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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 23
| Issue : 11 | Page : 1523-1529 |
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Analgesia for postoperative myomectomy pain: A comparison of ultrasound-guided transversus abdominis plane block and wound infiltration
O Osaheni, HO Idehen, CO Imarengiaye
Department of Anaesthesiology, University of Benin Teaching Hospital Benin City, Edo State, Nigeria
| Date of Submission | 22-Mar-2019 |
| Date of Acceptance | 29-Jun-2020 |
| Date of Web Publication | 21-Nov-2020 |
Correspondence Address:
C O Imarengiaye
Department of Anaesthesiology, University of Benin Teaching Hospital Benin City, Edo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njcp.njcp_162_19
 Abstract | | |
Background: Acute postoperative pain after myomectomy can impair patient function. Like all other postoperative pain, it is a challenge requiring solution, particularly in developing countries. Ultrasound-guided transversus abdominis plane (TAP) block and wound infiltration (WI) are both known to be effective in managing postoperative pain. It is not certain if transversus abdominis plain block would be superior to wound infiltration. Aims: It was hypothesized that the TAP block has similar analgesic effectiveness to wound infiltration. Subjects and Methods: This study was a randomized controlled trial involving, seventy-four (74) patients scheduled for myomectomy at the University of Benin Teaching Hospital Benin City, Nigeria under the subarachnoid block, which were randomized into TAP and WI group preoperatively. The ultrasound-guided bilateral TAP block group and wound infiltration group (subfascial and subcutaneous infiltration) each used 40 mL of 0.25% of plain bupivacaine to achieve postoperative analgesia. The time to first analgesic request, numerical pain rating scale (NRS) score at rest, and movement were assessed. Data were analyzed using SPSS version 16 (Chicago Il, USA). Results: The time to first analgesic request was significantly delayed in the TAP block group compared to the wound infiltration group [240 (131, 375) min vs 170 (128, 187) minutes. P = 0.006]. The proportions of patients with NRS score ≤3 at the time of first analgesic requests were significantly more in the TAP block group (P < 0.001). The analgesic consumed by the TAP block group was significantly low compared to the WI group. There were no incidences of complications due to TAP block or wound infiltration. Conclusion: TAP block provided a longer duration of analgesia and a clinically superior quality of analgesia to wound infiltration.
Keywords: Ultrasound-guided TAP block, wound infiltration, and post operative analgesia
How to cite this article:
Osaheni O, Idehen H O, Imarengiaye C O. Analgesia for postoperative myomectomy pain: A comparison of ultrasound-guided transversus abdominis plane block and wound infiltration. Niger J Clin Pract 2020;23:1523-9 |
How to cite this URL:
Osaheni O, Idehen H O, Imarengiaye C O. Analgesia for postoperative myomectomy pain: A comparison of ultrasound-guided transversus abdominis plane block and wound infiltration. Niger J Clin Pract [serial online] 2020 [cited 2022 Mar 6];23:1523-9. Available from: https://www.njcponline.com/text.asp?2020/23/11/1523/301143 |
| Introduction | |  |
Postoperative pain following myomectomy has both visceral and somatic components. The somatic component of pain experienced by these patients results from the abdominal wall afferent nerve that passes through the plane between the internal oblique and transversus abdominis muscles.[1] These afferents are important in myomectomy pain management because they are amenable to wound infiltration (WI) and transversus abdominis plane (TAP) block.
Effective post myomectomy pain relief leads to early mobilization, quick recovery, and shortened hospital stay.[2] However, post myomectomy pain like other postoperative pain is undertreated particularly in the developing countries where adequate pain management is affected by the limited availability of opioids, which is the mainstay of postoperative pain management.[3] Moreover, the use of appropriate doses of opioids is associated with side effects like respiratory depression, sedation, pruritus, nausea, and vomiting. Due to the problems associated with opioids, different approaches to pain management have been suggested to improve these patients' postoperative pain experience.[2],[3]
The multimodal strategy, which attempts to minimize these problems by combining the various modes of action of analgesics is the preferred method of pain management. The component of multimodal analgesia includes opioid and nonopioid analgesics. Wound infiltration and TAP block are some of the nonopioid local anesthetic (LA) components of multimodal analgesia. These two techniques are employed in postoperative pain control.[4]
Wound infiltration has been shown to improve postoperative analgesia in most surgeries.[5],[6] Similarly, the transversus abdominis plane (TAP) block provides analgesia in the postoperative period.[7],[8],[9],[10],[11],[12],[13] These two techniques block somatic afferents of the abdominal wall and improve pain control.
Wound infiltration is relatively cheaper, less expertise is involved in its administration, and it is less invasive compared to TAP block. It is, however, not clear if there is any difference in analgesic profile between the two despite the few reports that compared each with different methodologies.[14],[15] If the efficacy of wound infiltration is the same as the TAP block, it may be the preferred technique in multimodal postoperative pain management because of its cost-effectiveness and ease of administration. This study therefore aimed at evaluating the effectiveness of US-guided TAP block compared to wound infiltration as a component of postoperative pain management after myomectomy. It was hypothesized that there will be no difference in the time to first analgesic request between a patient that had wound infiltration and patients that had transversus abdominis plane block.
| Subjects and Methods | | |
This randomized clinical study was carried out between July 2016 and March 2017 at the University of Benin Teaching Hospital (UBTH) Benin City, Edo State, Nigeria after the approval of the Ethics and Research Committee of the hospital. The study population was drawn from consented American Society of Anesthesiologists (ASA) 1 or 2 patients scheduled for elective myomectomy. The primary outcome was time to first analgesic request. Sample Size was estimated from the result from the previous study, which showed that forty patients were required to demonstrate a mean difference of 174 min in the time to the first analgesic request after wound infiltration.[5] It was hoped that the transversus abdominis plane block would provide a 38% delay in the time to first analgesic request (240 min). Thirty-three patients were required per group to demonstrate this difference.[16] A ten percent loss of patients due to withdrawal and analgesic protocol violation was considered, and a total of seventy-four patients were recruited.
Patients who refused to participate in this study; patients with known allergy to bupivacaine; obese (BMI > 35 kg/m2) patients (potential technical difficulty); patients with weight below 50 kg; and patients with known contraindications to subarachnoid block were excluded from the study.
Randomization was done by blind balloting into the TAP block group and WI (wound infiltration) group. Patients were randomized using a folded labeled paper into two equal groups consisting of thirty-seven patients per group. They randomly picked their group from an opaque envelope, which contained seventy-four labeled white papers. Thirty-seven papers were written TAP (TAP group) while another thirty-seven had WI written on them (wound infiltration group). Group TAP received bilateral TAP block while group WI had post operative wound infiltration. Randomization was done while patients were in the preanesthetic room. The sealed envelopes bearing the group that the patient belonged to were given to a second anesthetist who was responsible for the coding and preparation of the study drug. Each patient was educated on the use and reporting of numerical pain rating score (NRS), nausea, vomiting score, and possible complications. They were encouraged to request for analgesic when NRS score exceeds 3 cm.
In the theater, monitoring was done according to the Harvard minimum standard. Baseline values were taken and recorded. Circulatory preload of 15 mL/kg of 0.9% saline was administered before initiation of the subarachnoid block. Subarachnoid block was done at L3–L4 interspace aseptically in the sitting position using 4 mL (15 mg) of 0.5% hyperbaric bupivacaine (Marcain AstraZeneca, North Ryde, Australia) and 15 mcg of fentanyl (Verve Human Care Laboratories, Ultarakhand, India) administered intrathecally. A block height of T6–T4 was required for the surgery.
The patient that complained of pain intraoperatively, or had a conversion to general anesthesia was excluded from the study. The duration of the SAB sensory block was taken as the time of the establishment of SAB to the time the sensory block regressed to T12.
At the end of the surgery, the SAB block height was recorded. Pain severity at rest and on knee flexion was measured using numerical pain rating score [NRS: A pain intensity measured from zero to 10 cm in which 0 indicated no pain, and 10 cm indicated the worst imaginable pain]. This initial NRS was regarded as a pain score at time zero.
Wound infiltration was done by the surgeon. The WI group had a subfascial (20 mL) and subcutaneous (20 mL) local anesthetic infiltration with 0.25% plain bupivacaine. Twenty milliliters of LA each were infiltrated 1 cm cephalad and caudal to the suture line. Subcutaneous infiltration was done using a similar method, volume, and concentration of LA after skin closure. Wound infiltration was done at an increment of 5 mL bolus after negative aspiration of blood to avoid intravascular injection.
Lateral TAP block approach was done for all patients in the TAP group immediately after skin closure with the patient lying supine on the operating table. All the TAP blocks were done by the primary investigator. The anterolateral abdominal wall was prepared aseptically with 2% chlorhexidine and 70% alcohol. For efficient transmission of ultrasound energy, an enhancing coupling gel was applied to a linear 7.5 MHz ultrasound probe (MLSPU24, Medsinglong, Guangzhou, China). This probe was positioned transversely on the anterolateral abdominal wall, midway on the midaxillary line cephalad to the iliac crest, and caudal to the costal margin. The view was considered satisfactory when the subcutaneous tissue, external oblique, internal oblique, transversus abdominis muscles, peritoneum, and intraperitoneal structures were clearly visualized.
A regional anesthetic needle (plexiform 20 G, 90 mm) attached with flexible tubing to a syringe filled with 20 mL of study drug was introduced obliquely in a gradual manner through the skin in the plane with the ultrasound beam into TAP. A second anesthetist served as an independent observer. He observed the ultrasound image and confirmed correct needle placement into TAP and also verified the spread of initial injection of 3 mL of study drug before any further injection into TAP was done. Subsequently, a total of 20 mL was injected into each TAP bilaterally at 5 mL boluses after repeated aspiration to avoid intravascular injection. An echolucent lens-shaped space within TAP was expected with a successful injection. A block height of T10–L1, thirty minutes from the injection of study drug was considered a successful block for the TAP group only.
At the completion of the procedure, patients were transferred to the postanesthetic care unit (PACU) where they were observed for thirty minutes before they were transferred to the ward. An independent investigator that was not aware of the group allocation and treatment assessed for time to first request for analgesia, sedation, nausea, the presence and severity of pain at rest and on movement (knee flexion) at the end of surgery (0), 30 mins, 2, 4, 6, 12, and 24 hours after TAP block and wound infiltration, respectively.
The time to first request for analgesia was defined as the time from the establishment of TAP block or WI to the time when the first analgesia was requested. Any patient that requested for analgesia was commenced on the hospital Obstetric and Gynecological Department (study center) postmyomectomy analgesic protocol, which consisted of intramuscular pentazocine 30 mg and intramuscular promethazine 12.5 mg every six hours, rectal diclofenac 50 mg every 8 hours, for twenty-four hours round the clock (RTC). However, intravenous pentazocine 30 mg start was offered to patients who still complained of pain on request (PRN). After the first twenty-four hours postoperatively, these patients were commenced on oral paracetamol 1 g 8 hourly and oral tramadol 50 mg 8 hourly. Patient satisfaction was assessed using the 4 point scale: dissatisfied, mildly satisfied, moderately satisfied, and fully satisfied. This study was limited to the first 24-hour postoperative period. Postoperative time was counted from the time the needle was completely withdrawn from the patient's abdominal wall after the successful conduct of bilateral TAP block or wound infiltration.
Data were analyzed using SPSS version 16 (Chicago Il, USA). Continuous data were summarized as mean, standard deviation, graph, and were compared with unpaired student's t-test (age, weight, height, duration of surgery, incision length, uterine size in centimeters, blood pressure, and heart rate). Discrete variables like the height of block, and satisfaction scale were reported as counts, percentages, charts, and comparison was done with Chi-square test or Fisher's exact test where appropriate. Data were tested for normality using the Kolmogorov–Smirnov normality test. Nonparametric data were presented as a graph, median, and interquartile range. Analysis of nonparametric data was done with the Mann–Whitney U test. A P value of less than 0.05 was considered significant.
| Results | | |
Eighty patients were recruited but seventy-four patients completed the study. These 74 patients were randomized into wound infiltration and TAP block group. Six patients were excluded from this study: three patients from each group. One patient from each group respectively was excluded on account of analgesic protocol violation while two others from both groups were also excluded because the anesthetic technique was converted from subarachnoid block to general anesthesia.
Sociodemographic and preoperative clinical characteristics of patients in this study are shown in [Table 1]. | Table 1: Socio-demographics and preoperative clinical characteristics of patients
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There was no difference in the baseline hemodynamic parameter; perioperative patients' characteristics (block height, incision length, blood loss, duration of surgery, and LA execution time)
The time to first analgesic request and NRS at rest and movement at the time of the first analgesic request is shown in [Table 2]. | Table 2: Time to first analgesic request and NRS at rest and movement at the time of first analgesic request
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[Table 3] shows the mean of total analgesic (mg) consumption in 24 hours by patients in both groups in the postoperative period.
[Table 4] shows the proportions of patients with NRS ≤ 3 at rest during the postoperative period. The two groups had similar proportions of patients with NRS at rest at various time of assessment (P > 0.05)
There was also no statistical difference in the proportion of patients with NRS ≤ 3 on movement at various times of assessment in the postoperative period except at the 2nd hour when the TAP block group had a significant proportion of patients with NRS ≤ 3{P = 0.007. [Table 5]}.
The proportion of patients with NRS ≤ 3 at the time of first analgesic request was significantly different between WI and TAP group [P < 0.001].
[Figure 1]a is a cluster box plot representing the postoperative 24-hour NRS at rest after analgesic intervention with WI or TAP block. The NRS scores were statistically similar (P > 0.05). The median NRS score on movement presented in [Figure 1]b was also similar between the two groups in the postoperative period (P > 0.05). | Figure 1: (a) Box plot of post operative NRS at rest (b) Box plot of post operative NRS on movement HRS: Hours; MOVT: Movement. Globally, P > 0.05
Click here to view |
There were no statistical differences between the two groups at any point in measurement of pulse rate, systolic, diastolic, and mean arterial blood pressure (P > 0.05). There were no reports of nausea and vomiting, local anesthetic toxicity, injury to organs during the TAP block.
The bars in [Figure 2] illustrate the grades of satisfaction in both groups. Although a moderate degree of satisfaction scores appears similar in both groups, patients were mildly and fully satisfied with TAP block control of postoperative pain compared to WI group (P = 0.004). None of the patients were dissatisfied with the pain control techniques (WI or TAP block).
| Discussion | | |
This study shows that transversus abdominis plane block provided superior analgesia when compared with wound infiltration as evidenced by delayed time to first analgesic request, low pain scores, and low mean total analgesic consumption in twenty-four hour. Patients in the TAP group expressed more satisfaction with the postoperative analgesia following the TAP block compared to the wound infiltration group. This improved analgesia was achieved with a low side effect profile.
The time to first request for analgesia by patients in the TAP block group was significantly prolonged compared to the wound infiltration group. This finding is in agreement with other studies.[17],[18] Amjad et al. reported a longer time to first analgesic requests in the TAP group compared to the WI group (472 ± 110 min versus 301 ± 157 min).[18] This observation should be treated with caution because the study population compared the heterogeneous population of patients from abdominal procedures. The lack of homogeneity could mean a great disparity in the intensity of pain. Abdominal surgeries are diverse with various degrees of pain. Thus, comparison of postoperative analgesic technique in nonhomogenous abdominal surgical procedures may not provide the desired information on the postoperative analgesia
Other authors have also established the superiority of TAP block over wound infiltration.[19],[20],[21] Vijayalakshmi and colleagues demonstrated the superiority of TAP block over WI in patients who had lower abdominal gynecological surgeries.[19] However, the reported mean time to first analgesic request when compared to the time to first analgesic request observed in this study is short (TAP group: 148 ± 46 min; WI group: 135 ± 38 min). The difference may have resulted from methodological approaches. They established TAP block prior to the surgical incision, whereas in this study it was done postoperatively after wound closure.
The time of administration of TAP block either preincision or post operatively seem to have a different outcome. McDonnell and colleagues also had a short time to first analgesic request.[21] A preincision landmark-guided TAP block was done after the induction of general anesthesia and patients required midline incision for the abdominal surgery. A higher degree of pain is expected from these surgeries compared to open myomectomy. Midline abdominal surgeries usually require sensory block height beyond T4, which the landmark-guided transversus abdominis block may not provide. These reasons could explain the source of variation of their result.
McDonnell et al.[22] investigated the analgesic efficacy of the TAP block administered after caesarean delivery. The time to first analgesic request was similar to that obtained from this study. The similarity may have resulted from the semblance of methodology. It may be too simplistic to assume that pain after cesarean delivery is akin to pain resulting from open myomectomy. Although the uterine incision is common to both surgeries, unlike cesarean delivery open myomectomy may require multiple uterine incision and manipulations to excise leiomyoma uteri.
Ghassan and colleagues[23] reported a similar duration in the time to first analgesic request with what was obtained in this study. However, they compared ultrasound-guided TAP block with subarachnoid morphine for postoperative analgesia after caesarean section that was performed under subarachnoid block. There were contrasting outcomes like the interquartile time to first analgesic request, VAS score up to the 4th hour although VAS score was similar thereafter. These differences may have resulted from the higher concentration of the local anesthetic agent that was administered and the use of additives. Bilateral TAP was done with 20 mL of plain bupivacaine 0.375% with 5 μg/mL of epinephrine. The addition of epinephrine delayed the absorption of the LA and prolonged the duration of the block. Nevertheless, the duration of the TAP block was not comparable to that of intrathecal morphine. This is because of the unique pharmacodynamics of morphine. Morphine has a long duration of action with somatic and visceral analgesic effects, unlike the TAP block, which provides only somatic analgesia.
The mean time to the first analgesic request after WI infiltration was similar to works by Ige and coworkers[5] (170 min vs 174 min). This may be due to similarity in methodology. Akin to this study, 20 mL of 0.25% plain bupivacaine each was administered into the subcutaneous tissue and subfacial plane. Conversely, the time to first analgesic request in WI group reported by Klein et al.[24] differs from our study. The differences in the technique of wound infiltration approach may explain variation in outcome. Klein and coworkers did a single plane wound infiltration (subcutaneous) compared to subfacial and subcutaneous wound infiltration that was done in this study.
Yu et al.[25] in a systematic review of four randomized control trials found early comparable analgesia profile between wound infiltration and TAP block. Nevertheless, the TAP block analgesic effect was observed to be of a longer duration. In a subsequent meta-analysis involving 15 randomized controlled trials,[26] TAP block was reported to have a consistent superior analgesic superiority over wound infiltration. This subtle difference resulted from the number of available randomized studies that were reviewed.
The mechanism for the superior analgesia from the transversus abdominis plane block is not quite clear. It has been speculated that analgesia may be associated with the delay in local anesthetic absorption from the transversus abdominis plane. It is believed that the TAP plane has poor blood supply compared to a subfascial and subcutaneous plane. Slow absorption of local anaesthetics leads to longer duration and better analgesic quality. These two factors are glaring when compared with placebo.
Gorkem and coworkers[27] suggested a postero-medial and cephald diffusion of local anesthetic along the fascial plane as a possible reason for the observed long duration of TAP block. The spread can extend into the thoracic region, quadratus lumborum muscular plane, and into the paravertebral plane, especially if the posterior approach to TAP is used.[28] Local anesthetic after lateral TAP blocks spreads from T7–L1 dermatome, unlike WI that is limited to the area of infiltration. Thus, further studies are required to determine the mechanism for the observed superior analgesia observed after TAP block compared to wound infiltration.
In the aforementioned studies, there were no reports of procedure-related complications similar to what was observed in this study. The direct vision that ultrasound-guided approach to TAP block provided, the precautionary measure adopted during TAP block, and the dose of local anaesthetics used in this study could be responsible for this result.
There was a significant difference in the degree of satisfaction expressed by patients about their pain control. Patients in the TAP block group were more satisfied with pain control compared to the WI group. Although a single point item scale does not fully capture the level of satisfaction, it demonstrates the importance of adequate patient education.[29]
Overall, this study is limited by its primary focus, which is to determine the effectiveness of TAP block compared to WI as a postoperative analgesia after lower abdominal surgery from a manageable homogenous patient population. As a part of the postoperative analgesia policy, it is expected, gleaning from this report, to be a basic component of protocol design for postoperative analgesia for lower abdominal surgeries.
In conclusion, this study demonstrated clinically and statistically that the TAP block provided superior postoperative analgesia compared to wound infiltration. Its use will be beneficial in a multimodal setting for postoperative pain management.
Financial support and sponsorship
Nil.
Conflicts of interest
There is none to declare.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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