The analgesic effects of intrathecal morphine in comparison with ultrasound‐guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital

Abstract

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, sideeffects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

Transversus Abdominis Plane Block versus Wound Infiltration with Conventional Local Anesthetics in Adult Patients Underwent Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

“…The neglected reason for the short duration of action of WI may be that WI could result in rapid drug absorption because the local anesthetics were not injected into the space between the muscles that contains abundant nerve branches [27] but rather into the muscular tissue, which is rich in blood capillaries and can accelerate drug absorption. However, in TAP block, local anesthetics are injected into the space between the transversus abdominis and internal oblique muscles [3], where thoracolumbar nerves run from the T6 to L1 spinal roots, which control the sense of the whole anterolateral abdominal wall [27], making the block more efficient.…”

“…2 Some data were collected from charts by a measurement tool or converted by a formula. 3 More than 200 patients were enrolled. 4 One study did not mention the randomization method, and one study did not mention how the blindness method was implemented.…”

“…Postoperative severe pain in patients comes mainly from the surgical incision, and visceral tissue damage is a common postoperative problem [1]. Transversus abdominis plane (TAP) block has gradually become an alternative postoperative analgesia technology since Rafi formally described it in 2001 [2], and it has resulted in effective pain relief in operations in which incisions are made in the abdomen [3][4][5][6]. However, traditional local anesthetic wound infiltration (WI) by injecting local anesthetics into the incision, favored by surgeons for its convenience, is still the major method used for postoperative analgesia in many areas.…”

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists

“…[ 28 ] A recent study showed that TAP block provided clinically similar outcomes (including numerical pain rating scores, the need for rescue medication, side effects, and patient satisfaction) as intra-thecal morphine (100 μg) after CD. [ 52 ] The quadratus lumborum block after CD was also effective for post-operative pain control as a part of a multi-modal approach. [ 53 ] But note that these techniques are performed when neuraxial morphine cannot be given, or as a rescue technique for breakthrough post-operative pain.…”

Anaesthetic research in low‐ and middle‐income countries

“…In this issue of Anaesthesia , Kwikiriza et al report a randomised controlled trial comparing the analgesic effects of intrathecal morphine with ultrasound‐guided transversus abdominis plane block after caesarean section at a Ugandan Regional Referral Hospital. The publication of this study, authored by an international team, represents an important example of the role of academic anaesthesia in global health.…”