Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series

Abstract

Purpose The role of routine transversus abdominis plane (TAP) blocks at the time of surgery for Cesarean delivery analgesia is uncertain. Previous studies have shown no additional analgesic benefit in patients receiving intrathecal morphine. We present a series of three cases where TAP blocks were used for rescue analgesia in patients who had severe post-Cesarean delivery pain after a standard spinal anesthetic containing bupivacaine 12 mg, fentanyl 10 lg, and morphine 200 lg. Clinical features All three women experienced severe incisional pain in the postanesthetic care unit (PACU) after offset of spinal anesthesia. When the pain did not subside with intravenous opioids, the women were offered either additional intravenous opioids or a TAP block. They chose the latter. Bilateral TAP blocks were performed in a sterile posterior approach under ultrasound guidance with 0.375% ropivacaine 20 mL with epinephrine 1:400,000. All three patients experienced significant pain relief that lasted 10-19 hr and allowed for a timely discharge from the PACU. Conclusion These cases show that TAP blocks may play a valuable role as a rescue analgesic technique rather than as a routine preemptive block for all Cesarean delivery patients. Use of TAP blocks reduced the need for escalating intravenous opioid doses and potential maternal opioid-related side effects. Rescue TAP blocks should be considered after Cesarean delivery when intrathecal morphine does not provide adequate pain relief or for early breakthrough pain after offset of spinal anesthesia. RésuméObjectif Le rôle du bloc dans le plan du muscle transverse de l'abdomen (transversus abdominis plane block -TAP block) de routine pour l'analge´sie au moment de la chirurgie pour un accouchement par ce´sarienne est incertain. Les e´tudes pre´ce´dentes n'ont de´montre´aucun avantage analge´sique supple´mentaire chez les patientes recevant de la morphine intrathe´cale. Nous pre´sentons une se´rie de trois cas dans lesquels des TAP blocks ont e´te´utilise´s pour une analge´sie de secours chez des patientes qui souffraient de fortes douleurs apre`s un accouchement par ce´sarienne, pour lequel elles avaient reçu un anesthe´sique rachidien standard contenant de la bupivacaı¨ne 12 mg, du fentanyl 10 lg et de la morphine 200 lg. É léments cliniques Les trois femmes ont souffert de fortes douleurs au site d'incision en salle de re´veil, une fois l'effet de la rachianesthe´sie passe´. Lorsque la douleur ne s'est pas amenuise´e avec des opioı¨des intraveineux, on a propose´aux patientes des opioı¨des intraveineux supple´mentaires ou des TAP blocks, qu'elles ont choisi. Des TAP blocks bilate´raux ont e´te´re´alise´s par une approche poste´rieure ste´rile sous e´choguidage avec 20 mL de ropivacaı¨ne 0,375 % et 1:400 000 d'e´pine´phrine. Les trois patientes ont ressenti un soulagement important de la douleur d'une dure´e 10-19 h, ce qui a permis un conge´opportun de la salle de re´veil. Conclusion Ces cas de´montrent que les TAP blocks pourraient jouer un rôle pre´cieux en tant que te...

Essentials of Our Current Understanding

“…This was illustrated by a case series of TAP blocks administered for severe incisional pain after resolution of the spinal block following cesarean delivery. 258 The blocks provided excellent pain relief for 10 to 19 hours and prevented further escalation in IV opioid requirements. Isolated case reports have also described the successful application of TAP blocks for intractable incisional neuropathic pain 259 and pain from an abdominal wall hematoma 260 following cesarean delivery, as well as abdominal wall pain during pregnancy.…”

Appendectomy Pain Control by Transversus Abdominis Plane (TAP) Block in Children

“…This study also revealed that there were few studies about the use of TAP block for pain relief after surgery (24). Several new studies have reported that TAP block is a safe and effective method for anesthesia in various surgeries such as cholecystectomy, laparoscopic inguinal surgery, and cesarean section; however, in order to obtain more definitive results, further investigation is needed in this area of research (11, 25). Finally, there is controversy in this field because of the complexity of the relationship between pain and analgesia induced by the TAP block.…”

Transversus Abdominis Plane Block

“…The TAP block may also have a role to play to play in rescue analgesia post-abdominal surgery as described by Carvalho et al [34], who utilized the TAP block to manage suboptimal analgesia post-Caesarean section. Also, the TAP block is increasingly being used for analgesia outside the original scope of the block, as recently described by Gebhardt and Wu [35], who utilized the TAP block to treat abdominal wall cancer pain, and Singh et al [36], who used bilateral TAP blocks in addition to noninvasive positive pressure ventilation in the management of a patient with impending respiratory failure resulting from excessive pain following emergency laparotomy.…”