Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section

Nived Mohanan; K Raghu

doi:10.4103/BJOA.BJOA_4_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 39-41

Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section

Nived Mohanan¹, K Raghu²
¹ Department of Anaesthesiology, Sakra World Hospital, Bengaluru, Karnataka, India
² Department of Anaesthesiology, 4 Air Force Hospital, Kalaikunda, West Bengal, India

Date of Submission	22-Jan-2020
Date of Decision	29-Feb-2020
Date of Acceptance	06-Mar-2020
Date of Web Publication	11-May-2020

Correspondence Address:
Dr. K Raghu
Department of Anaesthesiology, 4 Air Force Hospital, Kalaikunda, West Midnapore, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_4_20

Abstract

Background: Pain relief after cesarean section is essential for the early mobilization of the mother and proper care of the newborn. Among the several modalities available,transverse abdominis plane (TAP) block is newer and attractive. This study aims to compare the efficacy of TAP block compared to sodium diclofenac-acetaminophen combination for postoperative pain following cesarean section. Patients and Methods: Sixty patients undergoing elective cesarean section were included and divided into two groups: Group A received TAP block with 20 ml of 0.25% bupivacaine and Group B received 100 mg diclofenac suppositories followed by intravenous 1 g acetaminophen every 8 h. Participants were assessed for the severity of pain at 0, 4, 8, 12, 24, 36, and 48 h after surgery using the Numeric Rating Scale, the time of first demand for rescue analgesia, and total consumption of rescue analgesia. Results: Pain scores were lower at each point of time during 48 h in Group A as compared to Group B. Time of the first analgesia was statistically significantly longer (7.93 ± 0.70 vs. 4.47 ± 1.36;P < 0.001), and total consumption of rescue analgesia was also lower in Group A (78.13 ± 39.66 mg vs. 140.79 ± 40.15 mg;P < 0.001). Conclusion: TAP block was effective in controlling postoperative pain following cesarean section with a significant reduction in the use of rescue analgesia and their side effects.

Keywords: Bupivacaine, management, pain, regional anesthesia

How to cite this article:
Mohanan N, Raghu K. Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section. Bali J Anaesthesiol 2020;4:39-41

How to cite this URL:
Mohanan N, Raghu K. Transverse abdominis plane block versus sodium diclofenac-acetaminophen combination for postoperative analgesia following cesarean section. Bali J Anaesthesiol [serial online] 2020 [cited 2023 Mar 23];4:39-41. Available from: https://www.bjoaonline.com/text.asp?2020/4/2/39/284183

Introduction

Cesarean section is one of the commonly performed surgical procedures in the field of obstetrics. It accounts for more than one-fourth of all births worldwide.^[1] The most common undesirable outcome following cesarean section is postoperative pain. Failure to treat the pain not only causes distress to the mother but also affects mother-baby bonding, which, in turn, affects care and breastfeeding of the newborn.^[2]

Several modalities are available to combat the pain after cesarean section which includes parenteral or neuraxial opioids, parenteral nonsteroidal anti-inflammatory drugs (NSAIDs), and regional anesthesia techniques such as epidural analgesia.^[3] No single modality is utterly effective in relieving postoperative pain and has their own limitations. Opioids, even though effective against both somatic and visceral components of pain, are associated with side effects such as nausea, vomiting, pruritus, constipation, and respiratory depression.^[4] NSAIDs have fewer side effects compared to opioids but alone may be insufficient to treat pain.^[5] Epidural analgesia provides quality of pain relief without any sedation, but it may cause complications such as hypotension, urinary retention, and muscle paralysis.^[6]

Considering the complications associated with the above methods, there has been a recent trend toward a less invasive but effective method for pain relief. transverse abdominis plane (TAP) block is one such method which acts by blocking afferent impulse from T6 to L1. The main advantage of TAP block is safe, easy to perform, and devoid of complications such as bradycardia, hypotension, vomiting, immobility, sedation, and urinary retention. With the availability of Ultra sonography (USG), the safety and success rate of the block has increased many folds.^[7] This study was conducted to compare the efficacy of TAP block and sodium diclofenac-acetaminophen combination for postoperative pain following cesarean section.

Patients and Methods

This study was conducted at a tertiary care hospital during the period from October 2016 to September 2017. The Institutional Ethical Committee approval was obtained before the commencement of the study. This study involved 60 parturients belonging to the American Society of Anesthesiologists (ASA) physical Status I and II posted for elective cesarean section. Patients with a history of allergy to a local anesthetic, infection at the block site, bleeding disorders, history of neurologic or psychiatric disease, history of active liver or renal disease, and patient refusing to give consent were excluded from the study.

Patients were divided into two groups of thirty. Group A received subarachnoid block (SAB) with 0.5% bupivacaine heavy 2.5 ml, and USG-guided TAP block using 20 ml of 0.25% bupivacaine on either side of the abdomen, immediately in the recovery room. Group B received SAB with 0.5% bupivacaine heavy 3.0 ml and sodium diclofenac 100 mg suppositories and paracetamol 1 g every 8 h after surgery.

On the day of surgery, all patients received 500 ml Ringer's lactate solution. Standard ASA monitoring was applied. Under strict asepsis and local anesthetic infiltration in the sitting position using the midline approach, the dural puncture was carried out at L3–L4 level and bupivacaine heavy 0.5% 2.5 ml was injected intrathecally. Hemodynamics was monitored and treated accordingly. Postoperatively, respective groups received their analgesic modalities and were observed in the postoperative room. Each patient was assessed for the severity of pain at 0, 4, 8, 12, 24, 36, and 48 h after the surgery using the Numeric Rating Scale of 0–10. We used tramadol 1 mg/kg as rescue analgesia when the pain score reached >4. They were also assessed for the time of first demand for rescue analgesia and total consumption of rescue analgesia.

The sample size was calculated using STATA 10 StataCorp LLC. STATA Statistical software for data science for windows, Version 10, (Texas, USA) package on the basis of postulated difference of 10% between the study and control group. Student's t-test (two-tailed, independent) was used to find the significance of study parameters on a continuous scale between the two groups on metric parameters. P < 0.05 was considered statistically significant.

Results

Sixty female patients, of the reproductive age group, of ASA Grade I and II, undergoing lower segment cesarean section under SAB were included. Participants were divided into two groups of thirty, where Group A received TAP block, and Group B received a combination of suppository sodium diclofenac and intravenous paracetamol.

The two groups were similar for age, weight, and height [Table 1]. Mean pain score immediately after the surgery was similar in both the groups (2.01 ± 1.14 vs. 2.10 ± 0.30; P = 0.728). The mean pain scores at 0, 4, 8, 12, 24, 36, and 48 h after surgery were comparatively low in Group A and were statistically significant [Table 2]. The time needed for the patients to require the first dose of rescue analgesia was statistically significantly longer in Group A (7.93 ± 0.70 vs. 4.47 ± 1.36; P < 0.001). The total consumption of rescue analgesia was also lower in Group A (78.13 ± 39.66 vs. 140.79 ± 40.15; P < 0.001), as shown in [Table 3].

Table 1: Demographic data

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Table 2: Mean pain scale as per numeric rating scores (mean±standard deviation)

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Table 3: Rescue analgesic profiles comparison between the study groups

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Discussion

Pain is one of the most commonly faced complications during the postoperative period. The effects of pain are not only limited to the mother but also affects the newborn as it interferes with nursing care. Hence, pain relief not only relieves the physical distress of the mother but also improves the quality of care of the newborn.

Pain relief offered to mother should be safe, effective, and devoid of complications because excessive or inadequate pain relief has an impact on both the mother and the baby.^[8] Many modalities are available for the control of postoperative pain, which includes systemic or neuraxial opioids, NSAIDs, and epidural analgesia. These methods have their own complications.

Currently, there is a trend toward the methods which are more effective but are having fewer side effects. TAP block is one such method with excellent efficacy in controlling pain after a variety of abdominal surgeries. TAP is a neurovascular plane located between the internal oblique and transverse abdominal muscles where nerves supplying anterior abdominal wall pass through. TAP block acts by blockage of nerve impulses by local anesthetic, which is deposited in the space between above-said muscles.^[7] It was introduced in anesthesia practice by Rafi in 2001, and the USG -guided approach was first described in 2007 by Hebbard et al.^[9],[10]

In this study, we compared the TAP block with the conventional analgesic regimen in controlling the postoperative pain relief in patients undergoing cesarean section. We found that in patients given TAP block, the pain score and consumption of rescue analgesics were low at any given time.

We found out that the pain scores were significantly low in patients receiving TAP block when compared to the conventional analgesia at any point of the time during the first 48 h. This is comparable to the study by Sharma et al.^[11] who compared pain relief of TAP block to the systemic analgesic regimen in patients undergoing major abdominal surgeries. They concluded that the TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery without any complications. Similar results were observed in a study conducted by Naveen et al.^[12] and Kahsay et al.^[13]

The time for the first demand for rescue analgesia is prolonged in TAP block compared to the conventional analgesia. This was comparable to the study done by Naveen et al.^[12] and Srivastav et al.^[14] where the conventional group requested earlier rescue analgesia.

The total consumption of the rescue analgesic was low in TAP block when compared to the conventional group which was comparable to the study done by Kahsay et al.^[13] and Srivastav et al.^[14] They reported as much as 50% less use of opioids in the TAP block. This has an important implication in postoperative care as less use of opioids means less incidence of opioid-related side effects.

Conclusion

The TAP block provided effective and prolonged postoperative analgesia compared to the combination of sodium diclofenac-paracetamol with less requirement of rescue analgesic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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