Journal of Clinical Anesthesia (2015) 27, 579–584
Original Contribution
Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients G. Niraj MD, FRCA, FFPMRCA (Consultant in Anaesthesia)⁎, Aditi Kelkar MD, FRCA (Consultant in Anaesthesia), Elaine Hart FRCA (Consultant in Anaesthesia), Vipul Kaushik FRCA (Specialist Trainee in Anaesthesia), Danny Fleet MB, ChB (Specialist Trainee in Anaesthesia), John Jameson (Consultant in Colorectal Surgery) Department of Anaesthesia and Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK Received 21 April 2014; revised 8 April 2015; accepted 13 July 2015
Keywords: Continuous TAP analgesia; Four quadrant TAP analgesia
Abstract Study Objective: Transversus abdominis plane (TAP) blocks have been reported to be an effective method of providing analgesia after abdominal surgery. To perform a prospective audit on the effectiveness of a novel technique of providing continuous transversus abdominis plane (TAP) analgesia in patients undergoing emergency and elective abdominal surgery. Design: Prospective single center audit over a 3-year period. Setting: University hospital. Patients: One hundred twenty-four American Society of Anesthesiologists I to IV adult patients presenting for elective as well as emergency abdominal surgery in whom epidural analgesia was contraindicated or refused. Interventions: Four quadrant TAP blocks and continuous TAP analgesia. Measurements: Numerical rating scale pain scores at rest and on coughing, nausea scores, satisfaction scores, complications, frequency of analgesia failure, therapeutic failure with continuous TAP analgesia and opioid consumption. Results: One hundred twenty-four patients who received continuous TAP analgesia were audited. This included 34 patients for elective open surgery, 36 patients for emergency laparotomy, and 54 patients who underwent elective laparoscopic colorectal surgery. Surgical incision was within the dermatomal limit of the block in 70% of the patients (88/124). Therapeutic failure with the technique was 10%. Frequency of analgesic failure over the 48-hour period was none in 39% and below 5 episodes in 57%.
⁎ Corresponding author at: Department of Anaesthesia & Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW. Tel./fax: +44 116 258 4661. E-mail address: [email protected] (G. Niraj). http://dx.doi.org/10.1016/j.jclinane.2015.07.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
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G. Niraj et al. Conclusion: Four quadrant transversus abdominis plane blocks and continuous TAP analgesia is an effective technique for providing postoperative analgesia after abdominal surgery. It has the potential to be used as a sole analgesic technique when the surgical incision is within its dermatomal limit. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Effective analgesia is a vital component for enhancing recovery after abdominal surgery. There has been a move away from epidural analgesia that was once considered as the gold standard. New techniques have been described as possible alternatives and includes transversus abdominis plane (TAP) block [1–3]. However single shot TAP blocks fail to provide durable analgesia after major abdominal surgery [4,5]. There are 2 types of TAP blocks. Subcostal TAP block is effective for upper abdominal surgery where the surgical incision extends from T6 to T10 dermatomes. Posterior TAP block is effective in providing analgesia after lower abdominal surgery where the incision extends from T10 to L1 dermatomes. However, TAP block does not reliably cover surgical incisions that cross the T10 dermatome. The presence of a watershed line at T10 dermatome has been confirmed by anatomical studies as well as by clinical reports [5–8]. We developed a novel technique for providing continuous TAP analgesia that provides superior analgesia to allow early extubation of the trachea after surgery and provide durable analgesia. The 4 quadrant TAP block and continuous TAP analgesia was used to provide post operative analgesia for patients who underwent open or laparoscopic abdominal surgery. We prospectively audited this technique over a 3-year period in patients who did not receive epidural analgesia. The aim of this report is to present the results of our audit and raise awareness of the technique that has a favourable risk benefit profile.
used for the single shot TAP blocks. The 2 TAP catheters were attached to a Y connector that was then connected to the infusion device (Fig. 1). The infusion device containing bupivacaine 0.25% was run at 8 to 10 mL/h for 48 hours. Patients also received a standard postoperative analgesic regimen, consisting of regular paracetamol, regular diclofenac and tramadol as required. Patients received regular ondansetron 4 mg every 8 hours for the first 2 days after surgery. Patient controlled analgesia (PCA) with morphine was added to TAP analgesia if the surgical incision crossed the T10 dermatome. For this audit, therapeutic failure of TAP analgesia was defined as the addition of PCA with morphine when the surgical incision was within the dermatomal cover of the chosen (subcostal or posterior) TAP analgesia (Fig. 2). Outcomes audited included numerical rating scale (NRS) pain scores at rest and on coughing, nausea scores, morphine consumption, frequency of analgesic failure, patient satisfaction with the technique, and the therapeutic failure rate. Any complication with the technique was recorded. The ward nurse looking after the patient assessed pain scores and nausea scores at 4 hourly intervals. A team comprising of a research nurse and trainee anesthetists assessed the other outcomes. Analgesic failure was defined as NRS pain score ≥ 4 at rest or NRS ≥ 6 on coughing. If the patient complained of unilateral or bilateral pain, the patient received rescue analgesia with tramadol. If the patient continued to complain
2. Methods Adult patients who received 4 quadrant TAP blocks and continuous TAP analgesia for a 3-year period at Leicester General Hospital, Leicester were prospectively audited. The audit was registered with Clinical Audit, Safety and Effectiveness, University Hospitals of Leicester NHS Hospital Trust. Patients with contraindications to epidural analgesia, who refused epidural analgesia or had failed epidural analgesia, received the novel technique. Patients who received TAP analgesia as a part of a recently completed randomized trial were also included in this audit (ISRCTN 99313141). Technique: the patient underwent ultrasound guided single shot bilateral subcostal and posterior TAP blocks followed by insertion of bilateral TAP catheters. The catheters were inserted into either the subcostal or posterior TA plane depending on the site of the surgical incision. Levo-bupivacaine 0.375% was
Fig. 1 The 2 TAP catheters attached to a Y connector that is then attached to the infusion line with a filter at its end.
Continuous TAP analgesia
581 XIPHISTERNUM T6
Subcostal TAP
AXILLA
AXILLA
Anterior Axillary Line
T10
T10
Watershed Zone @ T 10
Posterior TAP L1 PUBIC TUBERCLE
Fig. 2
The dermatomal limit of the 2 types of TAP blocks and the watershed line at T10 that separates the 2 blocks.
of pain, the patient was commenced on PCA with morphine. The decision to commence PCA with morphine was taken by the acute pain team.
3. Results Over a 3-year period, 124 patients received continuous TAP analgesia. Patients have been divided into 3 groups: patients who underwent emergency laparotomy, elective open surgery, or elective laparoscopic colorectal surgery.
3.2. Group 2: Elective open surgery Thirty-four patients who underwent elective open laparotomy received TAP analgesia. In 16 patients, the surgical incision was within the dermatomal limit of the technique and in 15 patients (93%), it provided the sole analgesia. In 18 patients, the surgical incision crossed the T10 dermatome. The mean 48-hour morphine consumption was 67 mg. Procedures included radical cystectomy, liver resection, Whipple’s surgery and major colorectal surgery.
3.3. Group 3: Elective laparoscopic colorectal surgery 3.1. Group 1: emergency laparotomy Thirty-six patients received the technique. Procedures included laparotomy for perforation peritonitis (duodenal, large bowel), right hemicolectomy, bowel obstruction, incarcerated hernia repair, biliary peritonitis and gynecological emergencies. The surgical incision was within the dermatomal cover of the continuous TAP analgesia in 18 patients and the technique provided sole analgesia in 89% (16/18). Therapeutic failure rate in this group was 11%. In 18 patients, the surgical incision crossed the T10 dermatome and the patients also received additional PCA with morphine. The mean 48-hour morphine consumption in this group was 70 mg. Sepsis was the principal reason for not inserting an epidural catheter. Patient satisfaction with the technique was good or excellent in 88% (32/36).
Out of the 54 patients who received TAP analgesia, 88% (48/54) did not require PCA with morphine. Therapeutic failure rate was 12% (6/54). The 48-hour mean morphine consumption in the 6 patients was 50 mg. Patient satisfaction was excellent in 58% and good in 38%. Procedures included right hemicolectomy (56%), anterior resection (12%), sigmoid colectomy (11%), left hemicolectomy (5%), and ileocecal resection (5%). Combining the 3 groups reveals that the surgical incision was within the dermatomal limit of the technique in 88 patients, out of which only 9 patients required PCA with morphine (10%). Nine anesthetists were involved in inserting the catheters. TAP catheters were resited in the PACU in 10 patients (8%). Patient satisfaction with the technique was excellent (51%), good (43%), and fair (6%).
582 Four patients received continuous TAP analgesia via 4 catheters placed in the subcostal as well as posterior TAP planes. These patients had an absolute contraindication to epidural analgesia with a large surgical incision extending from T7 to L1 dermatome. Two patients had significant sensitivity to morphine and while 2 others had poor respiratory function. None of the 4 patients required PCA with morphine. Episodes of analgesic failure (NRS pain score ≥ 4 at rest or NRS ≥ 6 on coughing) over the 48-hour postoperative period were none (39%), 1 to 5 episodes (57%) and above 5 episodes (4%). Information obtained from the patient’s treatment charts revealed that the episodes of analgesic failure were treated with rescue analgesia within 30 minutes in over two-thirds of cases.
4. Discussion Optimal recovery after abdominal surgery is dependent on adequate postoperative analgesia. The last decade has seen the advent of new techniques for providing analgesia after both open and laparoscopic abdominal surgery [1–5,9–11]. Epidural analgesia continues to remains the gold standard after elective open surgery in many centres in the UK [12]. There is a trend to move away from epidural analgesia when it comes to laparoscopic surgery as well as emergency laparotomy in patients with features of systemic inflammatory response syndrome [10–14]. The principal reason may be the high-risk benefit profile associated with the technique. Opioid analgesia remains popular although it is ineffective in providing dynamic analgesia and side effects often retard recovery after bowel surgery [15]. Although single shot TAP blocks have undergone extensive investigation, continuous TAP analgesia has not gained popularity and one reason could be the technical difficulty in running an infusion with 2 catheters [4]. We believe that continuous TAP analgesia is an effective technique and has the potential to be a viable alternative to epidural analgesia in this population. We published the first clinical trial comparing TAP analgesia with epidural analgesia after upper abdominal surgery [5]. We have recently completed another trial in patients undergoing laparoscopic colorectal surgery (ISRCTN 99313141). Here we present the results of a 3-year audit on continuous TAP analgesia. The attractive features of the technique include effective dynamic analgesia as well as a favourable risk benefit profile. However, the principal drawback of the technique appears to be a dermatomal limitation. TAP block does not reliably cover the part of the surgical incision that crosses the T10 dermatome. The presence of a watershed line at the T10 dermatome has been proved by both clinical and anatomical studies [4–7]. This has clinical significance immediately after surgery as well as during the postoperative period. We describe a novel technique of providing TAP analgesia. The 4-quadrant TAP block involves performing bilateral subcostal as well as posterior TAP blocks followed by insertion of catheters in either the posterior or the subcostal TA plane,
G. Niraj et al. depending on the extent of the surgical incision (Fig. 2). The 4-quadrant TAP block provides analgesia to the entire anterior abdominal wall including the parietal peritoneum and has relevance in patients undergoing open as well as laparoscopic surgery. During emergency laparotomy, the surgical incision is often generous, crossing the T10 dermatome. On the other hand, the entire parietal peritoneum is stimulated during laparoscopic surgery although the port and extraction sites may be limited to the lower abdomen. The 4-quadrant TAP block covers the entire abdominal wall for the duration of block (6-8 hours) and allows early extubation of the trachea if other parameters are stable. The patient is then connected to the TAP infusion. If the surgical incision has crossed the T10 dermatome, the patient is also connected to PCA with morphine. The therapeutic failure rate of the technique using our predefined criterion was 10%. This implies that when the surgical incision is within the dermatomal cover of the TAP block, then continuous TAP analgesia can be used as the principal analgesic technique in a multimodal analgesic regimen. The other drawback of this technique is that it does not cover visceral pain. A large proportion (75-80%) of the pain after abdominal surgery is somatic in origin [6]. However visceral pain can be a significant issue in patients with inflammatory bowel disease and often requires the addition of opioids for the first 24 hours after surgery. Pre-emptive analgesia is not achieved with continuous TAP analgesia as the technique is usually performed at the end of the surgery. Although the technique can be performed after the induction of anaesthesia, it may be preferable to wait till the end of surgery. This allows the operator to insert the catheters in the appropriate TA plane (subcostal or posterior) based on the extent of surgical incision. There were 2 complications with the technique. One patient had a unilateral abdominal wall hematoma resulting in bowel stasis that resolved in 36 hours. Another patient had kinking of the catheter within the TAP plane, which was only identified when the catheter was removed at the end of the TAP infusion. This patient was also connected to PCA with morphine and had consumed 230 mg of morphine over 48 hours. Unilateral catheter kinking resulted in failure of TAP analgesia with significant morphine consumption. When compared to epidural analgesia, continuous TAP analgesia does not cause haemodynamic imbalance, preserves motor function of the lower limbs and can be used in patients with sepsis or coagulation disorders. TAP analgesia does not require high intensive nursing care. It is non-sedating, does not impede bowel or respiratory function when compared to opioid-based analgesia. When the surgical incision is within the dermatomal limit, continuous TAP analgesia could be used as an alternative to epidural analgesia. When the surgical incision violates the T10 dermatome, addition of PCA with morphine is recommended. Use of the 4-quadrant TAP block followed by continuous TAP analgesia can significantly reduce opioid consumption.
Continuous TAP analgesia
583 Analysis reveals TAP analgesia to be as effective as epidural analgesia [16]. Our audit includes 54 patients who underwent laparoscopic colorectal surgery. The success rate of TAP analgesia as the sole analgesic technique in providing optimal analgesia was 88%.
Based on our experience with continuous TAP analgesia, the authors recommend the following options for analgesia after abdominal surgery: Elective open surgery: Epidural analgesia appears to remain the superior technique for providing peri-operative analgesia. Continuous TAP analgesia is a viable option when the epidural is either contraindicated, fails or is refused. It can be used as the sole analgesic technique if the surgical incision is within the dermatomal limit of the block. PCA with morphine can be added to the TAP infusion if the incision crosses the T10 dermatome. Emergency open surgery: Continuous TAP analgesia has the potential to be used as the primary option for postoperative analgesia. It provides dynamic analgesia and does not require the addition of PCA with morphine if the incision is within the dermatomal limit. The other emerging options are rectus sheath catheter infusion and wound catheter infusion. Rectus sheath analgesia is an alternative to TAP analgesia for midline incisions. However they are ineffective for transverse incisions and fail to provide analgesia from pain arising from surgical drains or stoma sites that are placed in the lateral abdominal wall. They often require the addition of parenteral opioids [3]. Wound catheters have recently gained popularity and are placed by the surgeon. They usually require the addition of morphine PCA to provide effective analgesia. Laparoscopic colorectal surgery: There is an on going trend away from epidural analgesia. The emerging options include intrathecal opioids, continuous rectus sheath analgesia, wound catheter infusion and continuous TAP analgesia. Continuous TAP analgesia and continuous rectus sheath analgesia can be used as a sole analgesic technique when compared to the other 2 techniques. Both techniques have a superior risk benefit ratio when compared to neuraxial techniques. We have recently completed the first study comparing continuous TAP analgesia with epidural analgesia for patients undergoing laparoscopic colorectal surgery.
Continuous TAP analgesia using 4 catheters: The authors do not recommend this technique unless the patient has contraindications for epidural analgesia as well as opioid analgesia and has a large incision extending from T6 to L1 dermatome. In conclusion, the authors believe that continuous TAP analgesia is an effective analgesic technique following abdominal surgery with a favourable risk benefit profile.
Acknowledgement The authors would like to sincerely thank Consultants in Colorectal Surgery and Consultants in Hepatobiliary Surgery at Leicester General Hospital for their wholehearted support for this audit.
References [1] McDonnell JG, O’Donnell BD, Curley GCJ, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007;104:193-7. [2] Jouve P, Bazin JE, Petit A, Minville V, Gerard A, Buc E, et al. Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial. Anesthesiology 2013;118(3):622-30. [3] Parsons BA, Aning J, Daugherty MO, McGrath JG. The use of rectus sheath catheters as an analgesic technique for patients undergoing radical cystectomy. J Clin Urol 2011;4(1):24-30. [4] Taylor R Jr, Pergolizzi JV, Sinclair A, Raffa RB, Aldington D, Plavin S, et al. Transversus abdominis block: clinical uses, side effects, and future perspectives. Pain Pract 2013;13(4):332-44. [5] Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66(6): 465-71. [6] Tran TMN, Rozen W, Ashton M, Barrington M, Ivanusic J, Taylor G. Redefining the course of the intercostal nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 2008;21: 325-33. [7] Niraj G, Kelkar A, Fox AJ. Oblique sub-costal transversus abdominis plane (TAP) catheters: an alternative to epidural analgesia after upper abdominal surgery. Anaesthesia 2009;64(10):1137-40. [8] Borglum J, Jensen K, Christensen A, Hoegberg L, Johansen S, Lönnqvist PA, et al. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. RAPM 2012;37(3):294-301.
584 [9] Levy BF, Tilney HS, Dowson HMP, Rockall TA. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Dis 2010;12:5-15. [10] Joshi GP, Bonnet F, Kehlet H; on behalf of the PROSPECT collaboration. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2012;15: 146-55. [11] Kaba A, Detroz BJ, Laurent SR, Lamy ML, Joris JL. Acute rehabilitation program after laparoscopic colectomy using intravenous lidocaine. Acta Chir Belg 2005;105(1):53-8. [12] Walton B, Farrow C, Cook TM. A national survey of epidural use and management in elderly patients undergoing elective and emergency laparotomy. Anaesthesia 2006;61(3):456-61.
G. Niraj et al. [13] Nightingale JJ, Burmeister L, Hopkins D. A national survey of the use of epidural analgesia in patients with sepsis undergoing laparotomy. Anaesthesia 2011;66:311-22. [14] Rawal N. Epidural technique for postoperative pain: gold standard no more? RAPM 2012;37(3):310-7. [15] Nishimori M, Low JH, Zheng H, Ballantyne JC. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 2012;7:CD005059. [16] Niraj G, Kelkar A, Hart E, Horst C, Malik D, Yeow C, et al. Comparison of analgesic efficacy of four quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: An open-label, randomized, non-inferiority trial. Anaesthesia 2014;69(4):348-55.
Original Contribution
Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients G. Niraj MD, FRCA, FFPMRCA (Consultant in Anaesthesia)⁎, Aditi Kelkar MD, FRCA (Consultant in Anaesthesia), Elaine Hart FRCA (Consultant in Anaesthesia), Vipul Kaushik FRCA (Specialist Trainee in Anaesthesia), Danny Fleet MB, ChB (Specialist Trainee in Anaesthesia), John Jameson (Consultant in Colorectal Surgery) Department of Anaesthesia and Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK Received 21 April 2014; revised 8 April 2015; accepted 13 July 2015
Keywords: Continuous TAP analgesia; Four quadrant TAP analgesia
Abstract Study Objective: Transversus abdominis plane (TAP) blocks have been reported to be an effective method of providing analgesia after abdominal surgery. To perform a prospective audit on the effectiveness of a novel technique of providing continuous transversus abdominis plane (TAP) analgesia in patients undergoing emergency and elective abdominal surgery. Design: Prospective single center audit over a 3-year period. Setting: University hospital. Patients: One hundred twenty-four American Society of Anesthesiologists I to IV adult patients presenting for elective as well as emergency abdominal surgery in whom epidural analgesia was contraindicated or refused. Interventions: Four quadrant TAP blocks and continuous TAP analgesia. Measurements: Numerical rating scale pain scores at rest and on coughing, nausea scores, satisfaction scores, complications, frequency of analgesia failure, therapeutic failure with continuous TAP analgesia and opioid consumption. Results: One hundred twenty-four patients who received continuous TAP analgesia were audited. This included 34 patients for elective open surgery, 36 patients for emergency laparotomy, and 54 patients who underwent elective laparoscopic colorectal surgery. Surgical incision was within the dermatomal limit of the block in 70% of the patients (88/124). Therapeutic failure with the technique was 10%. Frequency of analgesic failure over the 48-hour period was none in 39% and below 5 episodes in 57%.
⁎ Corresponding author at: Department of Anaesthesia & Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW. Tel./fax: +44 116 258 4661. E-mail address: [email protected] (G. Niraj). http://dx.doi.org/10.1016/j.jclinane.2015.07.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
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G. Niraj et al. Conclusion: Four quadrant transversus abdominis plane blocks and continuous TAP analgesia is an effective technique for providing postoperative analgesia after abdominal surgery. It has the potential to be used as a sole analgesic technique when the surgical incision is within its dermatomal limit. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Effective analgesia is a vital component for enhancing recovery after abdominal surgery. There has been a move away from epidural analgesia that was once considered as the gold standard. New techniques have been described as possible alternatives and includes transversus abdominis plane (TAP) block [1–3]. However single shot TAP blocks fail to provide durable analgesia after major abdominal surgery [4,5]. There are 2 types of TAP blocks. Subcostal TAP block is effective for upper abdominal surgery where the surgical incision extends from T6 to T10 dermatomes. Posterior TAP block is effective in providing analgesia after lower abdominal surgery where the incision extends from T10 to L1 dermatomes. However, TAP block does not reliably cover surgical incisions that cross the T10 dermatome. The presence of a watershed line at T10 dermatome has been confirmed by anatomical studies as well as by clinical reports [5–8]. We developed a novel technique for providing continuous TAP analgesia that provides superior analgesia to allow early extubation of the trachea after surgery and provide durable analgesia. The 4 quadrant TAP block and continuous TAP analgesia was used to provide post operative analgesia for patients who underwent open or laparoscopic abdominal surgery. We prospectively audited this technique over a 3-year period in patients who did not receive epidural analgesia. The aim of this report is to present the results of our audit and raise awareness of the technique that has a favourable risk benefit profile.
used for the single shot TAP blocks. The 2 TAP catheters were attached to a Y connector that was then connected to the infusion device (Fig. 1). The infusion device containing bupivacaine 0.25% was run at 8 to 10 mL/h for 48 hours. Patients also received a standard postoperative analgesic regimen, consisting of regular paracetamol, regular diclofenac and tramadol as required. Patients received regular ondansetron 4 mg every 8 hours for the first 2 days after surgery. Patient controlled analgesia (PCA) with morphine was added to TAP analgesia if the surgical incision crossed the T10 dermatome. For this audit, therapeutic failure of TAP analgesia was defined as the addition of PCA with morphine when the surgical incision was within the dermatomal cover of the chosen (subcostal or posterior) TAP analgesia (Fig. 2). Outcomes audited included numerical rating scale (NRS) pain scores at rest and on coughing, nausea scores, morphine consumption, frequency of analgesic failure, patient satisfaction with the technique, and the therapeutic failure rate. Any complication with the technique was recorded. The ward nurse looking after the patient assessed pain scores and nausea scores at 4 hourly intervals. A team comprising of a research nurse and trainee anesthetists assessed the other outcomes. Analgesic failure was defined as NRS pain score ≥ 4 at rest or NRS ≥ 6 on coughing. If the patient complained of unilateral or bilateral pain, the patient received rescue analgesia with tramadol. If the patient continued to complain
2. Methods Adult patients who received 4 quadrant TAP blocks and continuous TAP analgesia for a 3-year period at Leicester General Hospital, Leicester were prospectively audited. The audit was registered with Clinical Audit, Safety and Effectiveness, University Hospitals of Leicester NHS Hospital Trust. Patients with contraindications to epidural analgesia, who refused epidural analgesia or had failed epidural analgesia, received the novel technique. Patients who received TAP analgesia as a part of a recently completed randomized trial were also included in this audit (ISRCTN 99313141). Technique: the patient underwent ultrasound guided single shot bilateral subcostal and posterior TAP blocks followed by insertion of bilateral TAP catheters. The catheters were inserted into either the subcostal or posterior TA plane depending on the site of the surgical incision. Levo-bupivacaine 0.375% was
Fig. 1 The 2 TAP catheters attached to a Y connector that is then attached to the infusion line with a filter at its end.
Continuous TAP analgesia
581 XIPHISTERNUM T6
Subcostal TAP
AXILLA
AXILLA
Anterior Axillary Line
T10
T10
Watershed Zone @ T 10
Posterior TAP L1 PUBIC TUBERCLE
Fig. 2
The dermatomal limit of the 2 types of TAP blocks and the watershed line at T10 that separates the 2 blocks.
of pain, the patient was commenced on PCA with morphine. The decision to commence PCA with morphine was taken by the acute pain team.
3. Results Over a 3-year period, 124 patients received continuous TAP analgesia. Patients have been divided into 3 groups: patients who underwent emergency laparotomy, elective open surgery, or elective laparoscopic colorectal surgery.
3.2. Group 2: Elective open surgery Thirty-four patients who underwent elective open laparotomy received TAP analgesia. In 16 patients, the surgical incision was within the dermatomal limit of the technique and in 15 patients (93%), it provided the sole analgesia. In 18 patients, the surgical incision crossed the T10 dermatome. The mean 48-hour morphine consumption was 67 mg. Procedures included radical cystectomy, liver resection, Whipple’s surgery and major colorectal surgery.
3.3. Group 3: Elective laparoscopic colorectal surgery 3.1. Group 1: emergency laparotomy Thirty-six patients received the technique. Procedures included laparotomy for perforation peritonitis (duodenal, large bowel), right hemicolectomy, bowel obstruction, incarcerated hernia repair, biliary peritonitis and gynecological emergencies. The surgical incision was within the dermatomal cover of the continuous TAP analgesia in 18 patients and the technique provided sole analgesia in 89% (16/18). Therapeutic failure rate in this group was 11%. In 18 patients, the surgical incision crossed the T10 dermatome and the patients also received additional PCA with morphine. The mean 48-hour morphine consumption in this group was 70 mg. Sepsis was the principal reason for not inserting an epidural catheter. Patient satisfaction with the technique was good or excellent in 88% (32/36).
Out of the 54 patients who received TAP analgesia, 88% (48/54) did not require PCA with morphine. Therapeutic failure rate was 12% (6/54). The 48-hour mean morphine consumption in the 6 patients was 50 mg. Patient satisfaction was excellent in 58% and good in 38%. Procedures included right hemicolectomy (56%), anterior resection (12%), sigmoid colectomy (11%), left hemicolectomy (5%), and ileocecal resection (5%). Combining the 3 groups reveals that the surgical incision was within the dermatomal limit of the technique in 88 patients, out of which only 9 patients required PCA with morphine (10%). Nine anesthetists were involved in inserting the catheters. TAP catheters were resited in the PACU in 10 patients (8%). Patient satisfaction with the technique was excellent (51%), good (43%), and fair (6%).
582 Four patients received continuous TAP analgesia via 4 catheters placed in the subcostal as well as posterior TAP planes. These patients had an absolute contraindication to epidural analgesia with a large surgical incision extending from T7 to L1 dermatome. Two patients had significant sensitivity to morphine and while 2 others had poor respiratory function. None of the 4 patients required PCA with morphine. Episodes of analgesic failure (NRS pain score ≥ 4 at rest or NRS ≥ 6 on coughing) over the 48-hour postoperative period were none (39%), 1 to 5 episodes (57%) and above 5 episodes (4%). Information obtained from the patient’s treatment charts revealed that the episodes of analgesic failure were treated with rescue analgesia within 30 minutes in over two-thirds of cases.
4. Discussion Optimal recovery after abdominal surgery is dependent on adequate postoperative analgesia. The last decade has seen the advent of new techniques for providing analgesia after both open and laparoscopic abdominal surgery [1–5,9–11]. Epidural analgesia continues to remains the gold standard after elective open surgery in many centres in the UK [12]. There is a trend to move away from epidural analgesia when it comes to laparoscopic surgery as well as emergency laparotomy in patients with features of systemic inflammatory response syndrome [10–14]. The principal reason may be the high-risk benefit profile associated with the technique. Opioid analgesia remains popular although it is ineffective in providing dynamic analgesia and side effects often retard recovery after bowel surgery [15]. Although single shot TAP blocks have undergone extensive investigation, continuous TAP analgesia has not gained popularity and one reason could be the technical difficulty in running an infusion with 2 catheters [4]. We believe that continuous TAP analgesia is an effective technique and has the potential to be a viable alternative to epidural analgesia in this population. We published the first clinical trial comparing TAP analgesia with epidural analgesia after upper abdominal surgery [5]. We have recently completed another trial in patients undergoing laparoscopic colorectal surgery (ISRCTN 99313141). Here we present the results of a 3-year audit on continuous TAP analgesia. The attractive features of the technique include effective dynamic analgesia as well as a favourable risk benefit profile. However, the principal drawback of the technique appears to be a dermatomal limitation. TAP block does not reliably cover the part of the surgical incision that crosses the T10 dermatome. The presence of a watershed line at the T10 dermatome has been proved by both clinical and anatomical studies [4–7]. This has clinical significance immediately after surgery as well as during the postoperative period. We describe a novel technique of providing TAP analgesia. The 4-quadrant TAP block involves performing bilateral subcostal as well as posterior TAP blocks followed by insertion of catheters in either the posterior or the subcostal TA plane,
G. Niraj et al. depending on the extent of the surgical incision (Fig. 2). The 4-quadrant TAP block provides analgesia to the entire anterior abdominal wall including the parietal peritoneum and has relevance in patients undergoing open as well as laparoscopic surgery. During emergency laparotomy, the surgical incision is often generous, crossing the T10 dermatome. On the other hand, the entire parietal peritoneum is stimulated during laparoscopic surgery although the port and extraction sites may be limited to the lower abdomen. The 4-quadrant TAP block covers the entire abdominal wall for the duration of block (6-8 hours) and allows early extubation of the trachea if other parameters are stable. The patient is then connected to the TAP infusion. If the surgical incision has crossed the T10 dermatome, the patient is also connected to PCA with morphine. The therapeutic failure rate of the technique using our predefined criterion was 10%. This implies that when the surgical incision is within the dermatomal cover of the TAP block, then continuous TAP analgesia can be used as the principal analgesic technique in a multimodal analgesic regimen. The other drawback of this technique is that it does not cover visceral pain. A large proportion (75-80%) of the pain after abdominal surgery is somatic in origin [6]. However visceral pain can be a significant issue in patients with inflammatory bowel disease and often requires the addition of opioids for the first 24 hours after surgery. Pre-emptive analgesia is not achieved with continuous TAP analgesia as the technique is usually performed at the end of the surgery. Although the technique can be performed after the induction of anaesthesia, it may be preferable to wait till the end of surgery. This allows the operator to insert the catheters in the appropriate TA plane (subcostal or posterior) based on the extent of surgical incision. There were 2 complications with the technique. One patient had a unilateral abdominal wall hematoma resulting in bowel stasis that resolved in 36 hours. Another patient had kinking of the catheter within the TAP plane, which was only identified when the catheter was removed at the end of the TAP infusion. This patient was also connected to PCA with morphine and had consumed 230 mg of morphine over 48 hours. Unilateral catheter kinking resulted in failure of TAP analgesia with significant morphine consumption. When compared to epidural analgesia, continuous TAP analgesia does not cause haemodynamic imbalance, preserves motor function of the lower limbs and can be used in patients with sepsis or coagulation disorders. TAP analgesia does not require high intensive nursing care. It is non-sedating, does not impede bowel or respiratory function when compared to opioid-based analgesia. When the surgical incision is within the dermatomal limit, continuous TAP analgesia could be used as an alternative to epidural analgesia. When the surgical incision violates the T10 dermatome, addition of PCA with morphine is recommended. Use of the 4-quadrant TAP block followed by continuous TAP analgesia can significantly reduce opioid consumption.
Continuous TAP analgesia
583 Analysis reveals TAP analgesia to be as effective as epidural analgesia [16]. Our audit includes 54 patients who underwent laparoscopic colorectal surgery. The success rate of TAP analgesia as the sole analgesic technique in providing optimal analgesia was 88%.
Based on our experience with continuous TAP analgesia, the authors recommend the following options for analgesia after abdominal surgery: Elective open surgery: Epidural analgesia appears to remain the superior technique for providing peri-operative analgesia. Continuous TAP analgesia is a viable option when the epidural is either contraindicated, fails or is refused. It can be used as the sole analgesic technique if the surgical incision is within the dermatomal limit of the block. PCA with morphine can be added to the TAP infusion if the incision crosses the T10 dermatome. Emergency open surgery: Continuous TAP analgesia has the potential to be used as the primary option for postoperative analgesia. It provides dynamic analgesia and does not require the addition of PCA with morphine if the incision is within the dermatomal limit. The other emerging options are rectus sheath catheter infusion and wound catheter infusion. Rectus sheath analgesia is an alternative to TAP analgesia for midline incisions. However they are ineffective for transverse incisions and fail to provide analgesia from pain arising from surgical drains or stoma sites that are placed in the lateral abdominal wall. They often require the addition of parenteral opioids [3]. Wound catheters have recently gained popularity and are placed by the surgeon. They usually require the addition of morphine PCA to provide effective analgesia. Laparoscopic colorectal surgery: There is an on going trend away from epidural analgesia. The emerging options include intrathecal opioids, continuous rectus sheath analgesia, wound catheter infusion and continuous TAP analgesia. Continuous TAP analgesia and continuous rectus sheath analgesia can be used as a sole analgesic technique when compared to the other 2 techniques. Both techniques have a superior risk benefit ratio when compared to neuraxial techniques. We have recently completed the first study comparing continuous TAP analgesia with epidural analgesia for patients undergoing laparoscopic colorectal surgery.
Continuous TAP analgesia using 4 catheters: The authors do not recommend this technique unless the patient has contraindications for epidural analgesia as well as opioid analgesia and has a large incision extending from T6 to L1 dermatome. In conclusion, the authors believe that continuous TAP analgesia is an effective analgesic technique following abdominal surgery with a favourable risk benefit profile.
Acknowledgement The authors would like to sincerely thank Consultants in Colorectal Surgery and Consultants in Hepatobiliary Surgery at Leicester General Hospital for their wholehearted support for this audit.
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