|Year : 2016 | Volume
| Issue : 1 | Page : 20-24
Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study
Khaled Elbahrawy, Alaa El-Deeb
Department of Anesthesiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||17-Sep-2015|
|Date of Acceptance||22-Nov-2015|
|Date of Web Publication||15-Jun-2016|
Assistant Prof., Department of Anesthesiology, Faculty of Medicine, Mansoura University, Mansoura 5333
Source of Support: None, Conflict of Interest: None
Background The transversus abdominis plane (TAP) block is a relatively simple technique that may prove useful in the management of postoperative pain. It decreases the amount of intraoperative and postoperative opioid requirements after surgery. Caudal block is a gold standard technique in pediatric surgeries.
Patients and methods Seventy-five children aged 1–7 years with ASA I or II scheduled for day-case unilateral lower abdominal surgeries were randomly allocated to two groups: group C (caudal block) and group T (TAP block). Group C received caudal 0.25% bupivacaine at 1 ml/kg and group T received 0.25% bupivacaine at 1 ml/kg. Time to first analgesic request, total intraoperative fentanyl consumption, postoperative tramadol requirement, sedation level, parent satisfaction scores, pain score, postanesthetic care unit time and day-surgery unit time, and side effects were reported.
Results The two groups were comparable in terms of total intraoperative fentanyl consumed, postoperative tramadol requirement, postoperative pain scores, time to first administration of rescue analgesia, and postanesthetic care unit time. Children in the TAP group were discharged home significantly earlier than those in the caudal group (306.8 ± 18 vs. 259 ± 22.4 min with P < 0.001). More children in the caudal group experienced vomiting when compared with the other group. Parent satisfaction score was statistically significantly higher in the TAP group when compared with the caudal group [80 (70–90) vs. 95 (80–95) with P < 0.001].
Conclusion TAP block and caudal block provided adequate relief from postoperative pain after day-case unilateral lower abdominal surgeries in children. However, TAP block resulted in better parent satisfaction and earlier home discharge with fewer side effects when compared with caudal block.
Keywords: caudal block, day-case surgeries, transversus abdominis plane block
|How to cite this article:|
Elbahrawy K, El-Deeb A. Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study. Res Opin Anesth Intensive Care 2016;3:20-4
|How to cite this URL:|
Elbahrawy K, El-Deeb A. Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2017 Dec 14];3:20-4. Available from: http://www.roaic.eg.net/text.asp?2016/3/1/20/184080
| Introduction|| |
The transversus abdominis plane (TAP) block is an excellent option for relief from parietal pain in the postoperative period. It has been used effectively in cesarean section, appendicectomy, and laparoscopic cholecystectomy in both adult and pediatric patients. It might be a good alternative to epidural anesthesia . TAP block was found to increase the consumption of low thoracic-epidural analgesia in ischemic heart disease patients after abdominal laparotomy . Rao Kadam et al.  found that there are comparable results between continuous TAP technique and epidural analgesia with regard to pain, analgesic use, and satisfaction after abdominal surgery. The TAP block affords effective analgesia with opioid-sparing effects, technical simplicity, and long duration of action. Some disadvantages include the need for bilateral block for midline incisions and absence of effectiveness for visceral pain . TAP block has been associated with good pain relief and decreased intraoperative and postoperative opioid requirements after laparoscopic surgery . The analgesic efficacy of TAP block has been demonstrated in prospective, randomized trials compared with placebo, in different surgical procedures such as laparoscopic cholecystectomy, abdominal surgery, retro pubic prostatectomy, cesarean section, appendectomy, and hysterectomy ,,,,,. All these studies have reported superiority of the TAP block in terms of reduction in visual analogue scale scores and morphine consumption. In this study we try to compare TAP blocks with caudal block for postoperative pain control after lower abdominal surgeries in children.
| Patients and Methods|| |
After IRB approval seventy-five children aged 1–7 years with American Society of Anesthesiologists physical status (ASA) I or II scheduled for day-case unilateral lower abdominal surgeries were eligible for this randomized study. Children with allergy to amide local anesthetics or with a history of epilepsy were excluded from the study. Children were monitored by means of ECG, pulse oximeter, and noninvasive blood pressure. After preoxygenation for 3 min, anesthesia was induced with 8% sevoflurane inhalation in 60% oxygen and 40% air; 1 μg/kg fentanyl was administered intravenously. A laryngeal mask was then applied when conditions were satisfactory (relaxed jaw, absence of lash reflex, and no coughing, gagging, or swallowing). Anesthesia was maintained with 2% sevoflurane, nitrous oxide. Mechanical ventilation was maintained by pressure mode to keep end-tidal CO2 at 30–35 mmHg. After induction of general anesthesia, children were divided randomly through computer-generated codes into two groups: group C, comprising children who received caudal 0.25% bupivacaine at 1 ml/kg, and group T, comprising children who received TAP block with 0.25% bupivacaine at 1 ml/kg guided by ultrasound (US).
In group C, the sacral hiatus was identified using a US machine (Philips, Japan) while the child was in left lateral position with the upper hip flexed at right angle. A spinal 25-G needle was passed through the sacrococcygeal ligament to inject a local anesthetic. The tip of the needle or the spread of the local anesthetic was not visualized as sacrum impedes the travel of the US beam. An inadvertent intravascular injection was excluded by pop sign as the needle traverses the sacrococcygeal ligament.
In group T, while the child was in the supine position, an US was used to identify the plane between the internal oblique and transversus abdominis muscles. The local anesthetic was injected and visualized as a hypoechoic shadow separating the two layers.
An increase in blood pressure or heart rate by more than 15% from preoperative value was defined as insufficient analgesia and was treated with fentanyl 0.5 μg/kg. Saline dextrose 5% solution was infused at a dose of 12 ml/kg/h. Patients received rectal paracetamol at 15 mg/kg every 6 h postoperatively. Pain was assessed using the modified Children's Hospital of Eastern Ontario Pain Scale, where minimum score is 4 and maximum score is 13, at the postanesthetic care unit (PACU) at 2, 4, 6, 8, 10, 12, 18, and 24 h after surgery. Pain was assessed through telephone interview after hospital discharge. Tramadol at 1 mg/kg intravenously was the rescue analgesic given in the hospital if the modified Children's Hospital of Eastern Ontario Pain Scale score was greater than or equal to 6.
Children were transferred from the PACU to day-surgery unit (DSU) if they achieved a modified Aldrete score of 10. Children were discharged from the DSU if guidelines for safe discharge after ambulatory surgery were fulfilled .
Primary outcome measure was time for first analgesic request. Secondary outcome measures included total intraoperative fentanyl consumption, postoperative tramadol, sedation level, parent satisfaction scores, pain score, PACU time, and DSU time.
Sedation was assessed using a four-point sedation scale: 0 = eyes open spontaneously; 1 = eyes open to speech; 2 = eyes open when shaken; and 3 = unrousable. Parent satisfaction regarding postoperative analgesia was assessed using the visual analogue score, on a scale of 1–100.
By assuming an effect size of 0.5, the sample size was determined to be 33 in both groups using software G power 3.1.3. We added 10% considering dropouts. Thus, the final sample size was fixed as 36 in both groups. Data were statistically analyzed using the Excel program for figures and SPSS (IBM). Quantitative data were described as mean ± SD and qualitative data as frequency and proportion. Scores were represented as median and range. Data were analyzed to test statistically significant differences between groups.
The Student t-test was used to compare quantitative data between two groups; scores were compared using the MannWhitney test. The c 2-test was used for qualitative data. P values of 0.05 or less were considered significant at confidence interval 95%.
| Results|| |
Out of 75 children scheduled for day-case unilateral lower abdominal surgeries, 72 were randomized into two groups. One child dropped out in the T group because of failure to communicate after home discharge ([Figure 1]). Both groups were comparable in terms of age, weight, sex, duration, and type of surgery ([Table 1]).
No statistically significant differences were observed between the two groups in terms of total intraoperative fentanyl, postoperative tramadol, time to first administration of rescue analgesia, and PACU time ([Table 2]). Children in the TAP group were discharged home significantly earlier than those in the caudal group ([Table 2]).
Postoperative pain score was statistically comparable between the two groups ([Figure 2]). The incidence of vomiting was statistically significantly lower and parent satisfaction score was statistically significantly higher in the TAP group when compared with the caudal group ([Table 3]).
|Figure 2: Postoperative pain scale. Data are presented as median (range). DSU, day-surgery unit; PACU, postanesthetic care unit. P < 0.05, significant compared with group T.|
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| Discussion|| |
TAP block has many potential advantages and drawbacks. It is a simple and effective analgesic technique especially for surgeries, whereas pain is mainly parietal. Also, it is a good alternative analgesic technique when a neuraxial block is contraindicated. However, it is not useful in bilateral conditions .
Caudal epidural analgesia is a popular and reliable technique in lower abdominal surgeries in children. However, using additives to caudal analgesia in day-care anesthesia is controversial and not recommended .
This study found that caudal and TAP blocks in children undergoing day-case unilateral lower abdominal surgeries have comparable time to first analgesic request and postoperative pain scores. In accordance with these results, El Fawy and El Gendy  reported similar pain scale score between TAP and caudal blocks in children undergoing open pyeloplasty upon arrival at the PACU, at the time of discharge from the PACU, and 14 and 22 h postoperatively. However, they found significantly lower pain scores in the TAP block group compared with the caudal group at other time points postoperatively. They failed to explain this controversy.
Moreover, a study by Bryskin et al.  compared caudal and TAP blocks in children undergoing intravascular ureteral reimplantation. They observed similar analgesia up to 6 h postoperatively. In contrast to our results, they found superior analgesia from 6 to 24 h postoperatively to be associated with less opioid consumption. This conflict might be explained by differences in types of surgery and because of the fact that day cases did not spend much time in the hospital. Also, in this study, bladder spasms and discomfort due to urinary catheter constituted an essential component of postoperative pain, which did not exist in our patients.
Another study by Alsadek et al.  reported that TAP, when compared with caudal, provided low pain scores and less need for rescue analgesics from 6 to 12 h postoperatively. In our study, most of the children fulfilled the criteria of readiness for home discharge within 6 h postoperatively and pain assessment at home was done by the parent.
Our study showed that parents of children who had undergone a TAP block were more satisfied when compared with those who had undergone caudal. Our results are consistent with those of Alsadek et al.  who enrolled 60 children undergoing lower abdominal surgeries to receive either TAP block or caudal block or conventional analgesia. They concluded that better parent satisfaction was achieved with TAP block. However, the reasons for the better satisfaction might be different as Alsadek and colleagues attributed it to decreased rescue postoperative analgesia and lower pain scores and our study attributed it to fewer side effects and more rapid achievement of criteria for home discharge in children with TAP.
Cheon et al.  who compared caudal block with local infiltration in children undergoing inguinal herniorrhaphy noticed that children in the caudal group did not need rescue analgesic; however, in that study postoperative pain was assessed for 2 h only.
Also, a meta-analysis comparing caudal block with noncaudal regional techniques for inguinal surgeries in children  found that caudal block might be a better analgesic in early and late postoperative periods, but with a significant risk for motor block and urinary retention. Such complications may preclude early discharge for day-case surgeries.
A limitation of our study is the absence of a placebo-controlled group as it was not logical to ignore caudal as the golden regional anesthetic technique in children. Another limitation of our study is pain assessment by parents after hospital discharge. Safe early discharge of day-case surgeries was associated not only with better parent satisfaction but also with preservation of hospital resources.
| Conclusion|| |
TAP block and caudal block provided adequate relief from postoperative pain after day-case unilateral lower abdominal surgeries in children. However, TAP block resulted in better parent satisfaction and earlier home discharge with fewer side effects when compared with caudal block.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]