Study of the analgesic efficacy Of transversus abdominis plane (TAP) block

in reducing post-operative pain and peri-operative requirement of fentanyl

in patients undergoing lower abdominal surgery using midline vertical incision:
Prospective, randomized double blind study

Dr. Sneha Pandit

P.D. HINDUJA HOSPITAL AND MRC Dr. Preeti Gupta
Dr. Manju Butani
 Introduction

• Abdominal surgeries tend to be

one of the most painful among
all types of surgeries
• Postoperative pain if treated
inadequately can cause
 shallow breathing
 atelectasis
 retention of secretions
 lack of co-operation during
physiotherapy
• This increases the incidence of post-operative morbidity, leads
to delayed recovery and prolongs hospital stay

• Good analgesia can reduce this deleterious effect and can

help to improve patient’s surgical outcome

• Patients with well controlled pain have improved quality of

health, use few resources and have overall greater satisfaction
• Pain following abdominal surgery has two components
incisional pain along the dermatomal supply and visceral
pain

• The nerves that supply the anterior abdominal wall [T6-L1]

course through the neurofascial plane between the internal
oblique and the transverses abdominis muscles

• By introducing local anaesthetic solution in this transverses

abdominis plane (TAP), it is possible to block the sensory
nerves of the anterior abdominal wall
• Multimodal analgesic techniques are recommended by the
latest ERAS guidelines which includes traditional drugs,
nerve block techniques and wound infiltration

• TAP block is a part of the multimodal analgesic approach

• Use of ultrasound for better localization, real time

visualization and precision

• This study was designed to elucidate the efficacy of

ultrasound guided bilateral pre incisional TAP block as part
of the multimodal analgesic approach in gynaecological
abdominal surgeries.
 METHODOLOGY

30 Patients scheduled for lower abdominal surgery for total abdominal

hysterectomy and bilateral salphingo-oopherectomy were recruited for this
study

Unwilling patients, history of allergy to any of the study drug was excluded
from the study

normal saline (GROUP S)

B/L USG guided Pre-incisional TAP block
N=15
was performed under GA by posterior
approach ropivacaine (GROUP R)
N=15
• With patient in supine
position area between the
iliac crest and subcostal
margin were scanned

• Transverse view image of

three abdominal muscle on
US monitor was obtained
EO
• Neuro fascial plane
between internal oblique IO
TA
and transversus abdominis
muscle was identified and
needle was introduced.
• After reaching the target plane
i.e TAP, placement of the
needle tip was confirmed by
injecting 5-10 ml of saline.

• Expansion of the local

anaesthetic solution as a dark
shadow between aponeurosis
of the Internal oblique that
moved anteriorly and the
Tranversus Abdominis muscles
pushing the muscle deeper
 IV paracetamol 1 gm and IV fentanyl in titrated doses

Intra operative fentanyl requirement and heart rate and blood

pressure was noted intraoperatively

After surgery Fentanyl Patient controlled analgesia (PCA) was

started in both the groups

Pain VAS score (at rest and on Movement in bed), Fentanyl requirement, Fentanyl bolus
vs demand ratio, Postoperative nausea and vomiting (PONV), Sedation scores were
followed up at 0 (immediate after operation in recovery), 4, 8 ,12 ,24 ,and 48 hours after
surgery.

Rescue analgesic requirement was noted in the PACU, and patients were given
Butorphanol 1gm or Tramadol 50 mg on demand or when VAS > 4

Occurrence of any study related complications and patient satisfaction with analgesia
were noted at 48 hours.
 STATISTICS
Quantitative data were represented in terms of mean ±
standard deviation if it passed the ‘normality test’
If this data failed the ‘normality test’ then median and
inter-quartile range was used.

Analysis of quantitative data between the two groups was

done using unpaired student t test or ANOVA test.

Qualitative data was presented with the help of Frequency

and Percentage table and analysis of qualitative data was
performed by Chi square test or Fishers exact test as
deemed necessary.

p value <0.05 - result statistically significant

 Results
Heart rate Blood pressure
120 120
100 100
80 80
60 60
40 40

20 20
0
0
Baseline Incision 1 hour 2 hours 3 hours 4 hours
Baseline Incision 1 hour 2 hours 3 hours 4 hours
Group S Group R
Group S Group R

Analysis of the hemodynamic parameters between Saline and Ropivacaine group,

showed that in Ropivacaine group,both heart rate and blood pressure was
significantly lower at incision [97(20) vs 72(15)] and at all hourly intervals throughout
the intra-operative period. When compared to baseline values within individual
groups it was seen that in the saline group it increased significantly at
incision[p=0.001]. The subsequent values in saline group were comparable to
baseline.
 Intraoperative fentanyl

300
Fentanyl (in micrograms)

250

200

150

100

50

0
GROUP S GROUP R

Requirement of intra-operative Fentanyl was significantly

higher in Saline group as compared to Ropivacaine
group[250 (70) vs 130(30) ]
 VAS scores at rest and movement
7 8

6 7

5 6
VAS scores

VAS scores
4
4
3
3
2
2
1
1
0
0
AT 0 AT 4 AT 8 AT 12 AT 24 AT 48
AT 0 HRSAT 4 HRS AT 8 HRS AT 12 AT 24 AT 48
HRS HRS HRS HRS HRS HRS
HRS HRS HRS
Postoperative time interval
Postoperative time interval

• The VAS scores both at rest and movement were less in R group
when till 24 hours (p <0.001).
• The overall Fentanyl requirement (microgram) showed no
significant difference
• Bolus dosing of fentanyl PCA(p=0.017, p=0.039) was significantly
decreased in early postoperative period upto 8 hours
 Postoperative analgesic
14 requirement
• Rescue analgesic
requirement was 12

noted in the PACU 10

Number of patients
8

• Ropivacaine group
6

showed lower rescue 4

analgesic requirement 2

0
NO ANALGESIC BUTORPHANOL TRAMADOL
Post operative analgesic
 Sedation scores were lower in Ropivacaine group
at immediate post-operative period

 Incidence of PONV was comparable in both

groups

 No complications associated with TAP block was

noted in any of the patients and degree of patient
satisfaction was better in Ropivacaine group.
 CONCLUSION-TAP BLOCK
Prevents intra-operative hemodynamic responses to surgical stimuli

Provides superior postoperative analgesia up to 24 hours

Better patient satisfaction

Safe technique when performed under USG guidance with minimal side effects

Component of a multimodal analgesic regimen

 LIMITATIONS
Sensory assessment of block could not be carried out as block was given under
General Anaesthesia.

Fentanyl PCA settings with continuous infusion given for 48 hours irrespective
of pain scores could have affected the result of Fentanyl bolus consumption and
VAS scores.

Time to first rescue analgesic was not assessed.

TAP block was performed post induction of anaesthesia and pre incisionally
therefore although it provided hemodynamic stability intra-operatively the
postoperative duration of analgesia might have been restricted.

The rescue analgesia given in recovery was not standardized. Institutional policy
of prescribing Butorphanol or Tramadol was applied to study population also
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Sample size calculation
 Discussion
• Findings of decrease in intraoperative fentanyl requirement
and maintenance of hemodynamic parameters were also
reported by Bhattercharjee et al.

• Meta-analysis done by M. Baeriswyl et al. and Nanze Yu et al.

demonstrated that TAP block reduces IV opioid consumption
for 24 hours and pain scores at rest and movement for 6 hours
postoperatively

• Reduced postoperative VAS scores and opioid requirement

was shown by Carney et al. and McDonnell et al.

• Lower postoperative rescue analgesic requirement were

consistent with study done by Gajanan et al. and Amr et al
 Objectives
Primary objective: To assess pain Visual Analogue Scale (VAS) scores at
rest and on movement in bed for 48 hours after surgery in both the
groups.

Secondary objective :
• To assess Intra operative fentanyl requirement and heart rate and blood
pressure base line, at incision and hourly during surgery.

• To assess postoperative rescue analgesia in recovery, postoperative

fentanyl consumption, fentanyl PCA bolus vs demand ratio, sedation
scores, post-operative nausea and vomiting (PONV) study related
complications or adverse effects and patient satisfaction for 48 hours post
operatively
 Ramsay sedation scores

• 1-patient anxious and agitated or restless or both

• 2-patient co-operative ,oriented and tranquil
• 3-patient responds to command only
• 4-brisk response to light glabellar tap or auditory
stimulus
• 5-Sluggish response to light glabellar tap or
auditory stimulus
• 6-no response to light glabellar tap or auditory
stimulus