Ashraf
Ashraf
Ashraf
Ultrasound Guided Bilateral Transversus Abdominis Plane Block Pak Armed Forces Med J 2020; 70 (1): 91-95
ABSTRACT
Objective: To compare the efficacy of ultrasound guided bilateral transversus abdominis plane block with
conventional analgesic technique for post-operative pain relief, time to first request for analgesic, early
mobilization, opioid related side effects in obstetric and gynecological surgeries.
Study Design: Quasi experimental study.
Place and Duration of Study: Obs & Gynae Department at Combined Military Hospital Lahore and Hyderabad,
from, Apr 2017 to Sep 2017.
Methodology: In this study 200 mothers were included. The population under study was divided into two
groups, group-A mothers had Transversus Abdominis Plane block and group B (control) without Transversus
Abdominis Plane block.
Results: The mean age was 34 years within a range of 20 to 50 years. Pain score, Visual Analogue Score, was
much lower in group A (with TAP block) in comparison to group B (without TAP block) (p-value=0.000). The
median time for asking for painkillers was 10 hrs (9, 11) in group A as compared to 3 hrs (2, 6) in group B.
Conclusion: Transversus Abdominis Plane block reduced pain intensity, delays the requirement of painkillers
and decreased any additional requirements of opiates-analgesics especially when those are used as a part of any
painkilling-regimens after obstetric and gynecological surgeries.
Keywords: Anaesthesia, Analgesia, Cesarean section, Early ambulation, Lower segment, Morphine, Nerve block,
Post-anaesthesia care.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Ultrasound Guided Bilateral Transversus Abdominis Plane Block Pak Armed Forces Med J 2020; 70 (1): 91-95
Among many techniques, TAP block is a gauge intravenous catheter was inserted in the
novel technique in a way that it inhibits the neu- left hand.
ral-afferents when a local anesthesia compound is TAP block was performed bilaterally at the
injected in-between the neurofascial plane i.e. end of the operation, when the patient was still
Internal oblique muscle and transversus abdomi- under general anaesthesia. The well qualified
nis muscle. The TAP block has also been shown anesthesiologists were usually employed for this
to reduce morphine consumption after caesarean technique who made best use of the ultrasono-
delivery under spinal anaesthesia. Increasing graphy to identify different muscles in the ante-
TAP blocks have been performed under ultra- rior abdominal wall, namely External Oblique,
sound guidance which may be more precise and Internal Oblique and Transversus Abdominis.
safer than the blind approach. RCTs have proved The injected area was first prepared by disinfec-
the effectiveness of TAP block technique when tants, then a 22G insulated needle which is about
given as a part of post-operative painkilling regi- 100mm in length is employed under ultrasonic
men following caesarean delivery and abdominal guidance, whose position was confirmed by
hysterectomy9,10. visualizing its tip in-between internal oblique
METHODOLOGY and transversus abdominus, it was also aspirated
This study was conducted at Obs & Gynae to check for any vascular injury and then 20cc
departments of CMH Lahore and Hyderabad. of bupivacaine 0.5 percent was injected in
The study duration was 6 months from April supplement of 5ml, the total quantity was kept
2017 to September 2017. Simple random sampling less than 40 ml, just enough for infiltrating the
technique was used for data collection. After both sides.
getting the approval of hospital ethical and After the successful surgery, thepatients
research committee, informed consent of patients were shifted to post-anesthesia Care Unit (PACU)
was obtained. Inclusion criteria were patients before shifting to the wards and a standard post-
willing to be included in this study, undergoing operativeanalgesic regime of intravenous 50mg of
Lower Segment Caesarean Section, abdominal Tramadol for the alleviation of severe pain were
hysterectomy orlaparotomy having age 25-50 given to the both groups in the initial 24 hours.
years, weight 70-80 kg and BMI 24-30. Whereas After transferring from the PACU towards all the
exclusion criteria were patients with any history patients were assessed at upto 24 hrs after the
of drug addiction e.g opioids/benzodiazepines, procedure for ‘pain’’&‘ nausea and vomiting’.
coagulopathy or psychological disorders and For pain scoring, patients were asked to rate their
sensitivity to any particular analgesic drugs. ‘pain-severity’ by employing Visual Analogue
A sample of 200 patients were divided equa- score as (0=absence of pain to 10=the worst
lly into two groups of 100 each. Sample size was pain), severity of nausea and vomiting by using
calculated by using WHO sample size calculator 4-point score rating (0=none 1=mild, 2=moderate,
keeping the confidence level of 95%. Patients 3=severe and 4=vomiting) and the ‘need for
were allocated randomly using a computer-gene- antiemetics’ and ‘satisfaction-scores’ of mothers
rated random number table to undergo TAP with and without TAP block. Analgesics’ con-
block (n=100) and standard care (control) with no sumption in the first 24 hours was also recorded.
block (n=100). 24 hours later, Ibuprofen was given in the dose of
800 mg orally and Acetaminophen 1000 mg orally
On arrival in the operating room, monitoring
8 hourly to each patient.
like pulse oximetry, continuous ECG and non-
invasive blood pressure measurement was All the collected data was entered and
started prior to induction of anaesthesia. An 18- analyzed in SPSS version 18. Descriptive statistics
such as mean, frequency and standard deviation
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Ultrasound Guided Bilateral Transversus Abdominis Plane Block Pak Armed Forces Med J 2020; 70 (1): 91-95
will be calculated for all numerical variables such while comparing to group-B (without TAP block)
as age, weight, height, BMI and type of surgeries at 2, 4 and 24 hours after the surgeries. (p<0.000,
in two different groups. Independent sample t-
Table-I: Distribution of patients.
Group-A (Transversus Group-B
Procedures Percentage
Abdominis Plane block) (Control)
Lower segment caesarean section 62 62 62
Abdominal hysterectomy 23 23 23
Laparotomy 15 15 15
Table-II: Comparing means of VAS of both groups.
Groups N Mean ± SD Std. Error Mean p-value
With TAP Block 100 0.95 ± 0.821 0.082
Pain score at 2 hours 0.000
With No Block 100 4.09 ± 1.334 0.133
With TAP Block 100 1.52 ± 0.502 0.050
Pain score at 6 hours 0.000
With No Block 100 3.35 ± 1.777 0.178
With TAP Block 100 1.38 ± 1.117 0.112
Pain score at 24 hours 0.000
With No Block 100 2.92 ± 0.825 0.082
test wasused to compare analgesic requirement in independent sample t-test) (table-II & figure).
post-operative period at 2, 6 and 24 hours post- Scores recorded for nauseating feeling were
operatively. Similar test was used to compare the markedly lower in group-A especially after 14
significance of nauseating feeling and maternal
satisfaction in both groups.
RESULTS
A total of 200 patients were included
according to the inclusion criteria of this study.
The patients were randomly divided into two
equal groups. Group-A had TAP block and
group-B without TAP block (control) (table-I).
Age, weight, height & BMI of the patients
were kept as independent variables. Group-A
patients experienced an increase in the duration
Figure: Post-operative pain and visual analog scores
of time for the first painkiller (Injection tramadol)
at rest and on movement.
demand. The median (interquartile-range) time
for demand of Tramadol for the first-time was 10 hours of the procedures. The median (maternal-
hrs (9,11) in group A (study group) as compared satisfaction scores) were markedly higher in
Table-III: Side effects in both groups (n=100).
Nausea Vomiting Sedation Requirement Early Mobilization
Transversus Transversus Transversus Transversus
Control Abdominis Control Abdominis Control Abdominis Control Abdominis
Plane Plane Plane Plane
Positive 11 02 16 05 42 10 23 71
Negative 89 98 84 95 58 90 77 29
to 3 hrs (2,5) in group B (control group) without group-A (having TAP block) while comparing to
TAP block. group-B (without TAP block).
Pain scores were much lower with statisti- A total of 11 patients had feeling of nausea in
cally significance in group-A (having TAP block) the post-operative period in the control group,
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Ultrasound Guided Bilateral Transversus Abdominis Plane Block Pak Armed Forces Med J 2020; 70 (1): 91-95
while in bilateral TAP-block-receiver group there rest, 24-hours following the discharge from ward
were only 2 patients. Nonetheless, it was not were the same in the both groups.
associated with any significant difference in the The pain and discomfort after caesarean
incidence of nauseating feeling or distribution section delays early mobilization in post-opera-
of nausea-scores in-between two groups in 24- tive-period. In our study early mobilization was
hours of observation. Moreover, the TAP-block seen in 70.86% and delayed mobilization in
markedly lessened the incidence of sedation, 29.14% In our study TAP block caused less pain-
from 30 - 40% in the control-group reaching upto intensity during movements like coughing in 24
10% in the TAP-block group. Early mobilization hours after caesarean section meaning by TAP
was seen in the patients who received bilateral block successfully reduced the somatic pain in
TAP block as compared to the control group our study.
(table-III).
In our study nausea and vomiting was seen
DISCUSSION in 2 and 5 patients respectively in group-A with
Post-operative pain control after Gynecolo- TAP block as compared to 11 and 16 patients in
gical & Obstetric surgeries especially caesarean group-B without TAP block respectively. The
section is a big challenge for obstetrician as it satisfaction level was higher in patients with TAP
should address both for mother’s comfort with block as compared to patients without TAP block.
equally no harmful-effects to the neonate. The CONCLUSION
neuraxial opioids provide excellent analgesia but
TAP block reduces pain intensity, prolongs
those are associated with various adverse effects
the time to first analgesic request and decrease
like feeling of nausea, vomiting and pruritis
supplemental opioids requirment when used as a
which can decrease patients’ satisfaction. Our
component of multimodel regimen for pain relief
study demonstrated that ultrasound-guided TAP
blocks decreased 24 hours post-operative pain- after caesarean section.
intensity as well as analgesic requirement, as CONFLICT OF INTEREST
group-A (TAP block) required few doses of This study has no conflict of interest to be
Injection Tramadol after 24 hours as compared declared by any author.
to group-B (without TAP block). Two different
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