Transient femoral nerve palsy complicating "blind" transversus abdominis plane block

Analgesic efficacy of ultrasound-guided bilateral transversus abdominis plane block in children: retrospective analysis of 97 cases

BACKGROUND

Transversus abdominis plane (TAP) block is a method for postoperative pain management. Studies on children are gradually increasing. The aim of this retrospective study was to evaluate effectiveness of TAP block on pain control, its side effects, and parental satisfaction levels in children.

METHODS

Study included patients operated between January 2019 and December 2020 in Gazi University Faculty of Medicine. Total of 97 patients (35 girls, 62 boys) between 5 and 18 years who had an ultrasound guided TAP block for lower abdominal or inguinal surgery were examined retrospectively. TAP block application time, hemodynamic variables, postoperative pain scores, postoperative analgesic requirement, sex, surgical history and satisfaction levels were evaluated.

RESULTS

: The average application time of TAP block was 9.48 ± 3.4 and the time between TAP block and surgical incision was 12.06 ± 6.1 min. Pain scores in postanesthesia care unit (PACU) and at the postoperative first hour decreased as the time between TAP block and surgical incision increased (p < 0.05). Girls have higher pain scores at PACU than boys (p < 0.05). Previous surgical history increased postoperative 1st hour pain scores (OR: 13.8; 95% CI 1.7-113.3; p = 0.01). There was a significant negative correlation between pain scores at PACU, postoperative 1st, 2nd, 4th, 6th, 12th and satisfaction levels (r = -0.45, r = -0.56, r = -0.60, r = -0.54, r = -0.52, r = -0,43, respectively, p < 0.05).

DISCUSSION

Ultrasound-guided TAP blocks can be performed safely in children in lower abdominal surgeries. However, the efficacy of TAP block on late term postoperative pain scores is limited. Time interval between the TAP block and the incision, sex, and pain memory, as well as other factors that may improve the quality of TAP block should be considered.

A Retrospective Comparison of Three Patient-Controlled Analgesic Strategies: Intravenous Opioid Analgesia Plus Abdominal Wall Nerve Blocks versus Epidural Analgesia versus Intravenous Opioid Analgesia Alone in Open Liver Surgery

Background: Adequate pain control is of crucial importance to patient recovery and satisfaction following abdominal surgeries. The optimal analgesia regimen remains controversial in liver resections. Methods: Three groups of patients undergoing open hepatectomies were retrospectively analyzed, reviewing intravenous patient-controlled analgesia (IV-PCA) versus IV-PCA in addition to bilateral rectus sheath and subcostal transversus abdominis plane nerve blocks (IV-PCA + NBs) versus patient-controlled thoracic epidural analgesia (TEA). Patient-reported pain scores and clinical data were extracted and correlated with the method of analgesia. Outcomes included total morphine consumption and numerical rating scale (NRS) at rest and on movement over the first three postoperative days, time to remove the nasogastric tube and urinary catheter, time to commence on fluid and soft diet, and length of hospital stay. Results: The TEA group required less morphine over the first three postoperative days than IV-PCA and IV-PCA + NBs groups (9.21 ± 4.91 mg, 83.53 ± 49.51 mg, and 64.17 ± 31.96 mg, respectively, p < 0.001). Even though no statistical difference was demonstrated in NRS scores on the first three postoperative days at rest and on movement, the IV-PCA group showed delayed removal of urinary catheter (removal on postoperative day 4.93 ± 5.08, 3.87 ± 1.31, and 3.70 ± 1.30, respectively) and prolonged length of hospital stay (discharged on postoperative day 12.71 ± 7.26, 11.79 ± 5.71, and 10.02 ± 4.52, respectively) as compared to IV-PCA + NBs and TEA groups. Conclusions: For postoperative pain management, it is expected that the TEA group required the least amount of opioid; however, IV-PCA + NBs and TEA demonstrated comparable postoperative outcomes, namely, the time to remove nasogastric tube/urinary catheter, to start the diet, and the length of hospital stay. IV-PCA with NBs could thus be a reliable analgesic modality for patients undergoing open liver resections.

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach

PURPOSE

Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology.

METHODS

We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science.We conducted the review according to the five-step methodology outlined by Arksey and O'Malley.

RESULTS

The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable.

CONCLUSIONS

Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.

Surgeon-administered ilio-inguinal and pudendal nerve blocks for major vulval surgery: An observational study with visual analogue pain scoring

Surgical excision of the groin and vulva is a painful procedure. Traditionally following general or regional anaesthesia, local anaesthetic was infiltrated around the wound. Thedistribution varied and the somatic pain control was not reliable. Inspired by the success of the application of peripheral nerve blocks for postoperative pain control with open abdominal procedures, we introduced blockade of the ilioinguinal nerve (IIN) and pudendal nerve (PN) into our vulval surgery to assess the requirement for parenteral and oral analgesia in the postoperative period. This is an observational study of all patients undergoing major vulval and/or related groin surgery. Sampling biopsies were excluded. Levobipuvicaine 0.25% (2.5 mg/ml) or 0.5% (5 mg/ml) was used for and dosage was calculated based on the patient's weight with no more than 2 mg/kg. For example, using 0.25% of levobupivacaine (2.5 mg/ml) for a 70 kg patient, 56 ml is administered divided into 4, giving 14mls at each site (2 sites abdominally for IIN block and 2 sites for pudendal block). Eighteen women were included in the analysis. Median age was 67 (range 34-81) years and thirteen (72%) were >60 years. Visual analogue scores (VAS) ranged from 0 to 3 for seventeen patients from day 0 to day 1 and fifteen patients from day 2 to day 5. Two patients had pain scores >4 on one or more postoperative days: one had chronic arthralgia and one had received a lower volume of bupivacaine. This observational study demonstrates that ilioinguinal and pudendal nerve LA blocks may be a valuable addition to the multimodal postoperative analgesic pathway for women undergoing major surgical excision in the vulva and groin.

Laparoscopic Posterior Versus Lateral Transversus Abdominis Plane Block in Gynecology

Background and Objectives

Transversus abdominis plane (TAP) block is a safe and effective type of regional anesthesia technique used in laparoscopic gynecologic surgery to minimize postoperative pain. Our study aimed to compare the analgesic effects of the posterior versus lateral approaches to laparoscopic-assisted TAP block in minimally invasive gynecologic surgery.

Methods

We performed a randomized controlled trial with 82 patients allocated to either posterior (n = 38) or lateral (n = 44) TAP block groups. Laparoscopic-assisted posterior or lateral TAP block was administered using liposomal bupivacaine mixture. All subjects were asked to fill out a questionnaire, which included postoperative pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h, as well as narcotic utilization postoperatively. Both groups were compared for postoperative pain scores, opioid consumption, perioperative, and demographic characteristics.

Results

A total of 67 patients were analyzed in our study (n = 33 in posterior arm, n = 34 in lateral arm). Demographic characteristics including race, body mass index, comorbidities, American Society of Anesthesiologists classification, pre-operative diagnosis, complication rates, length of stay, and estimated blood loss were comparable between the two groups. The distribution of different operative procedures was similar between the two groups. There was no statistically significant difference in pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h postoperatively between the two groups. However, patients receiving posterior TAP had a significant reduction in narcotic intake (p = 0.0009).

Conclusion

Laparoscopic-assisted TAP block is a safe and effective option for regional analgesia in laparoscopic gynecologic surgery. Posterior TAP block may help to reduce narcotic usage postoperatively.

Ultrasound-versus visual-guided transversus abdominis plane block prior to transabdominal preperitoneal ingunial hernia repair. A retrospective cohort study

BACKGROUND

The transversus abdominis plane block is a regional anesthesia technique. Recently, its impact on early chronic pain and the cumulative need of analgesic medication following inguinal hernia repair is being monitored. In terms of effectiveness and patient safety, it remains unclear whether the approach should be conducted preoperatively through ultrasound guidance, or through intraoperative visual guidance.The study at hand aims to provide more evidence on this topic.

METHODS

A monocentric retrospective matched pair analysis was performed. The intraoperative visual guided and ultrasound guided -transversus abdominis plane block prior to inguinal hernia repair in transabdominal preperitoneal technique were consecutively compared in regard to analgesic effectiveness and complication rate. The data of individuals who were operated on from June 2007 to February 2019 were analyzed. The matching criteria were ASA-Score, Gender, Age ( ±6 years), and hernia size (<1,5 cm, 1,5-3 cm, >1,5 cm).

RESULTS

A total of 116 patients were enrolled. Both groups were homogenous in terms of age, gender contribution, body mass index, ASA-Score, hernia type, and size. The pain score at the postoperative anesthesia care unit was lower in the ultrasound-guided-transversus abdominis plane group without being statistically significant (VAS-Score: 0.67 vs.0.84). Patients of the ultrasound-guided-transversus abdominis plane group received significantly less metamizole on the day of operation (1.29 g (0.96) vs. 1.68 g (0.70), p = 0.015).

CONCLUSION

Due to our findings, we assume that the ultrasound-guided-transversus abdominis plane -Block may reduce postoperative pain and analgesic consumption more effectively than the visual-guided-transversus abdominis plane lock. Further prospective clinical trials are mandatory.

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.

The analgesic efficacy of the transversalis fascia plane block in iliac crest bone graft harvesting: a randomized controlled trial

Background

Iliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting.

Methods

Fifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery.

Results

The TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively.

Conclusions

The TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.

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.

A Rare Complication of a TAP Block Performed after Caesarean Delivery

The transversus abdominis plane block is a regional anesthesia technique that has become popular. Being a relatively simple procedure, the TAP block has an excellent safety profile and major complications are rare. We present a case of transient femoral nerve palsy occurring after a TAP block with involvement of the sacral plexus for a patient who had undergone a caesarean section.

A Posterior TAP Block Provides More Effective Analgesia Than a Lateral TAP Block in Patients Undergoing Laparoscopic Gynecologic Surgery: A Retrospective Study

Background. There are a few papers that compared the lateral transversus abdominis plane (TAP) block with the posterior TAP block. Our study aimed to compare retrospectively the quality of analgesia after laparoscopic gynecologic surgery using the lateral TAP block with general anesthesia versus the posterior TAP block with general anesthesia. Method. Sixty-seven adult female patients were included in this retrospective study. Of these patients, thirty-four patients received the lateral TAP block with general anesthesia (lat. TAP group), and the rest of thirty-three patients received the posterior TAP block with general anesthesia (pos. TAP group). Pain scores both at rest and at movement and the use of additional analgesic drugs were recorded in the postoperative care unit within twenty-four hours after the operation. Postoperative complications were noted. Results. Patients who received pos. TAP reported lower visual analog scale (VAS) pain scores in all points, within twenty-four hours after the operation, than patients who received lat. TAP. Moreover, with the use of additional analgesic drugs, the incidence of nausea and vomiting during the first twenty-four hours after surgery was lower in the pos. TAP group than in the lat. TAP group. Conclusion. The posterior TAP block provided more effective analgesia than the lateral TAP block in patients undergoing laparoscopic gynecologic surgery.

Useful Points of Geometry and Topography of the Lumbar Triangle for Transversus Abdominis Plane Block

BACKGROUND

A new look at the topography of the lumbar triangle becomes a challenge for modern anesthesia. The aim of this study was to redefine the topography of the lumbar triangle for transverse abdominis plane block.

MATERIAL AND METHODS

We explored 74 lumbar regions in 37 preserved cadavers (17 F and 20 M).

RESULTS

The lumbar triangle was identified in 66 (89%) out of all explored cadavers' lumbar regions. The predominant triangle was the acute-angled shaped. It was identified in 39 (59%) out of all explored lumbar regions. The second type of dissected triangles had the obtuse-angled shaped. Most triangles of acute-angled shaped and obtuse-angled shaped (36) had medium surface (range from 3 cm2 to 6 cm2), which accounted for 55% of all dissected lumbar triangles. The mean surface of the lumbar triangle was 3.6±2.2 cm2. Based on other measurements, we demonstrated that the majority of the lumbar triangles (62 triangles) were beyond the posterior axillary line.

CONCLUSIONS

According to the obtained results, the randomized searching for lumbar triangle should be limited to the area situated beyond of the posterior axillary line. The region situated anteriorly to the midaxillary line was defined in the study as the critical area for finding the lumbar triangle. Outcomes from the study revealed that the size and the location of the lumbar triangle as the gate for the transverse abdominal plane block may be responsible for difficulties encountered by anesthetists. Thus, establishing the area with the highest probability of localization of the lumbar triangle can improve both safety and efficiency of transversus abdominis plane block.

Treatment of acute flares of chronic pancreatitis pain with ultrasound guided transversus abdominis plane block: a novel application of a pain management technique in the acute care setting

The use of transversus abdominis plane (TAP) block to provide either analgesia or anesthesia to the anterior abdominal wall is well described. The technique yields high analgesic effectiveness and is opioid sparing and potentially of long duration with reported analgesia lasting up to 36 hours. When compared to neuraxial analgesia, TAP blocks are associated with a lower incidence of hypotension and motor blockade. TAP blocks are typically described as providing somatic analgesia only without any effect on visceral pain. There may be, however, certain conditions in which TAP blocks can provide effective analgesia in pain of visceral or mixed somatic and visceral origin. We describe two cases in which TAP blockade provided complete control of pain considered to be of visceral origin.