Original Contribution
Ultrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial,☆☆,,★★

https://doi.org/10.1016/j.jclinane.2015.12.027Get rights and content

Highlights

  • We compared the analgesic efficacy of TAP block and wound infiltration.

  • TAP block is effective analgesic method in children with inguinal hernia surgery.

  • TAP block would be an important component of multimodal analgesia.

  • Important to formulate a volume, drug dose to avoid toxicity and achieve efficacy.

Abstract

Study Objective

To compare the analgesic efficacy of ultrasound-assisted transversus abdominis plane (TAP) block and wound infiltration during the first postoperative 24 hours.

Design

A prospective, observer-blinded, randomized, and controlled study

Setting

Operating room of a university hospital.

Patients

Forty patients received a TAP block (TAP group) and 40 patients received wound infiltration (INF group) at the end of the surgery.

Interventions

Patients were randomized to receive a TAP block or wound infiltration. Postoperative analgesics were administered on request and selected based on pain severity.

Measurements

Pain scores, analgesic drug requirement, and side effects were observed for 24 hours.

Main Results

Postoperative pain scores were lower in TAP group compared to INF group (P < .001). Analgesic consumption was significantly higher at the 5th minute and 1st, 6th, and 12th hours in the INF group (P < .001). The frequency of additional analgesic use in home and the total analgesic used during the postoperative 24 hours were significantly higher in INF group (P < .001). Side effects were lower in the TAP group. Parent's satisfaction scores were higher in TAP group.

Conclusion

Transversus abdominis plane block is effective method with convenient technique, drug dosage, and volume in pediatric patients undergoing inguinal hernia surgery.

Introduction

Inguinal hernia is one of the most common reasons of outpatient pediatric surgery with a rate of 3% and increases up to 10% in premature infants [1]. Effective and safe pain management causes fewer side effects and enables faster hospital discharge. It is also important in overcoming chronic pain in the late postoperative period [2]. The chronic pain which generally seen in postoperative hernia surgery is important problem. An inadequate pain management in early postoperative period and pain intensity may be the reasons of chronic pain. Different methods of analgesia may be used for the treatment of postoperative pain, but use of systemic analgesics may be responsible for the problems as increased rate of side effects and the unpredictable bioavailability of the oral drugs. Wound infiltration is common practice during inguinal area surgery.

Transversus abdominis plane (TAP) block which is one of the abdominal wall blocks is another alternative to reduce the pain. It was described by Rafi [3] in 2001 with blind technique in adult patients; the procedure provides analgesia blocking the anterior branches of the spinal nerves innerving anterior abdominal wall between thoracic 7 and 12 and lumbar 1 levels. Practice of TAP block with blind technique in pediatric patients is not safe because the fascias are weak in children and transition cannot be felt. First intervention with ultrasound in adult patients was practiced by Hebbard et al in 2007 and by Frederickson et al in 2008 in pediatrics [4], [5]. After 3 layers of muscles in anterolateral abdominal wall was visualized with the ultrasound, local anesthetic solution was injected to the neurofascial space between internal oblique and transversus abdominis muscles, and validation was achieved with observing separation of the 2 muscle layers. Hebbard et al [4] first described the technique where needle is inserted through the midaxillary line with medial approach; then they have also described subcostal approach technique. Suresh and Chan [6] described a technique in children where they suggested that, first, rectus muscle must be identified in the lateral of the umbilicus, and then by sliding the probe to the lateral, the TAP area (of the 3 muscles) can be seen easily.

Transversus abdominis plane block was started to be practiced in surgeries in various age groups even infants, but studies on its efficacy are few and the results are different in children [6], [7].

The aim of this study is to compare the analgesic efficacy of ultrasound-guided TAP block and wound infiltration during the first postoperative 24 hours.

Section snippets

Materials and methods

After getting ethical committee approval (83045809/18227) and parent consent, the prospective, observer-blinded clinical study was completed in the pediatric surgery operation theater of I.U. Cerrahpasa Medical School, Anesthesiology and Reanimation Department. Eighty-six American Society of Anesthesiologists (ASA) physical status I to II patients between 6 and 8 years old who planned to undergo unilateral inguinal surgery were included to the study. Patients with history of allergy,

Results

Eighty-six patients were included to the study; 6 of the patients were not eligible, and they were excluded from the study (Fig. 1). No significant difference was observed between groups in terms sex, age, weight, and ASA status (Table 1).

In TAP group, postoperative 5-minute and 1-, 2-, 3-, 6-, 12-, and 24-hour VAS scores were lower compared to INF group (P < .001; Fig. 2). In the pain evaluation, the number of patients with analgesic consumption was significantly higher at the 5th minute and

Discussion

In this study, we stated that Ultrasound (USG)-assisted TAP block delivers a better analgesia in the postoperative period in inguinal hernia surgery compared to wound infiltration.

Transversus abdominis plane block, which is an anterior abdominal wall compartment block, provides analgesia for parietal peritoneum, and its efficacy changes according to the location of the intervention. It was reported that subcostal approach for upper abdominal surgery and posterior approach for lower abdominal

Acknowledgments

The authors would like to thank the surgeons with whom they work together, for their cooperation in performing wound infiltration.

References (14)

There are more references available in the full text version of this article.

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  • Erector Spinae Plane Block vs Quadratus Lumborum Block for pediatric lower abdominal surgery: A double blinded, prospective, and randomized trial

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    Every technique has its own advantages and limitations. The TAP block has become popular due to its ease of application, and the QLB due to its superior analgesia [4,17]. The main problem with the TAP block is that different techniques have resulted in different analgesic outcomes [18].

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Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the ethics committee of Istanbul University Cerrahpasa Faculty of Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent: Informed consent was obtained from all individual participants included in the study.

Conflict of interest: The authors declare that they have no conflict of interest.

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Financial disclosure: The authors declared that this study has received no financial support.

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