|Year : 2014 | Volume
| Issue : 3 | Page : 377-382
Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies
Parasa Mrunalini, N Vijaya Rama Raju, Vemuri Nagendra Nath, Shaik Mastan Saheb
Department of Anesthesiology, NRI Medical College, Chinnakakani, Guntur, Andhra Pradesh, India
|Date of Web Publication||17-Oct-2014|
Department of Anaesthesiology, NRI Medical College, Chinnakakani, Guntur, Andhrapradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Pain experienced following laparotomy is largely due to abdominal wall incision. Effective mitigation of this pain is vital to improve patient satisfaction and for early ambulation. We evaluated the efficacy of transversus abdominis plane (TAP) block for postoperative analgesia, as a component of multimodal analgesia.
Materials and Methods: Sixty adult ASA physical status I to III patients undergoing emergency laparotomy under general anesthesia were recruited for this double-blind, randomized, controlled trial. The TAP block was performed before skin incision, using the double pop technique in the midaxillary line, at the level of the umbilicus with a 22 gauge blunt needle. The patients were randomly assigned to receive either 25 ml of 0.25% bupivacaine or normal saline (NS), bilaterally. Tramadol was used for postoperative analgesia via a patient-controlled analgesia pump (PCA) along with an intramuscular (IM) injection of diclofenac sodium, 12-hourly. Each patient was assessed in the Post Anesthesia Care Unit (PACU) immediately after shifting and every two hours thereafter, for 24 hours, for pain, nausea, sedation scores, and pruritus. The two-hourly and total tramadol consumption, over 24 hours, was assessed.
Results: The mean total pain scores were significantly less in the TAP block group (48.07 ± 6.76) when compared to the control group (62.63 ± 6.66). The total tramadol consumption was decreased by 36% in the TAP block group (281.33 ± 69.66 mg) compared to the control group (439 ± 68.59 mg). Tramadol consumption measured every two hours was also less up to 18 hours postoperatively, after which, there was an increase in pain scores and tramadol consumption in the TAP block group. There was no statistically significant difference between the two groups in terms of nausea, vomiting, sedation or pruritis.
Conclusion: TAP block is an effective component of the multimodal analgesia regimen for reducing postoperative pain and opioid requirement after emergency laparotomy.
Keywords: Laparotomies, multimodal analgesia, tap block
|How to cite this article:|
Mrunalini P, Rama Raju N V, Nath VN, Saheb SM. Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies. Anesth Essays Res 2014;8:377-82
|How to cite this URL:|
Mrunalini P, Rama Raju N V, Nath VN, Saheb SM. Efficacy of transversus abdominis plane block in patients undergoing emergency laparotomies. Anesth Essays Res [serial online] 2014 [cited 2020 Jul 11];8:377-82. Available from: http://www.aeronline.org/text.asp?2014/8/3/377/143153
| Introduction|| |
Postoperative pain is the major obstacle for early postoperative ambulation and increases the risk of venous thromboembolism and respiratory complications, and prolongs the hospital stay.  Parietal pain is the chief component of postoperative pain after abdominal surgeries.  Large doses of opioids are required to mitigate this pain, but they are poorly tolerated.  Multimodal analgesia is effective in handling postoperative pain and in attenuating the side effects of large doses of a single analgesic.
The TAP block, first described by Rafi in 2001, is comprised of deposition of a local anesthetic into the anatomical plane between the internal oblique and transverses abdominis muscles, where the thoracoabdominal nerves (T 6 -L 1 ) contribute to the main sensory supply of the skin, muscles, and parietal peritoneum of the anterior abdominal wall. ,, These nerves branch and communicate extensively with each other in the TAP. 
Although epidural analgesia is an effective modality for postoperative pain relief, it is contraindicated in patients with coagulopathies and sepsis. It poses technical difficulties in positioning, can precipitate hemodynamic instability, and decrease splanchnic blood supply leading to hypoperfusion of bowel anastomoses in cases of acute abdomen. 
Although intravenous patient-controlled analgesia (IV PCA) with opioids facilitates a greater degree of pain control, analgesia is often incomplete and the opioid-mediated side-effects remain common. 
For surgical procedures where parietal pain is the chief component of postoperative pain, the TAP block serves as a simple and effective analgesic technique, with the added advantage of preserved motor and bladder function and avoids hooking up the patient to infusion devices and IV poles, thereby allowing earlier ambulation.
Although the TAP block is relatively devoid of complications, cases of liver injury secondary to needle insertion have been reported. , Routine palpation of the liver edge prior to the landmark-based, right-sided TAP block is recommended to decrease the incidence of such a complication. Potential injury to the intraperitoneal structures, transient femoral nerve block, and local anesthetic toxicity should be borne in mind.  Limited analgesia lasting for only 24-48 hours is the main drawback, which can be overcome by placing a catheter for continuous infusion or intermediate boluses.
We hypothesized that the TAP block, as a part of the multimodal analgesia regimen, would result in decreased opioid consumption and improve analgesia in the first 24 hours after laparotomy, compared to the placebo. The purpose of this study was to test this hypothesis in patients undergoing emergency laparotomies for hollow viscus perforation or intestinal obstruction.
| Materials and methods|| |
After obtaining Institutional Ethical Committee approval and written informed consent, 60 adult patients aged 18-70 years, of American Society of Anesthesiologists (ASA) physical status I to III, scheduled for emergency laparotomies, either for hollow viscous perforation or for intestinal obstruction, between January 2013 to July 2013, under general anesthesia, were included in this study.
Patients with a history of relevant drug allergies, opioid dependence, morbid obesity (BMI >40 kg/m 2 ), and psychiatric disorders were excluded from the study. Following placement of the standard monitors, intravenous and intra-arterial access was secured and the patients were started on IV fluids. After administration of glycopyrrolate 0.05 mg/kg, anesthesia was induced with 0.04 mg/kg midazolam, 2 μg/kg fentanyl, and titrated doses of propofol. Endotracheal intubation was facilitated with 0.1 mg/kg of vecuronium bromide and mechanical ventilation was commenced with a tidal volume of 8 ml/kg and frequency adjusted to achieve end-tidal carbon dioxide of 35-40 mm of Hg. Sevoflurane 1-2%, in a mixture of oxygen and nitrous oxide, was used for anesthetic maintenance.
The patients were randomly allocated to receive TAP block (n = 30) with 25 ml of 0.25% bupivacaine or 25 ml of 0.9% normal saline on each side of the abdominal wall before the skin incision. The allocation sequence was generated by a random number table and group allocation was concealed in sealed opaque envelopes, which were not opened until patient consent had been obtained. The patient, their anesthesiologist, and the staff providing postoperative care were blinded to the group assignment. The TAP block was performed using a 21-gauge, 1.5-inch, blunted hypodermic needle, attached via flexible tubing to a syringe. Loss of resistance technique was used for identification of the desired plane of injection. With the patient in a supine position and the investigator standing on the same side, the skin over the midaxillary line at the level of umbilicus was pierced with the needle held at right angles to the coronal plane until resistance was encountered. The first loss of resistance indicated that the needle tip traversed the external oblique aponeurosis. Further gentle advancement resulted in the appreciation of a second loss of resistance as the needle traversed the internal oblique aponeurosis. After careful aspiration, 1 ml of the study drug was injected. The presence of substantial resistance to the injection suggested an incorrect needle tip position, indicating the need to reposition the needle. After correct placement of the needle tip, 25 ml of 0.25% bupivacaine or normal saline was injected. The block was repeated on the opposite side using an identical technique and volume of the test drug or placebo.
Twenty minutes before the completion of surgery all the patients received diclofenac 75 mg, ondansetron 0.1 mg/kg, and a loading dose of tramadol 1 mg/kg. After extubation, the patients were transferred to the Post Anesthesia Care Unit (PACU). A standard postoperative analgesia regimen consisted of IM diclofenac 75 mg, 12-hourly, and patient-controlled IV tramadol analgesia, with a demand dose of 20 mg, maximum dose of 120 mg/hour, and a lockout interval of 10 minutes.
The presence and severity of pain, total and cumulative tramadol consumption, incidence of nausea, vomiting, sedation, and pruritus at zero, two, four, six, and twenty-four hours was assessed by an investigator blinded to group allocation. The severity of pain at rest was assessed using a 10 cm visual analog scale (VAS) (0 = no pain and 10 = worst imaginable pain). Nausea was assessed using a categorical scoring system (0 = none, 1 = mild, 2 = moderate, 3 = severe). Nausea was defined as a nausea score of >0 at any point of time postoperatively. Rescue antiemetic ondansetron 0.1 mg/kg was given when a patient complained of nausea score 2 or more, or vomiting. Sedation was assessed using a four-point sedation scale (0 = awake and alert, 1 = quietly awake, 2 = asleep, but easily arousable, 3 = deep sleep). The presence of sedation was defined as a sedation score >0 at any postoperative point in time.
The primary outcome measure of the study was the 24-hour tramadol consumption. The secondary outcome measures of the study included VAS scores and opioid-related side effects.
The MedCalc statistical software, version (13.3) was used to analyze the data. The demographic data analysis, like differences in average age, height, weight, and body mass index (BMI) between the control and TAP block groups, was tested with a t-test. The difference between two independent samples was tested. The summary statistics, mean, median, and standard deviation were calculated for different parameters used under study. The mean and standard deviations were calculated for pain scores and tramadol consumption. The student t-test was used for analysis of the mean pain scores and mean tramadol consumption. A non-parametric test, the median test, was used to analyze the ordinal data like nausea, vomiting, and sedation scores between the two groups. A P value of <0.05 was considered statistically significant. The In Silico online power calculator for two means was used to calculate the power of the study. It was calculated on the basis of average tramadol consumption in the control and TAP block groups. Alfa = 0.05, β = 0, so power = 100%. Therefore, a selected sample size of 30 patients each in the control and TAP block groups was sufficient, and the results were generalizable.
| Results|| |
Sixty-six patients were enrolled into the study. Three patients from each group were excluded as they did not meet the extubation criteria immediately after surgery. Of the remaining 60 patients, 30 were randomized to undergo TAP block with bupivacaine and 30 patients with normal saline. Both the groups were comparable in terms of age, height, weight, BMI, and male to female ratio [Table 1]. Patients who received TAP block with bupivacaine had significantly less mean total pain scores (48.07 ± 6.77) when compared to the control group (62.63 ± 6.66) in the first 24 hours, with a P value of 0.0001 [Table 2], [Figure 1]. Two-hourly pain scores were less in the TAP block group up to 18 hours when compared to the control group. Both the groups showed a statistically significant difference in the mean total tramadol consumption in the first 24 hours postoperatively, which was 439 ± 68.59 mg in the control group and 281.33 ± 69.66 mg in the TAP block group, with a P value of 0.0001 [Table 3], [Figure 2]. Tramadol consumption measured two hourly was less in the TAP block group when compared to the control group up to 18 hours, after which there was an increase in tramadol consumption in the TAP block group (20, 22, 24 hours). Fourteen patients in the control group and 10 patients in the TAP block group had a nausea score of 1 or more. The median categorical nausea and vomiting score was 2 in the control group and 1 in TAP block group. There was no statistically significant difference between the two groups in nausea and vomiting P = 0.559. There was no statistically significant difference between the two groups in terms of the sedation score. The median categorical sedation score was 0 in both the groups. None of the patients from either groups had pruritus. No complication related to the block was reported in either of the groups.
|Figure 1: Mean visual analog pain (VAS) scores at 0-24 postoperative hours in the TAP block and control groups|
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|Figure 2: Mean tramadol consumption in milligrams at 0-24 hours in TAP block and control groups|
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|Table 2: Mean visual analog pain scores at 0 - 24 postoperative hours in the TAP block and control groups|
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|Table 3: Mean tramadol consumption at 0 - 24 postoperative hours in the TAP block and control groups|
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| Discussion|| |
This randomized, double-blinded, controlled trial demonstrated that supplementing TAP block to the multimodal postoperative analgesia regimen resulted in reduced pain scores and reduced tramadol consumption up to 18 postoperative hours, when compared with the control group. The TAP block reduced the total tramadol consumption by 36% in first 24 postoperative hours.
Studies on TAP block using various techniques were done in various subsets of surgeries like prostatectomy, large bowel resection, open or lap appendicectomy, C-sections, total abdominal hysterectomies, cholecystectomies, hepatic and renal surgeries, and abdominoplasties. ,,,,,,,,,, Our study was in a subset of patients posted for emergency laparotomy, secondary to hollow viscous perforations and intestinal obstructions, where the surgical incision usually extended above the umbilicus and administration of an epidural was relatively contraindicated in view of the difficulty in positioning due to pain and abdominal distention. Coagulopathies and hemodynamic instability associated with neuraxial sympathetectomy were also relative contraindications for epidurals. These surgeries involved less organ manipulation and dissection resulting in less visceral pain, making TAP block an ideal modality for postoperative pain relief. Prolonged duration of analgesia after a TAP block may be related to a relatively poorly vascularized plane, delaying the drug absorption and clearance. ,
Our technique differed from the conventional technique of administration of the TAP block, which was at the level of umbilicus in the midaxillary line with a large volume (25 ml of 0.25% bupivacaine) of local anesthetic, as the cases included in our study demanded a midline incision from the xiphisternum extending to or below the umbilicus. Superior spread of local anesthetic was required for an adequate dermatomal blockade.
The original description of the abdominal field block by Rafi was a landmark-based method, which was via the inferior lumbar triangle of Petit.  Although easy to perform, the landmark technique has several shortcomings. The inferior lumbar triangle of the Petit is not always present in all the individuals and its anatomical location may be inconsistent. , Ultrasound imagining has also revealed that the external oblique and latissimus dorsi muscles may overlap, leading to four muscle layers in this region, which can lead to failure of the block. In addition, the relevant nerves of the anterior abdominal wall did not always enter the TAP at the point of the lumbar triangle of Petit. The posterior position of the lumbar triangle of Petit would make the TAP block less convenient to perform in the supine position. 
In contrast to the study by McDonnell and colleagues,  a study by Tran et al. found that when 20 ml of aniline dye was given through the lumbar triangle of Petit in cadavers, it fixed at T10 L1. ,, Hence, a larger volume of the drug, at a much higher level, is needed to attain a higher level of sensory analgesia. The lower border of the liver was palpated before needle insertion to minimize the risk of liver injury. Although a relatively high volume of local anesthetic was used in this study, the dose was within the recommended safe dose range for bupivacaine.
Most of the studies done previously used morphine for postoperative analgesia. , We used tramadol, which was one-sixth to one-tenth as potent as morphine in our study, as it was routinely used for postoperative analgesia in our institute and was also devoid of remarkable respiratory depression, sedation, and dependence. , Tramadol had a higher incidence of nausea and vomiting than morphine.  Ten out of 30 patients in the TAP block and 14 out of 30 patients in the control group complained of nausea in our study, and this was relatively high, when compared to studies that used morphine for postoperative analgesia. ,, The incidence of nausea and vomiting with administration of tramadol was dose- and rate-related. To decrease the incidence of nausea, we administered the loading dose of tramadol 20 minutes before extubation.
The limitations of the study were that assessment of pain and postoperative analgesic consumption were limited to 24 hours postoperatively, as the patients were shifted out of the PACU after 24 hours. The success rate of the block and extent of abdominal wall sensory blockade were not assessed, as the block was administered after induction of general anesthesia. Ultrasound guidance was not used because of resource constraints.
Despite its simplicity, efficacy, low risk of complications, and a high success rate using modern techniques, the TAP block remains remarkably underutilized. The use of an ultrasound-guided TAP block has the advantage of direct visualization of the needle and the anatomical structures, and accurate and rapid injection of the drug into the target site, with improved success and decreased complications. ,,
We conclude that the TAP block holds considerable promise as a component of the multimodal analgesia regimen for emergency laparotomies.
Future trials are needed to determine the desired concentration and procedure-specific volumes of a local anesthetic and to evaluate the pharmacokinetic profile of local anesthetics after administration of the TAP block.
| Acknowledgment|| |
The authors would like to thank the statistician, N. Sarita, for her technical assistance in performing statistical analysis.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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