Header bg
  • Users Online: 196
  • Print this page
  • Email this page
Header bg


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 39-41

Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section


1 Department of Anaesthesiology, Sakra World Hospital, Bengaluru, Karnataka, India
2 Department of Anaesthesiology, 4 Air Force Hospital, Kalaikunda, West Bengal, India

Date of Submission22-Jan-2020
Date of Decision29-Feb-2020
Date of Acceptance06-Mar-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. K Raghu
Department of Anaesthesiology, 4 Air Force Hospital, Kalaikunda, West Midnapore, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_4_20

Rights and Permissions
  Abstract 

Background: Pain relief after cesarean section is essential for the early mobilization of the mother and proper care of the newborn. Among the several modalities available,transverse abdominis plane (TAP) block is newer and attractive. This study aims to compare the efficacy of TAP block compared to sodium diclofenac-acetaminophen combination for postoperative pain following cesarean section. Patients and Methods: Sixty patients undergoing elective cesarean section were included and divided into two groups: Group A received TAP block with 20 ml of 0.25% bupivacaine and Group B received 100 mg diclofenac suppositories followed by intravenous 1 g acetaminophen every 8 h. Participants were assessed for the severity of pain at 0, 4, 8, 12, 24, 36, and 48 h after surgery using the Numeric Rating Scale, the time of first demand for rescue analgesia, and total consumption of rescue analgesia. Results: Pain scores were lower at each point of time during 48 h in Group A as compared to Group B. Time of the first analgesia was statistically significantly longer (7.93 ± 0.70 vs. 4.47 ± 1.36;P < 0.001), and total consumption of rescue analgesia was also lower in Group A (78.13 ± 39.66 mg vs. 140.79 ± 40.15 mg;P < 0.001). Conclusion: TAP block was effective in controlling postoperative pain following cesarean section with a significant reduction in the use of rescue analgesia and their side effects.

Keywords: Bupivacaine, management, pain, regional anesthesia


How to cite this article:
Mohanan N, Raghu K. Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section. Bali J Anaesthesiol 2020;4:39-41

How to cite this URL:
Mohanan N, Raghu K. Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Jul 9];4:39-41. Available from: http://www.bjoaonline.com/text.asp?2020/4/2/39/284183


  Introduction Top


Cesarean section is one of the commonly performed surgical procedures in the field of obstetrics. It accounts for more than one-fourth of all births worldwide.[1] The most common undesirable outcome following cesarean section is postoperative pain. Failure to treat the pain not only causes distress to the mother but also affects mother-baby bonding, which, in turn, affects care and breastfeeding of the newborn.[2]

Several modalities are available to combat the pain after cesarean section which includes parenteral or neuraxial opioids, parenteral nonsteroidal anti-inflammatory drugs (NSAIDs), and regional anesthesia techniques such as epidural analgesia.[3] No single modality is utterly effective in relieving postoperative pain and has their own limitations. Opioids, even though effective against both somatic and visceral components of pain, are associated with side effects such as nausea, vomiting, pruritus, constipation, and respiratory depression.[4] NSAIDs have fewer side effects compared to opioids but alone may be insufficient to treat pain.[5] Epidural analgesia provides quality of pain relief without any sedation, but it may cause complications such as hypotension, urinary retention, and muscle paralysis.[6]

Considering the complications associated with the above methods, there has been a recent trend toward a less invasive but effective method for pain relief. transverse abdominis plane (TAP) block is one such method which acts by blocking afferent impulse from T6 to L1. The main advantage of TAP block is safe, easy to perform, and devoid of complications such as bradycardia, hypotension, vomiting, immobility, sedation, and urinary retention. With the availability of Ultra sonography (USG), the safety and success rate of the block has increased many folds.[7] This study was conducted to compare the efficacy of TAP block and sodium diclofenac-acetaminophen combination for postoperative pain following cesarean section.


  Patients and Methods Top


This study was conducted at a tertiary care hospital during the period from October 2016 to September 2017. The Institutional Ethical Committee approval was obtained before the commencement of the study. This study involved 60 parturients belonging to the American Society of Anesthesiologists (ASA) physical Status I and II posted for elective cesarean section. Patients with a history of allergy to a local anesthetic, infection at the block site, bleeding disorders, history of neurologic or psychiatric disease, history of active liver or renal disease, and patient refusing to give consent were excluded from the study.

Patients were divided into two groups of thirty. Group A received subarachnoid block (SAB) with 0.5% bupivacaine heavy 2.5 ml, and USG-guided TAP block using 20 ml of 0.25% bupivacaine on either side of the abdomen, immediately in the recovery room. Group B received SAB with 0.5% bupivacaine heavy 3.0 ml and sodium diclofenac 100 mg suppositories and paracetamol 1 g every 8 h after surgery.

On the day of surgery, all patients received 500 ml Ringer's lactate solution. Standard ASA monitoring was applied. Under strict asepsis and local anesthetic infiltration in the sitting position using the midline approach, the dural puncture was carried out at L3–L4 level and bupivacaine heavy 0.5% 2.5 ml was injected intrathecally. Hemodynamics was monitored and treated accordingly. Postoperatively, respective groups received their analgesic modalities and were observed in the postoperative room. Each patient was assessed for the severity of pain at 0, 4, 8, 12, 24, 36, and 48 h after the surgery using the Numeric Rating Scale of 0–10. We used tramadol 1 mg/kg as rescue analgesia when the pain score reached >4. They were also assessed for the time of first demand for rescue analgesia and total consumption of rescue analgesia.

The sample size was calculated using STATA 10 StataCorp LLC. STATA Statistical software for data science for windows, Version 10, (Texas, USA) package on the basis of postulated difference of 10% between the study and control group. Student's t-test (two-tailed, independent) was used to find the significance of study parameters on a continuous scale between the two groups on metric parameters. P < 0.05 was considered statistically significant.


  Results Top


Sixty female patients, of the reproductive age group, of ASA Grade I and II, undergoing lower segment cesarean section under SAB were included. Participants were divided into two groups of thirty, where Group A received TAP block, and Group B received a combination of suppository sodium diclofenac and intravenous paracetamol.

The two groups were similar for age, weight, and height [Table 1]. Mean pain score immediately after the surgery was similar in both the groups (2.01 ± 1.14 vs. 2.10 ± 0.30; P = 0.728). The mean pain scores at 0, 4, 8, 12, 24, 36, and 48 h after surgery were comparatively low in Group A and were statistically significant [Table 2]. The time needed for the patients to require the first dose of rescue analgesia was statistically significantly longer in Group A (7.93 ± 0.70 vs. 4.47 ± 1.36; P < 0.001). The total consumption of rescue analgesia was also lower in Group A (78.13 ± 39.66 vs. 140.79 ± 40.15; P < 0.001), as shown in [Table 3].
Table 1: Demographic data

Click here to view
Table 2: Mean pain scale as per numeric rating scores (mean±standard deviation)

Click here to view
Table 3: Rescue analgesic profiles comparison between the study groups

Click here to view



  Discussion Top


Pain is one of the most commonly faced complications during the postoperative period. The effects of pain are not only limited to the mother but also affects the newborn as it interferes with nursing care. Hence, pain relief not only relieves the physical distress of the mother but also improves the quality of care of the newborn.

Pain relief offered to mother should be safe, effective, and devoid of complications because excessive or inadequate pain relief has an impact on both the mother and the baby.[8] Many modalities are available for the control of postoperative pain, which includes systemic or neuraxial opioids, NSAIDs, and epidural analgesia. These methods have their own complications.

Currently, there is a trend toward the methods which are more effective but are having fewer side effects. TAP block is one such method with excellent efficacy in controlling pain after a variety of abdominal surgeries. TAP is a neurovascular plane located between the internal oblique and transverse abdominal muscles where nerves supplying anterior abdominal wall pass through. TAP block acts by blockage of nerve impulses by local anesthetic, which is deposited in the space between above-said muscles.[7] It was introduced in anesthesia practice by Rafi in 2001, and the USG -guided approach was first described in 2007 by Hebbard et al.[9],[10]

In this study, we compared the TAP block with the conventional analgesic regimen in controlling the postoperative pain relief in patients undergoing cesarean section. We found that in patients given TAP block, the pain score and consumption of rescue analgesics were low at any given time.

We found out that the pain scores were significantly low in patients receiving TAP block when compared to the conventional analgesia at any point of the time during the first 48 h. This is comparable to the study by Sharma et al.[11] who compared pain relief of TAP block to the systemic analgesic regimen in patients undergoing major abdominal surgeries. They concluded that the TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery without any complications. Similar results were observed in a study conducted by Naveen et al.[12] and Kahsay et al.[13]

The time for the first demand for rescue analgesia is prolonged in TAP block compared to the conventional analgesia. This was comparable to the study done by Naveen et al.[12] and Srivastav et al.[14] where the conventional group requested earlier rescue analgesia.

The total consumption of the rescue analgesic was low in TAP block when compared to the conventional group which was comparable to the study done by Kahsay et al.[13] and Srivastav et al.[14] They reported as much as 50% less use of opioids in the TAP block. This has an important implication in postoperative care as less use of opioids means less incidence of opioid-related side effects.


  Conclusion Top


The TAP block provided effective and prolonged postoperative analgesia compared to the combination of sodium diclofenac-paracetamol with less requirement of rescue analgesic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mittal S, Pardeshi S, Mayadeo N, Mane J. Trends in cesarean delivery: Rate and indications. J Obstet Gynaecol India 2014;64:251-4.  Back to cited text no. 1
    
2.
Leung AY. Postoperative pain management in obstetric anesthesia–new challenges and solutions. J Clin Anesth 2004;16:57-65.  Back to cited text no. 2
    
3.
Kwok S, Wang H, Sng BL. Post-caesarean analgesia. Trends Anaesth Crit Care 2014;4:189-94.  Back to cited text no. 3
    
4.
Dualé C, Frey C, Bolandard F, Barrière A, Schoeffler P. Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section. Br J Anaesth 2003;91:690-4.  Back to cited text no. 4
    
5.
Lowder JL, Shackelford DP, Holbert D, Beste TM. A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage. Am J Obstet Gynecol 2003;189:1559-62.  Back to cited text no. 5
    
6.
Chen LK, Lin PL, Lin CJ, Huang CH, Liu WC, Fan SZ, et al. Patient -controlled epidural ropivacaine as a post-cesarean analgesia: A comparison with epidural morphine. Taiwan J Obstet Gynecol 2011;50:441-6.  Back to cited text no. 6
    
7.
Mankikar MG, Sardesai SP, Ghodki PS. Ultrasound-guided transversus abdominis plane block for post-operative analgesia in patients undergoing caesarean section. Indian J Anaesth 2016;60:253-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Kerai S, Saxena KN, Taneja B. Post-caesarean analgesia: What is new? Indian J Anaesth 2017;61:200-14.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia 2001;56:1024-6.  Back to cited text no. 9
    
10.
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616-7.  Back to cited text no. 10
    
11.
Sharma P, Chand T, Saxena A, Bansal R, Mittal A, Shrivastava U. Evaluation of postoperative analgesic efficacy of transversus abdominis plane block after abdominal surgery: A comparative study. J Nat Sci Biol Med 2013;4:177-80.  Back to cited text no. 11
    
12.
Naveen S, Singh RK, Sharma PB, Anne S. Evaluation of transversus abdominis plane block for postoperative analgesia after lower segment cesarean section. Karnataka Anaesth J 2017;3:41-4.  Back to cited text no. 12
  [Full text]  
13.
Kahsay DT, Elsholz W, Bahta HZ. Transversus abdominis plane block after Caesarean section in an area with limited resources, Southern African. J Anaesth Analg 2017;23:90-5.  Back to cited text no. 13
    
14.
Srivastava U, Verma S, Singh TK, Gupta A, Saxsena A, Jagar KD, et al. Efficacy of trans abdominis plane block for post cesarean delivery analgesia: A double-blind, randomized trial. Saudi J Anaesth 2015;9:298-302.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed219    
    Printed23    
    Emailed0    
    PDF Downloaded52    
    Comments [Add]    

Recommend this journal