Comparison of Transversus Abdominis Plane Block Versus Spinal Morphine for Pain Relief after Cesarean Section

Abstract

The abstract does not do justice to the facts of the article. Yes, although the difference in the CI was approximately 8% higher in the lateral position than in the sitting position (statistically significant), BWe found no difference in healthy fetal blood flow indices among positions, suggesting these changes are not clinically significant.[ Statistical significance does not indicate clinical significance. The results of this study confirm to me that the sitting position for spinal or epidural placement in the obese parturient is the position of choice. I would have found it interesting had the investigators randomly assigned patients to either the lateral or sitting position for block placement and then compared the time in the positions to initiate the block and to obtain surgical anesthesia.I note that the supine position with 15-degree left lateral tilt had the lowest CI of the 4 positions, but again with no impairment in FHR, umbilical artery pulsatility, and resistivity indexes. This is a great relief to me. Now I do not have to Beat crow[ from the obstetricians whom I continually berate to maintain the supine position with 15-degree left lateral tilt until the baby is born. Even better, based on the results, I would not have to insist that the mother must be in the full lateral position until the baby is born by cesarean delivery. It would be excruciatingly difficult to convince obstetricians of the need for this! T ransversus abdominis plane (TAP) block is a regional technique used to block T6-L1 nerve branches and is increasingly used for postoperative analgesia after surgery on the lower abdomen. It has the potential to be an alternative to spinal opioid for analgesia after cesarean section. However, few data have been published on its comparative efficacy. This prospective, randomized, double-blinded, placebo-controlled trial compared the efficacy of the TAP block with and without spinal morphine after cesarean section in 80 women.Patients received a standard spinal anesthetic of 11 to 12.5 mg hyperbaric bupivacaine with 10 Hg fentanyl and then were randomized to 1 of 4 groups to a combination of spinal morphine or saline with TAP block containing local anesthetic or saline: S m T s , S m Tla, S s Tla, or S s T s , with 20 patients in each group. Patients also received 100 Hg spinal morphine or an equivalent volume (0.1 mL of saline. The bilateral TAP blockade was performed with bupivacaine 2 mg/kg, based on her weight when the patient first appeared at the hospital. All patients had standard monitoring and received rectal paracetamol and diclofenac immediately after surgery. All had standard postoperative analgesia with oral paracetamol, rectal diclofenac, and morphine via patient-controlled analgesia. The primary outcome was pain on movement; secondary outcomes were pain at rest, morphine consumption, proportion of patients who had adequate analgesia, satisfaction, sedation, nausea, and pruritus. Patients were evaluated at 6, 12, 24, 36, and 48 hours after TAP block.All patients completed the study...

Clinical effectiveness of transversus abdominis plane (TAP) blocks for pain relief after caesarean section: a meta-analysis

“…31 . Three trials compared ITM and placebo TAP block against an intrathecal placebo and TAP block 22,24,25 , and five compared ITM together with TAP block against ITM and placebo TAP block. 22,[26][27][28]32 The trial by McMorrow et al undertook all three comparisons.…”

“…Three trials compared ITM and placebo TAP block against an intrathecal placebo and TAP block 22,24,25 , and five compared ITM together with TAP block against ITM and placebo TAP block. 22,[26][27][28]32 The trial by McMorrow et al undertook all three comparisons. Trials, such as Puddy et al, reporting comparisons with intrathecal diamorphine were excluded from the meta-analysis since the analgesic profile of intrathecal diamorphine is substantially different to ITM, particularly in duration of action and side effects.…”

“…14-17, 21, 23-28, 30-32 and four trials used the anatomical landmark technique 18,20,22,29 whilst in the final study, the approach was unclear. 19 Bupivacaine was the local anaesthetic of choice in eight trials 14,16,18,22,24,32,29,31 whilst eight trials used Ropivacaine 15, 20,21,[25][26][27][28]30 , three others used Levobupivacaine. 17,19,23 Seventeen trials performed CS under spinal anaesthesia 14-17, 19-22, 24-32 , while general anaesthesia was used in two trials.…”

“…The majority of trials provided a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, the latter administered either orally or via patient controlled analgesia (PCA). 15,20,22,[24][25][26][27][28]32 Three studies solely used morphine PCA 14,17,23 , one used a combination of NSAIDs and intravenous opioids 18 . Paracetamol and ketoroloc were administered by Hoydonckx et al 19 McKeen et al prescribed women paracetamol, naproxen and oxycodone 21 analgesia in the form of paracetamol and diclofenac 31 , while the study by Bollag et al used paracetamol, diclofenac, intravenous morphine and for breakthrough pain, oral tramadol.…”

“…Where the primary outcome was explicitly stated by the included trials, the most frequently employed was morphine consumption (or equivalent), being specified by eight trials. 14,15,17,20,23,25,29,30 Other commonly measured outcomes included, pain scores at rest 18, 31 , pain on movement 22,[26][27][28]31 , wound hyperalgesia 16 and time to first analgesic request 24 Figure 2 depicts the quality of the trials included in this review (a more detailed breakdown is given in table 1). The majority of trial reports provided adequate information to assess quality criteria.…”