Essentials of Our Current Understanding: Abdominal Wall Blocks.

The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. It has a high margin of safety and is technically simple to perform, especially under ultrasound guidance. A growing body of evidence supports the use of TAP blocks for a variety of abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part, this may be related to the limited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of its clinical application. As such, we provide a brief historical perspective on the TAP block, describe relevant anatomy, review current techniques, discuss pharmacologic considerations, and summarize the existing literature regarding its clinical utility with an emphasis on recently published studies that have not been included in other systematic reviews or meta-analyses.

/pdf/clinical-implications-of-the-transversus-abdominis-plane-4cdeqk70hh.pdf

Clinical implications of the transversus abdominis plane block in adults.

Background The transversus abdominis plane (TAP) block involves injecting a large volume of local anaesthetic between the muscles of the abdominal wall. Plasma concentrations of ropivacaine after gynaecological laparotomy are potentially high enough to result in systemic toxicity, and there are pharmacokinetic reasons why pregnancy may increase susceptibility to local anaesthetic toxicity. Methods Adult female patients (n=30) undergoing elective Caesarean section under spinal anaesthesia received bilateral ultrasound-guided TAP blocks after wound closure (2.5 mg kg−1 of ropivacaine diluted to 40 ml). Venous blood samples were collected at 10, 20, 30, 45, 60, 90, 120, 180 and 240 min following the block. Blood samples were assayed for total and free ropivacaine concentrations. Patients were assessed for symptoms of local anaesthetic toxicity. Results The mean [standard deviation ( sd )] peak total concentration of ropivacaine occurred at 30 min post-injection and was 1.82 (0.69) μg ml−1. The maximum detected concentration in any patient was 3.76 μg ml−1 (at 10 min post-injection). Three patients reported symptoms of mild neurotoxicity, and the mean ( sd ) peak levels were elevated in these patients, 2.70 (0.46) µg ml−1. Conclusions TAP blocks can result in elevated plasma ropivacaine concentrations in patients undergoing Caesarean section, which may be associated with neurotoxicity.

Symptomatic local anaesthetic toxicity and plasma ropivacaine concentrations after transversus abdominis plane block for Caesarean section

https://rapm.bmj.com/content/rapm/37/3/294.full.pdf

Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block.

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.

/pdf/transversus-abdominis-plane-block-a-narrative-review-5fme75ckj4.pdf

Transversus Abdominis Plane Block: A Narrative Review

Background The transversus abdominis plane block is a novel technique involving injection of local anaesthetic between the internal oblique and the transversus abdominis muscles of the abdominal wall. It is possible that injection of a large dose of local anaesthetic into a relatively vascular plane may result in toxic concentrations. One previously published study examined plasma lidocaine concentrations after transversus abdominus plane block and showed potentially toxic plasma concentrations. Although ropivacaine is most commonly used for this technique, plasma concentrations of ropivacaine after this block have not been reported previously. Methods Adult female patients undergoing elective open gynaecological surgery received bilateral ultrasound-guided transverse abdominal plane blocks before surgical incision (3 mg kg−1 of ropivacaine diluted to 40 ml). Venous blood was collected each 15 min for the first hour, each 30 min for the second hour, and then at 3, 4, 12, and 24 h post-block. Results Twenty-eight patients were recruited. The mean (sd) peak total ropivacaine concentration occurred 30 min post-injection and was 2.54 (sd 0.75) µg ml−1. The highest measured concentration was 4.00 µg ml−1, also 30 min post-injection. Mean total concentrations remained above 2.20 µg ml−1 for up to 90 min post-injection. The mean unbound peak venous concentration was 0.14 (0.05) µg ml−1, and the peak was 0.25 µg ml−1. Conclusions Transversus abdominus plane block using 3 mg kg−1 of ropivacaine produces venous plasma concentrations that are potentially neurotoxic, although broadly consistent with plasma levels found after injection at other comparable sites.

Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block

Plasma Ropivacaine Concentrations After Ultrasound-guided Transversus Abdominis Plane Block

COMMENT The authors are to be commended on this study. It appears that they resourcefully took advantage of the M shortage from a few years ago to compare the clinical efficacy of spinal hydromorphone (HM) against morphine (M). Despite the relatively small numbers and the retrospective nature of this trial, the small differences they found between the drugs have the ring of clinical truth. Relative systemic potency reports between these 2 drugs range from 4 to 8:1 (HM:M). One early study sets it as high as 10:1.1 However, studies of neuraxial HM were scant until recent times. These authors chose a relatively high dose of spinal HM (0.04mg). Their results, although statistically not different between drugs, tended to show slightly higher side effects for HM over M, slightly less analgesia and shorter duration. A larger study population might find these differences to be real. Our own unpublished data with epidural HM after cesarean section found that it was not as clinically effective as M analgesia. This may have been because we used a relatively lower dose of 0.6-0.7mg HM compared to 4mg epidural MS. One final comment: Cost administrators (pharmacy) may like this study when confronted with another morphine shortage.

Symptomatic Local Anesthetic Toxicity and Plasma Ropivacaine Concentrations After Transversus Abdominis Plane Block for Cesarean Section

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Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block

Plasma Ropivacaine Concentrations After Ultrasound-guided Transversus Abdominis Plane Block

Symptomatic Local Anesthetic Toxicity and Plasma Ropivacaine Concentrations After Transversus Abdominis Plane Block for Cesarean Section