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ORIGINAL ARTICLE
Year : 2009  |  Volume : 3  |  Issue : 1  |  Page : 2-6

Preliminary experience with transversus abdominis plane block for postoperative pain relief in infants and children


Department of Anesthesiology, Chief, Division of Pediatric Anesthesiology, Russell and Mary Shelden Chair in Pediatric Intensive Care Medicine; Professor of Anesthesiology and Child Health, University of Missouri, Department of Anesthesiology, 3W-27G HSC, One Hospital Drive, Columbia, Missouri 65212.

Correspondence Address:
Joseph D Tobias
Department of Anesthesiology, Chief, Division of Pediatric Anesthesiology, Russell and Mary Shelden Chair in Pediatric Intensive Care Medicine; Professor of Anesthesiology and Child Health, University of Missouri, Department of Anesthesiology, 3W-27G HSC, One Hospital Drive, Columbia, Missouri 65212.

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.51827

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Date of Web Publication18-Jul-2009
 

   Abstract 

Background. In the adult population, analgesia following lower abdominal surgery and laparoscopic procedures can be provided by a transversus abdominis plane (TAP) block where local anesthetic is placed between the internal oblique and the tranversus abdominis muscles using an injection in the triangle of Petit. We present preliminary experience with the postoperative analgesic efficacy of TAP block in pediatric patients.
Patients and Methods. Ten pediatric patients, ranging in age from 10 months to 8 years were reviewed. Using ultrasound guidance, a TAP block was placed on both sides with 0.3 mL/kg of 0.25% bupivacaine with epinephrine 1:200,000 after the completion of the surgical procedure. The surgical procedures included ureteral reimplantation (n=3), colostomy takedown (n=2), pelvic laparoscopy for evaluation of abdominal pain (n=2), laparoscopic appendectomy (n=2), and bilateral inguinal hernia repair (n=1).
Results. In 8 of 10 patients, the TAP block was judged to be successful as no postoperative analgesic agents were required for the initial 7-11 postoperative hours. Four patients required no intravenous opioids postoperatively and were treated with oral opioids as outpatients. The other 4 patients required 0.15 ± 0.04 mg/kg of morphine during the first 24 postoperative hours. The TAP block was judged to be unsuccessful in 2 patients who required intravenous opioids during their immediate postoperative course, starting at 2 and 3 hours postoperatively. These two patients required 0.3-0.4 mg/kg of morphine during the first 24 postoperative hours. No adverse effects related to TAP block were identified.
Conclusion. Our preliminary experience suggests that TAP block provides effective analgesia following umbilical and lower abdominal surgery in infants and children.

Keywords: Pediatric analgesia; TAP block


How to cite this article:
Tobias JD. Preliminary experience with transversus abdominis plane block for postoperative pain relief in infants and children. Saudi J Anaesth 2009;3:2-6

How to cite this URL:
Tobias JD. Preliminary experience with transversus abdominis plane block for postoperative pain relief in infants and children. Saudi J Anaesth [serial online] 2009 [cited 2020 Jul 13];3:2-6. Available from: http://www.saudija.org/text.asp?2009/3/1/2/51827


   Introduction Top


Various regional anesthetic techniques have been used to provide postoperative analgesia in infants and children. Although caudal epidural blockade remains the most commonly employed regional block in the pediatric-aged patient, there is a trend toward the use of peripheral nerve blockade when applicable given the lower incidence of adverse effects when compared with neuraxial techniques. [1] Furthermore, there may be specific anatomic variations or abnormalities which preclude the use of caudal epidural blockade. In the adult population, it has been demonstrated that analgesia following lower abdominal surgery and laparoscopic procedures can be provided by a transversus abdominis plane (TAP) block where local anesthetic is placed between the internal oblique and the transversus abdominis muscles using a injection in the triangle of Petit. [2],[3],[4],[5] To date, there are limited reports regarding the use of TAP block in infants and children. We present preliminary experience with the postoperative analgesic efficacy of TAP in pediatric patients. The anatomic rationale of the TAP block is discussed and previous reports of its use in infants and children reviewed.


   Patients and Methods Top


Review of the patients' medicals records and presentation of this case series was approved by the Institutional Review Board of the University of Missouri. We retrospectively reviewed the perioperative course of infants and children who received a transversus abdominis plane (TAP) block for postoperative analgesia. The following demographic data were obtained: age, weight, gender, surgical procedure, and co-morbid diseases or anatomical issues which precluded the use of caudal epidural blockade. Information regarding the TAP block included the type and dose of local anesthetic administered. Prior to anesthetic emergence, a TAP block was placed using ultrasound guidance. The ultrasound probe was placed in the axial plane immediately cephalad to the iliac crest. A 22 or 24 gauge, 1 or 2 inch insulated block needle was inserted using an in­plane approach with the ultrasound until it was demonstrated that the needle was in the plane between the transverses abdominis and the internal oblique muscle. At that point, 0.3 mL/kg of 0.25% bupivacaine with epinephrine 1:200,000 was injected. The same procedure was repeated on the opposite side for all patients [Figure 1]. The efficacy of TAP block was evaluated by assessing postoperative pain scores, the time to the first administration of opioid analgesic agents, and opioid use during the initial 24 postoperative hours. Postoperative pain was assessed using an observational pain scale (FLACC score) which assigns a score of 0-2 for 5 categories (face, legs, activity, cry, and consolability) thereby resulting in a score ranging from 0 = no pain to 10 = severe pain. Supplemental analgesia was provided for pain scores ≥ 3.


   Results Top


The study cohort included 10 patients, ranging in age from 10 months to 8 years and in weight from 7.2 to 42 kilograms [Table 1]. Anesthetic induction included either an inhalation induction with an increasing concentration of sevoflurane in a mixture of oxygen and nitrous oxide or intravenous induction with propofol (3 mg/kg). Maintenance anesthesia included either desflurane or sevoflurane with fentanyl (3-5 µg/kg). Ketorolac (0.5 mg/kg) was administered at the completion of the surgical procedure.

The surgical procedure included ureteral reimplantation (n=3), colostomy takedown (n=2), pelvic laparoscopy for evaluation of abdominal pain (n=2), laparoscopic appendectomy (n=2), and bilateral inguinal hernia repair (n=1). In 8 of 10 patients, the TAP block was judged to be successful as no postoperative analgesic agents were required for the initial 7-11 postoperative hours (median time of 10 hours). Four patients required no intravenous opioids postoperatively and were treated with oral opioids as outpatients. The other 4 patients received 1 or 2 doses of intravenous morphine during the first 24 postoperative hours (0.15 ± 0.04 mg/kg during the first 24 postoperative hours). In 3 patients, emergence delirium was treated with dexmedetomidine (0.3 µg/kg) in the post anesthesia care unit. The TAP block was judged to be unsuccessful in 2 patients who required intravenous opioids during their immediate postoperative course, starting at 2 and 3 hours postoperatively. These two patients required 0.3-0.4 mg/kg of morphine during the first 24 postoperative hours. No adverse effects related to TAP block were identified.


   Discussion Top


The lateral abdominal wall contains three muscle layers including the external oblique, the internal oblique, and the transversus abdominis muscles and their associated fascial sheaths. The lower thoracic and upper lumbar nerves provide sensory innervation of the skin, muscles, and parietal peritoneum of the anterior abdominal wall. These nerves course in a plane between the transversus abdominis and internal oblique muscles. Given the anatomic localization of these nerves, McDonnell et al. described a unique approach which allows for blockade of these nerves with the administration of local anesthetic agents in the plane between the transversus abdominis and internal oblique muscles with a single injection administered in the triangle of Petit. [2],[3],[4],[5] The triangle of Petit is bounded posteriorly by the latissimus dorsi muscle, anteriorly by the external oblique muscle, and inferiorly by the iliac crest. In clinical practice, the TAP block is placed by using an ultrasound-guided technique with the ultrasound probe placed in the axial plane just above the iliac crest. A needle is inserted in line with the probe so that it can be demonstrated that the needle lies in the correct fascial plane prior to injection of the local anesthetic solution. The potential utility of the TAP block has been demonstrated by McDonnell et al. in a cadaveric and radiological evaluation. [3] Using a double pop or loss of resistance technique with a blunt block needle in a cadaver model, the authors demonstrated that methylene blue dye could be injected between the transversus abdominis and internal oblique muscles. The correct anatomic location of the dye was demonstrated by dissection of the cadaver specimens. This was followed by the demonstration of radiopaque dye in the correct fascial plane using computed tomography and magnetic resonance imagine in 3 healthy, adult volunteers.

In the adult population, the TAP block has been shown to provide effective analgesia following various types of lower abdominal procedures including retropubic prostatectomy, Cesarean section, and total abdominal hysterectomy. [2] ,[4],[5],[6] In a prospective randomized trial of 50 adults following Cesarean delivery, TAP block with 0.2 mL/kg of 0.75% ropivacaine on each side, resulted in decreased postoperative pain scores, delayed request for postoperative analgesia, and decreased morphine use during the initial 48 postoperative hours. [5] The median time to first request for postoperative analgesia was 90 minutes in the control group and 220 minutes in patients who received a TAP block. Morphine use during the initial 48 hour postoperative period was decreased by 70% in patients who received a TAP block (66 ± 26 mg in control patients versus 18 ± 14 mg in patients who received a TAP block, p<0.001). The same investigators evaluated the efficacy of the TAP block following total abdominal hysterectomy in 50 women. [5] After anesthetic induction and prior to surgical incision, a bilateral TAP block was placed using 0.2 mL/kg of 0.75% ropivacaine on each side. Patients who received a TAP block had decreased postoperative pain scores, delayed request for postoperative analgesia, and decreased morphine use during the initial 48 postoperative hours.

In our preliminary experience, TAP block provided effective analgesia following various surgical procedures involving the umbilicus and lower abdomen in our cohort of patients who ranged in age from 10 months to 8 years. Effective postoperative analgesia was achieved in 8 of the 10 patients with the first request for postoperative analgesia varying from 7 to 11 hours. Four of the patients received only oral analgesic agents while the other 4 patients received intravenous morphine (average total dose of 0.15 mg/kg during the initial 24 hour postoperative period). Of note, the efficacy of the TAP block was less than adequate in two of the patients undergoing ureteral reimplantation. Given the limited number of patients in our cohort, we can make no definitive statement regarding use of the TAP block in this patient population, but it would appear that the severity of pain should be similar to lower abdominal procedures such as Cesarean section or abdominal hysterectomy which has been adequately controlled with TAP block in the adult population. [5] ,[6]

To date, there are limited data regarding the use of TAP block in infants and children. [7],[8],[9] Mukhtar and Singh reported the successful use of TAP block to provide analgesia following laparoscopic appendectomy in 4 patients who ranged in age from 14 to 17 years. A bilateral TAP block was placed using 20 mL of 0.25% bupivacaine per side with ultrasound guidance. No patient required supplemental analgesic agents for the initial 12 postoperative hours with pain scores ranging from 0 to 2. Two patients required no analgesic agents during their postoperative course. Unilateral TAP block has also been shown to provide effective analgesia for inguinal hernia repair in a cohort of 8 children. [8] Intraoperative supplementation with fentanyl (0.5 µg/kg) was required in 3 of the patients during manipulation of the spermatic cord while one patient was given intravenous morphine to treat emergence agitation. All of the patients maintained pain scores of 0-2 during their postoperative course. Anecdotal success has also been reported with the use of a TAP block in a 3.6 kg infant with VACTERL syndrome undergoing colostomy placement on day of life 2. [9] The author chose TAP block as caudal epidural blockade could not be placed due to associated vertebral anomalies.

We found that the TAP block provided effective analgesia following various umbilical and lower abdominal procedures in infants and children. When compared with the usual practice of caudal epidural analgesia, the TAP block offers the advantage of being feasible even in patients with vertebral anomalies such as VACTERL syndrome as was present in two of our patients. The block may also be preferred over caudal epidural analgesia in older pediatric patients who weigh more than 20-25 kg and as the block does not involve needle placement near the neuraxial space or peripheral motor nerves, even in the adult population, the block has been performed following the induction of general anesthesia. Use of a TAP block has also been reported in a patient with an intracranial lesion which would preclude the use of neuraxial blockade due to concerns of increasing intracranial pressure with epidural aneshtesia. [9] The limited data in the pediatric literature suggest the use of 0.2-0.3 mL/kg per side of either 0.25% bupivacaine or 0.2% ropivacaine. However, future studies are needed to determine the optimal dosing regimen. As with many other regional anesthetic techniques, the use of ultrasound guidance should be considered to ensure correct needle location and improve the accuracy of the technique. [11] As with any regional anesthetic technique in infants and children, the most likely serious adverse event is local anesthetic toxicity and attention to volume and concentration is suggested with limitation of the total dose of bupivacaine or ropivacaine to less than 3 mg/kg. The only other adverse event reported in the literature is a single case of inadvertent trauma to the liver with the blunt regional needle. [12]

 
   References Top

1.Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: A 1-year prospective survey of the French Language Society of Pediatric Anesthesiologists. Anesth Analg 1996;83:904-912.  Back to cited text no. 1    
2.O'Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med 2006;31:91.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.McDonnell JG, O'Donnell BD, Farrell T, et al. Transversus abdominis plane block: A cadaveric and radiological evaluation. Reg Anesth Pain Med 2007;32:399-404.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.McDonnell JG, O'Donnell BD, Curley G, et al. Analgesic efficacy of transversus abdominis plane block (TAP) after abdominal surgery: a prospective, randomized controlled trial. Anesth Analg 2007;104;193-197.  Back to cited text no. 4    
5.McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after Cesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186-191.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Carney J, McDonnell JG, Ochana A, et al. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008;107:2056-2060.  Back to cited text no. 6    
7.Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesth 2008;102:143-144.  Back to cited text no. 7    
8.Frederickson M, Seal P, Houghton J. Early experience with the transverses abdominis plane block in children. Pediatr Anesth 2008;18:891-892.  Back to cited text no. 8    
9.Hardy CA. Transversus abdominis plane block in neonates: is it a good alternative to caudal anesthesia for postoperative analgesia following abdominal surgery? Pediatr Anesth 2008;19:56.  Back to cited text no. 9    
10.French JLH, McCullough J, Bachra P, Bedforth NM. Transversus abdominis plane block for analgesia after cesarean section in a patient with an intracranial lesion. Int J Obstet Anes 2009;18:52-54.  Back to cited text no. 10    
11.Tran TMN, Ivanusic JJ, Hebbard P, Barrington MJ. Determination of spread of injectate after ultrasound-guided transverses abdominis plane block: A cadaveric study. Br J Anaesth 2009;102:123-127.  Back to cited text no. 11    
12.Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transverses abdominis plane block. Reg Anesth Pain Med 2008;33:274­275.  Back to cited text no. 12  [PUBMED]  


    Figures

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    Tables

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