were collected and compared, including time to first morphine request, cumulative morphine consumption, visual analogue scale (VAS) score and adverse events. Due to propensity matching, there was no significant difference between the two groups in their baseline characteristics (all P>0.05). The log-rank test indicated no significant difference in the Kaplan-Meier curves for the time to first morphine request between the two groups (P=0.575). The VAS score and cumulative morphine consumption at 6 and 12 h was similar between the two groups (all P>0.05). However, these two parameters were significantly lower in the IHINB group at 24 and 48 h (P<0.001). Uni- and multivariate logistic regression analysis indicated that the method of block was not an independent influencing factor regarding postoperative pain relief (P=0.628). There was also no difference between the two groups in adverse events of analgesia (all P>0.05). In conclusion, the present study demonstrated that TAPB and IHINB achieved a comparably satisfactory analgesic effect after cesarean section. However, the analgesic effect of IHINB was better than that of TAPB at the later stages.

Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use

The prevalence of opioid use disorder in pregnancy has escalated markedly in recent years. Chronic opioid use during pregnancy poses several challenges for providing adequate analgesia and anesthesia in the peripartum period. These challenges include the potential for withdrawal, opioid tolerance and opioid-induced hyperalgesia. Here we discuss alterations in analgesic pharmacokinetics and pharmacodynamics that are associated with chronic opioid use. In addition, when treating pain in patients with opioid use disorder it is important to distinguish between different subgroups. In this review, we will discuss practical management strategies for parturients with (1) untreated opioid use disorder, (2) parturients on medication-assisted treatment (methadone, buprenorphine) and (3) patients recovering from opioid use disorder that are currently abstinent. Finally, we offer an overview of non-opioid strategies that may be utilized as part of a multimodal approach to providing optimal analgesia in this patient population.

Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial

Background

Adequate pain control after cesarean section (CS) is crucial for mothers caring for newborns, and early ambulation to avoid thromboembolism and chronic abdominal and pelvic pain. This randomized controlled trial compared the efficacy of quadratus lumborum block (QLB) and intrathecal morphine (ITM) for analgesia after CS.

Methods

Ninety women at ≥ 37 weeks pregnancy scheduled for elective CS were enrolled. All patients received spinal anesthesia and post-operative QLB. They were randomly allocated to Control (anesthesia: 0.1 ml saline, QLB: 24 ml saline), ITM (anesthesia: 0.1 mg morphine, QLB: 24 ml saline), or QLB groups (anesthesia: 0.1 ml saline, QLB: 24 ml 0.375% ropivacaine). Integrated analgesia score (IAS) and numerical rating scale (NRS) scores at rest and during movement, morphine requirements in the first 48 h, time to first morphine dose and morphine-related side effects were recorded.

Results

IASs and NRS scores at rest and during movement were significantly lower in QLB and ITM group than in Control group. Moreover, IASs and NRS scores at rest and during movement were lower in QLB group than in ITM group. Time to first morphine dose was significantly longer in QLB group than in ITM and Control group. Furthermore, morphine requirements in the first 48 h were significantly lower in QLB group than ITM and Control group. Incidence of morphine-related side effects was significantly higher in ITM group than in QLB and Control group.

Conclusions

QLB and ITM are effective analgesic regimens after CS. However, QLB provides better long-lasting analgesia and reduced total postoperative morphine consumption.

Effectiveness of Parecoxib Sodium Combined with Transversus Abdominis Plane Block for Pain Management After Hepatectomy for Hepatocellular Carcinoma: A Prospective Controlled Study

BACKGROUND This study aimed to investigate the effectiveness of perioperative parecoxib sodium combined with transversus abdominis plane (TAP) block on postoperative pain management following hepatectomy in patients with hepatocellular carcinoma (HCC). MATERIAL AND METHODS One hundred patients with HCC who underwent hepatectomy were randomized into a study group (n=51) and a control group (n=49). The study group received 40 mg of parecoxib sodium 30 minutes before anesthetic induction, and 150 mg of 0.375% ropivacaine with 5 mg dexamethasone as TAP inhibitors, before closing the abdominal incision. The control group received 40 mg of placebo 30 minutes before anesthetic induction, without TAP block. Postoperatively, all patients received patient-controlled intravenous analgesia (PCIA) and evaluation with subjective visual analog scale (VAS) pain scores. Data on adverse events, postoperative ambulation (>6 hours/day), time of flatus and defecation, and hospitalization duration were recorded. RESULTS Pain scores of the study group were significantly lower compared with the control group on the first three postoperative days. No significant differences were found between the two groups in terms of adverse events. In the study group, the number of cases of postoperative ambulation was significantly more than the control group. The onset of flatus and defecation and duration of hospital stay in the study group were significantly shorter in the study group compared with the control group. CONCLUSIONS Parecoxib sodium combined with TAP block effectively reduced postoperative pain, improved ambulation, improved gastrointestinal function, and shortened hospitalization time following hepatectomy in patients with HCC without adverse effects.