|Year : 2021 | Volume
| Issue : 1 | Page : 45-49
Low-cost techniques for bilateral intermittent transversus abdominis plane block using intravenous cannula following cesarean section
Syahrul Mubarak Danar Sumantri
Department of Anaesthesiology and Critical Care, Siloam Hospitals Jember, Jember, Indonesia
|Date of Submission||06-Aug-2020|
|Date of Decision||03-Sep-2020|
|Date of Acceptance||21-Sep-2020|
|Date of Web Publication||8-Feb-2021|
Dr. Syahrul Mubarak Danar Sumantri
Department of Anaesthesiology and Critical Care, Siloam Hospitals Jember, Jl. Gajah Mada No. 104, Jember, Jawa Timur 68131
Source of Support: None, Conflict of Interest: None
Transversus abdominis plane (TAP) block was developed as part of multimodal postoperative analgesia for cesarean section (CS) parturient. While continuous TAP block could provide satisfactory analgesia, the cost of the standard perineural catheters may limit its routine application. We present case reports of novel utilization of intravenous (IV) cannula as an alternative to the standard perineural catheters for postoperative intermittent TAP block. The results showed the feasibility and beneficial effect of IV cannula-facilitated TAP block in providing opioid-sparing postoperative acute pain management in CS parturient with minimal complication regarding its off-label application.
Keywords: Cesarean delivery, continuous transversus abdominis plane block, intravenous cannula, postoperative pain
|How to cite this article:|
Danar Sumantri SM. Low-cost techniques for bilateral intermittent transversus abdominis plane block using intravenous cannula following cesarean section. Bali J Anaesthesiol 2021;5:45-9
|How to cite this URL:|
Danar Sumantri SM. Low-cost techniques for bilateral intermittent transversus abdominis plane block using intravenous cannula following cesarean section. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Mar 1];5:45-9. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/45/308887
| Introduction|| |
Cesarean section (CS) is one of the major abdominal surgeries with significant postoperative discomfort and pain. Adequate postoperative pain management may improve early mobilization and self-maternal care of the newborn. However, anesthesiologists used to adapt conventional analgesic regimens of opioid administered intravenously rather than epidural analgesia due to strict Indonesian universal health coverage regulation. This practice led to many unwanted events such as sedation, nausea, and occasionally respiratory depression, not to mention prolonged bowel movement resumption that can lead to delayed postoperative oral intake. Nevertheless, paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are not sufficient to cover the pain alone.
Regarding these instances, interfacial plane trunk block-like transversus abdominis plane (TAP) block was developed to be additional armamentarium of multimodal analgesia following CS as alternatives to epidural analgesia. TAP block has long been appraised as an effective modality of multimodal analgesia following CS. The downsides of several studies regarding TAP block are its time-limited duration for a single-shot injection, yet for continuous one, it requires bilaterally implanted perineural catheters that are considered uneconomical, especially in developing countries like Indonesia.
While there is no specific consensus of preferred needle used for TAP block to date, it is not impossible for anesthesiologists to take advantage of the sheath from regular intravenous (IV) cannula to be left in situ, enabling intermittent administration of local anesthetics (LA) postoperatively in affordable costs. Throughout the extensive literature search, this report may be the first to address the feasibility of IV cannula as means for continuous TAP block following CS. Here, in this case report, we present our experience of three patients undergoing CS in which bilateral intermittent TAP block was successfully performed using IV cannula under ultrasound guidance.
| Case Report|| |
A 27-year-old female weighed 58 kg scheduled for elective CS under spinal anesthesia. She denied continuous epidural and fentanyl as part of multimodal analgesia but instead consented for bilateral continuous TAP block using IV cannula in consideration of limited expenses. She went an eventful perioperative period. The TAP block was performed bilaterally at the end of surgery using regular IV cannula. After confirming the correct position, the sheaths were left in situ and fixed at the lateral wall of the abdomen, followed by LA bolus of 20 ml for each side. On the pain scale of 0–10, the first 3-h dynamic pain score was two during postanesthesia care unit (PACU) admission. The bolus injection of LA was repeated every 8 h, providing dynamic pain scores 1–2 at the 1st and 2nd postoperative days. She was administered IV paracetamol 1 g, tramadol 50 mg, and ketorolac 20 mg twice, early after surgery and the next 6 h, followed by oral paracetamol 1 g, dexketoprofen 25 mg qid, and tramadol 50 mg as needed. No rescue analgesia was required during 2-day postoperative period.
A 30-year-old female weighed 66 kg scheduled for elective CS under spinal anesthesia. She experienced extreme nausea and vomiting during the previous CS postoperative period due to IV fentanyl; hence, she denied to be given such treatment. She refused epidural placement as well. The patient remained stable perioperatively and was administered TAP block bilaterally using regular IV cannula. The sheaths were left fixed and followed by LA bolus of 20 ml for each side. On the pain scale of 0–10, the first 3-h dynamic pain score was 1 during PACU admission. The bolus injection of LA was repeated every 8 h, providing dynamic pain scores 1–3 at the 1st and 2nd postoperative days. The patient was also given IV paracetamol 1 g, tramadol 50 mg, and ketorolac 20 mg twice, early after surgery and the next 6 h, followed by oral paracetamol 1 g, dexketoprofen 25 mg qid, and tramadol 50 mg as needed. The patient did not require rescue analgesia until the 2nd day postoperatively.
A 39-year-old female weighed 80 kg scheduled for elective CS under spinal anesthesia. She refused continuous epidural and fentanyl due to the limited expenses and agreed to be placed bilateral continuous TAP block using IV cannula as an alternative. She went an eventful perioperative period, and at the end of surgery, bilateral ultrasound-guided TAP blocks were placed using regular IV cannula. The sheaths were left in situ and followed by LA bolus of 20 ml for each side. On the pain scale of 0–10, the first 3-h dynamic pain score was one during PACU admission. The bolus injection of LA was repeated every 8 h, providing dynamic pain scores 1–3 at the 1st and 2nd postoperative days. She was given IV paracetamol 1 g, tramadol 50 mg, and ketorolac 20 mg twice, early after surgery and the next 6-h, followed by oral paracetamol 1 g, dexketoprofen 25 mg qid, and tramadol 50 mg as needed. No rescue analgesia was required during 2-day postoperative period.
Technique of block
Under strict aseptic technique, the author commenced ultrasound-guided TAP block in a supine position. The high-frequency 4–12 MHz L12-4s linear array probe (Mindray M7, Shenzhen, China) was placed at the axial plane of the abdomen exactly at the midaxillary line 2 cm above the height of spina iliaca anterior superior. Before needle insertion, the author evaluated the remaining height of sensory blockade from previous neuraxial anesthesia at the targeted level. With the remained sensory blockade bilaterally at the level of needle insertion in all of the patients, the author did not administer any skin LA infiltrations. Using the ultrasound-guided in-plane technique, the regular 16G 5.0-cm IV cannula (Terumo Surflo®, Japan) was inserted aiming precisely at the plane beneath the transversus abdominis fascia. Correct needle position was confirmed after a clear hydrodissection of the plane with 5 ml of normal saline followed by advancing needle toward the hydrodissected plane until the proximal hub of cannula stop at the level of punctured skin [Figure 1].
|Figure 1: (a) Probe positions and needle directions for lateral transversus abdominis plane block. (b) Ultrasound image of hydrodissection solution (Sol)|
deposited at the plane beneath the transversus abdominis fascia depressing the transversus abdominis muscle. The visibly three layers of muscle were external oblique muscle, internal oblique muscle, and transversus abdominis muscle. (c) Ultrasound image during intravenous cannula introducer being retracted, leaving the sheath in situ. Few centimeters of the sheath were visibly well placed at the correct plane. EOM: External Oblique Muscle, IOM: Internal Oblique Muscle, TAM: Transversus Abdominis Muscle
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After withdrawing the needle as depicted in Video 1, the cannula sheath left was once again injected with 5 ml of normal saline under ultrasound examination to exclude the event of catheter sheath dislodgement and kink. A 5-cm extension line was then attached to the proximal end of catheter sheath followed by in situ fixation using adhesive plaster. After confirming negative aspiration, an amount of LA was injected. The admixture of LA administered was lidocaine 0.8% +0.1 mg epinephrine (1:200,000) + 2.5 mg dexamethasone with total volume of 20 mL per side. A similar technique was performed on the contralateral side.
The cannula sheaths were examined daily for their function and any signs of infection at the entry points until removed on the 3rd day postoperatively. There were no signs of infection at the entry points on all of the patients. There were no reports of a dislodged cannula or difficult bolus injection during the postoperative period.
| Discussion|| |
Postoperative pain following CS may hinder early ambulation and limit mothers from nursing their newborn baby and hence require more attention from the attending anesthesiologist. Multimodal analgesia that has been strongly recommended by the enhanced recovery after surgery society for CS comprises intrathecal long-acting opioids, NSAIDs, paracetamol, and/or peripheral nerve blockades (PNBs). PNBs for the postoperative CS mothers, ranging from local infiltrative, TAP block to quadratus lumborum block (QLB), seem promising in several studies.
While a single-shot QLB may provide satisfactory pain control for CS patients for as long as 48 h postoperatively, significantly longer than the TAP block, the properly placed perineural catheter may enable anesthesiologists to administer a continuous or intermittent bolus of LA and hence ensure longer yet consistent sensory blockade both for QLB and TAP block; thus, a reduced opioid demand can be expected. On the other hand, continuous PNB is quite challenging to be generally applied in developing countries like Indonesia, where the government's National Health Insurance System involves tight budgeting for CS procedure.
High-priced nerve-block needles, including their perineural catheters, render local anesthesiologists toward various cheaper options from intermittent IV long-acting opioids to oral synthetic opioids, parallel with the recommendation of practice that mentions none of any truncal interfacial block as part of multimodal analgesia for postoperative CS.
Incomplete visceral pain blockade is often addressed as the main downside of truncal interfacial block application for analgesia after abdominal surgery. Still, on the contrary, the CS has an insignificant difference of visceral pain compared with vaginal delivery, indicating mild pain, and thus can be effectively treated by NSAIDs., Instead of its visceral nature, postoperative moderate-to-severe pain at movement in the CS parturient is rather classified as the somatic pain arising from the incisional wound which is supplied by the anterior divisions of T10-L1 spinal segmental nerves – for a Pfannenstiel incision – which travel laterally within the abdominal wall underneath the fascia covering the transversus abdominis muscle., The previous statement explains the promising pain relief caused by voluntary movement in the first 48 h postoperatively with significantly decreased morphine consumption by TAP block.
Although having similar potential, the QLB and TAP block has a different anatomical endpoint. Unlike the QLB that delivers LA inside the middle layer of the thoracolumbar fascia close to the lateral interfascial triangle, the TAP block allows LA spread underneath the fascial plane between the internal oblique and transversus abdominis muscles. Considering its nature as a deep interfascial plane block with a prominent risk of retroperitoneal hematoma related to the high vascularity and risk of limb weakness, QLB needed careful attention, especially preferred usage of blunt tip nerve block needle.,, Hence, with a limited expense of the patients, using IV cannula, the author preferred TAP block rather than the QLB. The lateral TAP block was chosen as it provides enough sensory block for a Pfannenstiel incision yet does not render difficulties in catheter fixation as estimated from the posterior approach.
These three cases signify the feasible application of IV cannula to deliver intermittent LA bolus resembling the characteristics of the original over-the-needle perineural catheters. The indwelling IV cannula allows effective LA deposition into TAP for 48 h after surgery indicated by satisfying dynamic pain control with a maximum score of 3 [Table 1]. All three patients did not request additional rescue analgesia with the initial two dosages of 50 mg IV tramadol as the only opioid administered during the perioperative period.
|Table 1: Individual patient-reported dynamic pain scores, rescue analgesia, and adverse events during postanesthesia care unit stay and postoperative admission|
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The utilization of ultrasound with a careful guard on needle shaft and tip visibility during TAP block in these three cases leads to zero accidental vascular and visceral organ puncture. Anticipating minimal tactile sensation during fascial pierce while using this sharp, regular-beveled IV cannula, the author applied frequent hydrodissection of normal saline to ensure the correct plane placement of needle tip before withdrawing the needle stylet leaving cannula in situ.
None of the IV cannula catheters in these cases had skin adhesive glue applied, yet no leak of LA solution was discovered during bolus injections by ward midwives. No cannula dislodgement has occurred despite the active mobility of parturients, with a single event of the kinked cannula at the proximal level next to the hub [Figure 2]. Still, nevertheless, it remained functional with no leakage nor difficulties in injecting a further bolus of LA. Eventually, assessment of anticipated adverse events resulted in the absence of hematoma, and no signs of indwelling catheter-related infection (erythema, swelling, or pain at the puncture site) were observed.
|Figure 2: (a) Postprocedural image showing intravenous cannula sheath fixation and relative position to the incision. (b) Patient no. 3 left-sided intravenous sheath kinked at the proximity of the hub|
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Compared to the experience utility of dedicated nerve block needle, the author deemed IV cannula has poor needle visibility under ultrasound; hence, frequent retreat-and-rock repositioning of the probe was required until the needle has parallel and less acute angle related to the ultrasound beam. This instance may lead to the significantly longer time needed to complete the TAP block than routine practice with a dedicated nerve block needle. The average time of the procedure was 246 s for each side of TAP blocks.
Despite its promising results, there are limitations in this case series. As a preliminary case reports in IV cannula application for intermittent TAP block, we were unable to confirm its difference nor lack of difference with standard nonregional anesthesia pain management, as well as its potential adverse event. The author did not perform any specific examination other than visible evaluation of kinked or pulled-out catheter. As the procedure was an off-label application, further study should include routine preinjection ultrasound scanning to rule out any possibility of catheter migration outside the desired abdominal plane. The skin-to-TAP depth was not measured in all patients. With the nature of catheter's limited length and stiff material, a steeply angled needle insertion due to increased depth, particularly in morbidly obese patients, may leave the attending anesthesiologist with kinked catheters and a low ratio of TAP to skin catheter length resulting in the possible high rate of catheter migration and block failure. However, there may be some advantages for its opioid-sparing nature, low rate of dislodgement, and LA leak based on our routine practice. Ultrasonography is paramount in the application of this sharp-tip IV cannula needle to avoid any unwanted vascular and organ puncture.
| Conclusion|| |
Our results using regular IV cannula for bilateral intermittent TAP block signify its feasibility and beneficial effect in providing opioid-sparing postoperative acute pain management in CS parturient with minimal complication, however, further research is needed to clarify this.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]