Scribd Logo
Upload

Welcome to Scribd!

  • 4 views

    IndianJPain 2021 35 3 254 334102

    Uploaded by

    manoj maji
    This letter discusses using a four-quadrant transverse abdominis plane (TAP) block for postoperative analgesia in two patients who underwent major abdominal surgery when conventional neuraxial blockade was not feasible. The block involves inserting four catheters under ultrasound guidance before extubation to provide long-acting local anesthesia in the postoperative period. Both patients experienced adequate pain control and were able to mobilize early with satisfaction scores of 9 out of 10 and no difficulty in recovery. The four-quadrant TAP block is presented as an effective alternative to epidural analgesia for large abdominal incisions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    IndianJPain 2021 35 3 254 334102

    Uploaded by

    manoj maji
    4 views3 pages
    This letter discusses using a four-quadrant transverse abdominis plane (TAP) block for postoperative analgesia in two patients who underwent major abdominal surgery when conventional neuraxial blockade was not feasible. The block involves inserting four catheters under ultrasound guidance before extubation to provide long-acting local anesthesia in the postoperative period. Both patients experienced adequate pain control and were able to mobilize early with satisfaction scores of 9 out of 10 and no difficulty in recovery. The four-quadrant TAP block is presented as an effective alternative to epidural analgesia for large abdominal incisions.

    Original Title

    IndianJPain_2021_35_3_254_334102

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This letter discusses using a four-quadrant transverse abdominis plane (TAP) block for postoperative analgesia in two patients who underwent major abdominal surgery when conventional neuraxial blockade was not feasible. The block involves inserting four catheters under ultrasound guidance before extubation to provide long-acting local anesthesia in the postoperative period. Both patients experienced adequate pain control and were able to mobilize early with satisfaction scores of 9 out of 10 and no difficulty in recovery. The four-quadrant TAP block is presented as an effective alternative to epidural analgesia for large abdominal incisions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4 views3 pages

    IndianJPain 2021 35 3 254 334102

    Uploaded by

    manoj maji
    This letter discusses using a four-quadrant transverse abdominis plane (TAP) block for postoperative analgesia in two patients who underwent major abdominal surgery when conventional neuraxial blockade was not feasible. The block involves inserting four catheters under ultrasound guidance before extubation to provide long-acting local anesthesia in the postoperative period. Both patients experienced adequate pain control and were able to mobilize early with satisfaction scores of 9 out of 10 and no difficulty in recovery. The four-quadrant TAP block is presented as an effective alternative to epidural analgesia for large abdominal incisions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Volume 35 | Issue 3 | September-December 2021

    PAIN
    Spine 3mm
    Indian Journal of Pain • Volume 35 • Issue 3 • September-December 2021 • Pages ****-****
    Letter to the Editor

    Four‑Quadrant Transverse Abdominis Plane Block: A Relatively


    New Frontier for Postoperative Analgesia after Major
    Abdominal Surgery
    Sir, nerves that must be blocked to provide analgesia for large
    abdominal incision poses significant problems in the search for
    Postoperative pain after major abdominal surgery is a challenge
    suitable regional anesthesia techniques. The abdominal wall is
    to treat effectively balancing the benefits and side effects of
    supplied by the lower six thoracic and upper two lumbar sensory
    the technique used. On one side adequate pain control is not
    nerves, either through extensions of the intercostal branches
    only the patient’s right but a requirement to prevent detrimental
    or, for the more caudal nerves, through the musculature of the
    effects on the recovery leading to morbidity as well as to prevent
    abdominal wall. Intraoperative analgesia was maintained with
    the persistent or chronic postsurgical pain syndrome recently
    infusion of fentanyl in our patients. In our institute, epidural
    getting favorable response is ultrasound‑guided (USG) truncal
    analgesia would be the method of choice but in these cases,
    blocks. Transverse abdominis plane (TAP) block provides an
    because it was not feasible, we had to look for alternative
    alternative to epidural analgesia, specifically in cases where
    way to achieve good analgesia in the postoperative period.
    putting an epidural catheter is contraindicated or not feasible With epidural analgesia and nonsteroidal anti‑inflammatory
    such as infection at the site of insertion, sepsis, coagulopathy, drugs (NSAIDs) (massive blood loss, around 5 l in both
    or fixed cardiac output states.[1] The four‑quadrant TAP block cases) not an option, and growing evidence supporting the
    has recently gain popularity in open as well as laparoscopic effectiveness of TAP blocks for various types of abdominal
    abdominal surgeries and found to be an effective tool of surgeries, a “Four‑quadrant TAP block” was thought as a good
    postoperative analgesia similar to thoracic epidural analgesia.[2] option. Subcostal TAP block is effective for upper abdominal
    Levobupivacaine local anesthetic is generally well tolerated surgery where the surgical incision extends from T6 to T10
    except that a dose adjustment may be needed in the elderly. dermatomes. Posterior TAP block is effective in providing
    Levobupivacaine is a long‑acting local anesthetic with analgesia after lower abdominal surgery where the incision
    a clinical profile closely resembling that of bupivacaine. extends from T10 to L1 dermatomes. Before extubation, under
    However, current safety and toxicity data show an advantage GA, USG‑guided four‑quadrant TAP blocks were performed
    for levobupivacaine over bupivacaine because it is less and four catheters were inserted and tunneled [Figure 1].
    cardiotoxic.[3,4] About 15 ml of 0.2% levobupivacaine was given every
    eight hourly through each catheter for 4 consecutive days.
    We hereby wish to share, postoperative analgesia management The pain was assessed by our acute pain service team in the
    in two patients who underwent major abdominal surgery postoperative period. As part of multimodal analgesia, both
    where conventional neuraxial blockade was a dilemma. First, received paracetamol 8 hourly for 4 days, tramadol 8 hourly
    a 65‑year‑old female known case of hypertension, diabetes, and for first 24 h following surgery, and single dose of NSAIDs on
    hypothyroid, who underwent inferior vena cava (IVC) sarcoma POD 2 and 3 for first case only. Worst numerical rating scale
    excision. The tumor mass on computerized tomography scan
    was 14 cm × 9.3 cm × 8.4 cm arising from intrahepatic IVC,
    encasing the descending aorta with angle of contact >180°
    with a filling defect noticed in the right external and internal
    iliac and right common femoral vein suggestive of thrombus.
    Furthermore, Doppler USG was suggestive of acute thrombus
    involving right external iliac vein, common femoral vein, a b
    and superficial femoral vein. Preoperatively, she was started
    on therapeutic dose of enoxaparin, with an advice to restart
    enoxaparin again on 1st postoperative day (POD).
    The second case was a 55‑year‑old male who underwent
    retroperitoneal sarcoma resection, iliofemoral artery, and vein
    c d
    reconstruction, left ureterolysis with DJ stenting, and required
    intraoperative as well as postoperative anticoagulation. Figure 1: a) Image showing ultrasound anatomy of subcostal transverse
    abdominis plane (TAP), b) needle between posterior rectus sheath and
    Surgical incision in both patients was extending from transverse abdominis muscle, c) needle insertion for TAP block; and d)
    xiphisternum to pubic symphysis. The extensive origin of the four catheters for four-quadrant TAP block

    254 © 2021 Indian Journal of Pain | Published by Wolters Kluwer - Medknow


    Letter to the Editor

    pain scores was 2 at rest and 3 on movement in first case and References
    3 at rest and 4 on movement in the second case, sedation and 1. Vadhanan P, Hussain M, Prakash R. The subcostal nerve as the target
    nausea score was 0 in the first 72 h postoperatively the patients for nerve stimulator guided transverse abdominis plane blocks – A
    had no difficulty in performing respiratory rehabilitation and feasibility study. Indian J Anaesth 2019;63:265‑9.
    mobilization in the postoperative period. The TAP catheters 2. Cata JP, Fournier K, Corrales G, Owusu‑Agyemang P, Soliz J, Bravo M,
    were removed on POD 4 and both patients were discharged on et al. The impact of thoracic epidural analgesia versus four quadrant
    transversus abdominis plane block on quality of recovery after
    POD 6. Patient satisfaction scores were found to be 9 out of
    cytoreductive surgery with hyperthermic intraperitoneal chemotherapy
    10. One of the drawbacks of TAP block is that it does not cover surgery: A single‑center, noninferiority, randomized, controlled trial.
    visceral pain. Almost 75%–80% of the pain after abdominal Ann Surg Oncol 2021;28:5297‑310.
    surgery is somatic in origin[5] and furthermore the proportion 3. Foster RH, Markham A. Levobupivacaine: A review of its pharmacology
    of visceral pain reduces after 24 h. In both the cases, visceral and use as a local anaesthetic. Drugs 2000;59:551‑79.
    4. Heppolette CA, Brunnen D, Bampoe S, Odor PM. Clinical
    component was not thought to be a major problem.
    pharmacokinetics and pharmacodynamics of levobupivacaine. Clin
    The four‑quadrant TAP block helps in providing analgesia Pharmacokinet 2020;59:715‑45.
    5. Venkatraman R, Saravanan R, Dhas M, Pushparani A. Comparison
    to the entire anterior abdominal wall including the parietal
    of laparoscopy‑guided with ultrasound‑guided subcostal transversus
    peritoneum.[6,7] Care must be taken removal of these catheters abdominis plane block in laparoscopic cholecystectomy – A prospective,
    as truncal blocks such as rectus sheath catheter can get randomised study. Indian J Anaesth 2020;64:1012‑7.
    entangled on itself and lead to knotting and need intervention.[8] 6. Bhatia P, Bihani P, Chhabra S, Sharma V, Jaju R. Ultrasound‑guided
    bilateral subcostal TAP block for epigastric hernia repair: A case series.
    In summary, the four‑quadrant TAP block has a role in managing Indian J Anaesth 2019;63:60‑3.
    postoperative pain following major abdominal surgeries with 7. Niraj G, Kelkar A, Hart E, Horst C, Malik D, Yeow C, et al. Comparison
    extended surgical incision as part of a multimodal analgesic of analgesic efficacy of four‑quadrant transversus abdominis plane (TAP)
    plan, especially with the current evidence of epidural analgesia block and continuous posterior TAP analgesia with epidural analgesia
    in patients undergoing laparoscopic colorectal surgery: An open‑label,
    no longer remaining the gold standard. randomised, non‑inferiority trial. Anaesthesia 2014;69:348‑55.
    Declaration of patient consent 8. Doctor JR, Solanki SL, Bakshi S. Knotty Catheter! – An unusual
    complication of rectus sheath block. Indian J Anaesth 2019;63:947‑8.
    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 This is an open access journal, and articles are distributed under the terms of the Creative
    Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix,
    understand that their names and initials will not be published tweak, and build upon the work non-commercially, as long as appropriate credit is given and
    and due efforts will be made to conceal their identity, but the new creations are licensed under the identical terms.
    anonymity cannot be guaranteed.
    Access this article online
    Financial support and sponsorship Quick Response Code:
    Nil. Website:
    www.indianjpain.org
    Conflicts of interest
    There are no conflicts of interest.
    DOI:
    10.4103/ijpn.ijpn_44_21
    Pankaj Singh Rana, Reshma P Ambulkar, Manoj Maji, Sohan Lal Solanki
    Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital,
    Homi Bhabha National Institute, Mumbai, Maharashtra, India
    How to cite this article: Rana PS, Ambulkar RP, Maji M, Solanki SL.
    Four-quadrant transverse abdominis plane block: A relatively new frontier
    Address for correspondence: Dr. Pankaj Singh Rana,
    for postoperative analgesia after major abdominal surgery. Indian J Pain
    Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building,
    2021;35:254-5.
    Tata Memorial Centre, Mumbai ‑ 400 012, Maharashtra, India.
    E‑mail: [email protected] © 2021 Indian Journal of Pain | Published by Wolters Kluwer ‑ Medknow

    Indian Journal of Pain ¦ Volume 35 ¦ Issue 3 ¦ September-December 2021 255

    You might also like