COMPARATIVE STUDY BETWEEN ULTRASOUND GUIDED(USG) TRANSVERSUS ABDOMINIS PLANE BLOCK(TAP BLOCK) AND PATIENT CONTROLLED ANALGESIA (PCA)AFTER CAESARIAN SECTION

INTRODUCTION

According to recent literature, the C-section rate has skyrocketed globally, including in Egypt. ¹ This increase is linked to a rise in women's awareness of the procedure and their requests for pain-free techniques both during and following the operation. This encourages obstetricians to experiment with new techniques and approaches rather than rely on traditional postsurgical analgesic techniques. In most cases, an uncomplicated caesarean delivery causes moderate to severe pain for the first 48 hours after the operation. ² As a result, pain alleviation is crucial, as it impacts both the mom and her newborn's care.

Furthermore, poor pain control may have a negative impact on healing and mother–infant bonding, leading to more prolonged postoperative pain.

Women who are having a caesarean section have even more compelling causes to have adequate pain relief,, because early mobilization is an important element in lowering the risk of thrombo-embolic illness, which would be recognized to be higher during gestation and puerperium. Pain alleviation for these mothers enhances their baby's care and allows them to nurse more effectively. ³

Controlling postsurgical pain can be done in a variety of ways. The hunt for the optimal technique, though, is still underway. Many methods have been employed. Nonetheless, the gold standard remains the use of opioids through various methods. ⁴

Transversus abdominis plane (TAP) block is a practical main analgesic for women who are not getting neuraxial morphine for any reason during caesarean delivery. TAP block is a type of assisted analgesic that is used to reduce the use of opioids in intraoperative and systemic analgesics for post-surgery pain control. The TAP block is a thoracolumbar nerve field block that runs in the fascial plane across the transversus abdominis muscles and the internal oblique. Near the midaxillary line, the anterior primary rami branch off into the lateral and anterior dermal nerves, running between the transversus abdominis muscles and the internal oblique. ⁵

Patient-controlled analgesia, or "PCA," improves patient satisfaction by reducing pain more effectively than non-patient opioid administrations.⁶

Furthermore, PCA has been advisable for women who are in labor. Pain associated with contractions could be efficiently controlled and decreased, especially when exacerbated with the administration of induction drugs such as oxytocin. ⁷

At a certain dosage and time, PCA is used to successfully control pain. This is accomplished through permitting patients to give a predefined bolus dosage of medicine on request. Each bolus can be given alone or in combination with another drug. PCA, on the other hand, is used to treat acute, chronic, postsurgical, and labor pain. Opioids and local anesthetics are the most widely used medications, but other analgesics may be used as well.⁸

The objective of this study was to see how ultrasound-guided TAP block compared to patient-controlled analgesia after caesarian section as regards safety and pain control as well as patient satisfaction.

PATIENTS AND METHODS

A cross-sectional study has been performed on 100 women at El-Sayed Galal University Hospital and El Hussein University Hospital, who were scheduled to have an elective C-section.

The patients were divided into groups: Group (1): Included 50 patients using ultrasound guided transversus abdominis plane (USG-TAP) block technique. Group (2): Included 50 patients using patient-controlled analgesia (PCA) technique.

Inclusion criteria: American society of anesthesiologist (ASA) physical status class II, age above 21 years, undergo CS with spinal anaesthesia, and primigravida beyond 37 weeks of gastation with singleton live baby.

Exclusion criteria: Patient refusal, patient with known reaction to study drugs, (BMI) ≥30 kg/m², patients on chronic analgesics, (ASA) physical status class III, IV, and patient with coagulation disorders and thrombocytopenia.

All the participants were requested a written informed consent regarding the procedure according to the study protocol, and no harm to the patients would be allowed and both groups were subjected to:

A 500 ml saline solution IV was giving in obstetric department before the operation.

They were monitored by standard method (non-invasive arterial blood pressure, heart rate, and pulse oximeter for the duration of CS).

A conventional spinal anesthesia was initiated as 2.2 ml of intrathecal hyperbaric bupivacaine (0.5%) was administrated using a 25-gauge spinal needle with patients in the sitting position at the L 4/5 interspace under strict septic precaution.

Ephidrine was 3mg titrate administered as needed to treat hypotension as well as IV infusion of 10 unit of oxytocin after delivery.

They were received 1gm of paracetamol every 6 hours.

The rescue pain analgesia was given postoperatively for VAS >3 by ketolac (30mg IV every 12 hours) and (VAS) was reassessed 15 minutes later to rescue analgesic injection.

In TAP block group: The TAP block was guided by ultrasound (USG) and after closure of the incision. Therefore, the injection is painless and would not be detected by the patient as they are still under spinal anesthesia. The TAP block was performed by using bupivacaine 0.25% (20 ml in each side) .

In PCA group: The PCA system is carefully expland to patient prior to CS and its filled by pethidine 5 ml/kg in 24 hours which diluted in 100 ml of normal saline via IV PCA device.

Statistical analysis:

The data was tallied and statistically analysed using SPSS 20.0 software (Statistical Package for Social Sciences). Descriptive statistics have been calculated for numerical parametric data as mean±SD and min and max ranges, as well as numerical non parametric data as median and first and third interquartile ranges, and categorical data as numbers and percentages. For quantitative variables, inferential analyses have been performed using the independent t-test when there were two independent groups having parametric data and the Mann Whitney U when there were two independent groups having non-parametric data. For qualitative data, inferential analyses have been performed using the Chi-square test for independent groups. P values of less than 0.050 have been considered significant; otherwise, they have been considered non-significant. The p-value is a statistical estimate of the likelihood that the outcomes of a study happened by coincidence.

RESULTS

Table 1: Comparison of demographic, anthropometric, and operation time data between the groups studied.

The age difference between the groups studied was statistically non-significant. Mean age in TAP block and PCA groups is 28.86 and 29.6 years respectively. In terms of weight, height, and body mass index, there were no statistically significant differences between the study groups. In terms of operation duration, there were no statistically significant differences between the groups tested (Table 1).

Table 2: Comparison of the study groups in terms of VAS over time

In the first hour, there were no statistically significant differences between the studied groups regarding VAS score. The VAS score at the 2nd, 4th, 8th, 12th, and 24th hrs following intervention was significantly lower in the PCA group, indicating a statistically significant difference between the tested groups. There is a significant change in VAS score in each group over time (Table 2)

Table 3: Comparison of the study groups in terms of heart rate intraoperatively

There are statistically non-significant differences between the study groups in respect of heart rate baseline, at the 5th, 10th, 15th, 20th, 30th, and 40th minutes. In each group, there is a significant change in heart rate over time (Table 3).

Table 4: Comparison of the study groups regarding analgesia duration and time to first ambulation

There have been statistically significant differences across the study groups regarding analgesia duration, which have been significantly greater among those in the PCA group. There have been statistically significant differences across the tested groups regarding time for ambulation, which was significantly lower among the PCA group (Table 4)

Table 5: Comparison of the study groups regarding the need for rescue analgesia

There have been statistically significant differences across the study groups regarding the time for first analgesia, which was later in the PCA group (mean 4.785 hours for the TAP block group versus 8.5 hours in the PCA group). There have been statistically significant differences across the tested groups regarding the frequency of patients who needed rescue analgesia. Twenty-two percent of those within the TAP block group versus 14% within the PCA group needed analgesia (Table 5).

Table 6: Comparison of the study groups regarding complications

There have been statistically significant differences across the study groups regarding nausea and vomiting (Table 6).