|Year : 2020 | Volume
| Issue : 1 | Page : 47-49
Prolonged analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in pediatric patients
Ravi Shankar Sharma, Mussavvir Agha, Raksha Vyas, Pradeep Bhatia, Ankur Sharma
Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
|Date of Submission||20-Jan-2020|
|Date of Acceptance||21-Feb-2020|
|Date of Web Publication||16-Apr-2020|
Dr. Ravi Shankar Sharma
Room Number 304, AIIMS PG Hostel, AIIMS Residential Complex, AIIMS, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
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|| |
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. 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., 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. In this study, we present three pediatric abdominal surgery cases, in which TAP block resulted in prolonged duration of analgesia.
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|
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| Results|| |
Results are shown in [Table 1] and [Table 2]
|Table 1: Demographic data of patients receiving transverse abdominis plane block|
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| Discussion|| |
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 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.
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.
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 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. 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.
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. 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|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]