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 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 34  |  Issue : 3  |  Page : 199-201

Ultrasound-guided transversus abdominis plane block in high-risk infants, better option than opioids: A series of five cases


Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission29-May-2020
Date of Decision14-Jul-2020
Date of Acceptance11-Aug-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Farah Nasreen
Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_73_20

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  Abstract 


Perioperative analgesia poses specific problems, especially when it comes to neonates and infants. The use of opioid in neonates is usually associated with the risk of delayed extubation and postoperative mechanical ventilation. Regional analgesia including epidural and caudal may be technically challenging or has limitations in a certain group of patients. Ultrasound (US)-guided transversus abdominis plane block (TAP) is gaining popularity as a new technique of regional anesthesia applicable to infants and children. Precise drug administration is a major concern with TAP blocks in pediatric patients, especially infants and neonates. The application of US has enhanced the accuracy of local anesthetic deposition and hence the efficacy of analgesia in TAP block. We, hereby, report a series of five high-risk infants and neonates posted for abdominal surgeries wherein an ultrasonography-guided TAP resulted in satisfactory perioperative analgesia obviating the need of systemic opioids.

Keywords: Abdominal surgery, high-risk infants, ultrasound-guided transversus abdominis plane block


How to cite this article:
Nasreen F, Khalid A, Mallur DS. Ultrasound-guided transversus abdominis plane block in high-risk infants, better option than opioids: A series of five cases. Indian J Pain 2020;34:199-201

How to cite this URL:
Nasreen F, Khalid A, Mallur DS. Ultrasound-guided transversus abdominis plane block in high-risk infants, better option than opioids: A series of five cases. Indian J Pain [serial online] 2020 [cited 2021 Jan 25];34:199-201. Available from: https://www.indianjpain.org/text.asp?2020/34/3/199/305148




  Introduction Top


Pediatric regional anesthesia is widely used to relieve postoperative pain following abdominal surgeries. Ultrasound (US)-guided transversus abdominis plane block (TAP) is gaining popularity as a new technique of regional anesthesia in the pediatric population. Recent literature highlights the efficacy of TAP block in neonates in providing adequate perioperative analgesia and reducing the opioid requirement, which can be detrimental to the respiratory functions.[1],[2]

We successfully applied ultrasonography (USG)-guided TAP block in five high-risk infants including neonates who underwent major abdominal surgeries under general anesthesia (GA) that resulted in satisfactory perioperative analgesia thus avoiding opioid-related complications in such patients.


  Case Series Top


After approval of the institutional ethical committee and parental consent, patients were shifted to the operation theater, and standard monitors were attached. Premedication was done with injection atropine 0.02 mg/kg i. v. GA was induced with 6%–8% sevoflurane in oxygen, and intubation was done with an appropriate size endotracheal tube. After intubation, atracurium 0.5 mg/kg iv was administered to achieve neuromuscular blockade. Maintenance of anesthesia was achieved with sevoflurane, oxygen, nitrous oxide, and intermittent dose of atracurium. Before the start of surgery, TAP block was placed through the linear transducer of an US machine at 13 MHz (M-Turbo C® ultrasound machine; Sonosite Inc., Bothell, Washington, USA) by in-plane technique [Figure 1] and 0.5 ml/kg of 0.375% ropivacaine was given in a plane between the internal oblique and transverse abdominis forming an elliptical pocket [Figure 2]. Surgery was allowed to start 10–15 min after TAP block. An increase in heart rate and or arterial blood pressure by more than 20% of baseline values in response to surgical stimulus or thereafter throughout the whole operation warranted administration of intravenous fentanyl (0.5 μg/kg).
Figure 1: Inser tion of needle in the transverse abdominis plane EO: External oblique, IO: Internal oblique, TA: Transversus abdominis

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Figure 2: Formation of an elliptical pocket between the internal oblique and transverse abdominis muscle

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  Discussion Top


The TAP block is gaining popularity among pediatric patients as an effective technique for perioperative analgesia following abdominal surgeries. However, there is a paucity of literature regarding the application of this block in neonates and infants. This case series highlights the analgesic efficacy of USG-guided TAP block in high-risk infants and neonates following major abdominal surgeries which can be considered a feasible alternative to opioids in such vulnerable group of patients.

The impact of painful experience on the young nervous system is quite significant. There is growing concern that the long-term consequences of repeated pain in vulnerable neonates may also include emotional, behavioral, and learning disabilities.[3] Modalities of pain relief after major abdominal surgery in neonate and infants usually include regional blocks and medications including opioids. Epidural analgesia is not commonly performed in neonates due to technical challenges and fear of significant neurological complications. Local wound infiltration technique has its limitation as they require high volume of LA and hence fear of toxicity in pediatric patients where the margin of safety is less. Vertebral column anomalies may limit the use of caudal block in certain cases.[4]

One of the major constraints in the peri-operative opioid use following abdominal surgeries in neonates and infants is subsequent respiratory depression, apnea, and ventilation in high dependency units. USG-guided TAP block is a useful adjunct to GA in pediatric patients. In the present case series, US-guided TAP block was given to all patients before the start of surgery [Table 1]. It was performed by an operator most experienced in pediatric regional US. The approach was subcostal in four out of five patients where the upper abdominal incision was given, and the lateral approach was employed in one syndromic baby posted for herniotomy. Hemodynamic stability was preserved in all the patients and none required intraoperative opioids. Postoperatively, one patient had analgesia for up to 24 h, whereas the other four had their first analgesic requirement around 10–12 h postoperatively as assessed by neonatal infant pain scale score. None of them required opioid, and all were extubated inside OT including one premature baby obviating the need of postoperative ventilation.
Table 1: Summary of patients receiving transversus abdominis plane block

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Carney et al.[5] conducted a double-blind, placebo-controlled trial on 40 children undergoing emergency open appendectomy to receive TAP block on the surgical side using a landmark technique and received either saline or ropivacaine. It was concluded that the use of unilateral TAP block as a part of multimodal analgesia regimen is superior to placebo in the first 48 h postoperatively. A retrospective study concluded that the application of TAP block results in low analgesic requirements and low incidence of postoperative intubation and mechanical ventilation in neonates and infants.[1]. Preserved hemodynamic stability is an added advantage using the block. Jacobs et al.[2] audited the quality and duration of analgesia following a TAP block in neonates and infants undergoing abdominal surgeries and demonstrated opioid-sparing effect of TAP block in such patients. In another case series by Chen et al.[6] in neonates and infants undergoing colostomy creation or reversal of stoma surgeries, USG-guided TAP block was found to be successful with minimal hemodynamic changes intraoperatively, and no additional systemic analgesic was needed. Different doses have been used in US-guided TAP blocks in neonates, infants, and children for different surgeries including 0.2, 0.3, 0.5, 0.8, and 1 ml/kg.[1],[2],[7],[8] We chose 0.5 ml/kg for use in our cases as the TAP block was unilateral, and we used higher concentration 0.375% of ropivacaine to provide intraoperative analgesic cover extending up to the postoperative period. Moreover, the cumulative dose of LA was well within the toxic upper limit of 2 mg/kg.

We conclude that US-guided TAP block is a technically feasible alternative to opioids for perioperative pain relief in high-risk infants undergoing major abdominal surgery. We hope that this report will promote further evaluation of this technique in a larger group of neonates and infants.

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.
Kendigelen P, Tütüncü C, Ashyralyyeva G, Ozcan R, Emre S, Altindas F, et al. Transversus abdominis plane (TAP) block for postoperative analgesia in neonates and young infants: Retrospective analysis of a case series. TAP blocks in neonates and young infants. Minerva Anestesiol 2017;83:282 -7.  Back to cited text no. 1
    
2.
Jacobs A, Bergmans E, Arul GS, Thies KC. The transversus abdominis plane (TAP) block in neonates and infants-result of an audit. Paediatr Anaesth 2011;21:1078-80.  Back to cited text no. 2
    
3.
Bhutta AT, Anand KJ. Vulnerability of the developing brain. Neuronal mechanisms. Clin Perinatol 2002;29:357-72.  Back to cited text no. 3
    
4.
Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: Executive summary 2015. Reg Anesth Pain Med 2015;40:401-30.  Back to cited text no. 4
    
5.
Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG. Ipsilateral transversus abdominis plane block provides effective analgesia after appendectomy in children: A randomized controlled trial. Anaesth Analg 2010;111:998-1003.  Back to cited text no. 5
    
6.
Chen CK, Teo SC, Phui VE, Saman MA. Analgesic efficacy of transversus abdominis plane block in neonates and early infants for colostomy and reversal of colostomy. Agri 2015;27:210-4.  Back to cited text no. 6
    
7.
Suresh S, Chan VW. Ultrasound guided transversus abdominis plane block in infants, children and adolescents: A simple procedural guidance for their performance. Paediatr Anaesth 2009;19:296-9.  Back to cited text no. 7
    
8.
Sola C, Menace C, Rochette A, Raux O, Bringuier S, Molinari N, et al. Ultrasound-guided tranversus abdominis plane block for herniorrhaphy in children: What is the optimal dose of levobupivacaine? Eur J Anaesthesiol 2014;31:327-32.  Back to cited text no. 8
    


    Figures

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