|Year : 2022 | Volume
| Issue : 1 | Page : 19-24
Comparing the intraoperative and postoperative analgesic effect of transabdominal block versus caudal block in children undergoing laparoscopic appendectomy
Saraswathi Nagappa, Nethra H Nanjundaswamy, Vinay Maralusiddappa, Vinayak Nayak
Department of Anesthesiology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||19-Jan-2021|
|Date of Decision||06-Jan-2022|
|Date of Acceptance||17-Jan-2022|
|Date of Web Publication||23-Mar-2022|
Dr. Saraswathi Nagappa
Department of Anesthesiology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic appendectomy is commonly performed in children. Regional anesthesia in children is complementary to general anesthesia, which allows conscious postoperative analgesia and reducing hospital stay. Caudal anesthesia and transverses abdominis plane (TAP) block is commonly used in children because it is easy to practice and provides effective analgesia during surgery. However, its efficacy in laparoscopic appendectomy is not tested much.
Aim: The aim of this study is to evaluate the analgesic efficacy of caudal block and TAP block, when used as pre-emptive analgesia using ropivacaine in terms of opioid consumption, postoperative visual analog score (VAS), duration of analgesia, time for rescue analgesia, postoperative nausea, and vomiting and other side effects following elective laparoscopic appendectomy.
Methodology: The study design was a prospective, double-blinded, comparative randomized trial on children undergoing laparoscopic appendectomy. Sixty patients between 12 and 18 years were included in the study. They were allocated into any one of two groups of 30 patients each, employing computer-generated randomization. Group I: receive ultrasound-guided caudal block using 0.2% ropivacaine 1 mL/kg. Group II: receive ultrasound-guided TAP block using 0.2% ropivacaine 1 mL/kg.
Results: Total intraoperative consumption of opioid fentanyl in Group I is 14.83 ± 18.78 compared to 25.50 ± 17.88 in Group II, which is statistically significant P = 0.028*. VAS score was significantly lower in Group II compared to Group I, P < 0.001**.
Conclusion: Caudal block is effective for intraoperative management, whereas TAP block is effective for postoperative management in children undergoing laparoscopic appendectomy.
Keywords: Analgesia, children, laparoscopy
|How to cite this article:|
Nagappa S, Nanjundaswamy NH, Maralusiddappa V, Nayak V. Comparing the intraoperative and postoperative analgesic effect of transabdominal block versus caudal block in children undergoing laparoscopic appendectomy. Indian Anaesth Forum 2022;23:19-24
|How to cite this URL:|
Nagappa S, Nanjundaswamy NH, Maralusiddappa V, Nayak V. Comparing the intraoperative and postoperative analgesic effect of transabdominal block versus caudal block in children undergoing laparoscopic appendectomy. Indian Anaesth Forum [serial online] 2022 [cited 2022 Jul 5];23:19-24. Available from: http://www.theiaforum.org/text.asp?2022/23/1/19/340489
| Introduction|| |
Pain after laparoscopic appendicitis in children is significant and is caused by the surgical wound and visceroperitonitic pain due to peritoneal inflammation, infection, and stretching, with hemodynamic disturbances due to sympathetic stimulation and vagal stimulation., Laparoscopic appendectomy through minimally invasive surgery, the pain is often short, yet intense, and up to 80% of patients will require opioid analgesia at some stage of perioperative. The use of regional techniques are increasingly utilized as opiate-sparing techniques, in children., The optimal analgesic regimen is important in an enhanced recovery after surgery program, suggesting regional anesthesia and minimally invasive incisions should go hand in hand to reduce morbidity and hospitalization in laparoscopic surgery in children for parent patient satisfaction.,
The caudal epidural blockade remains the most commonly employed regional block in pediatrics consisting of 49.5% of caudal blocks out of 61.5% of central blocks, as it is easy to practice and provides effective analgesia in surgery located under the diaphragm. However, its application in laparoscopic appendectomy is not studied much. Transverses abdominis–plane (TAP) block is a simple, safe efficient, and alternative regional anesthesia type for postoperative analgesia in abdominal surgery and also because of the lower incidence of adverse effects when compared with the neuraxial techniques; The TAP block has been shown to reduce perioperative opioid use in elective abdominal surgery, including open appendectomy, laparotomy, cesarean section, and laparoscopic cholecystectomy. The present study was designed to evaluate the analgesic efficacy of TAB block and caudal block in children undergoing laparoscopic appendectomy during intraoperatively and for the first 24 postoperative hours when applied as preemptive analgesia in terms of opioid consumption, postoperative visual analog score (VAS), duration of analgesia, time for rescue analgesia, hemodynamic response and postoperative nausea and vomiting (PONV) following elective laparoscopic appendectomy.
| Methodology|| |
The study design was a prospective, comparative randomized trial on sixty children between 12 years and 18 years, American Society of Anesthesiologist (ASA I/II) patients undergoing elective laparoscopic appendectomy in our Institute. Patients allergic to local anesthetic agents, skin conditions precluding the block, preoperative chronic dependence upon opioid medication, history of coagulopathy, psychiatric illness, weight greater than 60 kg, comorbid diseases (cardiac, pulmonary, neurological disease), and patient refusal for participation in the study were excluded from the study. The study duration was ten months. They were allocated into any one of two groups of 30 patients each, employing computer-generated randomization.
- Group I receive ultrasound-guided caudal block using 0.2% ropivacaine 1 mL/kg
- Group II receive ultrasound-guided subcostal transversus abdominis block using 0.2% ropivacaine 1 mL/kg.
Institutional ethics clearance and patient parents' written consent and assent from children was taken after proper explanation about the procedure. After shifting to the operation theater, monitors connected and baseline vitals are noted, hydrated well by infusing normal saline 10 mL/kg bolus and premeditated with injection glycopyrrolate 0.2 mg, injection midazolam 0.05 mg/kg body weight and injection fentanyl 2 mcg/kg body weight. After preoxygenation with 100% O2 for 3 min, induction was done with injection propofol 2 mg/kg body weight and sevoflurane, airway secured by using direct laryngoscopy after relaxation with injection atracuronium 0.5 mg/kg body weight, with appropriated cuffed endotracheal tubes, confirmed by equal bilateral air entry. After general anesthesia, under strict aseptic precaution, the Group I patients receives 0.2% ropivacaine 1 mL/kg caudally under the guidance of ultrasound using 22 G hypodermic needle in the lateral position, whereas in Group II, Patients receive ultrasound-guided bilateral subcoastal TAP block under ultrasound guidance (SONOSITE M TURBO). A 38 mm 6–13 MHz probe was placed in the midline of the abdomen 2 cm below the xiphisternum and moved right laterally along the subcostal margin to the anterior axillary line. The transversus abdominis muscle was identified lying beneath and extending laterally to the rectus abdominis muscle. A 25-G spinal needle was then guided, in the plane, to a point just inferior to the right costal margin at the anterior axillary line such that the tip lay between the transversus abdominis and internal oblique muscle within the neurovascular fascial with Ropivacaine 0.2% 1 mL/kg on each side in the supine position. Volume controlled ventilation continued with a high rate to maintain end-tidal CO2 between 35 and 40 mmHg surgeons were asked to wait for 20 min to put incision and minimize the intra-abdominal pressure (not above 12 mm of Hg) during pneumoperitoneum. Intraoperatively, opioid consumption during incision and pneumoperitoneum is noted along with heart rate (HR), mean arterial pressure (MAP) every half an hourly. In the postoperative period, all the patients were received injection paracetamol 15 mg/kg and if patients complain of pain (VAS >3), injection Tramadol 1 mg/kg would be given as rescue analgesia. The demographic data (age, weight, and ASA status, type of operation, and duration of surgery) and the following parameters were recorded. Baseline HR, MAP, and oxygen saturation noted. Postoperatively, HR mean arterial blood pressure (MAP) and VAS score was measured after 30 min, first hour, second hourly, fourth hourly, eight hourly, twelth hourly, and after 24 h, along with the duration of analgesia, time for rescue analgesia, Ramsay sedation score and any other side effects. Double-blind achieved by two anesthetists, one to give block and another to monitor children intraoperative and postoperatively along with the nursing staff. Sample size calculation based on TAP pain score in a two-group controlled study, with a difference of 8-9 score points, with 90% statistical power, 5% level of significance, the sample size of 60 (30 in each group) is adequate. Statistical methods include the Chi-square test, Fisher exact test, and Student's t-test.
| Results|| |
The following demographic data were obtained: age, weight, gender, surgical procedure, and duration of surgery. Two patients in Group II were excluded from the study as the laparoscopic procedure converted to open surgery. The mean age of patients in Group I (caudal) was 14.27 ± 1.89 years, whereas in Group II (TAP), it was 13.87 ± 1.59 years [Table 1]. The children in both groups were comparable for weight and gender [Table 2] and [Table 3].
Total intraoperative consumption of opioid fentanyl in Group I is 14.83 ± 18.78 compared to 25.50 ± 17.88 in Group II, which is statistically significant P = 0.028* [Table 4]. VAS score <3 in 18 children in Group I and 24 children in Group II, whereas VAS ≥3 in 12 children in Group I and 6 children in Group II during immediate postoperative period indicating good quality analgesia in Group II with P = 0.018*, statistically significant [Table 5] and [Figure 1]. Subsequently, the number of patients with adequate surgical analgesia declined much more rapidly in Group I (Caudal) as compared to Group II (TAP). This difference was statistically significant at 30 min P = 0.010*, 60 min P = 0.006**, 240 min P = 0.003**, 480 min P < 0.001**, 720 min P < 0.001**, 1440 min P < 0.001** [Table 6] and [Figure 2]. Mean duration of analgesia in Group I was 510.50 ± 520.90 compared to Group II was 1133.00 ± 570.77 which is statistically significant P < 0.001** [Table 7].
|Table 5: Immediate postoperative visual analogue score distribution in two groups of patients studied|
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|Figure 1: IMPOVAS distribution in two groups of patients studied. IMPOVAS: Immediate postoperative visual analogue score|
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|Table 6: Visual analogue score - A comparison in two groups of patients studied|
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|Figure 2: VAS- A comparison in two groups of patients studied. VAS: Visual analogue score in postoperative period|
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HRs were comparable in both the groups with P = 0.753 and P = 0.660 for baseline and pre-block HR respectively. MAP too comparable in both the groups with P = 0.152 and P = 0.179 for baseline and pre-block MAP, respectively. After that HR was increasing in Group II compared to Group I and statistically significant during incision P < 0.001**, pneumoperitoneum P = 0.002**, post block 10 min P = 0.002**, 20 min P = 0.002**. 30 min P = 0.001**, 60 min P = 0.001**, and 90 min P = 0.001** [Table 8] and [Figure 3], whereas MAP did not show much difference in Group I and Group II intraoperatively [Table 9] and [Figure 4].
|Table 8: Heart rate (beats per minute,) - A comparison in two groups of patients studied|
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|Figure 3: Heart rate (bpm) - A comparison in two groups of patients studied|
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|Table 9: Mean arterial pressure (mm Hg) - A comparison in two groups of patients studied|
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Postoperatively, HR did not show much difference between the two groups during immediate postoperative and 30 min after surgery. However, gradually increased in Group I compared to Group II and statistically significant at 120 min P = 0.015*, 240 min P = 0.034*, 480 min P = 0.014*, 720 min P0.003** and 1440 min P < 0.001**postoperatively [Table 8] and [Figure 3]. MAP was increased in Group I than in Group II and statistically significant at immediate postoperative P = 0.023*, 30 min P = 0.022*, 60 min P = 0.004**, 120 min P = 0.017* and 480 min P = 0.018* [Table 9] and [Figure 4]. Rescue analgesia was required in 83.3% in Group I to 23.3%, in Group II which is statistically significant P < 0.001** [Figure 5].
|Figure 5: Rescue analgesia distribution in two groups of patients studied. P < 0.001**, significant, Chi-square test|
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Three children had PONV in Group I as compared to two children in Group II, which is statistically insignificant. No change in Ramsay sedation score in both groups [Table 10]. Throughout the study, none of the patients had any significant complications such as retention of urine, motor block, fever, bradycardia, hypotension, and neurological sequelae in both groups. There were no reported cases of bleeding, swelling, or bruising at the TAP block injection site. Intraoperatively less opioid consumption in Group I with better hemodynamics parameters, whereas children along with their parents were comfortable and pain-free in Group II with lower VAS score for 24 h postoperatively.
|Table 10: Ramsay sedation score distribution in two groups of patients studied|
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| Discussion|| |
Laparoscopic-guided appendectomy is one of the most frequently performed surgical procedures in the pediatric population worldwide. Although laparoscopic surgeries have smaller incisions and reduced tissue trauma, there is still a need for good regional analgesia. We compared two commonly employed techniques that are caudal block and subcostal transverse abdominis block in children undergoing laparoscopic appendectomy. The results of the present study indicate that administration of 0.2% ropivacaine in a dosage of 1 mL/kg through ultrasound-guided caudal block reduces intraoperative fentanyl opioid consumption P = 0.028*, along with stable hemodynamic parameters (HR, MAP) especially during surgical incision and pneumoperitoneum compared to bilateral subcostal transversus abdominis block. Good pain relief with very low ≤3 VAS scores was achieved in the immediate postoperative period in both the groups but prolonged analgesia with a lower ≤3 VAS score, for 24 h postoperatively noticed in Group II TAP block P < 0.001, which is Similar to Neha and Sharmila study, in which, number of patients with mean VAS score >3 was more in group Caudal, compared to group TAP after first 3 to 4 h in children undergoing lower abdominal surgery. Similarly, in Wafaa et al.'s study, it was evaluated that, pain scores were lower along the whole 24 hours postoperatively in pediatric patients undergoing laparoscopic surgery. The mean total duration of analgesia time was significantly longer in Group II, (TAP) 1133.00 ± 570.77 than in Group I (caudal block) 510.50 ± 520.90 [Table 7], which is statistically significant P < 0.001**, indicating good prolonged postoperative analgesia with stable hemodynamic parameters (HR, MAP) in the TAP block group. Similar results in Ramzy Shaaban study, in which ultrasound-guided TAP block had increased mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5).
In our study, we found that rescue analgesia was required at a much earlier time in children who received caudal block (Group I). In TAP block (Group II), only seven children required rescue analgesia injection tramadol 1 mg/kg, when VAS score >3 compared to twenty-five children in caudal block group indicating reduced postoperative tramadol consumption. Carney et al. performed unilateral TAP block with 0.3 mL/kg ropivacaine 7.5 mg/ml in 45 children less than 16 years of age undergoing open appendectomy and concluded that unilateral TAP block as a component of multimodal analgesia regimen provided superior analgesia in form of decreased morphine consumption in the first 48 postoperative hours as compared to the placebo group. Thus from the above finding, we can say that caudal block is effective for intraoperative use with minimal opioid fentanyl requirement with stable HR and MAP. Whereas TAP block is effective in the postoperative period with lower VAS pain score for 24 hours, thus requiring less rescue analgesia with lesser VAS score in the immediate postoperative period when used preemptively, compared to Caudal block.
Limitation of study we did not monitor the preoperative VAS score of children as that may have an effect on postoperative pain score and also we were unable to evaluate the exact onset of the block under general anesthesia.
The future of the study is to increase the potency of the block by adding additives and increasing the duration of postoperative analgesia by using catheter infusion.
| Conclusion|| |
Caudal block is effective in minimizing the effects of the surgical incision and pneumoperitoneum stress response intraoperatively compared to TAP block, whereas TAP block is effective postoperatively with a lower VAS score and less requirement of rescue analgesia in children undergoing laparoscopic appendectomy.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]