Society for Obstetric Anesthesia and Perinatology

Section Editor: Cynthia A. Wong

The Analgesic Efcacy of Subarachnoid Morphine in Comparison with Ultrasound-Guided Transversus Abdominis Plane Block After Cesarean Delivery: A Randomized Controlled Trial
Ghassan E. Kanazi, MD,* Marie T. Aouad, MD,* Faraj W. Abdallah, MD,* Mohamad I. Khatib, PhD,* Al Moataz Billah F. Adham, MD,* Diala W. Harfoush, MD,* and Sahar M. Siddik-Sayyid, MD, FRCA*
BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the gold standard treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n 28) or transversus abdominis plane block (group TAP; n 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 g/mL in group TAP with 20 mL on each side. Postoperative analgesia for the rst 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to rst analgesic request. RESULTS: Median (range) time to rst analgesic request was longer in group SAM than in group TAP [8 (236) hours versus 4 (0.5 to 29) hours (P 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0 1) in group SAM versus 0 (0 2) in group TAP (P 0.03). Postoperative visceral pain scores at rest and on movement during rst the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects. (Anesth Analg 2010;111:47581)

ubarachnoid morphine is highly effective for the management of postoperative pain after cesarean delivery.13 However, its use is associated with undesirable adverse effects, particularly nausea, vomiting, and pruritus, which reduce overall patient satisfaction.4 More serious is the risk of delayed maternal respiratory depression due to rostral spread of morphine.5 Thus, alternative approaches to subarachnoid morphine are required, especially in the presence of medical contraindications or logistical issues limiting its use.
From the *Department of Anesthesiology, American University of BeirutMedical Center Beirut, Lebanon. Accepted for publication April 1, 2010. Funding was provided by the Department of Anesthesiology American University of Beirut-Medical Center. Address correspondence to Sahar M. Siddik-Sayyid, MD, FRCA, Department of Anesthesiology, American University of BeirutMedical Center, P.O. Box 11-0236, Beirut, Lebanon. Address e-mail to ss01@aub.edu.lb. Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181e30b9f

Transversus abdominis plane (TAP) block is a regional anesthetic technique that blocks the abdominal wall neural afferents by introducing local anesthetic into the neurofascial plane between the internal oblique and transversus abdominis muscles.6 Randomized controlled trials have demonstrated the efficacy of TAP block as a component of a multimodal regimen, in providing postoperative analgesia after abdominal surgery, including cesarean delivery.6 9 In the context of multimodal analgesia with diclofenac and acetaminophen, the use of morphine provides effective analgesia for a median (range) duration of 20 (6 33) hours10 as opposed to a shorter time with the TAP block [median (interquartile range) time 220 (150 380) minutes8 and 3 hours (interquartile range 1 hour)].9 In addition, subarachnoid morphine may effectively treat both somatic pain from the abdominal wall arising from the wound11 and visceral pain arising from the uterus,1214 whereas the TAP block covers only the pain derived from the abdominal wall incision. Thus, we hypothesized that subarachnoid morphine would provide more prolonged and superior
www.anesthesia-analgesia.org

August 2010 Volume 111 Number 2

475

Subarachnoid Morphine vs TAP Block

analgesia than would TAP block in patients undergoing elective cesarean delivery under spinal anesthesia. No randomized controlled trials have been previously conducted to compare these two modalities. Thus, we designed a randomized, double-blind study to compare subarachnoid morphine with TAP block under ultrasound guidance as part of a multimodal regimen for postcesarean delivery pain management. The primary outcome was time to first request for analgesia; secondary outcomes included pain scores, analgesic requirements, and side effects during the first 48 hours.

METHODS
After IRB approval, written informed consent was obtained from 60 ASA physical status I or II parturients, scheduled for elective cesarean delivery, via a Pfannenstiel incision, under spinal anesthesia. Exclusion criteria included body mass index 35 kg/m2, major systemic disease, chronic pain disorders, abuse of drugs or alcohol, and allergies to any medication included in the study protocol. Patients received no preoperative medications. Patients were randomly assigned using a computergenerated table of random numbers to receive subarachnoid morphine (group SAM) or TAP block (group TAP). Group allocation was concealed in sealed opaque envelopes that were not opened until patient consent had been obtained. In the operating room, all parturients were monitored by noninvasive arterial blood pressure monitoring, electrocardiogram, and peripheral pulse oximetry. Spinal anesthesia was initiated in the sitting position at the L2 to 3 or L3 to 4 interspace with 0.75% hyperbaric bupivacaine (Marcaine Spinal; bupivacaine hydrochloride in dextrose injection, USP, Lake Forest, Illinois) 12.75 mg (1.7 mL) combined with morphine (Laboratoire Renaudin, Itxassou, France) 0.2 mg (0.2 mL) in group SAM and with saline (0.2 mL) in group TAP. The parturient was placed in the supine position with 15 to 20 left uterine displacement, and supplemental oxygen was delivered through a facemask at 5 L/min. Surgery was allowed to proceed after T4 to 6 sensory blockade to pinprick sensation had been established. IV crystalloids and ephedrine or phenylephrine were administered as needed to treat hypotension. All patients received an IV infusion of oxytocin 30 IU after delivery. IV metoclopramide 10 mg was administered intraoperatively if nausea or vomiting was not corrected with vasopressor administration or occurred unrelated to hypotension. At the end of surgery, patients in both groups received rectal diclofenac 100 mg and IV paracetamol 1 g. After the wound was covered with a dressing, an ultrasound-guided TAP block was performed by 1 of 3 investigators (Sahar M. Siddik-Sayyid, Ghassan E. Kanazi, and Faraj W. Abdallah), all of whom had significant experience with this technique before conducting the investigation. In all cases, a second investigator was present and served as an independent observer by observing the images and verifying needle placement into the neurofascial plane and spread of the study solution. The procedure was performed using aseptic technique (gown, gloves, facemask, and protective sheath for the ultrasound probe). After preparing the skin with antiseptic solution, a linear

13- to 6-MHz ultrasound probe (SonositeTM, Bothell, Washington) was placed transversely on the anterolateral abdominal wall between the iliac crest and costal margin. The three layers of musclesthe external oblique, the internal oblique, and the transversus abdominiswere identified. A Pajunk 21-gauge, 100-mm needle (Medizintechnik, Geisingen, Germany), attached with flexible tubing to a syringe filled with dextrose 5%, was introduced through the skin anteriorly in the plane of the ultrasound beam, and advanced into the fascial plane between the internal oblique muscle and transversus abdominis muscles. Three milliliters of the dextrose 5% was injected to visualize the spread of the solution and confirm needle placement within the fascial plane. Patients in group SAM received 20 mL of normal saline, while those in group TAP received an identical volume of bupivacaine 0.375% with epinephrine 5 g/mL obtained by mixing 15 mL of bupivacaine 0.5% with 4 mL normal saline and 1 mL of 100 g epinephrine. The solutions in both groups were prepared in advance by an anesthesia resident not involved in the study. Solutions were injected in 5-mL increments after aspiration. The same steps were repeated on the opposite side. After each 5-mL bolus, patients were monitored for an increase in heart rate or signs of local anesthetic toxicity such as tinnitus, perioral numbness, metallic taste in mouth, slurring of speech, and mental status changes. Approximately 20 s elapsed between 5-mL increments. The patient, anesthesiologist, and staff providing postoperative care were blinded to the study group. The study group assignments remained concealed until all data were collected. Postoperatively, the patients were evaluated for pain, sedation, nausea or vomiting, pruritus, and respiratory depression in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours by an investigator blinded to group assignment. Pain level (somatic and visceral) at rest and on movement (knee flexion) was quantified with a 10-cm visual analog scale (VAS) pain score, with 0 representing no pain and 10 representing the worst imaginable pain. Somatic pain was defined as pain originating from the incision site; visceral pain was defined as cramping pain. Sedation level was evaluated with a 4-point scale (1 fully awake; 2 somnolent, responds to verbal stimuli; 3 somnolent, responds to tactile stimuli; and 4 somnolent, responds to painful stimuli). Nausea severity was graded by the patient according to a 4-point rating score with 1 absent, 2 mild, 3 moderate, 4 severe and vomiting. Pruritus was classified as 1 no pruritus; 2 mild pruritus, treatment not necessary; 3 moderate pruritus, treatment necessary; and 4 severe pruritus, treatment necessary. Respiratory depression was defined as respiratory rate 10 breaths per minute. For the first 24 hours, the protocol for postoperative analgesia consisted of standard orders for rectal diclofenac 100 mg every 12 hours and IV paracetamol 1 g every 6 hours. For breakthrough pain, patients were treated with IV tramadol 100 mg every 8 hours as necessary. For the second 24 hours, standard orders consisted of rectal diclofenac 100 mg every 12 hours. Two tablets of oral paracetamol 500 mg every 6 hours and IV tramadol 100 mg every 8 hours were administered upon patient request for breakthrough pain. The time to first analgesic request and

476

www.anesthesia-analgesia.org

ANESTHESIA & ANALGESIA

Figure 1. Consort ow diagram. *Patients were excluded because of postoperative analgesic protocol violations.

supplemental analgesic requirements over 48 hours were recorded. Nausea and vomiting were treated with IV metoclopramide 10 mg every 8 hours upon patient request. Patients whose pruritus score was 3 received IV diphenhydramine 25 mg or incremental doses of IV naloxone 0.04 mg. Forty-eight hours after surgery, the patients were asked to rate on a 3-point scale their satisfaction with pain management (1 highly satisfied, 2 satisfied, or 3 dissatisfied). The primary outcome measure in this study was the time to first analgesic request. The secondary outcome measures included the number of supplemental analgesic requirements, VAS pain, nausea, pruritus scores, and patient satisfaction. The sample size calculation was based on data from a pilot study, assuming a clinically significant 4-hour difference in the first request of analgesia with a SD of 5 hours. A calculation based on 0.05 and a power of 80% yielded a sample size of 26 patients per group using a 2-tailed test. Continuous data were reported as mean sd and were analyzed using Students t test. Categorical data were reported as numbers and percentages and were analyzed using chi-square or Fishers exact test as appropriate. Nonparametric data were reported as median and range, and analyzed using Mann-Whitney U test. The data were tested for normality using the KolmogorovSmirnov normality test. Repeated measurements (scores) were analyzed

by repeated-measures analysis of variance if normally distributed. For nonnormally distributed data, betweengroups comparisons at each time point were made using the Wilcoxons ranked sum test. The time to first request for analgesia was analyzed using the log-rank test. P 0.05 was considered significant. All analyses were performed using SPSS (version 16, Chicago, Illinois).

RESULTS
Sixty patients were enrolled in the study (Fig. 1). Two patients from group SAM and 1 patient from group TAP were excluded because of postoperative analgesic protocol violations. Fifty-seven patients were analyzed. There was no significant difference in demographic data between the groups (Table 1). In all patients, the transversus abdominis neurofascial plane was localized by ultrasound easily, and the block was performed without complication. Patients receiving subarachnoid morphine had a longer time to first analgesic request than did those in the TAP block group (Fig. 2). The median (range) time was 8 (236) hours in group SAM versus 4 (0.5 to 29) hours in group TAP (P 0.005). The median number of tramadol doses received between 0 and 12 hours was lower in the SAM group than in the TAP group, but was not significantly different between 13 and 24 hours (Table 2). The median number of oral paracetamol doses was not different

August 2010 Volume 111 Number 2

www.anesthesia-analgesia.org

477

Subarachnoid Morphine vs TAP Block

Table 1. Maternal and Intraoperative Characteristics

Group SAM (n 28) Age (years) Weight (kg) Height (cm) Gestational age (weeks) Nulliparous/multiparous (no.) Duration of anesthesia (minutes) Duration of surgery (minutes) Patients requiring intraoperative anti-emetics (no.) 33 6 82 13 163 7 38 1 11/17 68 13 53 11 9 Group TAP (n 29) 30 5 78 16 162 6 37 2 13/16 75 21 60 18 8

SAM subarachnoid morphine; TAP transversus abdominis plane. Data are presented as mean SD and numbers (no.).

Sedation scores were comparable between the 2 groups and were consistently 2 (Table 3). Nausea scores were higher at 2, 4, and 6 hours in the SAM group than were those in the TAP group (Table 3). Thirteen of 28 (46%) patients in group SAM versus 5 of 29 patients (17%) in group TAP developed moderate to severe nausea or vomiting (P 0.02). However, the median number of antiemetics received was similar between the 2 groups [0 (0 2) vs. 0 (0 2), P 0.14 for groups SAM and TAP, respectively]. Higher pruritus scores were recorded in group SAM than in group TAP at 2, 4, 6, and 12 hours postoperatively (Table 3). Eleven of 28 (39%) patients in group SAM developed pruritus requiring treatment versus none (0%) of the patients in group TAP (P 0.001). None of the patients developed respiratory depression. There was no difference in the satisfaction scores between the 2 groups (Table 3).

DISCUSSION
Our study demonstrated that, as part of multimodal analgesia, subarachnoid morphine provided better pain relief than did TAP block, as was evidenced by a delayed request for supplemental analgesic, less tramadol requirement during the first 12 hours postoperatively, and lower postoperative VAS visceral pain scores at rest and on movement during the first 4 hours in group SAM in comparison with group TAP. Pain scores did not differ at other time points because patients received supplemental analgesics immediately upon request for breakthrough pain. A recent Cochrane review has shown that women undergoing cesarean delivery who had local anesthetic infiltration or abdominal nerve block had reduction in the use of postoperative opioids.15 Mc Donnell et al. have shown that landmark-based TAP block can be used successfully to provide postoperative pain relief after cesarean delivery.8 Ultrasonography-guided nerve blocks offer the advantage of real-time imaging of the needle trajectory and injectate spread,16 which may improve both safety and block effectiveness. Recently, letters and clinical studies have been published regarding ultrasound-guided blockade of the abdominal wall for postopen appendectomy, laparoscopic cholecystectomy, and cesarean delivery analgesia.9,1720 A retrospective audit showed the analgesic benefit of ultrasound-guided TAP block when given in addition to subarachnoid morphine (100 to 150 g) after cesarean delivery performed under spinal anesthesia.17 Gusev et al. found that ultrasound-guided bilateral continuous ilioinguinaliliohypogastric blockade used in conjunction with oral ibuprofen resulted in satisfactory prolonged analgesia without nausea and vomiting after cesarean delivery in 3 patients.18 Belavy et al. evaluated the efficacy of ultrasound-guided TAP block with ropivacaine versus saline as part of a multimodal analgesic regimen in patients undergoing cesarean delivery.9 All patients received spinal anesthesia with bupivacaine and fentanyl, followed by postoperative acetaminophen, nonsteroidal anti-inflammatory drugs, and patient-controlled IV morphine without long-acting intrathecal opioids. They showed reduced median total morphine use in 24 hours (18 vs. 32 mg), improved patient satisfaction with the pain

Figure 2. KaplanMeier graph of the proportion of patients in each group over time who did not require supplemental analgesic (P 0.02, log-rank test). SAM subarachnoid morphine; TAP transversus abdominis plane.

Table 2. Postoperative Analgesic Data

Group SAM (n 28) Time to rst analgesic request (hours) Number of Tramadol doses received 012 hours Number of Tramadol doses received 1324 hours Number of oral paracetamol doses received 2548 hours 8 (236) 0 (01) 0 (01) 1 (03) Group TAP (n 29) 4 (0.529) 0 (02) 0 (01) 1 (03) P 0.01 0.03 0.49 0.80

SAM subarachnoid morphine; TAP transversus abdominis plane. Data are presented as median (range).

between 25 and 48 hours between the 2 groups (Table 2). None of the patients required tramadol between 25 and 48 hours. Postoperative VAS visceral pain scores at rest at 0, 2, and 4 hours, and on movement at 2 and 4 hours were lower in the SAM group than in the TAP group, and were not significantly different at all other time points (Fig. 3). No difference was noted in somatic pain scores at any time point.

478

www.anesthesia-analgesia.org

ANESTHESIA & ANALGESIA

Figure 3. Box plots of visual analog scale (VAS) scores of pain in each group over the rst 48 hours postoperatively. At each time point, the rst bar represents VAS scores of somatic pain at rest; the second bar, VAS scores of somatic pain on movement; the third bar, VAS scores of visceral pain at rest; and the fourth bar, VAS scores of visceral pain on movement in each group. The middle line in each box represents the median value, the outer margins of the box represent the interquartile range, and the whiskers represent the 10th and 90th percentiles for each time point. *Signicantly lower VAS pain scores in the subarachnoid morphine (SAM) group in comparison with the respective VAS in the transversus abdominis plane (TAP) group (P 0.05, Wilcoxons ranked sum test).

relief, and less anti-emetic requirement in patients receiving TAP block in comparison with those in the placebo group. However, the time to first morphine demand was only modestly increased with a median of 3 hours in the TAP block group versus 2 hours in the placebo group. Subarachnoid morphine is currently the gold standard treatment for pain after cesarean delivery.5 Neuraxial morphine mediates selective spinal analgesia by binding to opioid receptors in the substantia gelatinosa of the dorsal horn of the spinal cord near the site of injection.21 Subarachnoid morphine is effective in the treatment of both somatic11 and visceral pain.1214 In decerebrated, spinally transected cats, spinal morphine was capable of suppressing the evoked activity of the viscerosomatic convergent neurons, resulting in suppressing visceral and somatic pain behavioral reflexes.13 Another study demonstrated that tonic distension of the lower uterine segment and cervix to noxious levels for 60 minutes during laparotomy results in the postoperative appearance of behaviors in rats that are considered to indicate pelvic visceral pain. Intrathecal and, to a lesser extent, systemic morphine reduces the incidence of these abnormal behaviors, while increasing exploratory and feeding behavior, consistent with analgesia.14 In our study, subarachnoid morphine may have affected both the superficial and the deep visceral postoperative pain, whereas the TAP block affected only the superficial (somatic) incisional pain. This can explain the superiority of

subarachnoid morphine in comparison with TAP block for the management of postcesarean pain. Of note, the addition of morphine to local anesthetic at the time of spinal anesthesia is easier to perform, less time consuming, and does not require technical skills or extra equipment in comparison with the TAP block. Unfortunately, in comparison with the TAP block, subarachnoid morphine was associated with more undesirable side effects. The major side effects of neuraxial morphine include pruritus, nausea, vomiting, and delayed respiratory depression. Nausea and vomiting are among the most common side effects of intrathecal opioids occurring in as many as 30% of patients.22 The incidence of pruritus varies widely from 0% to 100% and occurs with varying degrees of severity.22 In our study, 46% of patients who received subarachnoid morphine developed moderate to severe postoperative nausea and vomiting, and 39% developed pruritus requiring treatment. Delayed respiratory depression is the most serious side effect of subarachnoid morphine, although the incidence requiring intervention is 1%.23 We did not find any clinically detectable respiratory depression when using subarachnoid morphine 0.2 mg. The presence of side effects associated with subarachnoid morphine has been shown to have a negative impact on patient satisfaction.4 This may have contributed to the lack of difference in overall satisfaction scores in our

August 2010 Volume 111 Number 2

www.anesthesia-analgesia.org

479

Subarachnoid Morphine vs TAP Block

Table 3. Sedation, Nausea, Pruritus, and Satisfaction Data

Group SAM (n 28) 1 (12) 1 (12) 1 (12) 1 (12) 1 (12) 1 (11) 1 (11) 1 (11) 1 (14) 1 (14) 1 (14) 1 (14) 1 (13) 1 (11) 1 (12) 1 (11) 1 (11) 1 (13) 2 (14) 2 (14) 1 (13) 1 (12) 1 (11) 1 (11) 11 15 2 Group TAP (n 29) 1 (12) 1 (12) 1 (11) 1 (12) 1 (11) 1 (11) 1 (11) 1 (11) 1 (13) 1 (12) 1 (14) 1 (12) 1 (12) 1 (11) 1 (13) 1 (12) 1 (11) 1 (11) 1 (11) 1 (11) 1 (11) 1 (11) 1 (11) 1 (11) 11 11 7 P 0.13 0.32 0.16 0.58 0.33 1 1 1 0.05 0.001 0.04 0.01 0.26 1 1 0.33 0.31 0.002 0.001 0.001 0.001 0.32 0.31 0.31 0.19

Sedation 0 2 4 6 12 24 36 48 Nausea 0 2 4 6 12 24 36 48 Pruritus 0 2 4 6 12 24 36 48 Satisfaction scores Highly satised (no.) Satised (no.) Dissatised (no.)

SAM subarachnoid morphine; TAP transversus abdominis plane. Data are presented as median (range) and numbers (no.).

A dye injection study in a cadaver model has shown that ultrasound-guided TAP block is likely to involve the peripheral branches that originate from T10 L1 nerve roots, and this finding implies that the technique may be limited to use in lower abdominal surgery.27 A limitation of our study is that we did not assess the success rate or sensory distribution of the resulting block, because residual sensory block from spinal anesthesia may remain in the early postoperative period. Additionally, we wished to maintain blinding of the investigator and patient to the group allocation. Thus, failed blocks cannot be excluded as a cause for analgesia inefficacy. However, TAP blocks were performed by 3 investigators who gained significant experience with this technique before conducting the investigation. Also, operator error was minimized by the presence in all cases of an independent observer who observed the images during block performance. In addition, we used the technique of maintaining the needle in the plane of the ultrasound, because this may reduce the risk of needle misplacement and block failure. In conclusion, our study showed that patients receiving subarachnoid morphine (0.2 mg) for postcesarean pain management reported longer duration of analgesia, improved early visceral pain scores, and less use of tramadol during the first 12 hours, but at the cost of increased severity and incidence of nausea, vomiting, and pruritus in comparison with the ultrasound-guided TAP block. Future studies are needed to evaluate analgesic efficacy and side effects of lower doses of subarachnoid morphine used in conjunction with TAP block.
REFERENCES 1. Chadwick HS, Ready LB. Subarachnoid and epidural morphine sulfate for postcesarean analgesia: a clinical comparison. Anesthesiology 1988;68:9259 2. Palmer CM, Emerson S, Vollgoropolous D, Alves D. Dose response relationship of subarachnoid morphine for postcesarean analgesia. Anesthesiology 1999;90:437 44 3. Yang T, Breen TW, Archer D, Fick G. Comparison of 0.25 mg and 0.1 mg subarachnoid morphine for analgesia after cesarean section. Can J Anaesth 1999;46:856 60 4. Farragher RA, Laffey JG. Postoperative pain management following cesarean section. In: Shorten G, Carr D, Harmon D, Puig MM, Browne J, eds. Postoperative pain management: an evidence-based guide to practice. 1st ed. Philadelphia, PA: Saunders Elsevier, 2006:22538 5. Dahl JB, Jeppesen IS, Jorgensen H, Wetterslev J, Moiniche S. Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology 1999;91:1919 27 6. McDonnell JG, ODonnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007;104:1937 7. Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. Transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008;107:2056 60 8. McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, Laffey JG. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186 91 9. Belavy D, Cowlishaw PJ, Howes M, Phillips F. Ultrasoundguided transversus abdominis plane block for analgesia after cesarean delivery. Br J Anaesth 2009;103:726 30

patients despite better pain relief in the SAM group than in the TAP group. Also, the 4-point categorical measure of satisfaction may not have been sufficiently sensitive to detect a difference between groups. Our institution emphasizes good communication between staff and patients, and this may have contributed to the good satisfaction scores despite the occurrence of side effects. Because bupivacaine and levobupivacaine have similar potency, we elected to use a dose of bupivacaine similar to that of levobupivacaine used in a previous study by McDonnell et al.6 The dose of bupivacaine was within the recommended safe dose range (2.5 mg/kg not to exceed 175 mg total dose). Nevertheless, we should acknowledge the theoretical risk of cardiac arrest with this 150-mg dose after inadvertent intravascular injection.24 Strategies to mitigate this risk such as careful aspiration before injection, addition of epinephrine to monitor increase in heart rate, fractionation of the injection, and close monitoring for signs of local anesthetic toxicity are recommended. Ultrasound-guided TAP block appears to be safe (injecting local anesthetic into an intermuscular plane), but case reports have indicated that visceral injury can occur with both ultrasound- and landmark-guided TAP blockade.25,26 Using an ultrasound-guided technique, we did not observe any visceral injury or local anesthetic toxicity in our group of patients. Nevertheless the safety of ultrasound-guided TAP blocks needs to be further investigated, because the study was not designed to specifically address this topic.

480

www.anesthesia-analgesia.org

ANESTHESIA & ANALGESIA

10. Milner AR, Bogod DG, Harwood RJ. Intrathecal administration of morphine for elective caesarean section. A comparison between 0.1 mg and 0.2 mg. Anaesthesia 1996;51:8713 11. Gadsden J, Hart S, Santos AC. Post-cesarean delivery analgesia. Anesth Analg 2005;101:S629 12. Scott PV, Bowen FE, Cartwright P, Rao BC, Deeley D, Wotherspoon HG, Sumrein IM. Intrathecal morphine as sole analgesic in labor. BMJ 1980;281:3513 13. Omote K, Kawamata M, Iwasaki H, Namiki A. Effects of morphine on neuronal and behavioral responses to visceral and somatic nociception at the level of spinal cord. Acta Anaesthesiol Scand 1994;38:514 7 14. Tong C, Conklin D, Eisenach JC. A pain model after gynecologic surgery: the effect of intrathecal and systemic morphine. Anesth Analg 2006;103:1288 93 15. Bamigboye AA, Hofmeyr GJ. Local anaesthetic wound infiltration and abdominal nerves block during cesarean section for postoperative pain relief. Cochrane Database of Syst Rev 2009; 3:CD006954. 16. Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study. Anaesthesia 2009;64:74550 17. Hebbard P, Royse C. Audit of transversus abdominis plane block for analgesia following caesarean section. Anaesthesia 2008;63:1382 18. Gusev G, Yasui GM, Chang T-Y, Lee J. Bilateral ultrasoundguided continuous ilioinguinaliliohypogastric block for pain relief after cesarean delivery. Anesth Analg 2008;106:1220 2

19. Niraj G, Searle A, Mathews M, Misra V, Baban M, Kiani S, Wong M. Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing open appendicectomy. Br J Anaesth 2009;103:6015 20. El-Dawlalty AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, Kapral S, Marhofer P. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth 2009;102:7637 21. Yaksh TL, Rudy TA. Analgesia mediated by a direct spinal action of narcotics. Science 1976;192:1357 8 22. Chaney MA. Side-effects of intrathecal and epidural opioids. Can J Anaesth 1995;42:891903 23. Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth 1991;16:137 40 24. Albright GA. Cardiac arrest following regional anesthesia with etidocaine and bupivacaine. Anesthesiology 1979;51:2857 25. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia while performing transversus abdominis plane block. Region Anesth Pain M 2008;33:274 5 26. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg 2008;107:1758 9 27. Tran TM, Ivanusic JJ, Hebbard P, Barrington MJ. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study. Br J Anaesth 2009;102:1237

August 2010 Volume 111 Number 2

www.anesthesia-analgesia.org

481