The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Intravenous versus epidural administration of hydromorphone. Effects on analgesia and recovery after radical retropubic prostatectomy. Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing open appendicectomy. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Transversus abdominis plane block does not provide additional benefit to multimodal analgesia in gynecological cancer surgery. Intraoperative epidural analgesia combined with ketamine provides effective preventive analgesia in patients undergoing major digestive surgery. Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery.
The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. We evaluated its analgesic efficacy in patients during the first 24 postoperative hours after abdominal surgery, in a randomized, controlled, double-blind clinical trial.
                Thirty-two adults undergoing large bowel resection via a midline abdominal incision were randomized to receive standard care, including patient-controlled morphine analgesia and regular nonsteroidal antiinflammatory drugs and acetaminophen (n = 16), or to undergo TAP block (n = 16) in addition to standard care (n = 16). After induction of anesthesia, 20 mL of 0.375% levobupivacaine was deposited into the transversus abdominis neuro-fascial plane via the bilateral lumbar triangles of Petit. Each patient was assessed by a blinded investigator in the postanesthesia care unit and at 2, 4, 6, and 24 h postoperatively.
                The TAP block reduced visual analog scale pain scores (TAP versus control, mean +/- sd) on emergence (1 +/- 1.4 vs 6.6 +/- 2.8, P < 0.05), and at all postoperative time points, including at 24 h (1.7 +/- 1.7 vs 3.1 +/- 1.5, P < 0.05). Morphine requirements in the first 24 postoperative hours were also reduced (21.9 +/- 8.9 mg vs 80.4 +/- 19.2 mg, P < 0.05). There were no complications attributable to the TAP block. All TAP patients reported high levels of satisfaction with their postoperative analgesic regimen.
                The TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery. The transversus abdominis plane (TAP) block is an effective method of providing postoperative analgesia in patients undergoing midline abdominal wall incisions. We evaluated its analgesic efficacy over the first 48 postoperative hours after cesarean delivery performed through a Pfannensteil incision, in a randomized controlled, double-blind, clinical trial.
                Fifty women undergoing elective cesarean delivery were randomized to undergo TAP block with ropivacaine (n = 25) versus placebo (n = 25), in addition to standard postoperative analgesia comprising patient-controlled IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a standard spinal anesthetic, and at the end of surgery, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side. Each patient was assessed postoperatively by a blinded investigator: in the postanesthesia care unit and at 2, 4, 6, 12, 24, 36, and 48 h postoperatively.
                The TAP block with ropivacaine compared with placebo reduced postoperative visual analog scale pain scores. Mean (+/- sd) total morphine requirements in the first 48 postoperative hours were also reduced (66 +/- 26 vs 18 +/- 14 mg, P < 0.001), as was the 12-h interval morphine consumption up to 36 h postoperatively. The incidence of sedation was reduced in patients undergoing TAP blockade. There were no complications attributable to the TAP block.
                The TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia when compared with placebo block up to 48 postoperative hours after elective cesarean delivery. Patients undergoing total abdominal hysterectomy suffer significant postoperative pain. The transversus abdominis plane (TAP) block is a recently described approach to providing analgesia to the anterior abdominal wall. We evaluated the analgesic efficacy of the TAP block in patients undergoing total abdominal hysterectomy via a transverse lower abdominal wall incision, in a randomized, controlled, double-blind clinical trial.
                Fifty females undergoing elective total abdominal hysterectomy were randomized to undergo TAP block with ropivacaine (n = 24) versus placebo (n = 26) in addition to standard postoperative analgesia comprising patient-controlled IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a general anesthetic and, before surgical incision, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side. Each patient was assessed postoperatively by a blinded investigator in the postanesthesia care unit and at 2, 4, 6, 12, 24, 36, 48 h postoperatively.
                The TAP block with ropivacaine reduced postoperative visual analog scale pain scores compared to placebo block. Mean (+/-SD) total morphine requirements in the first 48 postoperative hours were also reduced (55 +/- 17 mg vs 27 +/- 20 mg, P < 0.001). The incidence of sedation was reduced in patients undergoing TAP blockade. There were no complications attributable to the TAP block.
                The TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia when compared to placebo block up to 48 postoperative hours after elective total abdominal hysterectomy. It remains unclear whether epidural administration of hydromorphone results in spinal analgesia or clinical benefit when compared with intravenous administration. Therefore, we undertook this study to determine whether epidural administration of hydromorphone resulted in decreased opioid requirement, improved analgesia, reduced side effects, more rapid return of gastrointestinal function, or shorter duration of hospital stay than intravenous administration.
                Sixteen patients undergoing radical retropubic prostatectomy were randomized in a double-blind manner to receive either intravenous or epidural hydromorphone via patient-controlled analgesia (PCA) for postoperative analgesia. All patients underwent a standardized combined epidural and general anesthetic and all received ketorolac for 72 h postoperatively. To decrease variability, patients were cared for according to a standardized protocol and were deemed ready for discharge according to prospectively defined criteria.
                Patients in the intravenous PCA group required approximately twice as much opioid than the epidural PCA group (P < 0.008), but there were no differences between groups in pain scores or patient satisfaction. Epidural administration resulted in a greater incidence of pruritus (P = 0.02). Gastrointestinal function recovered quickly in all patients with little variation, and there were no differences between groups. All patients were deemed ready for discharge by the third postoperative day, and removal of surgical drains was the last discharge criterion reached in all patients.
                Our results indicate that epidural administration of hydromorphone results in spinally mediated analgesia. However, epidural administration did not provide significant benefits in terms of postoperative analgesia, recovery of gastrointestinal function, or duration of hospitalization. Furthermore, we suggest that radical retropubic prostatectomy no longer be used as a model to assess the effects of analgesic technique on postoperative recovery, because control of discharge criteria revealed that hospital discharge was primarily dependent on removal of surgical drains. Transversus abdominis plane (TAP) block is a new regional anaesthetic technique that blocks abdominal neural afferents by introducing local anaesthetic into the neuro-fascial plane between the internal oblique and the transversus abdominis muscles. We evaluated its analgesic efficacy in patients undergoing open appendicectomy in a randomized controlled double-blinded clinical trial.
                Fifty-two adult patients undergoing open appendicectomy were randomized to undergo standard care (n=26) or to undergo a right-sided TAP block with bupivacaine (n=26). In addition, all patients received patient-controlled i.v. morphine analgesia, regular acetaminophen, and non-steroidal anti-inflammatory drug, as required, in the postoperative period. All patients received standard anaesthetic, and after induction of anaesthesia, the TAP group received an ultrasound-guided unilateral TAP block. Each patient was assessed after operation by a blinded investigator at 30 min and 24 h after surgery.
                Ultrasound-guided TAP block significantly reduced postoperative morphine consumption in the first 24 h [mean (sd) 28 (18) vs 50 (19) mg, P<0.002]. Postoperative visual analogue scale pain scores were also reduced in the TAP block group soon after surgery [median (IQR) 4.5 (3-5.3) vs 8.5 (7.5-10), P<0.001] and at 24 h [5.2 (4-6.2) vs 8 (7-8.5), P<0.001]. There were no complications attributable to the TAP block.
                Ultrasound-guided TAP block holds considerable promise as a part of a balanced postoperative analgesic regimen for patients undergoing open appendicectomy. The transversus abdominis plane (TAP) block is usually performed by landmark-based methods. This prospective, randomized, and double-blinded study was designed to describe a method of ultrasound-guided TAP block and to evaluate the intra- and postoperative analgesic efficacy in patients undergoing laparoscopic cholecystectomy under general anaesthesia with or without TAP block.
                Forty-two patients undergoing laparoscopic cholecystectomy were randomized to receive standard general anaesthetic either with (Group A, n=21) or without TAP block (Group B, n=21). Ultrasound-guided bilateral TAP block was performed with a high frequent linear ultrasound probe and an in-plane needle guidance technique with 15 ml bupivacaine 5 mg ml(-1) on each side. Intraoperative use of sufentanil and postoperative demand of morphine using a patient-controlled analgesia device were recorded.
                Ultrasonographic visualization of the relevant anatomy, detection of the shaft and tip of the needle, and the spread of local anaesthetic were possible in all cases where a TAP block was performed. Patients in Group A received significantly less [corrected] intraoperative sufentanil and postoperative morphine compared with those in Group B [mean (SD) 8.6 (3.5) vs 23.0 (4.8) microg, P<0.01, and 10.5 (7.7) vs 22.8 (4.3) mg, P<0.05].
                Ultrasonographic guidance enables exact placement of the local anaesthetic for TAP blocks. In patients undergoing laparoscopic cholecystectomy under standard general anaesthetic, ultrasound-guided TAP block substantially reduced the perioperative opioid consumption. The transversus abdominis plane (TAP) block is a recently described technique involving injecting local anesthetic between the internal oblique and transversus abdominis layers of the abdominal wall. It has been shown to be effective in reducing morphine consumption and improving postoperative pain relief in several clinical settings.
                We performed a randomized placebo-controlled trial comparing bilateral ultrasound-guided TAP blocks (2 x 20 mL 0.5% ropivacaine or 0.9% saline) in adult female patients undergoing midline laparotomy for known or presumed gynecological malignancy. Both groups received multimodal IV analgesia. The primary outcomes for the study were defined as the incidence of "inadequate" analgesia (defined as a score >50 mm on a visual analog scale) with forced expiration at 2 hours postoperatively and total postoperative morphine consumption at 2 hours and 24 hours.
                Data from 65 patients were included in the study. The groups were comparable in terms of age, weight, surgical duration, and intraoperative morphine doses. There were no significant differences between the control and treatment groups in the proportion of patients with inadequate analgesia either at rest (39% vs. 22%, P = 0.13) or with coughing (61% vs. 53%, P = 0.54) at 2 hours. There was no significant difference in postoperative morphine consumption between the placebo and treatment groups at 2 hours (13.5 mg vs. 11.87 mg, P = 0.53) or 24 hours (34.0 mg vs. 36.1 mg, P = 0.76). There were no significant differences in the incidence of opioid side effects or patient satisfaction.
                This study demonstrated that TAP blockade conferred no benefit in addition to multimodal analgesia in women undergoing major gynecological cancer surgery. As a broader definition of preemptive analgesia, preventive analgesia aims to prevent the sensitization of central nervous system, hence the development of pathologic pain after tissular injury. To demonstrate benefits from preventive treatment, objective measurement of postoperative pain such as wound hyperalgesia and persistent pain should be evaluated. The current study assessed the role and timing of epidural analgesia in this context.
                In a randomized, double-blinded trial, 85 patients scheduled to undergo neoplastic colonic resection were included. All the patients received a thoracic epidural catheter, systemic ketamine at a antihyperalgesic dose, and general anesthesia. Continuous infusion of analgesics belonging to the same class was administered by either intravenous or epidural route before incision until 72 h after surgery. Patients were allocated to four groups to receive intraoperative intravenous lidocaine-sufentanil-clonidine or epidural bupivacaine-sufentanil-clonidine followed postoperatively by either intravenous (lidocaine-morphine-clonidine) or epidural (bupivacaine-sufentanil-clonidine) patient-controlled analgesia. Postoperative pain scores (visual analog scale), analgesic consumption, wound area of punctuate hyperalgesia, residual pain, and analgesics needed from 2 weeks until 12 months were recorded.
                Analgesic requirements, visual analog scale scores, and area of hyperalgesia were significantly higher in the intravenous treatment group (intravenous-intravenous), and more patients reported residual pain from 2 weeks until 1 yr (28%). Although postoperative pain measurements did not differ, postoperative epidural treatment (intravenous-epidural) was less effective to prevent residual pain at 1 yr (11%; P = 0.2 with intravenous-intravenous group) than intraoperative one (epidural-epidural and epidural-intravenous groups) (0%; P = 0.01 with intravenous-intravenous group).
                Combined with an antihyperalgesic dose of ketamine, intraoperative epidural analgesia provides effective preventive analgesia after major digestive surgery. We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine.
                Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.
No studies have compared TAP block with other analgesics such as epidural analgesia or local anaesthetic infiltration into the abdominal wound. There is only limited evidence to suggest use of perioperative TAP block reduces opioid consumption and pain scores after abdominal surgery when compared with no intervention or placebo. There is no apparent reduction in postoperative nausea and vomiting or sedation from the small numbers of studies to date. Many relevant studies are currently underway or awaiting publication.