Subarachnoid block and ultrasound-guided transversalis fascia plane block for caesarean section: A randomised, double-blind, placebo-controlled trial

Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: A randomised clinical trial

BACKGROUND

Caesarean section is a widely performed surgical procedure that often results in moderate-to-severe postoperative pain. If left untreated, this pain can lead to short-term and long-term consequences. Transversalis fascia plane (TFP) block and transversus abdominis plane (TAP) block are among the regional anaesthesia techniques employed for managing pain after a caesarean section.

OBJECTIVE

We aimed to compare the impact of these two blocks on the quality of recovery in patients undergoing elective caesarean section under spinal anaesthesia.

DESIGN

A single-centre, double-blind, randomised trial.

SETTINGS

Operating room, postanaesthesia recovery unit, and ward in a tertiary hospital.

PARTICIPANTS

Ninety-three patients (ASA 2 to 3) were recruited. After exclusion, 79 patients were included in the final analysis: 40 in the TFP block group and 39 in the TAP block group.

INTERVENTIONS

After surgery, participants received either TFP block (20 ml 0.25% bupivacaine for each side) or TAP block (20 ml 0.25% bupivacaine for each side).

MAIN OUTCOME MEASURES

The primary outcome was the difference in obstetric quality of recovery 11-Turkish (ObsQoR-11T) scores between groups. Secondary outcomes included pain scores, opioid consumption and incidence of opioid-related complications.

RESULTS

The mean ObsQoR-11T score was higher in the TFP block group compared with the TAP block group (97.13 ± 6.67 points vs. 87.10 ± 9.84 points, respectively; P  < 0.001). The pain scores in the TFP block group were slightly lower between postoperative 4 and 24 h. The mean total morphine consumption was 15.08 ± 2.21 mg in the TFP block group and 22.21 ± 3.04 mg in the TAP block group ( P  < 0.001). More patients required rescue analgesia between 4 and 8 h in the TAP block group [2.00 (5.00%) vs. 9.00 (23.08%), P  = 0.02]. No significant differences were observed between groups in terms of opioid-related side effects.

CONCLUSION

TFP block used for analgesic purposes yielded a better quality recovery period than TAP block and also reduced opioid consumption.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05999981).

VISUAL ABSTRACT

http://links.lww.com/EJA/B6 .

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%.

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.

Comparison of ultrasound-guided transversalis fascia plane block and anterior quadratus lumborum block in patients undergoing caesarean delivery: a randomized study

BACKGROUND

Cesarean section is becoming increasingly common. Well-managed postoperative analgesia improves patient comfort while encouraging early ambulation and breastfeeding. The analgesic efficacy of transversalis facial plane block (TFPB) vs. anterior quadratus lumborum block (QLB) was compared in this study.

METHODS

We analyzed the data of 49 pregnant women (gestation, ≥ 37weeks; age, 18-45years) scheduled for elective cesarean delivery (CD) under general anesthesia. They were randomly divided into TFPB and anterior QLB groups. All blocks were administered bilaterally with 25mL of 0.25% bupivacaine under ultrasound guidance prior to extubation. Postoperative morphine consumption and numerical rating scale (NRS) pain scores (static and dynamic [during coughing]) were recorded at 1, 3, 6, 9, 12, 18, and 24h.

RESULTS

There was no difference in postoperative morphine consumption between the groups at the third, sixth, and ninth hours, but the anterior QLB group consumed less morphine at the 12th, 18th, and 24th hours. Except for the first hour, resting and dynamic NRS scores were comparable between the groups. The first-hour resting and dynamic NRS scores were lower in the TFPB group (resting NRS, anterior QLB group, median [interquartile range], 2 [2-3] vs. TFPB group, 2 [0-2], p = 0.046; dynamic NRS, anterior QLB group, median [interquartile range], 3 [2-4] vs. TFPB group 2 [0-3], p = 0.001).

CONCLUSIONS

In patients undergoing CD, anterior QLB decreased morphine consumption in the late period (9-24h) compared to TFPB, while pain scores were similar between both groups. The reduction in morphine consumption was statistically significant, but not clinically significant.

Ultrasound-guided transversalis fascia plane block versus lateral quadratus lumborum plane block for analgesia after inguinal herniotomy in children: a randomized controlled non-inferiority study

BACKGROUND

Surgical repair of inguinal hernia is one of the most common day case surgeries in the pediatric population. This study compared the postoperative analgesic effects of transversalis fascia plane block (TFB) versus quadratus lumborum block (QLB) in children scheduled for open unilateral inguinal herniotomy.

METHODS

In this prospective, randomized, double-blind, controlled non-inferiority study, 76 eligible patients were recruited. Patients were randomly allocated to either the TFB or QLB group. The primary outcome measure was the proportion of patients who needed rescue analgesia during the first postoperative 12 h. The secondary outcomes were, the time needed to perform the block, the postoperative FLACC score, intraoperative heart rate (HR) and mean arterial pressure (MAP).

RESULTS

The proportion of patients who required a rescue analgesic was comparable (p = 1.000) between the TFB group (7/34, 20.5%) and the QLB group (6/34, 17.6%). The median [Q1-Q3] time needed to perform the block (min) was significantly longer (p < 0.001) in the QLB group (5[5]) compared with the TFB group. The postoperative FLACC pain scale was comparable between the two groups at all-time points of assessment. There is no difference regarding the heart rate and mean arterial blood pressure values at the time points that the values were recorded. (P > 0.005).

CONCLUSIONS

Both TFB and QLB similarly provide good postoperative analgesia by reducing the proportion of patients who required rescue analgesia, pain scores and analgesic consumption. Moreover, TFB is technically easier than QLB.

Efficacy of transversalis fascia plane block as a novel ındication for varicocelectomy surgery: prospective randomized controlled study

BACKGROUND

Varicocele occurs as a result of dilatation of the pampiniform plexus in the spermatic veins. In this study, our primary aim was to evaluate the effect of Transversalis Fascia Plane Block (TFPB) on pain scores in the postoperative period in patients undergoing varicocelectomy surgery, and our secondary aim was to evaluate the effect of TFPB on analgesic consumption.

METHODS

The study was initiated following local ethics committee approval, and sixty ASA I-II patients > 18y scheduled to undergo varicocelectomy and who consented to participation were enrolled. Before the procedure, the patients were randomly assigned two groups: Transversalis Fascia Plan block group (Group TFPB) or surgical incision site infiltration group (Group I).All surgeries were carried out under general anesthesia, and microsurgery using the subinguinal approach. After surgical suturing, TFPB and local infiltration blocks were applied prior to termination of anesthesia.For each block, 20 mL of 0.25% bupivacaine was utilized. Patients' demographic information, passive and active VAS ratings after surgery, usage of non steroidal anti-inflammatory medications and rescue analgesia, and the requirement for rescue analgesia, were recorded.

RESULTS

A total of 60 patients were included in the study. In terms of demographic data, there was no difference between the groups. At all hours, there was a statistically significant decrease in favor of Group TFPB in terms of active and passive VAS scores (p < 0.001), non steroidal anti-inflammatory analgesic use (p < 0.05), and tramadol requirement (p < 0.001).

CONCLUSION

This study has shown that TFPB can provide a more effective analgesia when compared to surgical site infiltration.

Ultrasound-guided transversalis fascia plane block versus wound infiltration for both acute and chronic post-caesarean pain management - A randomised controlled trial

BACKGROUND AND AIMS

Ultrasound-guided transversalis fascia plane block (USG-guided TFPB) has recently been evaluated for post-caesarean acute pain management. We compared it with standard wound infiltration for both acute and chronic post-caesarean pain management.

METHODS

All patients undergoing caesarean section (CS) under subarachnoid block were included and randomised. Patients in group C received standard wound infiltration (20 ml of 0.375% ropivacaine) and group-T received bilateral USG-guided TFPB (20 ml of 0.375% ropivacaine) at the end of the surgery. Acute pain assessed using numeric rating scale (NRS), time to first request of analgesia and total rescue analgesic consumption in 24 hours. The incidence of chronic persistent post-surgical pain (CPSP), neuropathic pain component and quality of life (QoL) were assessed. Fisher's exact test, Chi-square test, unpaired Student's t-test and Mann-Whitney U test were used.

RESULTS

Sixty patients were included with 30 in each group. NRS score on rest at 6th and 24th hour and on active movement at 1st hour was significantly decreased in group T. The "time to first request of analgesia" was statistically higher in group T, that is, 10.77 ± 1.39 h versus 6.30 ± 1.60 h. Five (16.6%) and two (6.6%) patients in groups C and T, respectively, required rescue analgesia in first 24 hours. 30% (n = 6) and 10% (n = 2) patients in groups C and T, respectively, developed CPSP. The neuropathic pain component was significantly reduced and QoL was significantly improved in group T.

CONCLUSION

TFPB is efficacious for management of both acute and chronic post-caesarean pain management.

Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Objective

Cesarean section (CS) is one of the most frequently performed major surgical interventions. Local anesthetic techniques, a universal component of perioperative multimodal analgesia, are reportedly effective in reducing pain scores and opioid requirements. However, the optimal local anesthetic technique for postoperative CS pain remains unclear.

Methods

Six databases were searched, and a Bayesian network meta-analysis was performed. The outcomes included cumulative morphine consumption and pain scores at four time points, time to first analgesic request, postoperative nausea and vomiting, pruritus, and sedation.

Results

Sixty-eight studies with 5039 pregnant women were included. Six local anesthetic techniques were involved, including transversus abdominis plane block (TAPB), ilioinguinal and iliohypogastric nerve block, quadratus lumborum blocks, transversalis fascia plane block, erector spinae block, and wound infiltration. Compared to inactive controls, TAPB reduced cumulative morphine consumption at 6, 12, 24, and 48 h, pain scores at 6, 12, and 24 h (with the exception of 24 h at rest), the risk of postoperative nausea and vomiting, and sedation. Compared with inactive controls, ilioinguinal and iliohypogastric nerve block reduced cumulative morphine consumption at 6 and 24 h and pain scores at 6, 12, and 24 h during movement. Compared with inactive controls, quadratus lumborum blocks reduced cumulative morphine consumption at 24 and 48 h and pain scores at 6 and 12 h and lengthened the time to first analgesic request. Compared with inactive controls, wound infiltration reduced cumulative morphine consumption at 12 and 24 h, pain scores at 12 and 24 h during movement, and risk of sedation. Compared with inactive controls, erector spinae block reduced pain scores at 6 and 12 h. Transversalis fascia plane block was found to have similar outcomes to inactive controls.

Conclusion

TAPB is the most comprehensive local anesthetic technique for postoperative CS analgesia in the absence of intrathecal morphine.

Preemptive analgesic efficacy of ultrasound-guided transversalis fascia plane block in children undergoing inguinal herniorrhaphy: a randomized, double-blind, controlled study

Background

Surgical repair of congenital inguinal hernia results in significant postoperative discomfort and pain. The aim of the current study was to evaluate the pre-emptive analgesic efficacy of a transversalis fascia plane (TFP) block after pediatric inguinal herniorrhaphy.

Methods

Forty-four patients aged 12 to 60 months who underwent unilateral inguinal herniorrhaphy were enrolled. Four patients were excluded, and the remaining were allocated to the control group and the TFP block group. In the TFP block group, 0.4 ml/kg bupivacaine 0.25% was instilled in the plane between the transversus abdominis and transversalis fascia, while in the control group 0.9% saline was used instead of bupivacaine. The collected data were the total dose of paracetamol consumed during the first 12 h postoperatively, the postoperative Face, Leg, Activity, Cry, Consolability (FLACC) pain score, time to first use of rescue analgesia, number of patients required additional postoperative analgesics, and parents' satisfaction.

Results

The median paracetamol consumption was significantly lower in the TFP block group than in the control group, and FLACC pain scores were significantly lower for all study times in the TFP block group with higher parental satisfaction scores than those for the control group. The number of patients who required additional analgesics was significantly lower in the TFP block group than in the control group.

Conclusions

The use of a TFP block decreases postoperative analgesic consumption and postoperative pain intensity after pediatric inguinal herniorrhaphy. Future studies with larger sample size are required to evaluate the actual complications rate of TFP block.