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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 691-695  

A comparative study between transversus abdominis block with ropivacaine (0.2%) and fentanyl versus plain ropivacaine (0.2%) for postoperative analgesia in lower abdominal surgeries under general anesthesia


Department of Anaesthesiology, Dr. DY Patil Medical College and Research Centre, Pune, Maharashtra, India

Date of Submission20-Jan-2021
Date of Decision24-Oct-2021
Date of Acceptance24-Oct-2021
Date of Web Publication09-Aug-2022

Correspondence Address:
Dr. Dheeraj Gopal Ravindran
Department of Anaesthesiology, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_37_21

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  Abstract 


Background: Lower abdominal surgeries are associated with significant visceral, somatic, and neuropathic pain in postoperative period. Transversus abdominis plane block (TAP) is a technique used in the management of surgical abdominal pain by injecting local anesthetic in the plane between internal oblique and transversus abdominis muscles. We compared utility of TAP block using ropivacaine alone and also in combination with fentanyl for patients undergoing abdominal surgeries. Aim: To compare ropivacaine (0.2%) versus ropivacaine (0.2%) plus fentanyl (1 mcg/kg) used in transversus abdominal plane for the management of postoperative abdominal pain. Objective: To evaluate quality and duration of analgesia in the management of patients. Materials and Methods: Thirty patients undergoing abdominal surgeries were equally divided into two groups. Group-I received ropivacaine (0.2%) and Group-II received ropivacaine (0.2%) along with fentanyl (1 mcg/kg) as transversus abdominal block. Patients with stable hemodynamic parameters, American Society of Anesthesiologists grade I and II, and undergoing elective procedures were included in the study. Patients with significant comorbidities and emergency procedures were excluded. Vitals were recorded intraoperatively and subsequent to the procedure. Visual analog scale was recorded at 2nd, 4th, 12th, and 24th h postoperatively. Results: The hemodynamic parameters including blood pressure and heart rate were similar in both the groups with nonsignificant difference. Time to rescue analgesia in the form of injection tramadol was significantly earlier in the group that received ropivacaine alone. Patients receiving ropivacaine significantly had a higher severity pain at all the time points. No serious adverse events were noted in the either of the groups. Conclusion: TAP block using ropivacaine along with fentanyl may provide a higher quality of analgesia in patients undergoing abdominal surgeries in postoperative period.

Keywords: Fentanyl, ropivacaine, transversus abdominis plane block


How to cite this article:
Suryawanshi CM, Kabra P, Ravindran DG, Singh A. A comparative study between transversus abdominis block with ropivacaine (0.2%) and fentanyl versus plain ropivacaine (0.2%) for postoperative analgesia in lower abdominal surgeries under general anesthesia. Med J DY Patil Vidyapeeth 2022;15:691-5

How to cite this URL:
Suryawanshi CM, Kabra P, Ravindran DG, Singh A. A comparative study between transversus abdominis block with ropivacaine (0.2%) and fentanyl versus plain ropivacaine (0.2%) for postoperative analgesia in lower abdominal surgeries under general anesthesia. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 26];15:691-5. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/691/353617




  Introduction Top


Postoperative pain management is an important component of care for patients undergoing major surgeries. Adequate prevention and management of pain is essential to reduce psychophysiological side effects associated with pain.[1] Transversus abdominis plane (TAP) block is being widely used in abdominal surgeries for the management of postoperative pain.[2] Studies have shown that it can reduce pain significantly, thereby leading to lesser use of opioids, in turn leading to lesser morbidity and mortality due to use of opioids.[3] It is now being considered as part of multimodal analgesic techniques in the postoperative period, thereby leading to a better postsurgical outcome.[4],[5],[6]

Ropivacaine is an amide anesthetic, known for efficacy and safety for the purpose of regional anesthesia. It has minimal hemodynamic fluctuations and systemic toxic effects. The sensory block is known to happen early with ropivacaine and gets accelerated with addition of opioids like fentanyl.[7],[8],[9]

We compared utility of TAP block using ropivacaine alone and also in combination with fentanyl for patients undergoing abdominal surgeries for effective analgesia.


  Materials and Methods Top


This was a prospective, cross-sectional study that was carried between February 2020 and April 2020 at the Department of Anaesthesiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune.

Prior ethical clearance was obtained from the institutional ethics committee (Research Protocol No. IESC/FP/2020/18). Scientific committee approval was obtained with ref no-DYPMC/CSC/67/2020, date– 28/01/2020.

The aim of the study is to compare ropivacaine (0.2%) versus ropivacaine (0.2%) plus fentanyl (1 mcg/kg) used in transversus abdominal plane for the management of postoperative abdominal pain. A total of 30 patients were recruited. Informed consent of the patients was obtained. The total number of patients undergoing abdominal surgeries were equally divided into two groups of 15 each, after satisfying the inclusion and exclusion criteria.

Inclusion criteria

  1. American Society of Anesthesiologists (ASA) grade I and ASA grade II fit patients
  2. Patients posted for lower abdominal surgery under general anesthesia
  3. Haemodynamically stable patients with all routine investigations within normal limits and without any other comorbidities
  4. Availability of informed consent and willingness of the patient to be a part of the study.


Exclusion criteria

  1. Patients with ASA physical status III or more
  2. Patients posted for emergency procedures
  3. Patients with major neurological, cardiac, respiratory, renal, hepatic, or coagulation abnormalities
  4. Patients having a history of hypersensitivity to local anesthetic and opioids.


Sample size calculation

The sample size was estimated to be 30 patients. The confidence interval was set at 95%, with a study precision of 7.5% using WinPepi statistical package.

Methodology

Since the patients were undergoing lower abdominal surgeries under general anesthesia, they included patients who mainly refused neuraxial blockade for lower abdominal surgeries. They were kept nil per oral for at least 6 h prior to surgery. Standard monitoring of vital parameters such as heart rate (HR), noninvasive blood pressure, respiratory rate, pulse oximetry (SpO2), and electrocardiography were applied. Intravenous access was secured with 20G IV cannula. Baseline vitals of the patients were recorded prior to administration of general anesthesia. Preoxygenation with 100% oxygen for 3 min was given. Premedications administered included injection glycopyrrolate 0.2 mg, injection midazolam 1 mg, injection fentanyl 1.5 mcg/kg and injection ondansetron 0.01 mg/kg. Induction agent used was injection propofol 2 mg/kg body weight. This was followed by administration of injection succinylcholine 2 mg/kg body weight. Patients were then intubated with appropriate sized ET tube and bilateral air entry was confirmed by auscultation, following which the endotracheal tube was fixed. Anesthesia was maintained with air (50%) and oxygen (50%) and isoflurane as required. Nondepolarizing muscle relaxant used was injection vecuronium 0.1 mg/kg given i.v. Vitals were recorded intraoperatively. Ultrasonographic-guided TAP block was performed at the end by an experienced anesthesiologist.

  • Group-I received 6 ml injection ropivacaine (0.5%) + 14 ml NS = 20 ml ropivacaine (0.2%)
  • Group-II received 6 ml injection ropivacaine (0.5%) + 14 ml NS = 20 ml ropivacaine (0.2%) along with fentanyl (1 mcg/kg).


These drugs were given by double blinding method.

Vital parameters were monitored and recorded during and subsequent to the administration of TAP block. Visual analog scale (VAS) was recorded at 2nd, 4th, 12th, and 24th h postoperatively. Time to rescue analgesia was noted in both the groups.

Note

The investigators who measured the endpoints of the study (time to rescue analgesia) were kept blinded to the group identity to avoid any bias in the study findings.

Statistical analysis

The statistical analysis was done by evaluating the quantitative data that were analyzed using unpaired Student's t-test, whereas qualitative data were analyzed by Chi-square test. P value was considered statistically significant at a value of <0.05 set at 95% confidence intervals.


  Results Top


The mean age in Group-I was 40.4 years/standard deviation (SD) = 6.86, whereas in Group-II it was 37.23 years/SD = 7.97 with a nonsignificant P value of 0.1. Both the groups had equal number of males and females when compared to each other (males = 8, females = 7). Patients with ASA grade I were 6 each and ASA grade II were 9 in both the groups.

[Table 1] shows the comparison of pulse rate between the two study groups at baseline, intraoperative, 0 h postoperative, 2 h postoperative, 4 h postoperative, 12 h postoperative, and 24 h postoperative.
Table 1: Pulse rate comparison

Click here to view


The mean and SD were analyzed and found to be nonsignificant.

[Table 2] shows the comparison of systolic blood pressure between the two study groups at baseline, intraoperative, 0 h postoperative, 2 h postoperative, 4 h postoperative, 12 h postoperative, and 24 h postoperative.
Table 2: Systolic blood pressure comparison

Click here to view


The mean and SD were analyzed and found to be nonsignificant.

[Table 3] shows the comparison of diastolic blood pressure between the two study groups at baseline, intraoperative, 0 h postoperative, 2 h postoperative, 4 h postoperative, 12 h postoperative, and 24 h postoperative.
Table 3: Diastolic blood pressure comparison

Click here to view


The mean and SD were analyzed and found to be nonsignificant.

[Table 4] shows the comparison of mean time to rescue analgesia between the two study groups. The comparison was found to be significant in Group II with a P < 0.0001.
Table 4: Time to rescue analgesia

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[Table 5] shows the comparison of VAS score between the two study groups at 2 h postoperative, 4 h postoperative, 12 h postoperative, and 24 h postoperative. The mean and SD were calculated at every stage.
Table 5: Visual analog scale score comparison

Click here to view


The mean and SD were found to be nonsignificant at 2 h postoperative, whereas was found to be significant at 4, 12, and 24 h postoperative with a P value of 0.00168, <0.0001, and 0.0063, respectively.


  Discussion Top


The anterolateral abdominal wall has four muscles: the rectus abdominis, external oblique, internal oblique (IO), and transversus abdominis muscles. The TAP anatomical compartment is a plane that is located between the IO and transversus abdominis muscles and contains the T6–L1 thoracolumbar nerves. The sensitive innervation of the anterolateral abdominal wall results from the spinal nerves, anterior rami. Immediately after exiting from their respective intervertebral foramina, spinal nerves divide into anterior and posterior rami. The anterior rami split into two branches, the anterior and lateral cutaneous nerves. The anterior cutaneous nerve from the T6–T11 segments gives rise to intercostal (IC) nerves, which supply sensitivity to the skin and muscles of the anterior abdominal wall. The T9–T11 IC and T12 subcostal (SC) nerves penetrate the TAP compartment posterior to the midaxillary line. The lower thoracic IC and SC nerves innervate the skin of the infraumbilical area between the midline and midclavicular lines. L1 lumbar plexus gives rise to ilioinguinal (II) and iliohypogastric (IH) nerves. II and IH provide sensory innervation to the upper hip, groin, and thigh. Branches of all these nerves variably travel between the transversus abdominis (TA) and IO muscles in the TAP compartment. US-guided TAP block implicates the injection of LA in between the TA and IO muscles.[15] The TAP block can also be targeted using anatomical landmarks at the level of the Petit triangle. This interfascial plane contains the IC, SC, IH, and ilioinguinal nerves. These nerves give sensation to the anterior and lateral abdominal wall as well as the parietal peritoneum, providing only somatic and not visceral analgesia.[1]

The TAP block can be for postoperative analgesia management in open and laparoscopic abdominal surgeries as well as inpatient and outpatient surgical procedures.[12],[13] Unilateral left- or right-sided blocks are used for unilateral surgical procedures, such as cholecystectomy, appendectomy, nephrectomy, or renal transplants, while bilateral TAP blocks are used for midline and transverse abdominal incisions, such as umbilical or ventral hernia repair, cesarean deliveries, hysterectomy, and prostatectomy.[14] TAP blocks are part of multimodal pain management for abdominal surgeries, which adds analgesic benefit to the patients, reducing postoperative opioid requirements.

From the results of our study, there was no significant difference between hemodynamic parameters such as systolic blood pressure, diastolic pressure, and HR between two groups at any point of time. The time to rescue analgesia was 6.4 h in the ropivacaine alone group, whereas it was 9.3 h when combined with fentanyl. The P value was highly significant. The VAS score was consistently higher when ropivacaine alone was given and this difference was significant at all points of time except at 2nd h postoperatively. This trend of stable hemodynamics and increased duration of time to rescue analgesia into the postoperative period suggests that sensory block duration increases on addition of opioids like fentanyl along with ropivacaine and hence provides longer duration of analgesia.[7],[8]

A study by Chen et al.[10] evaluated efficacy of TAP block using ropivacaine alone and also in combination with other drugs such as dexmedetomidine and fentanyl. Request for patient-controlled analgesia was at duration of 7.86 ± 0.56 h with ropivacaine alone and 8.79 ± 0.55 when ropivacaine was used in combination with fentanyl.

In other study by Patil SS et al.,[11] the authors noted that combining ropivacaine and bupivacaine in the concentration of 0.125% with fentanyl 1 ug/ml is equally safe, with minimal motor block and is effective in providing postoperative analgesia in patients undergoing major abdominal surgeries.

Limitations of the study

  1. The sample size is small and it is suggested to evaluate higher number of patients for further conclusive results
  2. Use of other comparators which are commonly used such as dexmedetomidine and lignocaine was not evaluated
  3. Complications/adverse events subsequent to TAP block procedure were not discussed.



  Conclusion Top


We noted that the analgesic effect subsequent to TAP block using a combination of ropivacaine in combination with fentanyl increased the duration of time to first rescue analgesia. VAS scores were significantly better in patients receiving the combination up to 24 h postoperatively in comparison to those receiving ropivacaine alone. We suggest to use ropivacaine along with fentanyl in TAP block in patients undergoing lower abdominal surgeries.

Ethical issues

Institutional ethics committee clearance was taken prior to start of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mavarez AC, Ahmed AA. Transabdominal plane block, 2020 July 28. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 1
    
2.
Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 1996;12:50-5.  Back to cited text no. 2
    
3.
Jakobsson JG, Wickerts L, Forsberg S, Ledin G. Transversus abdominal plane (TAP) block for postoperative pain management: A review. [version 1; peer review: 2 approved]. F1000Research 2015, 4(F1000 Faculty Rev):1359.  Back to cited text no. 3
    
4.
Peng K, Ji FH, Liu HY, Wu SR. Ultrasound-guided transversus abdominis plane block for analgesia in laparoscopic cholecystectomy: A systematic review and meta-analysis. Med Princ Pract 2016;25:237-46.  Back to cited text no. 4
    
5.
Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth 2011;23:7-14.  Back to cited text no. 5
    
6.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after cesarean delivery: A systematic review and meta-analysis. Can J Anaesth 2012;59:766-78.  Back to cited text no. 6
    
7.
Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: A systematic review and meta-analysis. Colorectal Dis 2012;14:e635-42.  Back to cited text no. 7
    
8.
Agarwal A, Verma RK, Shrivastava S. Ropivacaine-the latest local anesthetic in the Indian market. J Anesth Clin Pharmacol 2010;26:223-8.  Back to cited text no. 8
    
9.
Eledjam JJ, Ripart J, Viel E. Clinical application of ropivacaine for the lower extremity. Curr Top Med Chem 2001;1:227-31.  Back to cited text no. 9
    
10.
Chen Q, Liu X, Zhong X, Yang B. Addition of dexmedetomidine or fentanyl to ropivacaine for transversus abdominis plane block: Evaluation of effect on postoperative pain and quality of recovery in gynecological surgery. J Pain Res 2018;11:2897-903.  Back to cited text no. 10
    
11.
Patil SS, Kudalkar AG, Tendolkar BA. Comparison of continuous epidural infusion of 0.125% ropivacaine with 1 μg/ml fentanyl versus 0.125% bupivacaine with 1 μg/ml fentanyl for postoperative analgesia in major abdominal surgery. J Anaesthesiol Clin Pharmacol 2018;34:29-34.  Back to cited text no. 11
    
12.
Zhao X, Tong Y, Ren H, Ding XB, Wang X, Zong JY, et al. Transversus abdominis plane block for post operative analgesia after laparoscopic surgery: A systemic review and meta-analysis. Int J Clin Exp Med 2014;7:2966-75.  Back to cited text no. 12
    
13.
De Oliveira GS Jr., Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: A meta-analysis of randomized controlled trials. Anesth Analg 2014;118:454-63.  Back to cited text no. 13
    
14.
Lissauer J, Mancuso K, Merritt C, Prabhakar A, Kaye AD, Urman RD. Evolution of the transversus abdominis plane block and its role in postoperative analgesia. Best Pract Res Clin Anaesthesiol 2014;28:117-26.  Back to cited text no. 14
    
15.
Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: A meta-analysis. Anesth Analg 2015;121:1640-54.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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