EVALUATION OF EFFECT OF ULTRASOUND GUIDED(USG) TRANSVERSUS ABDOMINIS PLANE BLOCK(TAP BLOCK) ON POSTOPERATIVE PAIN AFTER CAESARIAN SECTION

INTRODUCTION

Surgery and anesthesia are important healthcare procedures that strive to reduce the risk of death and disability. Furthermore, anesthetic treatments aid in reducing the occurrence and severity of acute discomfort during and soon after surgery.¹ According to recent research, the caesarean birth rate has risen dramatically globally, including in Egypt.²

Fetal discomfort, presenting abnormalities, numerous pregnancies, fetal anomalies, past uterine surgery, systemic disorders, vertical maternal infections, and indications for labor or delivery are all reasons for a caesarean birth. The mother's request should not be the only cause for a caesarean section; it should be considered when the individual is suffering from a psychiatric disorder such as severe dread, worry, or panic.³

Postoperative pain typically contains nociceptive qualities, meaning it is caused by tissue or organ lesions that produce painful nociceptive impulses. Neuropathic pain may occur as a result of direct nerve damage, as well as tension or compression. In this scenario, very common surgeries like caesarean sections require extra attention, as they occur during a period of significant hormonal and emotional changes related to pregnancy and the birth of the baby, which can have a negative impact on postoperative pain, given the multifaceted nature of this experience.⁴

Controlling postoperative pain may be done in a variety of ways. The hunt for the optimal approach, however, is still underway. Several methods have been used. Nonetheless, employing opioids in a variety of ways is still the standard.⁵

The TAP block is a localized anesthetic technique that blocks the thoracolumbar nerves that run between the internal oblique and transversus abdominis muscles in the fascial plane. It's gaining popularity as a postoperative analgesic for lower abdominal procedures. ⁶

The efficacy of TAP block in postoperative analgesia is comparable to morphine, with the added advantages of increased duration of analgesia, reduced postoperative opioid consumption, adequate pain management, and minimal adverse effects.⁷

Despite the fact that TAP block has a low complication risk and a high success rate when performed with ultrasonography, it is underused. This might be owing to a lack of ultrasound availability in most facilities, as well as absence of training in ultrasonography-guided block technique. ⁸

The goal of this research was to see how effective an ultrasound-guided transversus abdominis plane block (TAP BLOCK) following a caesarian section was in terms of safety, pain management, and patient satisfaction.

PATIENTS AND METHODS

Prospective observational research was undertaken on 200 women who were scheduled for an optional caesarean section at Salah El-Awady Maternity Hospital and El-Hussein University Hospital.

The patients were divided into groups: Group (A): Included 100 women using ultrasound guided transversus abdominis plane (USG-TAP) block technique. Group (B): Included 100 women not using TAP block technique.

Inclusion criteria: age above 21 years, undergo CS with spinal anaesthesia and Body mass index (BMI)

Exclusion criteria: Patient refusal, patient with known reaction to study drugs, patients on chronic analgesics and patients with coagulation disorders and thrombocytopenia.

All women were requested a written informed consent regarding the procedure according to the study protocol, and no harm to the women would be allowed and both groups were subjected to: History taking focusing on age, weight, height, personal habits, gravity, parity, history of abortion and number of times of abortion if present, medical history of being on any longtime medical treatment, surgical and family history and LMP for EDD, Patient examination focusing on abdomen and lower limbs for edema and varicosities if present, Investigations: according to departmental guidelines including: foetal ultrasonography, complete urine analysis, blood group, complete blood picture, liver function and enzymes, kidney functions, bleeding and clotting time, ECG, HIV antibodies, HCV antibodies and HBV antigens, A 500 ml saline solution IV was given before the operation, they were monitored by standard method (non-invasive arterial blood pressure, heart rate, and pulse oximiter for the duration of CS), a conventional spinal anesthesia was initiated as 2.2 ml of intrathecal hyperbaric bupivacaine (0.5%) was injected using a 25-gauge spinal needle with patients in the sitting position at the L 4/5 interspace under strict a septic precaution. To address hypotension, an IV crystalloid and ephedrine were given as required, as well as an IV infusion of oxytocin following birth. All women received 75mg diclofenac sodium IM /12 hours postoperatively. The rescue pain analgesia was given postoperatively for VAS >3 by ketolac (30mg IV).

In TAP block group: The TAP block was performed after the incision was closed and was guided by ultrasonography (USG). Bupivacaine 0.25 percent (20 ml) was used to accomplish the TAP block. One of the symptoms that medication has been deposited in the TAP plane in the fascial layer between the Internal Oblique and Transversus Abdominis muscles is drug backflow after injection. The technique is done on the other side, resulting in a bilateral TAP block.

In the other group: No additional procedure done after closure of the incision.

Follow up: for pain severity using VAS scale, time to the first analgesic request, total rescue analgesia consumption in 24 hours, intestinal motility, and time for first ambulation, breast feeding, and postoperative complications if present.

Statistical analysis: The data was gathered and tabulated using Microsoft Excel for Windows Office 2010 and statistically analysed utilising SPSS software version 20.0.0.0 programme (Statistical Package for Social Sciences). Descriptive statistics were calculated for numerical parametric data as median ±SD (standard deviation) and minimum and maximum ranges, as well as numerical non parametric data as median and first and third interquartile ranges, and categorical data as number and percentage. Tables and graphs were used to convey the data as needed. The mean and standard deviation were used to convey quantitative data, whereas the number and proportion were used to express qualitative data. T-test (for quantitative data) and chi-square (for qualitative data) were used to make comparisons (for qualitative data). A p-value of

There was statistically non- substantial variance between the studied groups regarding age. Mean age in TAP block and non TAP block groups is 27.2 and 28.6 years respectively. There was statistically non- substantial variance between the studied groups regarding weight, height, body mass index and duration of operation (Table 1).

t: Student t test

Table 2: Comparison of the researched groups in terms of obstetric data

Studying obstetric data of patients showed that in Group A Gravity ranged from 1.0 –6.0 and  parity ranged from 0.0 – 5.0 in addition 18 patients (18 %) suffered from abortion before. While in Group B Gravity ranged from 1.0 – 5.0  and parity ranged from 0.0 – 4.0 in addition 20 patients (20 %) suffered from abortion before. There was no statistically substantial variance between the two groups regarding gravity, parity, and history of abortion at p-value of 0.051, 0.057 and 0.718 respectively (Table 2).

t: Student t test         p≤0.001* is statistically highly substantial

Table 3: Comparison of the researched groups in terms of VAS over time after surgery

There was statistically substantial variance between the studied groups regarding VAS score at 2nd, 4th, 8th, 12th, and 24th hours after surgery which was substantially less in TAP block group. In each group, there is substantial change in VAS score over time (Table 3).

χ2 : chi square test                   t :  student t test       p≤0.001* is statistically highly substantial

Table 4: Comparison of the researched groups in terms of need for rescue analgesia

There was statistically substantial variance between the studied groups regarding time for first analgesia which was later in TAP group (mean 2.6   hour for Non TAP block group versus 8.2 hours in TAP block group).There was statistically substantial variance on the studied groups regarding frequency of patients who needed rescue analgesia. 42% of those within TAP block group versus all the patients (100 %) within Non TAP block group needed analgesia (Table 4).

c2: Chi square test                  MC: Monte Carlo

p: p value for analyzing the groups that were examined

* Statistically substantial at p ≤0.05       

Table 5: Comparison of the researched groups in terms of Total postoperative rescue analgesia requirement

In addition, there was a substantial variance between the analyzed groups according to total postoperative rescue analgesia of ketolac at p-value of <0.001*(Table 5).

c2: Chi square test 

*: Statistically substantial at p ≤ 0.05

Table 6: Comparison of the researched groups in terms of intestinal motility

Regarding intestinal motility, there was statistically substantial variance in auscultation using a stethoscope between the studied groups at 2 hours postoperatively at p-value of <0.001* while there was no substantial variance between both groups at 4, 8, 12 and 24 hours postoperatively (Table 6).

t: Student t test         p≤0.001* is statistically highly substantial

Table 7: Comparison of the researched groups in terms of time for first ambulation

There was statistically substantial variance in the examined groups in terms of time for ambulation which was substantially lower among TAP block group (Table 7).

c2: Chi square test  FE: Fisher Exact test

*: Statistically substantial at p ≤0.05

Table 8: Comparison of the researched groups in terms of breast feeding over time

There was statistically substantial variance between the studied groups regarding breast feeding early at 2 and 4 hrs post operatively at p-value of <0.001, however there was no substantial variance difference later on post operatively (Table 8).

FE: Fisher Exact test                                                               χ2 chi square test

 *p

Table 9: Comparison of the researched groups in terms of nausea and vomiting

There was statistically substantial variance between the studied groups regarding nausea and vomiting at 2 h post operatively at p-value of 0.037, however there was no statistically substantial variance later on post operatively (Table 9).