Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online:834
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 34  |  Issue : 1  |  Page : 47-49

Prolonged analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in pediatric patients


Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission20-Jan-2020
Date of Acceptance21-Feb-2020
Date of Web Publication16-Apr-2020

Correspondence Address:
Dr. Ravi Shankar Sharma
Room Number 304, AIIMS PG Hostel, AIIMS Residential Complex, AIIMS, Jodhpur - 342 005, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_8_20

Rights and Permissions
  Abstract 

Transversus abdominis plane (TAP) block has been used for postoperative pain relief in various abdominal surgeries as part of the multimodal analgesic approach. In adults, the duration of action of this block is quite variable, with variable duration of effective analgesia from a single injection. In this study, we present three pediatric abdominal surgery cases, in which TAP block resulted in prolonged duration of analgesia.

Keywords: Multimodal analgesic approach, postoperative pain, transversus abdominis plane


How to cite this article:
Sharma RS, Agha M, Vyas R, Bhatia P, Sharma A. Prolonged analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in pediatric patients. Indian J Pain 2020;34:47-9

How to cite this URL:
Sharma RS, Agha M, Vyas R, Bhatia P, Sharma A. Prolonged analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in pediatric patients. Indian J Pain [serial online] 2020 [cited 2020 Jul 5];34:47-9. Available from: http://www.indianjpain.org/text.asp?2020/34/1/47/282557


  Introduction Top


Transversus abdominis plane (TAP) block has been used for postoperative pain relief in various abdominal surgeries as part of the multimodal analgesic approach. It creates satisfactory somatic analgesia with insignificant or no visceral blockade.[1] Recent studies suggest that the TAP block is an effective regional technique for perioperative analgesia in abdominal surgery, but there is little supporting evidence of this in children.[2],[3] In adults, the duration of action of this block is quite variable, with one source reporting up to 36 h of effective analgesia from a single injection.[4] In this study, we present three pediatric abdominal surgery cases, in which TAP block resulted in prolonged duration of analgesia.

Procedure

Three pediatric patients received TAP block following abdominal surgery using laparoscopy followed by an open incision. Consent was obtained prior to the procedure in all the three cases. In each case, general anesthesia was given using injection propofol –2 mg/kg, fentanyl –2 μg/kg, and atracurium −0.5 mg/kg. All of them were intubated using adequate-sized cuffed endotracheal tube. Maintenance anesthesia included 100% O2, sevoflurane, fentanyl, and atracurium. All the patients were monitored with standard American Society of Anesthesiologists monitors throughout the procedure. Following completion of surgery using sterile precautions, a real-time technique, utilizing in-plane ultrasound visualization, was used for analyzing the performance of TAP block. GE (General Electric, healthcare, US) Logiq portable ultrasound machine was used with a linear high-frequency (6–13 MHz) linear probe during the procedure. A transducer was placed at the lateral aspect of the abdomen between the iliac crest and costal margin at the level of triangle of Petit. The three layers of abdominal wall muscles were visualized: external and internal oblique as well as the transversus abdominis muscles, and finally 0.2% of ropivacaine in total doses of up to 2 mg/kg was deposited in the fascial plane between the internal oblique and the transversus abdominis muscles using 50-mm B. Braun Stimuplex® needle in the midaxillary line [Figure 1]. The same procedure was repeated on the other side. All the patients were extubated at the end of procedure following adequate reversal. Postoperative pain was assessed at 30 min in the postanesthesia care unit, then at 2, 6, 10, 14, and 18 h in the ward using an observational pain scale (FLACC score) which assigns a score of 0–2 for five categories (face, legs, activity, cry, and consolability), thereby resulting in a score ranging from 0 = no pain to 10 = severe pain.
Figure 1: Sonoanatomy of transversus abdominis plane demonstrating needle placement and drug delivery

Click here to view



  Results Top


Results are shown in [Table 1] and [Table 2]
Table 1: Demographic data of patients receiving transverse abdominis plane block

Click here to view
Table 2: Postoperative FLACC scores

Click here to view



  Discussion Top


This case series reflects the prolonged duration of pain relief in pediatric patients who received TAP block for abdominal surgery.

In order to search for a near ideal option of postoperative pain relief in terms of simplicity, safety, efficacy, and feasibility, regional anesthesia techniques come into consideration. One such regional anesthesia technique is TAP block which has been used successfully in adults as a component of the multimodal analgesic approach. It blocks the thoracolumbar nerves T10 to L1[5] and provides adequate somatic analgesia with little or no visceral blockade. This block is commonly placed at the level of triangle of Petit which is bounded posteriorly by the latissimus dorsi muscle, anteriorly by the external oblique muscle, and inferiorly by the iliac crest. In the adult population, the TAP block has been shown to provide effective analgesia following various types of lower abdominal procedures including retropubic prostatectomy, cesarean section, and total abdominal hysterectomy but till date, there are limited data regarding the use of TAP block in infants and children.

Mukhtar and Singh reported the successful use of TAP block to provide analgesia following laparoscopic appendectomy in four patients who ranged in age from 14 to 17 years which yielded 12 h of postoperative pain relief.[6]

In another study by Karnik et al., the authors compared ultrasoundguided bilateral TAP block with local infiltration during pediatric laparoscopic surgeries and found that TAP block is superior to local infiltration for intra- and immediate postoperative analgesia in pediatric laparoscopic surgeries.[7]

In another study carried out by Bergmans et al., a prospective service evaluation was done to assess the quality of pain control after preoperative TAP block in 100 children undergoing abdominal surgery[8] and concluded that TAP block may eliminate the need for intravenous (IV) opioids. Kupeli and Salcan carried out a randomized controlled trial where 100 patients aged between 2 and 6 years were enrolled and divided into the following five groups: TAP block with ketamine; II/IH block with ketamine; TAP block with sevoflurane; II/IH block with sevoflurane; and control group with sevoflurane alone. The results showed that TAP or ilioinguinal/iliohypogastric regional blocks could have same intraoperative/postoperative effects regarding hemodynamics and intraoperative analgesia in lower abdominal pediatric surgery.[9] Our study results are similar to those of a case series carried out by Çevikkalp et al. where ultrasound-guided TAP block was used for postoperative analgesia in five children with spinal dysraphism. The authors found that Faces Pain Scale-Revised remained 0 even after 24 h postoperatively.[10]

Referring to our cases, time to first request of analgesia was 17, 21, and 19 h consecutively. Ultrasound guidance increases block efficacy, decreases failure rates, reduces dose, and prolongs the postoperative pain-free period. Bergmans et al.[8] suggest that TAP plane is continuous with paravertebral space, thus it also blocks postoperative visceral pain due to lower abdominal surgeries. We assume this effect to be pronounced in neonates and small infants, alleviating or even eliminating the need for IV opioids. Although more studies are required in this regard, we prescribe TAP block for better and prolonged postoperative analgesia in pediatric population.


  Conclusion Top


Our preliminary experience suggests that TAP block provides effective analgesia following abdominal surgery in children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence-based medicine: Ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010;35:S36-42.  Back to cited text no. 1
    
2.
Hamer C, Murphy P, Diwan R. Does neonatal transverse abdominal plane block remove the need for postoperative opioid infusion? A case series of neonatal laparotomies. Pediatr Anesth 2012;22:913-4.  Back to cited text no. 2
    
3.
Masters OW, Thies KC. TAP block and low-dose NCA for major upper abdominal surgery. Paediatr Anaesth 2011;21:87-8.  Back to cited text no. 3
    
4.
McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2008;106:186-91.  Back to cited text no. 4
    
5.
Tsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, et al. Transversus abdominis plane block: an updated review of anatomy and techniques. Biomed Res Int 2017;2017:8284363.  Back to cited text no. 5
    
6.
Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesth 2008;102:143-4.  Back to cited text no. 6
    
7.
Karnik PP, Dave NM, Shah HB, Kulkarni K. Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries. Indian J Anaesth 2019;63:356-60.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Bergmans E, Jacobs A, Desai R, Masters OW, Thies KC. Pain relief after transversus abdominis plane block for abdominal surgery in children: A service evaluation. Local Reg Anesth 2015;8:1-6.  Back to cited text no. 8
    
9.
Kupeli I, Salcan S. Ultrasound-guided transversus abdominis plane block versus ilioinguinal/iliohypogastric block in intraoperative anesthesia and analgesia in pediatric patients: A randomized controlled study. Iran Red Crescent Med J 2018;20:e65163-.  Back to cited text no. 9
    
10.
Çevikkalp E, Erbüyün K, Erbüyün S, Ok G. Ultrasound guided transversus abdominis plane block. Postoperative analgesia in children with spinal dysraphism. Saudi Med J 2018;39:92-6.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed281    
    Printed2    
    Emailed0    
    PDF Downloaded32    
    Comments [Add]    

Recommend this journal