Randomised comparison of three types of continuous anterior abdominal wall block after midline laparotomy for gynaecological oncology surgery.

Effective analgesia after midline laparotomy surgery is essential for enhanced recovery programs. We compared three types of continuous abdominal wall block for analgesia after midline laparotomy for gynaecological oncology surgery. We conducted a single-centre, double-blind randomised controlled trial. Ninety-four patients were randomised into three groups to receive two days of programmed intermittent boluses of ropivacaine (18 ml 0.5% ropivacaine every four hours) via either a transversus abdominis plane (TAP) catheter, posterior rectus sheath (PRS) catheter, or a subcutaneous (SC) catheter. All groups received patient-controlled analgesia with morphine, and regular paracetamol and non-steroidal anti-inflammatory medication. Measured outcomes included analgesic and antiemetic usage and visual analog scores for pain, nausea, vomiting, and satisfaction. Eighty-eight patients were analysed (29 SC, 29 PRS and 30 TAP). No differences in the primary outcome were found (median milligrams morphine usage on day two SC 28, PRS 25, TAP 21, P=0.371). There were differences in secondary outcomes. Compared with the SC group, the TAP group required less morphine in recovery (0 mg versus 6 mg, P=0.01) and reported less severe pain on day one (visual analog scores 36.3 mm versus SC 55 mm, P=0.04). The TAP group used fewer doses of tropisetron on day one compared with the PRS group (8 versus 21, P=0.016). Programmed intermittent boluses of ropivacaine delivered via PRS, TAP and SC catheters can be provided safely to patients undergoing midline laparotomy surgery. Initially TAP catheters appear superior, reducing early opioid and antiemetic requirements and severe pain, but these advantages are lost by day two.

Ultrasound-guided transversus abdominis plane block for analgesia after Caesarean delivery.

BACKGROUND: The landmark-guided transversus abdominis plane (TAP) block is an effective method of providing postoperative analgesia in patients undergoing lower abdominal surgery. We evaluated the analgesic efficacy of the ultrasound (US)-guided TAP block in patients undergoing Caesarean delivery. METHODS: A randomized, double-blind, placebo-controlled trial was performed at a tertiary maternity hospital. Fifty women undergoing Caesarean delivery received bilateral US-guided TAP blocks with either ropivacaine 0.5% or saline. All participants received a spinal anaesthetic with bupivacaine and fentanyl, followed by postoperative acetaminophen, non-steroidal anti-inflammatory drugs, and patient-controlled i.v. morphine without long-acting intrathecal opioids. Each patient was assessed 24 h after delivery for morphine usage, average pain score, nausea, vomiting, pruritus, drowsiness, and satisfaction with pain relief. RESULTS: Forty-seven participants completed the trial, 23 in the active group and 24 in the placebo group. Total morphine use in 24 h was reduced in the active group (median 18.0 mg) compared with the placebo group (median 31.5 mg, P<0.05). The active group reported improved satisfaction with their pain relief measured by visual analogue scale compared with the placebo group (median 96 vs 77 mm, P=0.008). Fewer patients required antiemetics in the active group (P=0.03). There were no local complications attributable to the TAP block, but one participant had an anaphylactoid reaction after ropivacaine injection. CONCLUSIONS: The US-guided TAP block reduces morphine requirements after Caesarean delivery when used as a component of a multimodal analgesic regimen. Registered with the Australia New Zealand Clinical Trials Registry ACTRN12608000540314. URL: http://www.anzctr.org.au/trial_view.aspx?ID=83176.