|Year : 2013 | Volume
| Issue : 1 | Page : 32-35
The analgesic effect of a perioperative continuous transversus abdominis plane block in renal transplanted patients
Ahmed A Badawy, Amira Refaie, Inas Samir
Department of Anesthesia, Cairo University, Cairo, Egypt
|Date of Submission||19-Jan-2013|
|Date of Acceptance||16-Mar-2013|
|Date of Web Publication||26-Jun-2014|
Ahmed A Badawy
MD, Department of Anesthesia, Cairo University, 1007 Cournich Al Nile, Cairo
Source of Support: None, Conflict of Interest: None
To investigate the analgesia of a continuous transversus abdominis plane (TAP) block over the first 24 postoperative hours in renal transplanted patients.
Patients and methods
This prospective randomized study included 40 adult patients scheduled for living-related kidney transplantation. They were randomized into two equal groups: group I underwent a ultrasound-guided continuous TAP block with 20 ml bupivacaine 0.5% bolus, followed by a continuous infusion of 10 ml/h of bupivacaine (0.25%) for 24 h and group II received the same block with the same volume and infusion rate as isotonic saline. Pain at rest and on sitting, sedation, and nausea and vomiting were assessed at 2, 6, 12, and 24 h postoperatively. The total intraoperative analgesic requirement, time for the first request for analgesia, and total postoperative meperidine over 24 h were assessed.
Postoperative Visual Analogue Scale scores at rest were significantly lower in the Bupivacaine group between 2 and 12 h postoperatively and Visual Analogue Scale scores on movement were significantly lower in the Bupivacaine group at 2, 6, 12, and 24 h postoperatively. Postoperative sedation scores were significantly higher in the Control group at 4 and 6 h. The total meperidine requirement was significantly higher in the Control group (161±31 mg) compared with the Bupivacaine group (57±30 mg) (P<0.001). There was no significant effect of TAP on postoperative nausea.
TAP block appears to be a good alternative for postoperative analgesia following living-related kidney transplantation. It reduced pain scores and opioid consumption in the first 24 h.
Keywords: analgesic effect, renal transplant, transverses abdominis plane block
|How to cite this article:|
Badawy AA, Refaie A, Samir I. The analgesic effect of a perioperative continuous transversus abdominis plane block in renal transplanted patients. Egypt J Cardiothorac Anesth 2013;7:32-5
|How to cite this URL:|
Badawy AA, Refaie A, Samir I. The analgesic effect of a perioperative continuous transversus abdominis plane block in renal transplanted patients. Egypt J Cardiothorac Anesth [serial online] 2013 [cited 2020 Feb 26];7:32-5. Available from: http://www.ejca.eg.net/text.asp?2013/7/1/32/135460
| Introduction|| |
Renal transplantation has become the best therapeutic option for end-stage renal disease 1. The 5-year survival rate is ∼70% compared with 30% for a similar group of patients undergoing dialysis 2.
Postoperative pain management following renal transplantation is a concern because of the underlying comorbidities and the variable responses of the graft. Improper pain control may lead to agitation, hypertension, tachycardia, and increased risk of respiratory complications 3,4.
Systemic analgesia is an option following renal transplantation. However, it may not be a good option in case of impaired graft function. Epidural analgesia, in contrast, is risky in patients on dialysis because of platelet dysfunction and the residual heparin used during dialysis 4–6.
Postoperative analgesia with opioids may result in significant adverse effects, including sedation, nausea, and vomiting 1–3. Multimodal postoperative analgesia reduces the requirement for opioids and usually incorporates blockade of the abdominal wall, with wound infiltration, and ilioinguinal blockade 2,3.
The abdominal wall consists of three layers of muscles: the external oblique, the internal oblique, the transversus abdominis, and their fascial sheaths. The central part of the abdominal wall includes the rectus abdominis muscles and its fascial sheath. The abdominal wall is innervated by nerves that course through the transversus abdominis plane (TAP) between the internal oblique and the transverse abdominis muscles 2. TAP block is a relatively new technique involving the injection of a local anesthetic into the plane between the internal oblique and the transversus abdominis muscles.
TAP block has been shown to be effective in improving postoperative pain and reducing morphine consumption in several clinical settings, including cesarean delivery, prostatectomy, appendectomy, hysterectomy, and in patients after colonic resection 6. Ultrasound-guided TAP block has been described in children undergoing inguinal hernia repair and in adult patients undergoing appendectomy 7,8.
This study was designed to investigate the effect of an ultrasound-guided continuous TAP block on the perioperative hemodynamics and pain scores in the first 24 h in live-donor kidney transplanted recipients.
| Patients and methods|| |
After obtaining approval by the Hospital Ethics Committee and obtaining written informed consents, 40 adult patients with end-stage renal disease scheduled for living-related renal transplantation were enrolled in this prospective randomized blind study. Patients were excluded if they have BMI above 35 kg/m2, a history of relevant drug allergy, infection at the site of the block, coagulation disorder (patients were excluded if their platelet count was <100 000/cc or INR was >1.4), and opioid tolerance.
Patients were allocated randomly to one of two parallel groups using the sealed envelope technique. Patients in group I (Bupivaciane group, n=20) underwent an ultrasound-guided perioperative continuous TAP block with 20 ml bupivacaine 0.5% bolus, followed by a continuous infusion of 10 ml/h of bupivacaine 0.25% (continued in the post-transplant care unit for 24 h). Patients in group II (Control group, n=20) underwent the same block with isotonic saline 0.9% with the same volume and infusion rate as in group I.
Standard monitoring for continuous noninvasive arterial blood pressure, heart rate, ECG, Oxygen saturation (SpO2), and end-tidal CO2 was applied to all patients (Viralert 2000, Drager, USA).
All patients received standardized general anesthesia. Induction of anesthesia was with intravenous fentanyl (1–2 μg/kg) and propofol (2 mg/kg). Endotracheal intubation was facilitated with atracurium (0.5 mg/kg) and anesthesia was maintained by sevoflurane and 50% O2 in air. Fentanyl bolus doses (1–2 μg/kg) were adjusted to maintain the heart rate within 20% of the preinduction values. Continuous atracurium infusion was started 20 min after induction (0.5 mg/kg/h).
Invasive arterial blood pressure measured through a radial artery catheter was maintained above 140/80 mmHg and central venous pressure measured through an internal jugular vein catheter was maintained at 15–18 mmHg to maintain adequate renal perfusion.
After induction of anesthesia, stabilizing the patient’s hemodynamics, and before surgical incision, TAP block on the same side of the surgical incision was performed. With the patient in the supine position after proper antiseptic precautions, a linear ultrasound probe (Sonosite, Bothell, Washington, USA) was placed transversely on the anterolateral abdominal wall midway between the iliac crest and the costal margin. After identification of the three muscle layers, external oblique, internal oblique, and transversus abdominis, a Toughy18-G, 90-mm needle (Medizintechnik, Geisingen, Germany) was introduced through the skin anteriorly in the same plane of the ultrasound beam and advanced into the fascial plane between the internal oblique and the transversus abdominis muscles. Three milliliters of the local anesthetic solution (or isotonic saline in group II) was injected through a syringe and attached to the needle in order to confirm the correct needle placement within the fascial plane by visualizing the spread of the injected solution and then the syringe was disconnected from the needle and a catheter was inserted under ultrasound vision and advanced for 3 cm beyond the tip of the needle, which was then removed, and the catheter was fixed to the skin with sterile adhesive tape.
Paracetamol (1 gm) was infused over the last 15 min of the procedure before conclusion of anesthesia for all patients of both groups. At the end of surgery, atracurium infusion was stopped and neuromuscular blockade was reversed with neostigmine (0.04 mg/kg) and atropine (0.01 mg/kg).
After tracheal extubation, patients were transferred to the post-transplant care unit, where the pain at rest and during movement, sedation as well as nausea and vomiting were assessed at 2, 6, 12, and 24 h postoperatively. Pain severity was assessed using the Visual Analogue Scale (VAS), where 0=no pain and 10=worst pain. Sedation was assessed at the same time interval as VAS using a four-point scale (1=fully awake; 2=somnolent, responds to verbal stimuli; 3=somnolent, responds to tactile stimuli; and 4=somnolent, responds to painful stimuli). Nausea was measured using a categorical scoring system (none=0, mild=1, moderate=2, and severe=3). Ondansetron (4 mg intravenously) was prescribed for patients who complained of nausea or vomiting.
The total intraoperative fentanyl requirement, time to the first request for analgesia, and the total postoperative meperidine dose over 24 h were all calculated. A standard postoperative analgesia regimen was prescribed for all patients in both groups as paracetamol (1 gm/6 h intravenously) infusion and meperidine (50 mg) if the VAS was at least 3 or as save our souls between the assessment intervals.
Data were analyzed using IBM SPSS Advanced Statistics, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Numerical data were expressed as mean and SD or median and range as appropriate. The &khgr;2-test (Fisher’s exact test) was used to examine the relation between qualitative variables. For quantitative data, comparison between two groups was carried out using the Mann–Whitney U-test. A P value less than 0.05 was considered significant.
| Results|| |
There was no significant difference between the two study groups in patients’ characteristics and operative data. Intraoperative fentanyl requirements were statistically significantly lower in the Bupivacaine group (P<0.01; [Table 1].
|Table 1: Patients’ characteristics and operative data in the study groups (mean±SD)|
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VASs for postoperative pain (at rest) showed significantly lower values in the Bupivacaine group compared with the Control group when assessed at 2, 6, and 12 h, but not at 24 h postoperatively [Table 2]. VASs for postoperative pain (on movement) showed statistically significantly lower values in the Bupivacaine group compared with the Control group when assessed at 2, 6, 12, and 24 h postoperatively [Table 3].
|Table 2: Postoperative Visual Analogue Scale at rest at different time points of the study (median and range)|
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|Table 3: Postoperative Visual Analogue Scale during movement at different time points of the study (median and range)|
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Postoperative sedation scores were significantly higher at 4 and 6 h in the Control group compared with the Bupivacaine group, but not at 2, 12, and 24 h postoperatively [Table 4].
|Table 4: Postoperative sedation score for patients at different time points of the study (median and range)|
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Time to the first request for analgesia was significantly shorter in the Control group (3.7±0.8 h) compared with the Bupivacaine group (6.2±1.3 h) (P<0.001). The total postoperative 24 h meperidine requirement was significantly higher in the Control group (161±31 mg) compared with the Bupivacaine group (57±30 mg) (P<0.001; [Table 5].
|Table 5: Time for first request for analgesia and total postoperative 24 h meperidine requirements postoperatively in the studied groups|
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There was no significant difference between the two groups studied in the postoperative nausea at different time points of the study.
| Discussion|| |
The results of this study show that TAP block is effective in producing a good postoperative analgesic effect following living-related kidney transplantation. TAP block significantly reduces pain at rest and on movement and prolonged time to the first request for analgesia (P<0.001) and reduced total meperidine requirement during the first postoperative 24 h. Patients were well sedated, with no significant increase in the occurrence or postoperative nausea and vomiting.
The postoperative period after renal transplantation is crucial for a successful outcome. Fluid management and pain management are important in the postoperative period and nausea and vomiting are challenging complications. Significant accumulation of potent metabolites might be a factor complicating postoperative analgesia. Management of postoperative pain may be accomplished by epidural analgesia or patient-controlled analgesia (PCA). PCA was reported to improve patient satisfaction after major surgery. It has a minor effect on cardiovascular or respiratory postoperative morbidity and on hospital stay 1.
A survey in UK reported that intravenous opioid administration was the main regimen utilized for analgesia following renal transplantation, mainly with morphine, with a minority using PCA fentanyl without apparent problems 2. Solonynko et al. 3 reported epidural analgesia to be effective and without significant complications in a limited series.
The use of epidural catheters in renal transplant patients who have the risks of tendency to coagulation – mainly platelet – dysfunction may develop epidural hematoma and also other complications, mainly cardiovascular disturbances and perioperative fluid shifts, leading to hypotension with hence reduced graft perfusion 2.
TAP block was attempted after laparoscopic cholecystectomy. It was found to exert a positive effect in reducing pain during coughing but not at rest and it reduced opioid requirements. However, the authors found the effect to be rather minor 4. TAP block was reported to be successful in reducing postoperative pain and opioid requirements after cesarean delivery 5, 6, 9, 10, abdominoplasty 11, open appendicectomy in adults 7 and children 8, total abdominal hysterectomy 12, and esthetic postbariatric abdominoplasty 13. However, it did not confer any additional benefit in women undergoing major gynecological cancer surgery 14.
Two recent systemic reviews reported the safety and efficiency of TAP block in different types of abdominal surgery. One review that included five studies comparing TAP block with saline placebo reported that TAP block led to significantly lower postoperative requirement for opioids at 24 h. Pain at rest was significantly reduced in some of the studies. TAP blocks had no impact on sedation scores or nausea and vomiting 15. Another systematic review of nine randomized-controlled trials evaluated the effectiveness of TAP block in abdominal surgery involving 413 patients. TAP block resulted in significant reduction of 24 h morphine utilization and incidence of postoperative nausea and vomiting 16. Similar results have been reported from a review of 14 studies 17.
TAP block seems to be a good alternative in cases of renal transplantation because of effective analgesia in addition to hemodynamic stability. TAP block with levobupivacaine was assessed in 65 adults undergoing renal transplantation in a randomized-controlled trial versus 0.9% saline. The authors reported no difference in morphine requirements or pain scores between the two groups. Nausea was reported in 53% of patients in the TAP group and 24% of patients in the Control group. Consequently, they did not recommend the use of TAP block in these cases 18.
| Conclusion|| |
We can conclude that TAP block appears to be a good alternative for postoperative analgesia following living-related kidney transplantation. It reduced pain scores and opioid consumption in the first 24 h. It did not have an apparent impact on postoperative nausea. To our knowledge, there are no studies that compare TAP block with other analgesic regimens. The results of the current study need to be confirmed by a larger series by comparison with other analgesic techniques.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]