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LETTER TO EDITOR
Year : 2013  |  Volume : 29  |  Issue : 4  |  Page : 581-582

Use of transversus abdominis plane block as an anesthetic technique in a high risk patient for abdominal wall surgery


1 Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
2 Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan

Date of Web Publication1-Oct-2013

Correspondence Address:
Samina Ismail
Department of Anaesthesia, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.119176

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How to cite this article:
Ismail S, Khan MR, Urooj S. Use of transversus abdominis plane block as an anesthetic technique in a high risk patient for abdominal wall surgery. J Anaesthesiol Clin Pharmacol 2013;29:581-2

How to cite this URL:
Ismail S, Khan MR, Urooj S. Use of transversus abdominis plane block as an anesthetic technique in a high risk patient for abdominal wall surgery. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Apr 20];29:581-2. Available from: http://www.joacp.org/text.asp?2013/29/4/581/119176

Sir,

Transversus abdominis plane (TAP) block produces a reversible blockade of peripheral nerves that provides sensation to the lower abdominal wall from T9 to L1. It has been successfully used as a part of postoperative multimodal analgesia in abdominal surgery since 2001, but its role as a sole anesthetic agent has not been defined. [1],[2],[3],[4]

A 46-year-old male, weighing 98 kg was scheduled for urgent excision of carbuncle over the right lower quadrant of abdominal wall. The presenting complaint was tenderness, redness, and swelling on the right lower abdomen accompanied by fever for the last 8 days. He was a known case of ischemic heart disease (IHD), hypertension, insulin dependent diabetes mellitus, obesity (body mass index (BMI) of 38), and chronic obstructive pulmonary disease. Patient complained of dyspnea on climbing one flight of stairs and frequent episodes of orthopnea and paroxysmal nocturnal dyspnea. He never had an angiography and was only on medical therapy. Chest auscultation revealed occasional basal crackles with normal heart sounds. He was hemodynamically stable and except for raised blood sugar in the range of 350-390 mg/dl; white blood cell (WBC) of 17,200; and erythrocyte sedimentation rate (ESR) of 46; all his other routine blood investigations including coagulation profiles and biochemical assays were normal. Electrocardiography (ECG) showed left atrial enlargement and Q waves in lead II, III, aVF; and chest leads from V1 to V5. His echocardiography report showed an ejection fraction of 20%. His medications included aspirin, clopidgrel, amiloride hydrochloride, furosemide, beta-blockers, and insulin. According to the patient, he had stopped clopidgrel 4 days before coming to the hospital.

Patient was given a detailed explanation about the technique of TAP block and written informed consent was obtained. After all aseptic measures, ultrasound-guided TAP block technique similar to the method described by Hebbard and colleagues was used. [5] We used Mindray Diagnostic Ultrasound System (Model M7SN # NW-2001730 Shenzhen Mindray bio-medical electronics Co. Ltd China). A 38 mm linear array ultrasound probe (13-6 MHz) (Model: 14-6NSSN#PCG22001516 Shenzhen Mindray Bio-Medical Electronics Co. Ltd China) was positioned in the mid-axillary line in the axial plane halfway between the iliac crest and the costal margin. View was considered satisfactory, when the subcutaneous fat, external oblique muscle, internal oblique muscle, transversus abdominis muscle, peritoneum, and intraperitoneal structures were identified. Local infiltration with a 27 G long needle was done with 1-2 cm 3 of 2% xylocaine at the needle insertion site. A 150 mm long, 20 G short-bevel needle (Stimuplex, B. Braun Melsungen AG, Germany) was introduced anteriorly and inserted in plane under real-time ultrasound guidance to lie between the internal oblique and the transversus abdominis muscles with the tip in the mid-axillary line. Test injection with 1 ml of 0.9% normal saline was permitted to confirm needle location. A total of 20 ml of 0.25% of bupivacaine was injected on each side after aspiration to avoid intravascular placement. Successful injection was confirmed by an echo-lucent lens-shaped space between the two muscles. Patient was given 4 l of oxygen via facemask and his numeric rating score for pain from (0 no pain and 10 worst possible pain) and sedation score (1 awake and 3 deep sleep) was monitored. Surgery was allowed to start after 20 min, after checking the level of block from T9 and below with pinprick method. During the whole procedure, patient's pain score remained 1 and sedation score from 1 to 2.

The surgical procedure included excision of approximately 10 × 15 cm of area of skin and the subcutaneous tissue on the right and inferior aspects of the umbilicus. The subcutaneous tissue had pockets of pus and necrotic tissues. The inflammatory process was extending up to the anterior layer of rectus sheath. The whole area was excised up to the healthy margins and hemostasis was secured. The wound was packed with saline soaked dressing and covered with sterile gauze [Figure 1]. Patient remained pain free in the postoperative period and was discharged after 24 h of surgery.
Figure 1: A view of periumblical region of abdominal wall after excision of carbuncle showing healthy lateral deep margins

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Anesthetists are often faced with the challenge of anesthetizing patients with suboptimal cardiac functions presenting for urgent surgeries. Both general and central neuraxial anesthesia with varying degree of myocardial depression and vasodilatation have detrimental effect on the sympathetically driven circulation of these compromised patients. While choosing anesthetic technique for this patient, we considered the fact, that anatomically, sympathetic and somatic innervation are closely related near the neuraxis, but become separated peripherally and nerve blocks like TAP block only affect somatic innervation and leave the sympathetic efferent intact. [5] Therefore, ultrasound-guided TAP block holds potential for a safer and effective block in future practice for high risk patients, however future studies are necessary so as to fully understand its potential as sole anesthetic technique in non-diabetic patients.


  Acknowledgement Top


Published with written consent of the patient.



 
  References Top

1.Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia 2001;56:1024-6.  Back to cited text no. 1
    
2.McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg 2007;104:193-7.  Back to cited text no. 2
    
3.Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008;107:2056-60.  Back to cited text no. 3
    
4.McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2008;106:186-91.  Back to cited text no. 4
    
5.Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616-7.  Back to cited text no. 5
    


    Figures

  [Figure 1]


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