Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2019  |  Volume : 12  |  Issue : 4  |  Page : 373--375

Continuous transverse abdominis plane catheter for postoperative analgesia in pediatric abdominal surgery


Sushama Raghunath Tandale, Kalpana V Kelkar, Shriaunsh R Abhade, Ramchandra N Lawate 
 Department of Anaesthesiology, BJMC and SGH, Pune, Maharashtra, India

Correspondence Address:
Kalpana V Kelkar
Department of Anaesthesiology, BJMC and SGH, Pune, Maharashtra
India

Abstract

Transversus abdominis plane (TAP) block is relatively newer method for the management of postoperative pain after abdominal surgery in pediatric patients. Although there is emerging evidence proving the safety and efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. This technique involves the injection of local anesthetics into the plane between the internal oblique and transversus abdominis muscle and thus giving pain relief. The technique when performed under ultrasound guidance or under vision after dissection of the plane between two muscles is most effective and safe. This helps in significant reduction in the analgesic requirement postoperatively and hence the side effects with their use. We report successful pain management postoperatively in three pediatric patients, in whom neuraxial block was contraindicated.



How to cite this article:
Tandale SR, Kelkar KV, Abhade SR, Lawate RN. Continuous transverse abdominis plane catheter for postoperative analgesia in pediatric abdominal surgery.Med J DY Patil Vidyapeeth 2019;12:373-375


How to cite this URL:
Tandale SR, Kelkar KV, Abhade SR, Lawate RN. Continuous transverse abdominis plane catheter for postoperative analgesia in pediatric abdominal surgery. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Nov 20 ];12:373-375
Available from: http://www.mjdrdypv.org/text.asp?2019/12/4/373/262225


Full Text



 Introduction



Regional anesthesia is an integral component of postoperative pain relief in pediatric patients. These techniques are safe as well as effective and becoming increasingly popular in them. Transversus abdominis plane (TAP) catheter is an effective alternate for laparotomy with a transverse incision in pediatric patients, in whom neuraxial block is contraindicated. We discuss postoperative analgesia of three children with TAP continuous catheter.

 Case Reports



Cases 1 and 2

Two infants weighing 3.5 kg and 4.5 kg, respectively, were planned for portoenterostomy in view of biliary cirrhosis. Epidural analgesia was not planned due to subnormal hepatocellular function with deranged the international normalized ratio. General anesthesia was administered. A right subcostal incision was taken for surgical exposure. Intraoperative course was uneventful. At closure, due to unavailability of ultrasound, surgical team was asked to dissect the plane between transversus abdominis and internal oblique muscle, and a 21G catheter was placed in the plane under vision and secured to the skin in both infants [Figure 1]. Bupivacaine 0.1% 3.5 cc and 0.1% 4.5 cc was given through the catheter in infants 1 and 2, respectively, and repeated 12 hourly for postoperative 3 days. Coanalgesic included intravenous (IV) paracetamol 5 mg/kg and tramadol 1 mg/kg every 12 hourly for 48 h under vigilant monitoring for respiratory depression. Both infants were pain-free (The Face, Legs, Activity, Cry, Consolability scale score <4 in both the infants), and catheters were removed on postoperative day 4. The catheter sites were healthy. IV paracetamol continued on requirement basis postoperatively.{Figure 1}

Case 3

A 7-year-old male child weighing 15 kg, known case of thalassemia major, was posted for splenectomy in view of hypersplenism. Epidural analgesia was not planned due to thrombocytopenia (40,000/mm 3). Left subcostal incision was made for surgical exposure. At the wound closure, TAP catheter was inserted by surgical team after dissection of plane between transversus abdominis and internal oblique [Figure 2]. Bupivacaine 0.2% 15 cc was given through catheter and repeated 12 hourly for postoperative 3 days. Coanalgesic included IV paracetamol 150 mg every 8 hourly and IV tramadol 15 mg 12 hourly for 48 h under vigilant monitoring for respiratory depression. The pain relief was adequate (visual analog scale score <3) and the catheter was removed on postoperative day 4. Catheter site was healthy. IV paracetamol was continued on requirement basis postoperatively.{Figure 2}

 Discussion



In certain situations when neuraxial blocks are contraindicated, alternative peripheral techniques of regional anesthesia are of particular benefits. Analgesia options in very young patients are limited due to organ immaturity, and opioid use in them is associated with undesirable side effects such as nausea, vomiting, sedation, and respiratory depression, hence making the peripheral regional block as indispensable part of postoperative analgesic regimen in those patients. TAP block has been found safe and effective technique for postoperative analgesia in a variety of upper and lower abdominal surgeries among the adult population.[1],[2] However, there is limited literature regarding the use of continuous TAP catheters in pediatric population.[3],[4] Use of ultrasound guidance as well as placement under vision by surgeons has increased the safety and efficacy of block in pediatric patients.[5],[6] TAP block is a peripheral nerve block of intercostal, subcostal, and first lumbar nerves that contribute to innervations of the anterior abdominal wall which runs in the neurovascular plane located between internal oblique and transversus abdominis muscle.[7]

We used the subcostal approach for placement of catheters. Catheter tip was pointed toward the xiphisternum, along with an oblique subcostal line at the level of anterior axillary line. Currently, there are no recommendations on volume and dose of local anesthetics for TAP block in pediatric patients. Different dosing patterns are used in pediatric patients in different studies.[5],[8] We used high volume of local anesthetics, 1 ml/kg through these catheters, with care not to exceed the toxic dose of it. We specifically had chosen high volume due to lengthy oblique abdominal incision and compensation for the dilution as well as escape of the drug through dissected planes as the extent of the dermatomal block provided by TAP block is uncertain. Further studies are required to determine the optimal dosing regimen. In pediatric patients, close attention to volume and concentration of local anesthetics is more important as they are prone to local anesthetics toxicity owing to their decrease plasma protein binding and reduced clearance. Hence, care should be taken not to exceed maximal permissible dose.

Single injection technique carries the disadvantage of the limited duration of analgesia; hence, we used continuous catheter technique for the provision of effective postoperative analgesia. However, TAP block covers only the somatic component of surgical pain, for visceral pain analgesia has to be supplemented with other analgesic agents, hence, it cannot be used as sole anesthetic technique.[9]

Technical problems with this approach would be possible damage to the underlying tissue while passing a needle from the skin to desired plane which makes it a considerable distance, damage to the liver or spleen as they are prominent in younger patients,[7] possible diffusion or leakage of drug through dissection of plane between internal oblique and transversus abdominis,[8] misplacement or migration of catheter due to improper fixation, or blockage of catheter due to cellular debris or clot. Anatomical problems would be ambiguity in landmark technique due to small size of patient and anatomical variation in the distribution of nerves. Another and perhaps the most important concern is local anesthetic toxicity as large volumes of drugs are being used and accidental removal of catheter.

Advantages of continuous TAP catheter with GA are decrease in requirement of rescue analgesic, decrease in postoperative opioid consumption, enhanced recovery, and early mobilization. Use of continuous wound infiltration catheter is also an effective and safe alternative in major laparotomy for postoperative analgesia, although diffuse innervations of anterior abdominal wall and intraperitoneal viscera pose a challenge for complete denervation with selective wound infiltration.[10]

 Conclusion



TAP catheters are effective analgesia technique for laparotomy with transverse incision in pediatric patients when neuraxial anesthesia is contraindicated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T, et al. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: A systematic review and meta-analysis. Colorectal Dis 2012;14:e635-42.
2Atim A, Bilgin F, Kilickaya O, Purtuloglu T, Alanbay I, Orhan ME, et al. The efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing hysterectomy. Anaesth Intensive Care 2011;39:630-4.
3Kanojia N, Ahuja S. Comparison of transversus abdominis plane block and caudal block for postoperative analgesia in children undergoing lower abdominal surgery. Int J Sci Res 2015;4:1585-7.
4El-Fawy DM, El-Gendy HA. Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative pain relief in infants and children undergoing surgical pyeloplasty. Ain Shams J Anesthesiol 2014;7:177-8.
5Sahin L, Sahin M, Gul R, Saricicek V, Isikay N. Ultrasound-guided transversus abdominis plane block in children: A randomised comparison with wound infiltration. Eur J Anaesthesiol 2013;30:409-14.
6Zhong T, Wong KW, Cheng H, Ojha M, Srinivas C, McCluskey SA, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: A prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg 2013;66:329-36.
7Yuratich D, Bhalla T, Jayanthi VR, Tobias JD. Bilateral transversus abdominis plane (TAP) catheters for postoperative analgesia in a child with spinal dysraphism. Anaesth Pain Intensive Care 2012;16:276-9.
8Bakshi SG, Doctor JR, Trivedi BD, Qureshi SS. Transversus abdominis plane catheters for postoperative pain relief in pediatric patients. J Anaesthesiol Clin Pharmacol 2017;33:121-2.
9Kerai S, Dabas N, Sehrawat L, Gupta N. Transversus abdominis plane block as sole anaesthetic technique for inguinal hernia repair in two patients having complex medical conditions. Indian J Anaesth 2015;59:754-6.
10Scott NB. Wound infiltration for surgery. Anaesthesia 2010;65 Suppl 1:67-75.