Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study

Quadratus lumborum block vs. transversus abdominis plane block for postoperative pain control in patients with nephrectomy: A systematic review and network meta-analysis

STUDY OBJECTIVE

This systematic review and network meta-analysis aimed to compare the analgesic efficacy of transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) on nephrectomy.

DESIGN

Systematic review and network meta-analysis.

PATIENTS

Patients undergoing nephrectomy.

INTERVENTIONS

TAPB and QLB for postoperative analgesia.

MEASUREMENTS

The primary outcome was 24 h morphine-equivalent consumptions after surgery. Secondary outcomes included postoperative pain scores, postoperative opioid consumption, postoperative rescue analgesia, postoperative nausea and vomiting (PONV), length of hospital stay after surgery, and patient satisfaction.

MAIN RESULTS

Fourteen studies involving 883 patients were included. Seven studies compared TAPB to control, six studies compared QLB to control, and one study compared TAPB to QLB. For direct meta-analysis of the post-surgical 24 h morphine-equivalent consumption, QLB was lower than control (mean difference [95%CI]: -18.16 [-28.96, -7.37]; I2 = 88%; p = 0.001), while there was no difference between TAPB and control (mean difference [95%CI]: -8.34 [-17.84, 1.17]; I2 = 88%; p = 0.09). Network meta-analysis showed similar findings that QLB was ranked as the best anesthetic technique for reducing postoperative 24 h opioid consumption (p-score = 0.854). Moreover, in direct meta-analysis, as compared to control, the time of first postoperative rescue analgesia was prolonged after QLB (mean difference [95%CI]: 165.00 [128.99, 201.01]; p < 0.00001), but not TAPB (mean difference [95%CI]: 296.82 [-91.92, 685.55]; p = 0.13). Meanwhile, QLB can effectively reduce opioid usages at intraoperative period, as well as at postoperative 6 h and 48 h, while TAPB can only reduce opioid consumption at 6 h after surgery. As compared to control, both TAPB and QLB exhibited the reduction in PONV and pain scores at post-surgical some timepoints. Also, QLB (mean difference [95%CI]: -0.29 [-0.49, -0.08]; p = 0.006) but not TAPB (mean difference [95%CI]: 0.60 [-0.25, 1.45]; p = 0.17) exhibited the shorter postoperative length of hospital stay than control.

CONCLUSIONS

QLB is more likely to be effective in reducing postoperative opioid use than TAPB, whereas both of them are superior to control with regard to the reduction in postoperative pain intensity and PONV.

TRIAL REGISTRATION

PROSPERO identifier: CRD42022358464.

Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study

Background

Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects.

Objective

To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia.

Methods

Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant.

Results

Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size.

Conclusion

The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.

Analgesic Effect of Quadratus Lumborum Block Type III and Type II Versus Lateral Transversus Abdominis Plane Block in Cesarean Section: A Randomized Controlled Multicenter Trial

Background

Appropriate pain management promotes immediate mobilization and allows the parturient to adequately care for her neonate after cesarean section (CS).

Objectives

This trial objective was to compare the type III and type II quadratus lumborum block (QLB) to transversus abdominis plane block (TAPB) regarding postoperative analgesic effect in CS.

Methods

This randomized, controlled, single-blind trial involved 60 women presenting for CS under spinal anesthesia. The patients were assigned randomly to either the QLB type III, QLB type II, or lateral TAPB group. All blocks were performed using 20 mL of bupivacaine 0.25% bilaterally at the end of the operation with ultrasound guidance. Pain was assessed using the numerical rating scale (NRS) score at the post-anesthesia care unit (PACU) at 2, 4, 6, 8, 12, 18, and 24 hours. The level of patient satisfaction was graded on a 5-point Likert scale.

Results

Numerical rating scale measurements at 6, 8, and 12 hours and total consumed meperidine in the 1st 24 hours after the operation were reduced significantly in QLB III than in QLB II and TAPB groups (P < 0.05) with an insignificant difference between the QLB II and TAPB groups (P > 0.05). The onset of the first request for analgesia was delayed significantly in QLB III, compared to QLB II and TAPB groups (P < 0.05), without a significant difference between the QLB II and TAPB groups (P > 0.05). Patient satisfaction and adverse events (e.g., postoperative nausea and vomiting, bradycardia, and hypotension) exhibited insignificant differences among the three groups (P > 0.05).

Conclusions

The QLB type III ensured better analgesia as evidenced by significantly lower pain measurements and amount of meperidine in the first 24 hours after the operation with delayed time of the first rescue analgesia in comparison to QLB II and TAPB; however, QLB II and TAPB were similar.

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%.

The effectiveness of erector spina plane, quadratus lumborum blocks, and intrathecal morphine for analgesia after cesarean: a randomized study

OBJECTIVE

This prospective randomized study was conducted at Ataturk University Medical Faculty Hospital, Department of Anesthesia and Reanimation, from June 2022 to May 2023. The aim of this study was to compare the effectiveness of ultrasound-guided erector spinae plane block, quadratus lumborum block, and intrathecal morphine to decrease postoperative pain after cesarean section.

METHODS

Sixty-term pregnant women who were scheduled for elective cesarean sections with spinal anesthesia were included. Patients were randomly divided into three groups (n=20 for each group): Group 1: Patients were administered intrathecal morphine during spinal anesthesia; Group 2: Patients performed bilateral erector spinae plane block postoperatively; and Group 3: Patients performed bilateral quadratus lumborum block postoperatively. In the postpartum care unit, patients received intravenous Patient-Controlled Analgesia. The Patient-Controlled Analgesia devices were set to administer an intravenous bolus of 25 μg fentanyl, with a lockout interval of 10 min. Opioid consumption and maximum pain score in the 24 postoperative hours were recorded.

RESULTS

Patients in Group 1 had a longer time to first analgesic requirement compared to Group 2 (p=0.017). Opioid consumption and resting and moving visual analog score scores in the first 24 h postoperatively were similar between groups.

CONCLUSION

All three methods, including intrathecal morphine, erector spinae plane block, and quadratus lumborum block, are efficacious and comparable in providing postoperative analgesia after cesarean under spinal anesthesia.

Evaluation of the Analgesic Efficacy of Surgically Assisted Linea Semilunaris Block for Post-operative Analgesia in Patients Undergoing Caesarean Section Under Spinal Anaesthesia

BACKGROUND

Post-operative pain following a caesarean section has been described as moderate to severe. If left untreated, the pain has a negative impact on maternal recovery and psychology. Surgically assisted linea semilunaris anterior abdominal block has been proposed to be an efficacious analgesic modality in such cases.

AIM

The study aims to evaluate the efficacy of post-operative analgesia provided by linea semilunaris block in patients undergoing caesarean section under spinal anaesthesia.

METHODS

Eighty parturients planned for elective caesarean section under spinal anaesthesia were randomised into two groups. In group B, a surgically assisted Linea semilunaris anterior abdominal block was given bilaterally after the closure of the uterine incision using 20 mL of 0.375% ropivacaine with 1:200,000 adrenaline. For group C, conventional analgesia protocols were followed in the post-op period. Inj. paracetamol 1 g i.v. was routinely administered, and inj. tramadol 50 mg i.v. was given as a rescue analgesic in both groups. The primary outcome of the present study was the total amount of rescue analgesia consumed over 24 hours. Secondary outcomes included resting and dynamic pain scores [Numerical Rating Scale (NRS)], time to first rescue analgesia, quality of sleep, and patient satisfaction using the Likert scale.

RESULTS

The mean total amount of rescue analgesia consumed over 24 hours was significantly higher in group C (150.00 ± 0.00) than in group B (125.75 ± 25.32); p = 0.001. The mean NRS at 2, 4, 12, and 24 hours was significantly higher in group B than in group C. The time to first rescue analgesia was longer in group B, with better sleep quality, patient satisfaction, and fewer complications.

CONCLUSION

The linea semilunaris block provided effective analgesia and can be considered an alternative analgesic modality to other conventional abdominal wall blocks for post-caesarean pain relief.

Efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery under spinal anaesthesia: A non-randomised clinical trial

Background and Aims

Our aim was to assess the efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery (CD) under spinal anaesthesia (SA).].

Methods

A total of 457 healthy parturients undergoing CD under SA were included in this prospective, observational study. Groups differed in the postoperative analgesic strategies received by the parturient at the end of surgery: group D (n = 148) received intramuscular diclofenac sodium, group I (n = 153) received bilateral IIIH block with bupivacaine plus clonidine and group T (n = 156) received bilateral TAP block with bupivacaine plus clonidine. Total duration of postoperative analgesia, numerical pain rating scale (NRS) scores, patient satisfaction score, rescue analgesics in the first 48 h postoperatively and adverse effects were observed. A value of P < 0.05 was taken as significant.

Results

Total duration of analgesia was longest (18.2 ± 1.3 h) in group T and shortest in group D (6.3 ± 0.8 h) compared to group I (13.1 ± 1.2 h) (P < 0.001). Total analgesic requirement in postoperative 48 h was lowest in group T (152.1 ± 34.9 mg), highest in group D (355.0 ± 25.6 mg) and intermediate in group I (221.0 ± 30.0 mg) (P < 0.001). Mean NRS scores were lower in group T compared to those in groups D and I. The patients in group T were extremely satisfied, in group I were satisfied and in group D were dissatisfied (P < 0.001).

Conclusion

Bilateral TAP block with bupivacaine and clonidine after CD under SA increases the duration of postoperative analgesia.

Analgesic effect of erector spinae plane block after cesarean section: A randomized controlled trial

Background

Ultrasound-guided bilateral erector spinae plane block is also a technique for providing analgesia after a cesarean section.

Aim

We hypothesized that bilateral erector spinae plane block applied from the transverse process of T9 who underwent elective cesarean section could provide effective postoperative analgesia.

Patients and Methods

Fifty parturients who were scheduled to undergo elective cesarean section under spinal anesthesia were included in the study. Group SA (n = 25) was categorized as the group in which spinal anesthesia alone (SA) was performed, and Group SA+ESP (n = 25) was categorized as the group in which SA + ESP block was performed. All patients were given a solution containing 7 mg isobaric bupivacaine + 15 μg fentanyl intrathecally through spinal anesthesia. In the SA + ESP group, the bilateral ESPB was performed at level T9 with 20 ml 0.25% bupivacaine + 2 mg dexamethasone immediately after the operation. Total fentanyl consumption in 24 h, the visual analogue scale for pain, and time to the first analgesic request were evaluated postoperatively.

Results

The total fentanyl consumption in 24 h was statistically significantly lower in the SA + ESP group than the SA group (279 ± 242.99 μg vs. 423.08 ± 212.55 μg, respectively, P = 0.003). The first analgesic requirement time was statistically significantly shorter in the SA group than the SA + ESP group (150.20 ± 51.83 min vs. 197.60 ± 84.49 min, respectively, P = 0.022). Postoperative VAS scores at 4^th, 8^th, and 12^th h at rest were statistically significantly lower in group SA + ESP than in group SA (P = 0.004, P = 0.046, P = 0.044, respectively). VAS scores during the postoperative 4^th, 8^th, and 12^th h cough were statistically significantly lower in group SA + ESP than in group SA (P = 0.002, P = 0.008, P = 0.028, respectively).

Conclusion

Ultrasound-guided bilateral ESP provided adequate postoperative analgesia and significantly decreased postoperative fentanyl consumption in patients having cesarean section. Also, it has a longer analgesia time than the control group, and it has been shown to delay the first analgesic requirement.

Addition of preoperative transversus abdominis plane block to multimodal analgesia in open gynecological surgery: a randomized controlled trial

BACKGROUND

Transversus abdominis plane (TAP) block can provide effective analgesia for abdominal surgery. However, it was questionable whether TAP had additional effect in the context of multimodal analgesia (MMA). Therefore, this study aimed to assess the additional analgesic effect of preoperative TAP block when added to MMA protocol in open gynecological surgery.

METHODS

In this prospective, randomized-controlled trial, 64 patients scheduled for open gynecological surgery were randomized to receive preoperative TAP block (Study group, n = 32) or placebo (Control group, n = 32) in addition to MMA protocol comprising dexamethasone, acetaminophen, flurbiprofen and celecoxib, and rescued morphine analgesia. The primary outcome was rescued morphine within 24 h after surgery. Secondary outcomes included pain scores, adverse effects, quality of recovery measured by 40-item quality of recovery questionnaire score (QoR-40) at 24 h, and quality of life measured with short-form health survey (SF - 36) on postoperative day (POD) 30.

RESULTS

The Study group had less rescued morphine than the control group within 24 h [5 (2-9) vs. 8.5 (5-12.8) mg, P = 0.013]. The Study group had lower pain scores at 1 h [3 (2-4) vs. 4 (3-5), P = 0.007], 2 h [3 (2-4) vs. 3.5 (3-5), P = 0.010] and 6 h [3 (2-3) vs. 3 (2.3-4), P = 0.028], lower incidence of nausea at 48 h (25.8% vs. 50%, P = 0.039), and higher satisfaction score [10 (10-10) vs. 10 (8-10), P = 0.041]. The SF-36 bodily pain score on POD 30 was higher in the Study group (59 ± 13 vs. 49 ± 16, P = 0.023).

CONCLUSIONS

Preoperative TAP block had additional analgesic effect for open gynecological surgery when used as part of multimodal analgesia. Rescued morphine within 24 h was significantly reduced and the SF-36 bodily pain dimension at 30 days after surgery was significantly improved.

TRIAL REGISTRATION

www.chictr.org.cn (ChiCTR2000040343, on Nov 28 2020).

Multimodal opioid-sparing pain management for emergent cesarean delivery under general anesthesia: a quality improvement project

Background

Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia.

Methods

Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively.

Results

Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids.

Conclusions

Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery.

Comparison of the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block versus thoracic erector spinae block for postoperative analgesia in caesarean section parturients under spinal anaesthesia-A randomised study

Background and Aims

Truncal blocks play an important role in multimodal analgesia regimens to manage the postoperative pain after lower segment caesarean section (LSCS). This study was aimed to compare the analgesic efficacy of ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) and thoracic erector spinae plane block (TESPB) in parturients of LSCS done under subarachnoid block (SAB).

Methods

In a randomised and double blind study, 60 parturients scheduled for LSCS under spinal anaesthesia were randomly divided into two equal groups: group E (n = 30) and group Q (n = 30). After surgery, each parturient received either US guided bilateral TQLB (group Q) or TESPB (group E) with 20 ml 0.375% ropivacaine and 4 mg dexamethasone on each side. Assessments were done at 2, 4, 6, 8, 10, 12 and 24 h. The primary objective was to compare the duration of analgesia (first request to rescue analgesia) and the secondary objectives were to compare pain scores [numerical rating score (NRS)], total amount of tramadol consumption, incidence of nausea-vomiting, parturient satisfaction and other adverse effects in 24 hours postoperatively.

Results

The duration of analgesia (mean ± standard deviation) was comparable in group E (11.90 ± 2.49 h) and group Q (12.56 ± 3.38 h), P = 0.19. Pain scores (NRS) at rest and on movement were comparable at all time points of 2, 4, 6, 8, 10, 12, and 24 h (P > 0.05). The amount of tramadol used was comparable in group E and group Q (P = 0.48).

Conclusion

TESPB and TQLB are equally efficacious to provide postoperative analgesia after LSCS done under SAB when used as a part of multimodal analgesia.

Post-cesarean section analgesia

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

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.

Transversus abdominis plane block provides effective and safe anesthesia in the cesarean section for an amyotrophic lateral sclerosis parturient: A case report

RATIONALE

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease with the fatal course of muscle weakness. The published experience of anesthesia management in the cesarean section with ALS parturient is scant.

PATIENT CONCERNS

A 34-year-old woman was admitted to our center complaining of obvious dysphagia together with atrophy and weakness of quadriceps at 24 weeks of her pregnancy. Cesarean was planned at 36 weeks' gestation due to the rapid deterioration of the mother.

DIAGNOSES

The results of neurological examination, electromyography and spinal magnetic resonance imaging suggested ALS according to the EI Escorial World Federation of Neurology criteria.

INTERVENTIONS

Ultrasound-guided transversus abdominis plane block with 0.6 minimum alveolar concentration sevoflurane was used in this ALS parturient during her cesarean section procedure.

OUTCOMES

This anesthesia strategy successfully met the demands of the surgery, helped avoid prolonged ventilation and prevent maternal respiratory complications.

LESSONS

Transversus abdominis plane block with subanesthetic concentrations of sevoflurane can provide effective and safe anesthesia in the cesarean section for a patient with ALS.

Quadratus lumborum or transversus abdominis plane block for postoperative analgesia after cesarean: a double-blinded randomized trial

Background

Multimodal analgesia (MMA) is the current standard practice to provide post-cesarean analgesia. The aim of this study was to compare the analgesic efficacy of quadratus lumborum (QL) block and transversus abdominis plane (TAP) block as an adjunct to MMA.

Methods

Eighty mothers undergoing cesarean delivery under spinal anesthesia were randomized to receive either TAP or transmuscular QL block (QLB) with 20 mL 0.375% ropivacaine on each side. Postoperatively, all the subjects were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcomes were the pain scores during rest and movement, number of doses of tramadol, postoperative nausea-vomiting, sedation, and mother’s satisfaction with the pain management.

Results

The median (IQR) time to first analgesic request was 12 (9.25, 13) hours in the QL group and 9 (8.25, 11.37) hours in the TAP group (p = 0.0008). Patients in QL group consumed less doses of tramadol than those in TAP group (p < 0.0001). Pain scores were significantly lower in the QL group at all time points (p < 0.0001) except at 8^th hour when at rest, p = 0.0024, and on movement, p = 0.0028. The maternal satisfaction was significantly higher in the QL group (p = 0.0017).

Conclusion

Our study showed the significant delay in time to first analgesic request in QL group patients. Patients in the QL group had lower pain scores, required fewer analgesic supplements, and had more satisfaction. Nausea-vomiting and sedation were comparable.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

A randomised comparative study of transversus abdominis plane block with or without intravenous diclofenac sodium as a component of multimodal regimen for post-operative analgesia following caesarean section

Aims

Post-operative analgesia is a major component of perioperative care. An ideal method of pain relief after caesarean section should be cost-effective and safe for mother and baby. This study aims to evaluate the analgesic efficacy of transversus abdominis plane (TAP) block combined with intraoperative diclofenac aqueous for post-operative analgesia in caesarean section.

Methods

A prospective randomised double-blind study was conducted on 60 patients over a period of six months. Patients were enrolled in two groups (n = 30). Group A and Group B both received bilateral landmark based TAP block using ropivacaine 0.75% (1.5 mg/kg), 20 ml at end of surgery. Group B received diclofenac sodium aqueous 75 mg intravenous intraoperatively.

Results

The difference of visual analogue score (VAS) at movement was significant at 4 and 6 h in Group A versus Group B (3.00 ± 0.64 versus 2.37 ± 0.89, 4.43 ± 0.68 versus 3.53 ± 1.2). At rest, VAS score was lower in Group B than in Group A at all time intervals (P < 0.05). Time to demand of first dose of rescue analgesic was prolonged in Group B (11.5 ± 4.1 h) than in Group A (7.55 ± 1.41 h). Mean dose of analgesic consumption in first 24 h was lesser in Group B (61.67 ± 34.57 mg) than in Group A (98.33 ± 37.68 mg). Patient satisfaction score was higher in Group B (8 ± 1.04) than in Group A (6.23 ± 1.04).

Conclusion

TAP block along with intraoperative diclofenac aqueous as component of multimodal regimen provides superior post-operative analgesia and better patient satisfaction as compared to TAP block alone.

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence

PURPOSE OF REVIEW

In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD).

RECENT FINDINGS

Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.

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

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

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

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

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery

OBJECTIVE

To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery.

METHODS

A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018.

RESULTS

A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41).

CONCLUSION

An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

The analgesic efficacy compared ultrasound-guided continuous transverse abdominis plane block with epidural analgesia following abdominal surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This review and meta-analysis aims to evaluate the analgesic efficacy of continuous transversus abdominis plane (TAP) block compared with epidural analgesia (EA) in adults after abdominal surgery.

METHODS

The databases PubMed, Embase and Cochrane Central Register were searched from inception to June 2019 for all available randomized controlled trials (RCTs) that evaluated the analgesic efficacy of continuous TAP block compared with EA after abdominal surgery. The weighted mean differences (WMDs) were estimates for continuous variables with a 95% confidence interval (CI) and risk ratio (RR) for dichotomous data. The pre-specified primary outcome was the dynamic pain scores 24 h postoperatively.

RESULTS

Eight trials including 453 patients (TAP block:224 patients; EA: 229 patients) ultimately met the inclusion criteria and seven trials were included in the meta-analysis. Dynamic pain scores after 24 h were equivalent between TAP block and EA groups (WMD:0.44; 95% CI: 0.1 to 0.99; I² = 91%; p = 0.11). The analysis showed a significant difference between the subgroups according to regularly administering (4 trials; WMD:-0.11; 95% CI: - 0.32 to 0.09; I² = 0%; p = 0.28) non-steroidal anti-inflammatory drugs (NSAIDs) or not (3 trials; WMD:1.02; 95% CI: 0.09 to 1.96; I² = 94%; p = 0.03) for adjuvant analgesics postoperatively. The measured time of the urinary catheter removal in the TAP group was significantly shorter (3 trials, WMD:-18.95, 95% CI:-25.22 to - 12.71; I² = 0%; p < 0.01), as was time to first ambulation postoperatively (4 trials, WMD:-6.61, 95% CI: - 13.03 to - 0.19; I² = 67%; p < 0.05).

CONCLUSION

Continuous TAP block, combined with NSAIDs, can provide non-inferior dynamic analgesia efficacy compared with EA in postoperative pain management after abdominal surgery. In addition, continuous TAP block is associated with fewer postoperative side effects.

Surgeon-delivered laparoscopic transversus abdominis plane blocks are non-inferior to anesthesia-delivered ultrasound-guided transversus abdominis plane blocks: a blinded, randomized non-inferiority trial

BACKGROUND

The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery.

METHODS

This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively.

RESULTS

60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median [IQR] milligrams of morphine, 1.8 [0-4.5] UTAP vs. 0 [0-8.7] LTAP P = .32), 6 h post-operatively (5.4 [1.8-17.1] UTAP vs. 3.6 [0-12.6] LTAP P = .28), at 12 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .51), at 24 h post-operatively (9.0 [3.6-29.4] UTAP vs. 7.2 [0.9-22.5] LTAP P = .63), and 48 h post-operatively (39.9 [7.5-70.2] UTAP vs. 22.2 [7.5-63.8] LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h.

CONCLUSIONS

Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period.

TRIAL REGISTRY

The trial was registered at clinicaltrials.gov Identifier NCT03577912.