Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial

OBJECTIVE

In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence.

METHODS

This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications.

RESULTS

After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001).

CONCLUSIONS

After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model.

TRIAL REGISTRATION

ChiCTR2100051784.

Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.

The Role of Ultrasound-Guided Multipoint Fascial Plane Block in ElderlyPatients Undergoing Combined Thoracoscopic-Laparoscopic Esophagectomy: A Prospective Randomized Study

INTRODUCTION

We estimated the safety and efficacy of ultrasound-guided multipoint fascial plane block, including serratus anterior plane block (SAPB) and bilateral transversus abdominis plane block (TAPB) in elderly patients who underwent combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

The authors enrolled 80 patients in this prospective study after patient selection using the inclusion and exclusion criteria who were scheduled for elective TLE from May 2020 to May 2021. Patients were randomly assigned to the treated group (group N) or the control group (group C) (n = 40 per group) using the sealed-envelope method. Multipoint fascial plane blocks, including serratus anterior plane block (SAPB) and bilateral TAPB, were performed on patients undergoing TLE using a solution of 60 mL 0.375% ropivacaine plus 2.5 mg dexamethasone by 3 injections of 20 mL each (group N) or no interventions (group C).

RESULTS

Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at T incision and 30 min after T incision were significantly higher in group C than in group N, and also significantly higher than at baseline (P < 0.01). Blood glucose at 60 min, 2 h after T incision, was significantly higher in group C than in group N and significantly higher than at baseline (P < 0.01). Compared to group N, the dosages of propofol and remifentanil used during surgery in group C were more than those in group N (P < 0.01). The time to first rescue analgesic in group C was earlier than in group N. The total postoperative use of sufentanil, and the number of patients requiring rescue analgesics in group C, were more than in group N (P < 0.01).

CONCLUSIONS

This study showed that applying the multipoint fascia pane block technique in TLE for elderly patients could significantly reduce postoperative pain, decrease the dosages of drugs used in general anesthesia, improve the quality of the awakening, and have no obvious adverse reactions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR-2000033617).

How to do subcostal transversus abdominis plane catheters during midline laparotomy

Accessing the transversus abdominis plane during midline laparotomy.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis.

METHODS

We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system.

RESULTS

Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr.

CONCLUSIONS

Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr.

TRIAL REGISTRATION

PROSPERO (CRD42021238916); registered 25 February 2021.

Comparison of the analgesic effects continuous epidural anesthesia and continuous rectus sheath block in patients undergoing gynecological cancer surgery: a non-inferiority randomized control trial

PURPOSE

We investigated the non-inferiority of continuous rectus sheath block to continuous epidural anesthesia for postoperative analgesia of gynecological cancer patients.

METHODS

One hundred ASA-PS 1-2 patients via a median incision up to 5 cm above the navel were randomized into a continuous epidural anesthesia (CEA) group and a continuous rectus sheath block (CRSB) group. Following surgery, they have controlled with intravenous patient-controlled analgesia (IV-PCA) as basal postoperative analgesia. For patients in the CEA group were administered 0.25% levobupivacaine at 5 mg/h. Patients in the CRSB group, catheters were inserted on both sides of the posterior rectus sheath after surgery. They received 0.25% levobupivacaine on both sides at 7.5 mg/h. To determine whether CRSB is non-inferior to CEA in postoperative treatment, pain at rest and movement was assessed using the Numerical Rating Scale (NRS). The non-inferiority margin of NRS difference between CRSB and CEA was set at 1.3 difference in means. The primary outcome was non-inferiority comparisons of NRS at rest/at movement after surgery, while the secondary outcome included the frequency of requesting IV-PCA and rescue drugs.

RESULTS

NRS at rest in the CRSB group was not inferior to that in the CEA group. On the other hand, the NRS at movement at 4, 6, 8, 12 h following surgery in the CRSB group was inferior to CEA. There was no difference in the frequency of requesting IV-PCA and rescue drugs.

CONCLUSIONS

CRSB showed the non-inferiority to CEA for postoperative analgesia at rest, while CRSB was not non-inferior to CEA at movement in gynecological cancer patients. CRSB would be a substitute when CEA is contraindicated as a component of postoperative multimodal analgesia.

European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

Postoperative analgesic efficacy of modified continuous transversus abdominis plane block in laparoscopic colorectal surgery: a triple-blind randomized controlled trial

BACKGROUND

The optimal opioid-sparing analgesic regimen following laparoscopic colorectal surgery (LCS) remains uncertain. We sought to determine the efficacy of low-dose bupivacaine infusion via surgeon-inserted modified continuous transversus abdominis plane (mcTAP) catheters after LCS.

METHODS

A parallel-group, placebo-controlled, randomized single-centre trial was conducted between April 2017 and February 2018. Block-of-four randomization and allocation concealment by sequentially-numbered, opaque sealed envelopes were used. Patients, surgeons and assessors were blinded. Fifty-two patients were randomized to receive either 0.2% bupivacaine or saline through mcTAP catheters. A 5 ml bolus followed by a 72 h infusion at 2 ml/h was started, with patient-controlled fentanyl analgesia and oral paracetamol given on demand. Primary outcomes were fentanyl consumptions in the first 24 h, second 24 h, and third 24 h following surgery. Secondary outcomes were pain numeric rating scores, recovery outcomes and complications.

RESULTS

Twenty-five patients in the bupivacaine group and 26 in the control group were analysed. Patients in the bupivacaine group required significantly less fentanyl overall (106.1 vs 484.5 mcg, p < 0.001) and at all time points (first 24 h: 61.0 vs 324.3 mcg, p < 0.001; second 24 h: 36.3 vs 119.0 mcg, p = 0.033; third 24 h: 8.8 vs 41.2, p = 0.030) when compared to placebo. Significantly lower pain scores at rest at 6 h (2.32 vs 4.0, p = 0.002), and 12 h (1.80 vs 3.08, p = 0.011) and on coughing at 6 h (4.56 vs 5.84, p = 0.019), 12 h (3.76 vs 4.96, p = 0.009), and 24 h (3.44 vs 4.24, p = 0.049) as well as significantly lower opioid-related complications such as nausea or vomiting (9 (36%) vs 1 (4%), p = 0.005) were observed in the bupivacaine group. There were no major block-related complications, and recovery outcomes were similar in both groups.

CONCLUSIONS

McTAP block reduces postoperative fentanyl consumption and pain scores after LCS, highlighting its role as a safe and useful opioid-sparing analgesia.

REGISTRATION NUMBER

TCTR20150831001 (Thai Clinical Trials Registry). Full trial protocol can be assessed at https://www.clinicaltrials.in.th/ .

Ultrasound-Guided Oblique Sub-Costal Transversus Abdominis Plane Block as the Principal Anesthesia Technique in Peritoneal Dialysis Catheter Implantation and Plasma Ropivacaine Concentration Evaluation in Esrd Patients: A Prospective, Randomized, Double-Blinded, Controlled Trial

Background

The ultrasound-guided transversus abdominis plane (TAP) block is generally used for analgesia but not for anesthesia. A TAP block has a partial analgesic effect on the parietal peritoneum in abdominal surgeries. We hypothesized that an ultrasound-guided oblique subcostal TAP block, used as the principal anesthesia technique, could provide a better anesthetic effect on peritoneum stimulation in peritoneal dialysis catheter (PDC) implantation in end-stage renal diseases (ESRD) patients than local anesthetic infiltration (LAI).

Methods

End-stage renal disease patients undergoing PDC implantation were randomized into 3 groups: LAI Group, unilateral TAP group (Uni-TAP Group) and bilateral TAP group (Bi-TAP Group). A 40-mL dose of 0.25% ropivacaine was used for the regional block (LAI or TAP). The quality of anesthesia, visual analogue scale (VAS) of pain, cumulative rescuing sufentanil consumption, and venous plasma ropivacaine concentrations were compared among the 3 groups.

Results

Sixty-nine patients were enrolled, and higher ‘Satisfied’ anesthesia rates from nephrologists and patients were recorded in the 2 TAP groups, compared with the LAI Group. Significantly lower VAS scores were observed in the Uni-TAP Group at a majority of time points compared with the LAI Group. Less cumulative rescuing sufentanil was used in the 2 TAP groups (2.5 ± 2.7 and 3.0 ± 2.8 μg, respectively) compared with the LAI Group (5.8 ± 2.6 μg, p < 0.05). The median peak venous plasma ropivacaine concentrations were below the reported toxic threshold in all 3 groups.

Conclusions

As the principal anesthesia technique, an ultrasound-guided unilateral oblique subcostal TAP block with 40 mL of 0.25% ropivacaine provided better anesthetic effect in PDC implantations in ESRD patients than LAI.

Randomized clinical trial of continuous transversus abdominis plane block, epidural or patient-controlled analgesia for patients undergoing laparoscopic colorectal cancer surgery

Background

The optimal analgesia regimen after laparoscopic colorectal cancer surgery is unclear. The aim of the study was to characterize the beneficial effects of continuous transversus abdominis plane (TAP) blocks initiated before operation on outcomes following laparoscopic colorectal cancer surgery.

Methods

Patients undergoing surgery for colorectal cancer were divided randomly into three groups: combined general–TAP anaesthesia (TAP group), combined general–thoracic epidural anaesthesia (TEA group) and standard general anaesthesia (GA group). The primary endpoint was duration of hospital stay. Secondary endpoints included gastrointestinal motility, pain scores and plasma levels of cytokines.

Results

In total, 180 patients were randomized and 165 completed the trial. The intention-to-treat analysis showed that duration of hospital stay was significantly longer in the TEA group than in the TAP and GA groups (median 4·1 (95 per cent c.i. 3·8 to 4·3) versus 3·1 (3·0 to 3·3) and versus 3·3 (3·2 to 3·6) days respectively; both P &lt; 0·001). Time to first flatus was earlier in the TAP group (P &lt; 0·001). Visual analogue scale (VAS) scores during coughing were lower in the TAP and TEA groups than the GA group (P &lt; 0·001). Raised plasma levels of vascular endothelial growth factor C, interleukin 6, adrenaline and cortisol were attenuated significantly by continuous TAP block.

Conclusion

Continuous TAP analgesia not only improved gastrointestinal motility but also shortened duration of hospital stay. A decreased opioid requirement and attenuating surgical stress response may be potential mechanisms. Registration number: ChiCTR-TRC-1800015535 (http://www.chictr.org.cn).

Anesthetic techniques: focus on transversus abdominis plane (TAP) blocks

Transverse abdominis plane (TAP) blocks, over the past decade, have emerged as a reliable tool in multimodal analgesia. Although they block only the somatic component of pain, studies have still revealed a consistent benefit in the first 24-48 hours after surgery in terms of pain scores and overall opioid consumption. The safety and dependability has increased with ultrasound usage. The aim of this review is to help the reader appreciate the applied anatomy required for a TAP block and its congeners, to standardize its nomenclature, and to help choose between variants of a TAP block and its complications and safety profile.

Regional Anesthesia for Ambulatory Anesthesiologists

Proper pain control is critical for ambulatory surgery. Regional anesthesia can decrease postoperative pain, improve patient satisfaction, and expedite patient discharge. This article discusses the techniques, clinical pearls, and potential pitfalls associated with those blocks, which are most useful in an ambulatory perioperative setting. Interscalene, supraclavicular, infraclavicular, axillary, paravertebral, erector spinae, pectoralis, serratus anterior, transversus abdominis plane, femoral, adductor canal, popliteal, interspace between the popliteal artery and capsule of the knee, and ankle blocks are described.

Effects of transversus abdominis plane blocks after hysterectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Transversus abdominis plane (TAP) block can provide effective analgesia for abdominal surgery. However, many randomized controlled trials (RCTs) have shown controversial results in hysterectomy. We conducted a meta-analysis of RCTs to investigate the effectiveness of TAP block after hysterectomy.

METHODS

Studies were gathered from PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov databases up to March 2018. RCTs involving TAP blocks in women undergoing hysterectomy were selected. The primary outcome of mean 24 hours morphine consumption and other outcomes, such as time to first request for analgesic, rest, and pain scores on movement at different times, and rates of nausea and vomiting, were compared between TAP block and no or sham block groups.

RESULTS

A total of 841 participants were included in the 13 selected RCTs. Compared with no or sham blocks, TAP block reduced mean 24-hour morphine consumption in abdominal hysterectomy (AH) (weighted mean difference [WMD] -10.77 mg, P=0.04) but not in laparoscopic hysterectomy (LH)/robotic-assisted hysterectomy (RH) (WMD -1.39 mg, P=0.24). TAP block in AH prolonged analgesic time and reduced nausea and vomiting rates. TAP block also reduced the postoperative pain score at rest and on movement at different times in the AH subgroup, but it did not significantly reduce the postoperative pain score at rest, 6-8, and 24 hours, as well as the pain score on movement at 2, 6-8, and 24 hours in the LH/RH subgroup.

CONCLUSION

TAP block is an effective analgesic for AH. TAP block can reduce postoperative morphine consumption in AH and pain scores at rest and on movement for AH without increasing side effects. However, TAP block has limited analgesic effects for women undergoing LH/RH, as it does not reduce postoperative morphine consumption and pain scores at rest and on movement.

The Efficacy of Transversus Abdominis Plane Block for Abdominal Hysterectomy Post-operative Analgesia

Introduction/background Abdominal hysterectomy is an open surgical procedure associated with considerable post-operative pain. Narcotics are often required during patient recovery but can result in adverse side effects. Transversus abdominis plane block (TAP block) is a regional anesthetic technique that is found to be an effective post-operative analgesia for many types of abdominal surgeries, including abdominal hysterectomies. However recent literature shows contradicting results regarding TAP block's analgesic effect on recovery from abdominal hysterectomies. This study investigated the efficacy of TAP block to reduce narcotic consumption and improve pain scores in abdominal hysterectomy patients. Methods A single-center retrospective cohort study was performed. The inclusion criteria was patients who underwent abdominal hysterectomy at Winnie Palmer Hospital for Women & Babies (WPH) between January 12, 2015 and December 31, 2015. Exclusion criteria were patients who received a second surgery within the same hospitalization, experienced an in-hospital mortality event, received hysterectomy for known malignancy, stayed in the hospital less than 24 hours, and whose charts contained missing data points. Data collected were: age, weight, height, body mass index (BMI), length of hospital stay, total narcotic consumption (intra-operation, in the post-anesthesia care unit (PACU), first 24 hours after admittance, during entire hospital stay, total patient-controlled analgesia (PCA) quantity, and total oral narcotics quantity. All narcotics were converted into parental morphine units for analysis. Numeric pain rating scale (NPRS) scores at two, four, eight, 12, 16, 20, and 24 hours after leaving the PACU were collected. Two-tailed paired T-test was performed to compare the narcotic consumption and pain scores between the TAP block group and the non-TAP block group. Results WPH used ultrasound-guided bilateral TAP block for patients undergoing abdominal hysterectomies. 63 patient charts were evaluated with 32 in the TAP block group and 31 in the non-TAP block group. Narcotic consumption was significantly different in the PACU with TAP block group consuming less narcotics than non-TAP block group (5.05 vs 8.65 IV morphine equivalents, p=0.012). TAP block group's mean narcotic consumption was not significantly lower than Non-TAP block group's mean consumption during intra-operation, first 24 hours after admittance, and total hospital stay (p=0.419, p=0.533, p=0.754 respectively). Mean NPRS scores at all hours (2, 4, 8, 12, 16, 20, and 24) displayed no statistical difference between the two groups. Total patient-controlled analgesia (PCA) and total overall oral narcotic usage showed no statistically significant differences between TAP block group and Non-TAP block group (p=0.252, 0.669 respectively). Conclusion The results of this study demonstrated that TAP block did reduce narcotic requirement in the PACU but did not exhibit superior analgesic efficacy after discharge from the PACU, nor reduce the total length of hospital stay.

TAP-block as a component of multimodal analgesia for postoperative anesthesia in obstetrics and gynecology

Postoperative pain relief is still quite actual problem in medicine, particularly in obstetrics and gynaecology. The most appropriate method of adequate post-operative anesthesia is multimodal analgesia. This article describes the features of multimodal analgesia using TAP-block combined with NSAIDs in obstetric and gynaecological patients, advantages and disadvantages of this combination and our own experience of applying this method in our clinic.

Effect of different anesthesia and analgesic methods on recovery of gastrointestinal function in elderly patients after open surgery

AIM

To explore the effect of different anesthesia and analgesia methods on gastrointestinal function recovery in elderly patients after open surgery.

METHODS

A total of 100 elderly patients undergoing open surgery from April 2016 to December 2017 were selected and divided into a control group (n = 50) and an observation group (n = 50) according to the method of anesthesia and analgesia. In the control group, systemic intravenous anesthesia and meridian analgesia were used. In the observation group, combined spinal and epidural anesthesia and epidural analgesia were used. Time to first defecation, time to recovery of gastrointestinal peristalsis, and time to food intake were recorded. Immunoradiometric method was used to determine plasma motilin levels before and after anesthesia and analgesia. The visual analog scale (VAS) was used to evaluate the pain degree of the two groups before anesthesia and analgesia and 6 h, 12 h, 18 h and 24 h after anesthesia and analgesia. The incidence of complications such as nausea and vomiting, elevated blood pressure, abnormal liver and kidney function, and post-cognitive dysfunction (POCD) were also recorded.

RESULTS

Time to first defecation, time to recovery of gastrointe-stinal peristalsis, and time to food intake in the observation group were significantly shorter than those in the control group (P < 0.05). Plasma motilin levels in the observation group after anesthesia and analgesia were significantly higher in the observation group than in the control group (P < 0.05). VAS scores at 6 h, 12 h, and 18 h after anesthesia and analgesia were significantly lower than those before anesthesia and analgesia in both groups, and were significantly lower in the observation group than in the control group (P < 0.05). The incidence of nausea and vomiting, diarrhea, elevated blood pressure, abnormal liver and kidney function, and POCD was significantly lower in the observation group than in the control group (P < 0.05).

CONCLUSION

The combination of lumbar-sparing anesthesia and epidural analgesia in elderly patients undergoing laparo-tomy can promote the early recovery of gastrointestinal function and reduce pain, and has a low incidence of postoperative complications.

Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques

Purpose of Review

Transversus abdominis plane (TAP) block is a regional technique for analgesia of the anterolateral abdominal wall. This review highlights the nomenclature system and recent advances in TAP block techniques and proposes directions for future research.

Recent Findings

Ultrasound guidance is now considered the gold standard in TAP blocks. It is easy to acquire ultrasound images; it can be used in many surgeries involving the anterolateral abdominal wall. However, the efficacy of ultrasound-guided TAP blocks is not consistent, which might be due to the use of different approaches. The choice of technique influences the involved area and block duration. To investigate the actual analgesic effects of TAP blocks, we unified the nomenclature system and clarified the definition of each technique. Although a single-shot TAP block is limited in duration, it is still the candidate of the analgesic standard for abdominal wall surgery because the use of the catheter technique and liposomal bupivacaine may overcome this limitation.

Summary

Ultrasound-guided TAP blocks are commonly used. With the unified nomenclature and the development of catheter technique and/or liposomal local anesthetics, TAP blocks can be applied more appropriately to achieve better pain control.

Randomised Comparison of Three Types of Continuous Anterior Abdominal Wall Block after Midline Laparotomy for Gynaecological Oncology Surgery

Effective analgesia after midline laparotomy surgery is essential for enhanced recovery programs. We compared three types of continuous abdominal wall block for analgesia after midline laparotomy for gynaecological oncology surgery. We conducted a single-centre, double-blind randomised controlled trial. Ninety-four patients were randomised into three groups to receive two days of programmed intermittent boluses of ropivacaine (18 ml 0.5% ropivacaine every four hours) via either a transversus abdominis plane (TAP) catheter, posterior rectus sheath (PRS) catheter, or a subcutaneous (SC) catheter. All groups received patient-controlled analgesia with morphine, and regular paracetamol and non-steroidal anti-inflammatory medication. Measured outcomes included analgesic and antiemetic usage and visual analog scores for pain, nausea, vomiting, and satisfaction. Eighty-eight patients were analysed (29 SC, 29 PRS and 30 TAP). No differences in the primary outcome were found (median milligrams morphine usage on day two SC 28, PRS 25, TAP 21, P=0.371). There were differences in secondary outcomes. Compared with the SC group, the TAP group required less morphine in recovery (0 mg versus 6 mg, P=0.01) and reported less severe pain on day one (visual analog scores 36.3 mm versus 55 mm, P=0.04). The TAP group used fewer doses of tropisetron on day one compared with the PRS group (8 versus 21, P=0.016). Programmed intermittent boluses of ropivacaine delivered via PRS, TAP and SC catheters can be provided safely to patients undergoing midline laparotomy surgery. Initially TAP catheters appear superior, reducing early opioid and antiemetic requirements and severe pain, but these advantages are lost by day two.