This study investigated the efficacy of a new ilioinguinal-transversus abdominis plane block when used as a component of multimodal analgesia. We conducted a prospective, triple-blind, placebo-controlled randomised study of 100 women undergoing elective caesarean section. All women had spinal anaesthesia with hyperbaric bupivacaine, 15 μg fentanyl and 150 μg morphine, as well as 100 mg diclofenac and 1.5 g paracetamol rectally. Women were randomly allocated to receive the ilioinguinal-transversus abdominis plane block or a sham block at the end of surgery. The primary outcome was the difference in fentanyl patient-controlled analgesia dose at 24 h. Secondary outcomes included postoperative pain scores, adverse effects and maternal satisfaction. The cumulative mean (95%CI) fentanyl dose at 24 h was 71.9 (55.6-92.7) μg in the ilioinguinal-transversus abdominis group compared with 179.1 (138.5-231.4) μg in the control group (p < 0.001). Visual analogue scale pain scores averaged across time-points were 1.9 (1.5-2.3) mm vs. 5.0 (4.3-5.9) mm (p = 0.006) at rest, and 4.7 (4.1-5.5) mm vs. 11.3 (9.9-13.0) mm (p = 0.001) on movement, respectively. Post-hoc analysis showed that the ilioinguinal-transversus abdominis group was less likely to use ≥ 1000 μg fentanyl compared with the control group (2% vs. 16%; p = 0.016). There were no differences in opioid-related side-effects or maternal satisfaction with analgesia. The addition of the ilioinguinal-transversus abdominis plane block provides superior analgesia to our usual multimodal analgesic regimen.
(Anaesthesia. 2018;73:594–602)
Moderate or severe pain after cesarean section has been reported in 7% of women. The ilioinguinal-iliohypogastric block and the transversus abdominis plane (TAP) block have both been effective at reducing postoperative opioid requirements after lower abdominal surgery. However, in studies that compared either of these blocks with spinal morphine, there was no benefit found with the nerve blocks. Regardless, some patients do develop postcesarean pain despite receiving spinal morphine. At the investigators’ institution they began performing a combined ilioinguinal-transversus abdominis plane (I-TAP) nerve block and found it provided improved analgesia. Therefore, this prospective, randomized, placebo-controlled trial was performed to formally evaluate the efficacy of the I-TAP block, hypothesizing that the addition of the block to a multimodal analgesic regimen that included spinal morphine would reduce opioid consumption in the first 24 hours after cesarean section.
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