|Year : 2022 | Volume
| Issue : 3 | Page : 323-328
Is ultrasound-guided transversus abdominis plane block superior to a caudal epidural or wound infiltration for intraoperative and postoperative analgesia in children undergoing unilateral infraumbilical surgery? A double-blind randomized trial
Mukesh Singh Rautela1, Ameeta Sahni2, Niti Dalal2
1 Department of Anaesthesia and Intensive Care, Synergy Institute of Medical Sciences, Dehradun, Uttrakhand, India
2 Department of Anaesthesia and Critical Care, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||06-Apr-2021|
|Date of Decision||07-Jul-2021|
|Date of Acceptance||02-Sep-2021|
|Date of Web Publication||12-May-2022|
Dr. Niti Dalal
Department of Anaesthesia and Intensive Care, VMMC and Safdarjung Hospital, New Delhi - 110 023
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Aim: Caudal block (CB) is the standard of care in pediatric surgeries. Ultrasound (USG) transversus abdominis plane (TAP) block has also been used as an effective regional anesthesia technique. We compared the duration of postoperative and intraoperative analgesia between TAP block, CB, and local wound infiltration (LI) in children undergoing unilateral infraumbilical abdominal surgery.
Materials and Methods: One hundred and twenty children, 3–10 years old and American Society of Anesthesiologists Grade I and II, undergoing elective unilateral infraumbilical abdominal surgery were allocated to three groups. Group TAP: USG-guided TAP block with 0.5 ml/kg of 0.25% bupivacaine; Group CB: CB with 0.75 ml/kg of 0.25% bupivacaine; and Group LI: Local wound infiltration along the incision with 0.5 ml/kg of 0.25% bupivacaine. The primary outcome was the efficacy of postoperative analgesia using modified objective pain score (MOPS), and the secondary outcome was to determine intraoperative analgesia with fentanyl requirement and minimum alveolar concentration (MAC) hour of isoflurane among the three groups.
Results: The MOPS was statistically better in Group TAP compared to group CB and group LI at 8 and 24 h postoperatively. The mean ± standard deviation duration of postoperative analgesia in groups CB, LI, and TAP was 6.84 ± 0.47, 2.3 ± 1.26, and 9.78 ± 1.02 h, respectively. The intraoperative requirement of fentanyl and MAC hour was least in Group CB.
Conclusion: We found that USG-guided TAP block is a good alternative, with longer and effective postoperative analgesia compared to CB. However, the quality of intraoperative analgesia was best in group CB. Local infiltration was a poor alternative.
Keywords: Analgesia, caudal block, local infiltration, pediatric unilateral infraumbilical abdominal surgery, transversus abdominis plane block
|How to cite this article:|
Rautela MS, Sahni A, Dalal N. Is ultrasound-guided transversus abdominis plane block superior to a caudal epidural or wound infiltration for intraoperative and postoperative analgesia in children undergoing unilateral infraumbilical surgery? A double-blind randomized trial. J Indian Assoc Pediatr Surg 2022;27:323-8
|How to cite this URL:|
Rautela MS, Sahni A, Dalal N. Is ultrasound-guided transversus abdominis plane block superior to a caudal epidural or wound infiltration for intraoperative and postoperative analgesia in children undergoing unilateral infraumbilical surgery? A double-blind randomized trial. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 May 22];27:323-8. Available from: https://www.jiaps.com/text.asp?2022/27/3/323/345132
| Introduction|| |
In pediatric anesthesia, good and long-lasting analgesia is necessary during perioperative period for pain-free children and satisfied parents. A central neuraxial block like the caudal epidural block (CB) is the gold standard for abdominal and lower limb surgery in children. Epidural block may be contraindicated; for instance in sepsis, coagulation abnormalities, and spinal deformities. In such situations, the surgeon often infiltrates the wound with local anesthetic as a simple alternative.
In recent years, there has been a shift from neuraxial to peripheral nerve blocks due to their better safety profile, especially in children. One such peripheral block, transversus abdominis plane (TAP) block, provides good analgesia to the parietal peritoneum, skin, and muscle of the anterior abdomen wall, which works well when postoperative pain is mainly somatic. With the advent of ultrasound (USG)-guided technique, TAP block has increased in popularity, due to its improved success rate, as drug is delivered under direct visualization.
We planned to compare the efficacy and duration of postoperative analgesia between the three study groups, for example, CB, LI, TAP in children undergoing unilateral infraumbilical abdominal surgery, using the modified objective pain score (MOPS), time to first rescue analgesia and total analgesic requirement in 24 h. For intraoperative analgesia, we noted the total fentanyl requirement and minimum alveolar concentration (MAC) hour of isoflurane during surgery.
| Materials and Methods|| |
This was a prospective, randomized, double-blind (observer-blinded) study conducted in a tertiary care hospital from 2013 to 2016 after approval from the Institutional Ethics Committee (IEC/VMMC/SJH/Thesis/Nov-13/11). The trial was registered with the Clinical Trials Registry India (CTRI/2014/09/005023). Written informed parental consent was taken for all patients. One hundred and twenty American Society of Anesthesiologists physical status I/II, children aged 3–10 years, weighing <20 kg scheduled for unilateral infraumbilical abdominal surgery were randomized using a computer-generated random number chart and allocated by sealed envelope technique to receive one of three blocks. Children whose parents did not consent, those who had blood coagulopathies, local infection, bilateral lower abdominal surgery were excluded from the study.
The interventions were divided into three groups:
- Group CB: Received caudal block with 0.25% bupivacaine in a dose of 0.75 ml/kg body weight
- Group LI: Received local wound infiltration with 0.25% bupivacaine in the line of incision by the surgeon to a maximum of 0.5 ml/kg body weight
- Group TAP: Received USG TAP block with 0.25% bupivacaine in a dose of 0.5 ml/kg body weight.
All patients underwent a preanesthetic check-up. A local anesthetic cream was applied to the area 30 min prior to surgery. Oral midazolam 0.5 mg/kg body weight was given as premedication. Vitals and oxygen saturation were monitored preoperatively. An intravenous line was secured.
In the operation theatre, the electrocardiogram, pulse oximetry (sPO2), and noninvasive blood pressure (NIBP) were monitored, and the baseline values were recorded. The patients were induced intravenously with injection fentanyl (2 ug/kg body weight) followed by injection propofol (2–3 mg/kg body weight). The airway was secured with an appropriate size Proseal laryngeal mask airway. Correct placement was confirmed, and anesthesia was maintained on isoflurane in N2O/O2 in 3:2 ratio on spontaneous respiration. Intraoperatively, a balanced salt solution (Ringer Lactate) was given at 15 ml/kg body weight/hour. Group TAP patients were placed, supine, and abdominal skin preparation was done. A 5–10 MHz USG linear probe, covered with a sterile plastic cover, was placed in the horizontal plane just below the umbilicus to identify the posterior rectus sheath and the rectus abdominis muscle. As the probe was moved laterally, a distinct plane between external oblique, internal oblique, and transversus abdominis muscle was seen. A 50 mm, 22G blunt needle was inserted in an in-plane approach close to the anterior axillary line and positioned in the fascial plane between the internal oblique and transversus abdominis. After negative aspiration, the predetermined dose of local anesthetic was injected. An oval spread in the fascial plane between internal oblique and transversus abdominis confirmed correct placement [Figure 1]. In Group CB, patients were placed in the lateral position with one or both hips flexed, and the sacral hiatus was palpated. After sterile preparation, a needle (22G) was advanced at 60° angle cephalad until a pop was felt as the needle pierced the sacrococcygeal ligament and then advanced 2 mm. The needle position was confirmed by the whoosh test. Aspiration for blood and cerebrospinal fluid was done to rule out intravascular or intrathecal placement and if negative the calculated amount of the local anesthetic drug was injected slowly in small aliquots with repeated negative aspiration.
|Figure 1: Image of the abdominal wall showing the plane of infiltration of the local anesthetic external oblique, internal oblique, transversus abdominis with local anesthetic deposition in the transversus abdominis plane|
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In Group LI, at the start of surgery, the surgeon infiltrated the line of incision in layers with bupivacaine 0.25% up to a maximum of 0.5 ml/kg body weight. Before handing over the patient to the surgeon, a rectal suppository of acetaminophen 20–25 mg/kg body weight was administered in all three groups. The surgical incision commenced 5 min after the block.
Intraoperatively, heart rate, NIBP, SPO2, and end-tidal CO2 were recorded throughout the surgery at fixed intervals. If there was an increase in heart rate or blood pressure by 25% at the time of skin incision, additional fentanyl 1 ug/kg was given. At the end of the surgery, MAC hour and the total amount of fentanyl per kg body weight were calculated. The patient was transferred to the postanesthesia care unit (recovery room) for further monitoring.
During the postoperative period, the vital signs were monitored (heart rate, blood pressure, and saturation), and assessment of pain was done using MOPS (crying, movement, agitation, posture, verbal and each criterion had a score of 0, 1, 2 at 0 h, 1 h, 2 h, 4 h, 8 h, 12 h, and 24 h, respectively). Rescue analgesia (syrup paracetamol 15 mg/kg body weight or injection paracetamol 10 mg/kg body weight) was given at a score of 4. Time to first rescue analgesia and the total dose of paracetamol used in the first 24 h postoperatively was noted.
The sample size was calculated to detect a mean difference in efficacy and duration of analgesia among the three groups. To detect the difference with 95% confidence level and 80% power, we enrolled 40 patients in each group.
The data were recorded in a predesigned pro forma and managed using a Microsoft Excel spreadsheet. For quantitative variables, the data were presented in terms of range (minimum, maximum), mean and standard deviation or median (Q1, Q2). Qualitative variables were summarized as frequency (%). The statistical significance of quantitative variables in the three groups was done using ANOVA for normally distributed data and the Kruskal–Wallis test for data that were not normally distributed. The Chi-square/Fisher's exact test was used to compare the frequency of qualitative variables among the groups. A P ≤ 0.05 was considered statistically significant. SPSS 21.0 statistical software version (IBM, Chicago, Illinois, USA) was used for data analysis.
| Results|| |
One hundred and twenty patients (40 per group), undergoing elective unilateral infraumbilical surgery were included in the study [Figure 2]. Age, weight, gender and type of surgery were comparable across the three groups with no significant difference [Table 1].
The total amount of fentanyl/kg body weight used intraoperatively was different in all groups and was found to be statistically significant between CB and LI, CB and TAP [Table 2].
Variations were observed intraoperatively in MAC hour and duration of anesthesia (minutes) in all three groups. Mean values of MAC hour were noted, which was statistically significant between groups CB and TAP and groups CB and LI. The difference in the mean duration of anesthesia was statistically significant among all three groups [Table 3].
|Table 3: Intraoperative variation of minimum alveolar concentration and duration of anesthesia (min)|
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Postoperative MOP score was observed for 24 h. The values were significantly different between groups CB and TAP at 8 h, between groups LI and TAP at 0, 1, 2, and 4 h and between groups CB and LI at 0, 1, 2, and 4 h, respectively [Table 4] and [Figure 3].
|Figure 3: Postoperative variation of modified objective pain (MOP) score between three groups, over a period of time|
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The time to first rescue analgesia (hours) defining the duration of analgesia is shown in [Table 5] and was significantly different between all the groups.
The total dose of analgesic administered over 24 h (syrup paracetamol 15 mg/kg body weight) was also significantly different between all the groups [Table 6].
The variations in intraoperative hemodynamic parameters such as heart rate, systolic blood pressure, and diastolic blood pressure were comparable among patients across the three groups. There were no side effects such as nausea, vomiting, urinary retention, and prolonged motor block which could have delayed discharge.
| Discussion|| |
Our results showed that USG-guided TAP block provided longer and superior postoperative analgesia compared to caudal block and local infiltration. The mean duration of postoperative analgesia in the TAP group was nearly 10 h [Table 5], and the MOP scores show that the effect of caudal block waned after 4 h while that of TAP block persisted for longer (8 h). However, intraoperatively, caudal block had a lower requirement of fentanyl and isoflurane (MAC hour) indicating that intraoperatively caudal analgesia was better than with TAP block. Local infiltration provided the least analgesia among the three methods.
In a study by Kumar et al., 112 children (age group 2–8 years) who were undergoing elective inguinal hernia repair received either received USG-guided TAP block (n = 56) with 0.5 ml/kg of 0.2% ropivacaine and a similar number received caudal block with 1 ml/kg of 0.2% ropivacaine. USG-guided TAP block provided prolonged analgesia as compared with the caudal block at 6–24 h after the block, as shown by a statistically significant fewer number of rescue analgesic doses and lesser total rescue analgesic consumption in 24 h. We too found that the total rescue consumption of analgesic doses of paracetamol was lower in the TAP group compared to the other two groups.
Al Sadek et al. compared 3 groups in lower abdominal operations – ultrasound-guided TAP block (received 0.5 ml/kg bupivacaine 0.25%) to ultrasound-guided caudal block (received 1 ml/kg bupivacaine 0.25%) and conventional analgesia (n = 20, control group). They used Children's Hospital Eastern Ontario Pain Scale, objective pain scale (OPS), postoperative complications, patient and parent satisfaction, and postoperative analgesia to assess pain. They found similar pain scores in the TAP and caudal group though the analgesic requirements were higher in the caudal group. The control group needed the maximum analgesia. Patient and parent satisfaction was the most in the TAP group and least in the control group. Our results were similar to their study, however, our third group received local anesthetic in the wound.
On the other hand, Elbahrawy and El-Deeb, compared CB and TAP block in children undergoing daycare unilateral lower abdominal surgeries and found that postoperative pain score, time to first administration of rescue analgesia was statistically similar between the two groups. The parent satisfaction score was however better with the TAP group.
Faried et al. compared ultrasound-guided TAP block to ilioinguinal/iliohypogastric nerve blocks in unilateral lower abdominal surgery. Similar to our results, the mean duration of analgesia as well as the time to first rescue analgesia was longer in the TAP block group than in the nerve blocks group.
Similarly, Shaaban compared ultrasound-guided TAP block to local wound infiltration in children operated for appendectomy and inguinal hernia and found TAP block increased the time for the first analgesic dose by almost double when compared with the local infiltration group. In our study too, the findings were similar.,
In our study, the total analgesic requirement in the first 24 h was the least in the TAP group. In fact, it was almost half the requirement in the other two groups. These observations too are consistent with the study by Tobias, where children between 10 months and 8 years of age who had umbilical and lower abdominal surgery were included. Ultrasound-guided TAP block was given on both sides with 0.3 ml/kg of 0.25% bupivacaine with epinephrine 1:200,000 after completion of the surgical procedure. Adequate postoperative analgesia was seen in 8 of the 10 patients with the first request for postoperative analgesia varying from 7 h to 11 h.
In our study, intraoperative analgesia was assessed by comparing total fentanyl requirement and MAC hour values. The CB group required the least amount of fentanyl intraoperatively as compared to the other two groups. Furthermore, we observed that the intraoperative variation of MAC hour was least in the CB group. Both these findings suggest that TAP block and local infiltration did not block visceral pain during surgery.
Similar to our results, Ahmed and Rayan observed an increased requirement of intraoperative fentanyl in TAP block as compared to CB in unilateral groin surgery. In contrast, Elbahrawy and El-Deeb, found no statistically significant differences between TAP and CB in terms of total intraoperative fentanyl use, postoperative tramadol requirement, time to first administration of rescue analgesia, and time in the post-anesthesia care unit in children undergoing day-care unilateral lower abdominal surgeries.
On comparing the duration of anesthesia, TAP had the longest duration as the preparation and completion time was longer compared to the other two groups. This difference was statistically significant. Faried et al. showed that the time required for ilioinguinal/iliohypogastric nerve blocks was significantly more, by an average of 58 seconds, as compared to TAP block.
As in previous studies, we too did not find any difference in the hemodynamic parameters intraoperatively between the three groups, nor were there any side-effects that could have delayed discharge.,
Thus, TAP block provided superior postoperative analgesia with longer duration and was more efficacious as compared to caudal block and local infiltration of the wound. However, intraoperatively better analgesia was obtained with caudal block. The foremost disadvantage of TAP block is that it requires an anesthetist with expertise in ultrasound scanning and the availability of an ultrasound machine.
An USG TAP block is a relatively easy one; however, USG is time-consuming, needs added manpower to get the machine ready and the probe covered. This may be possible only in a tertiary center with added facilities. However, where a caudal block is contraindicated for some reason, a USG guided TAP block maybe a better alternative than wound infiltration.
We did not assess patient or parent satisfaction with the block administered. This would have allowed for a more comprehensive assessment of the quality of analgesia. We also did not assess motor effects of the block as these could have affected discharge of the patient.
Another aspect we feel is that of the surgeon satisfaction. Some minor surgeries maybe better off with wound infiltration and postoperative paracetamol. As an USG TAP block is time-consuming and may require an induction room to save on OT time.
| Conclusion|| |
We suggest that ultrasound-guided TAP block is a good alternative, with longer and effective postoperative analgesia, as compared to caudal block, especially in situations where a caudal block may be contraindicated. However, it requires an ultrasound machine for correct placement of the drug. The caudal block provides good intraoperative analgesia, has moderate postoperative analgesia, and does not necessarily need an ultrasound machine. Local wound infiltration is a poor substitute, both in the intraoperative and postoperative period, as higher amounts of anesthetic drug are required.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Willschke H, Kettner S. Pediatric regional anesthesia: Abdominal wall blocks. Paediatr Anaesth 2012;22:88-92.
Johr M, Berger TM. Caudal blocks. Pediatr Anesth 2012;22:44-50.
Ecoffey C, Lacroix F, Giaufré E, Orliaguet G, Courrèges P; Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF). Epidemiology and morbidity of regional anesthesia in children: A follow-up one-year prospective survey of the French-language society of paediatric anaesthesiologists (ADARPEF). Paediatr Anaesth 2010;20:1061-9.
Mai CL, Young MJ, Quraishi SA. Clinical implications of the transversus abdominis plane block in pediatric anesthesia. Paediatr Anaesth 2012;22:831-40.
Ahmed AA, Rayan AA. Ultrasound guided transversus abdominal plane (TAP) block versus caudal block for postoperative analgesia in children undergoing unilateral open inguinal herniotomy: A comparative study. Ains Shams J Anesthesiol 2016;9:284-9.
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.
Kumar A, Dogra N, Gupta A, Aggarwal S. Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing inguinal hernia surgery: A comparative study. J Anaesthesiol Clin Pharmacol 2020;36:172-6. [Full text]
Al Sadek WM, Al-Gohari MM, Elsonbaty MI, Nassar HM, Alkonaiesy RM. Ultrasound guided TAP block versus ultrasound guided caudal block for pain relief in children undergoing lower abdominal surgeries. Egypt J Anaesthesia 2015;31:155-60.
Elbahrawy K, El-Deeb A. Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: A prospective, randomized study. Res Opin Anesth Intens Care 2016;3:20-4.
Faried AM, Lahloub FM, Elzehery MM. Ultrasound guided transverses abdominal plane block versus ilioinguinal/iliohypogastric nerve blocks for postoperative analgesia in children undergoing lower abdominal surgery. Enliven: J Anesthesiol Crit Care Med 2014;1:1-5.
Shaaban AR. Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial. Egypt J Anaesth 2014;30:377-82.
Sahin L, Sahin M, Gul R, Saricicek V, Isikay N. Ultrasound-guided transversus abdominis plane block in children: A randomised comparison with wound infiltration. Eur J Anaesthesiol 2013;30:409-14.
Tobias JD. Preliminary experience with transverses abdominis plane block for postoperative pain relief in infant and children. Saudi J Anaesth 2009;3:2-6.
Kanojia N, Ahuja S. Comparison of transverses abdominis plane block and caudal block for postoperative analgesia in children undergoing lower abdominal surgery. Int J Sci Res 2013;4:1585-7.
Aveline C, Le Hetet H, Le Roux A. Comparison between ultrasound-guided transverses abdominis plane and conventional ilioinguinal/iliohypogatric nerve blocks for day case open inguinal hernia repair. Br J Anaesth 2010;106:380-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]