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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Dhanjal ST, Jannace KC, Giordano NA, Highland KB. Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq. Mil Med 2020; 185:e573-e578. [PMID: 31889192 DOI: 10.1093/milmed/usz455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). MATERIALS AND METHODS In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. RESULTS 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha = 0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. CONCLUSIONS This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.
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Affiliation(s)
- Sandeep T Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston TX 78234
| | - Kalyn C Jannace
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852
| | - Nicholas A Giordano
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD 20852.,Henry M Jackson Foundation, 6720A Rockledge Drive, Bethesda, MD 20817
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Burch R, Miller M. Response to: 'Posterior quadratus lumborum block in the combat environment' by Dhanjal et al. Reg Anesth Pain Med 2020; 45:rapm-2020-101355. [PMID: 32114482 DOI: 10.1136/rapm-2020-101355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Robert Burch
- Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael Miller
- Anesthesiology, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
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Pain management in trauma patients affected by the opioid epidemic: A narrative review. J Trauma Acute Care Surg 2020; 87:430-439. [PMID: 30939572 DOI: 10.1097/ta.0000000000002292] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.
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Zhang D, Zhou C, Wei D, Ge L, Li Q. Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0209646. [PMID: 30620730 PMCID: PMC6324803 DOI: 10.1371/journal.pone.0209646] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/10/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the analgesic efficacy of dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plane (TAP) block for the patients after abdominal surgery. METHODS PubMed, CENTRAL, EMBASE, Web of science were searched to identify eligible randomized controlled trials (RCTs) that compared dexamethasone added to local anesthetics in ultrasound-guided TAP block with control for postoperative analgesia in adult patients undergoing abdominal surgery. Primary outcomes included postoperative pain intensity, the time to the first request for additional analgesics, and opioid consumption over 24 h after surgery. Secondary outcome was the incidence of postoperative nausea and vomiting. Analysis was performed by RevMan 5.3 software and the quality of evidence was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. RESULTS Nine RCTs involving 575 patients were included. Compared to the control, dexamethasone added to local anesthetics in ultrasound-guided TAP block significantly decreased visual analogue scale (VAS) scores at rest at 4h (mean difference [MD] = -1.01; 95% confidence intervals [CI], -1.29 to -0.73; P<0.00001; moderate quality of evidence), 6h (MD = -1.21; 95% CI, -1.74 to -0.69; P<0.00001; low quality of evidence), and 12h after surgery (MD = -0.79; 95% CI, -0.97 to -0.60; P<0.00001; moderate quality of evidence). No difference was found at 2h (MD = -0.64; 95% CI, -1.35 to 0.08; P = 0.08; low quality of evidence) and 24 h (MD = -0.41; 95% CI, -0.91 to 0.09; P = 0.11; moderate quality of evidence) in VAS scores. The time to the first request for additional analgesics was prolonged in the dexamethasone group (MD = 3.08; 95% CI, 2.37 to 3.78; P<0.00001; moderate quality of evidence). Opioid consumption over 24 h after surgery was also reduced (MD = -5.42; 95% CI, -8.20 to -2.63; P = 0.0001; low quality of evidence). Meanwhile, the incidence of postoperative nausea and vomiting was significantly decreased in the dexamethasone group (risk ratios [RR] = 0.40; 95% CI, 0.28 to 0.58; P<0.00001; high quality of evidence). No complications were reported in all the included studies. CONCLUSIONS Dexamethasone added to local anesthetics in ultrasound-guided TAP block was a safe and effective strategy for postoperative analgesia in adult patients undergoing abdominal surgery.
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Affiliation(s)
- Donghang Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Cheng Zhou
- Lab of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dang Wei
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Long Ge
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Continuous transversus abdominis plane block for analgesia in three dogs with abdominal pain. Vet Anaesth Analg 2018; 45:581-583. [DOI: 10.1016/j.vaa.2018.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/15/2018] [Accepted: 02/16/2018] [Indexed: 11/19/2022]
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Bhakta A, Glotzer O, Ata A, Tafen M, Stain SC, Singh PT. Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery. Am J Surg 2017; 215:643-646. [PMID: 29061282 DOI: 10.1016/j.amjsurg.2017.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/21/2017] [Accepted: 09/05/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS). DESIGN Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012-December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales. RESULTS The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group. CONCLUSIONS TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.
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Affiliation(s)
| | - Owen Glotzer
- Albany Medical Center, Albany, NY, United States
| | - Ashar Ata
- Albany Medical Center, Albany, NY, United States
| | - Marcel Tafen
- Albany Medical Center, Albany, NY, United States
| | | | - Paul T Singh
- Albany Medical Center, Albany, NY, United States
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Khatibi B, Said ET, Sztain JF, Monahan AM, Gabriel RA, Furnish TJ, Tran JT, Donohue MC, Ilfeld BM. Continuous Transversus Abdominis Plane Nerve Blocks: Does Varying Local Anesthetic Delivery Method-Automatic Repeated Bolus Versus Continuous Basal Infusion-Influence the Extent of Sensation to Cold?: A Randomized, Triple-Masked, Crossover Study in Volunteers. Anesth Analg 2017; 124:1298-1303. [PMID: 28319550 DOI: 10.1213/ane.0000000000001939] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It remains unknown whether continuous or scheduled intermittent bolus local anesthetic administration is preferable for transversus abdominis plane (TAP) catheters. We therefore tested the hypothesis that when using TAP catheters, providing local anesthetic in repeated bolus doses increases the cephalad-caudad cutaneous effects compared with a basal-only infusion. METHODS Bilateral TAP catheters (posterior approach) were inserted in 24 healthy volunteers followed by ropivacaine 2 mg/mL administration for a total of 6 hours. The right side was randomly assigned to either a basal infusion (8 mL/h) or bolus doses (24 mL administered every 3 hours for a total of 2 bolus doses) in a double-masked manner. The left side received the alternate treatment. The primary end point was the extent of sensory deficit as measured by cool roller along the axillary line at hour 6 (6 hours after the local anesthetic administration was initiated). Secondary end points included the extent of sensory deficit as measured by cool roller and Von Frey filaments along the axillary line and along a transverse line at the level of the anterior superior iliac spine at hours 0 to 6. RESULTS Although there were statistically significant differences between treatments within the earlier part of the administration period, by hour 6 the difference in extent of sensory deficit to cold failed to reach statistical significance along the axillary line (mean = 0.9 cm; SD = 6.8; 95% confidence interval -2.0 to 3.8; P = .515) and transverse line (mean = 2.5 cm; SD = 10.1; 95% confidence interval -1.8 to 6.8; P = .244). Although the difference between treatments was statistically significant at various early time points for the horizontal, vertical, and estimated area measurements of both cold and mechanical pressure sensory deficits, no comparison remained statistically significant by hour 6. CONCLUSIONS No evidence was found in this study involving healthy volunteers to support the hypothesis that changing the local anesthetic administration technique (continuous basal versus hourly bolus) when using ropivacaine 0.2% and TAP catheters at 8 mL/h and 24 mL every 3 hours significantly influences the cutaneous effects after 6 hours of administration. Additional research is required to determine whether changing variables (eg, local anesthetic concentration, basal infusion rate, bolus dose volume, and/or interval) would provide different results.
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Affiliation(s)
- Bahareh Khatibi
- *Department of Anesthesiology, University of California, San Diego, La Jolla, California; †School of Medicine, University of California San Diego, La Jolla, California; ‡Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California; and §Outcomes Research Consortium
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George E, Elman I, Becerra L, Berg S, Borsook D. Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties. Prog Neurobiol 2016; 141:25-44. [PMID: 27084355 DOI: 10.1016/j.pneurobio.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/23/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.
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Affiliation(s)
- E George
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States; Commander, MC, USN (Ret), United States
| | - I Elman
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Psychiatry, Boonshoft School of Medicine and Dayton VA Medical Center, United States; Veterans Administration Medical Center, Dayton, OH, United States
| | - L Becerra
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States
| | - Sheri Berg
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States
| | - D Borsook
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States.
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study. J Anesth 2015; 30:39-46. [PMID: 26511998 DOI: 10.1007/s00540-015-2085-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/27/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors. METHODS Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade. RESULTS Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24-48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02). CONCLUSIONS In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.
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Litwack K. Pain management in military trauma. Crit Care Nurs Clin North Am 2015; 27:235-46. [PMID: 25981726 DOI: 10.1016/j.cnc.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The wounded warrior requires immediate care, and at times, evacuation from injury. Care may be self-regulated, or may require more advanced care under the direction of medics or advanced practitioners, including physicians and surgeons. While survivability is the immediate priority, pain management has become a military initiative, recognizing that poor management of acute pain may lead to the development of chronic pain and post-traumatic stress disorder. This article reviews current initiatives used in current conflict situations, as well as those in continued care following initial stabilization.
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Affiliation(s)
- Kim Litwack
- University of Wisconsin-Milwaukee College of Nursing, 1921 East Hartford Avenue, Milwaukee, WI 53201, USA; Advanced Pain Management, 34 Schroeder Ct, Madison, WI 53711, USA.
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Abstract
Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72 hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.
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Affiliation(s)
- William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK; Faculty of Health and Medical Sciences, Duke of Kent Building, University of Surrey, Guildford GU2 7TE, UK.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada
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Unilateral Transversus Abdominis Plane Block Catheter for the Treatment of Abdominal Wall Pain in Pregnancy. Reg Anesth Pain Med 2015; 40:720-2. [DOI: 10.1097/aap.0000000000000296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Heil JW, Nakanote KA, Madison SJ, Loland VJ, Mariano ER, Sandhu NS, Bishop ML, Agarwal RR, Proudfoot JA, Ferguson EJ, Morgan AC, Ilfeld BM. Continuous Transversus Abdominis Plane (TAP) Blocks for Postoperative Pain Control after Hernia Surgery: A Randomized, Triple-Masked, Placebo-Controlled Study. PAIN MEDICINE 2014; 15:1957-64. [DOI: 10.1111/pme.12530] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Preparedness of anesthesiologists working in humanitarian disasters. Disaster Med Public Health Prep 2014; 7:408-12. [PMID: 24229525 DOI: 10.1017/dmp.2013.40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Many skills needed to provide patients with safe, timely, and adequate anesthesia care during humanitarian crisis and disaster relief operations are not part of the daily routine before deployment. An exploratory study was conducted to identify preparedness, knowledge, and skills needed for deployment to complex emergencies. METHODS Anesthesiologists who had been deployed during humanitarian crisis and disaster relief operations completed an online questionnaire assessing their preparedness, skills, and knowledge needed during deployment. Qualitative data were sorted by frequencies and similarities and clustered accordingly. RESULTS Of 121 invitations sent out, 55 (46%) were completed and returned. Of these respondents, 24% did not feel sufficiently prepared for the deployment, and 69% did not undertake additional education for their missions. Insufficient preparedness involved equipment, drugs, regional anesthesia, and related management. CONCLUSIONS As the lack of preparation and relevant training can create precarious situations, anesthesiologists and deploying agencies should improve preparedness for anesthesia personnel. (Disaster Med Public Health Preparedness. 2013;0;1-5).
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Serag Eldin M, Mahmoud F, El Hassan R, Abdel Raouf M, Afifi MH, Yassen K, Morad W. Intravenous patient-controlled fentanyl with and without transversus abdominis plane block in cirrhotic patients post liver resection. Local Reg Anesth 2014; 7:27-37. [PMID: 24971036 PMCID: PMC4070863 DOI: 10.2147/lra.s60966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Coagulation changes can complicate liver resection, particularly in patients with cirrhosis. The aim of this prospective hospital-based comparative study was to compare the postoperative analgesic efficacy of intravenous fentanyl patient-controlled analgesia (IVPCA) with and without transversus abdominis plane (TAP) block. Methods Fifty patients with Child’s A cirrhosis undergoing liver resection were randomly divided into two groups for postoperative analgesia, ie, an IVPCA group receiving a 10 μg/mL fentanyl bolus of 15 μg with a 10-minute lockout and a maximum hourly dose of 90 μg, and an IVPCA + TAP group that additionally received TAP block (15 mL of 0.375% bupivacaine) on both sides via a posterior approach with ultrasound guidance before skin incision. Postoperatively, bolus injections of bupivacaine 0.375% were given every 8 hours through a TAP catheter inserted by the surgeon in the open space during closure of the inverted L-shaped right subcostal with midline extension (subcostal approach) guided by the visual analog scale score (<3, 5 mL; 3 to <6, 10 mL; 6–10, 15–20 mL) according to weight (maximum 2 mg/kg). The top-up dosage of local anesthetic could be omitted if the patient was not in pain. Coagulation was monitored using standard coagulation tests. Results Age, weight, and sex were comparable between the groups (P>0.05). The visual analog scale score was significantly lower at 12, 18, 24, 48, and 72 hours (P<0.01) in IVPCA + TAP group. The Ramsay sedation score was lower only after 72 hours in the IVPCA + TAP group when compared with the IVPCA group (1.57±0.74 versus 2.2±0.41, respectively, P<0.01). Heart rate, systolic blood pressure, and fentanyl consumption were lower in the IVPCA + TAP group at 24, 48, and 72 hours (P<0.05). Intensive care unit stays were significantly shorter with TAP (2.61±0.74 days versus 4.35±0.79 days, P<0.01). Prothrombin time and International Normalized Ratio indicated temporary hypocoagulability in both groups. Conclusion Combining TAP with IVPCA improved postoperative pain management and reduced fentanyl consumption, with a shorter stay in intensive care. TAP block can be included as part of a balanced multimodal postoperative pain regimen.
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Affiliation(s)
- Manar Serag Eldin
- Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt
| | - Fatma Mahmoud
- Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt
| | - Rabab El Hassan
- Department of Anaesthesia, Faculty of Medicine, Menoufiya University, Shebin El-Kom, Egypt
| | - Mohamed Abdel Raouf
- Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt
| | - Mohamed H Afifi
- Department of Anaesthesia, Faculty of Medicine, Menoufiya University, Shebin El-Kom, Egypt
| | - Khaled Yassen
- Department of Anaesthesia, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt
| | - Wesam Morad
- Department of Community Medicine and Public Health, Liver Institute, Menoufiya University, Shebin El-Kom, Egypt
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Merritt CK, Mariano ER, Kaye AD, Lissauer J, Mancuso K, Prabhakar A, Urman RD. Peripheral nerve catheters and local anesthetic infiltration in perioperative analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:41-57. [DOI: 10.1016/j.bpa.2014.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 02/09/2014] [Accepted: 02/19/2014] [Indexed: 11/16/2022]
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Wassef M, Lee DY, Levine JL, Ross RE, Guend H, Vandepitte C, Hadzic A, Teixeira J. Feasibility and analgesic efficacy of the transversus abdominis plane block after single-port laparoscopy in patients having bariatric surgery. J Pain Res 2013; 6:837-41. [PMID: 24348067 PMCID: PMC3849080 DOI: 10.2147/jpr.s50561] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The transversus abdominis plane (TAP) block is a technique increasingly used for analgesia after surgery on the anterior abdominal wall. We undertook this study to determine the feasibility and analgesic efficacy of ultrasound-guided TAP blocks in morbidly obese patients. We describe the dermatomal spread of local anesthetic in TAP blocks administered, and test the hypothesis that TAP blocks decrease visual analog scale (VAS) scores. Patients and methods After ethics committee approval and informed consent, 35 patients with body mass index >35 undergoing single-port sleeve gastrectomy (SPSG) were enrolled. All patients received balanced general anesthesia, followed by intravenous patient-controlled analgesia (IV-PCA; hydromorphone) postoperatively; all reported VAS >3 upon arrival to the recovery room. From the cohort of 35 patients having single-port laparoscopy (SPL), a sealed envelope method was used to randomly select ten patients to the TAP group and 25 patients to the control group. The ten patients in the TAP group received ultrasound-guided TAP blocks with 30 mL of 0.2% Ropivacaine injected bilaterally. The dermatomal distribution of the sensory block (by pinprick test) was recorded. VAS scores for the first 24 hours after surgery and opioid use were compared between the IV-PCA+TAP block and IV-PCA only groups. Results Sensory block ranged from T5–L1. Mean VAS pain scores decreased from 8 ± 2 to 4 ± 3 (P=0.04) within 30 minutes of TAP block administration. Compared with patients given IV-PCA only, significantly fewer patients who received TAP block had moderate or severe pain (VAS 4–10) after block administration at 6 hours and 12 hours post-surgery. However, cumulative consumption of hydromorphone at 24 hours after SPSG surgery was similar for both groups. Conclusion Ultrasound-guided TAP blocks in morbidly obese patients are feasible and result in satisfactory analgesia following SPSG in the immediate postoperative period.
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Affiliation(s)
- Michael Wassef
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - David Y Lee
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Jun L Levine
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Ronald E Ross
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Hamza Guend
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Catherine Vandepitte
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Admir Hadzic
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Julio Teixeira
- Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
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Taylor R, Pergolizzi JV, Sinclair A, Raffa RB, Aldington D, Plavin S, Apfel CC. Transversus Abdominis Block: Clinical Uses, Side Effects, and Future Perspectives. Pain Pract 2013; 13:332-44. [DOI: 10.1111/j.1533-2500.2012.00595.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 06/27/2012] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Robert B. Raffa
- Department of Pharmaceutical Sciences; Temple University School of Pharmacy; Philadelphia; Pennsylvania; U.S.A
| | | | | | - Christian C. Apfel
- 1Perioperative Clinical Research Core, Department of Anesthesia and Perioperative Care; University of California at San Francisco; San Francisco; California; U.S.A
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Schaeffer E, Millot I, Landy C, Nadaud J, Favier JC, Plancade D. Another use of continuous transversus abdominis plane (TAP) block in trauma patient: pelvic ring fractures. PAIN MEDICINE 2013; 15:166-7. [PMID: 23294595 DOI: 10.1111/pme.12029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elodie Schaeffer
- Department of Emergency, Anesthesiology and Critical Care, Legouest Military Teaching Hospital, France
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Analgesic effectiveness of transversus abdominis plane blocks after hysterectomy: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2013; 166:1-9. [DOI: 10.1016/j.ejogrb.2012.09.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 09/06/2012] [Indexed: 11/18/2022]
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Transversus abdominis plane catheter bolus analgesia after major abdominal surgery. Anesthesiol Res Pract 2012; 2012:596536. [PMID: 22666242 PMCID: PMC3361995 DOI: 10.1155/2012/596536] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 03/13/2012] [Indexed: 11/24/2022] Open
Abstract
Purpose. Transversus abdominis plane (TAP) blocks have been shown to reduce pain and opioid requirements after abdominal surgery. The aim of the present case series was to demonstrate the use of TAP catheter injections of bupivacaine after major abdominal surgery. Methods. Fifteen patients scheduled for open colonic resection surgery were included. After induction of anesthesia, bilateral TAP catheters were placed, and all patients received a bolus dose of 20 mL bupivacaine 2.5 mg/mL with epinephrine 5 μg/mL through each catheter. Additional bolus doses were injected bilaterally 12, 24, and 36 hrs after the first injections. Supplemental pain treatment consisted of paracetamol, ibuprofen, and gabapentin. Intravenous morphine was used as rescue analgesic. Postoperative pain was rated on a numeric rating scale (NRS, 0–10) at regular predefined intervals after surgery, and consumption of intravenous morphine was recorded. Results. The TAP catheters were placed without any technical difficulties. NRS scores were ≤3 at rest and ≤5 during cough at 4, 8, 12, 18, 24, and 36 hrs after surgery. Cumulative consumption of intravenous morphine was 28 (23–48) mg (median, IQR) within the first 48 postoperative hours. Conclusion. TAP catheter bolus injections can be used to prolong analgesia after major abdominal surgery.
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Sakamoto B, Kuber S, Gwirtz K, Elsahy A, Stennis M. Neurolytic transversus abdominis plane block in the palliative treatment of intractable abdominal wall pain. J Clin Anesth 2012; 24:58-61. [PMID: 22284321 DOI: 10.1016/j.jclinane.2011.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 04/13/2011] [Accepted: 04/20/2011] [Indexed: 11/17/2022]
Abstract
A 45 year old man with metastatic colon cancer presented with uncontrollable abdominal wall pain. Transversus abdominis plane (TAP) block with ropivacaine and methylprednisolone was performed with excellent pain relief, which allowed a significant weaning of the patient's opioid requirements. A second TAP block was performed with a 33% ethanol solution (ethanol and ropivacaine) with excellent pain relief. The neurolytic block appeared to offer better pain control for more than 5 days after placement until the patient finally succumbed to his illness.
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Affiliation(s)
- Bryan Sakamoto
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Plunkett A, Turabi A, Wilkinson I. Battlefield analgesia: a brief review of current trends and concepts in the treatment of pain in US military casualties from the conflicts in Iraq and Afghanistan. Pain Manag 2012; 2:231-8. [DOI: 10.2217/pmt.12.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SUMMARY Battlefield analgesia and post-injury pain management is a high priority within the military medical community. The combined military services of the USA have developed a Pain Task Force and clinical practice guidelines to ensure that adequate analgesia is provided to our wounded soldiers as far forward as the point of injury on the battlefield. As a result of this emphasis, novel analgesic techniques and equipment have led to improved pain management. Continuous peripheral nerve blocks, intranasal ketamine, battlefield acupuncture and other adjuncts have all been utilized safely and successfully. The ability to provide rapid analgesia as early in the course of injury as possible not only helps with the immediate pain of the soldier, but potentially minimizes the risk of developing chronic postinjury pain. During the long medical evacuation system the risks of both undertreatment and overtreatment of pain are very real. Future studies and observation will help to delineate best treatment regimens and pave the way for the next generation of medical providers to positively impact a soldier’s recovery. This article is written from the perspective of the USA with a focus on the conflicts in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom).
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Affiliation(s)
| | - Ali Turabi
- Landstuhl Regional Medical Center, Landstuhl, Germany
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Bollag L, Richebe P, Ortner C, Landau R. Transversus abdominis plane catheters for post-cesarean delivery analgesia: a series of five cases. Int J Obstet Anesth 2012; 21:176-80. [DOI: 10.1016/j.ijoa.2011.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 10/18/2011] [Accepted: 10/20/2011] [Indexed: 01/08/2023]
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Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract 2012; 2012:731645. [PMID: 22312327 PMCID: PMC3270549 DOI: 10.1155/2012/731645] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 09/21/2011] [Accepted: 09/27/2011] [Indexed: 11/18/2022] Open
Abstract
The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. It has a high margin of safety and is technically simple to perform, especially under ultrasound guidance. A growing body of evidence supports the use of TAP blocks for a variety of abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part, this may be related to the limited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of its clinical application. As such, we provide a brief historical perspective on the TAP block, describe relevant anatomy, review current techniques, discuss pharmacologic considerations, and summarize the existing literature regarding its clinical utility with an emphasis on recently published studies that have not been included in other systematic reviews or meta-analyses.
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