الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 76 |  |  |
| | | from | 76 | | |
Abstract
Caesarean delivery and total abdominal hysterectomy are major surgical procedures, after which substantial postoperative discomfort and pain can be anticipated. The provision of effective postoperative analgesia is of key importance to facilitate early ambulation, infant care, (including breast feeding, maternal-infant bonding) and prevention of postoperative morbidity.These patients require a multimodal postoperative pain treatment regimen that provides high quality analgesia with minimal side effects. Opioids, such as morphine, remain the mainstay of postoperative analgesic regimens for patients post- abdominal surgery. However, the use of opioids can result in significant adverse effects, including sedation, nausea, and vomiting. An important component of the pain experienced by patients after abdominal surgery derives from the abdominal wall incision. The lateral abdominal wall consists of three muscle layers, the external oblique, the internal oblique and the transversus abdominis, and their fascial sheaths. The central abdominal wall also includes the rectus abdominis muscles and its fascial sheath. The nerves that supply the anterior abdominal wall course through the neurofascial plane between the internal oblique and the transversus abdominis muscles.TAP block was performed either by the conventional method where loss of resistance technique was used after palpation of the triangle of petit as an access point to this neurofascial plane Or by the ultrasound-guided technique where in-plane technique using broad linear array probe with an imaging depth of 4-6 cm was performed. By introducing local anesthetics into the transversus abdominis plane (TAP), it is possible to block the sensory nerves of the anterior abdominal wall before they leave this plane and pierce the musculature to innervate the entire anterior abdominal wall. Aim of the work:The purpose of this study was to compare the TAP block using the conventional technique versus ultrasound-guided technique for postoperative analgesiain patients undergoing elective caesarean delivery and total abdominal hystererctomy via a Pfannenstiel abdominal wall incision. METHODS:After obtaining approval by the Benha university Hospital Ethics Committee, and written informed consent from the patient, we studied 60 ASA physical status I–III patients scheduled for caesarean delivery or total abdominal hysterectomy via a Pfannenstiel incision, in a randomized, double-blind, clinical trial. Patients were excluded if there was a history of relevant drug allergy.Patients were randomly allocated into two equal groups undergo conventional TAP block (cTAP group) (n = 30) or ultrasound-guided TAP block (uTAP group) (n = 30) with 20 ml bupivacaine 0.25% per side. Randomization was done by online randomization program which used to generate random number list. Patient randomization numbers were concealed in opaque envelops which were opened by the study investigator. The patients, their anesthesiologists, and staff providing postoperative care were blinded to group assignment. All patients received a standard general anesthesia consisting of fentanyl 1-2 mcg/kg and propofol 1–3 mg/kg followed by rocuronium 0.6 mg/kg to facilitate endotracheal intubation. Fentanyl dose was hold for patients underwent Cesarean delivery until clamping the umbilical cord. Anesthesia was maintained with isoflurane 1.2% and rocuronium 0.15 mg/kg as a maintenance dose every 30 minutes till the end of the procedure. At the end of the operation, bilateral transversus abdominis plane (TAP) block with Bupivacaine was placed right before tracheal extubation either by conventional or ultrasound guided technique according to the patient group.In cTAP groupLoss of resistance technique was used, the landmark for palpation is the triangle of petit which lies above the pelvic rim in the midaxillary line. The inferior border of the triangle is formed by the iliac crest. The anterior border of the triangle is formed by the lateral edge of the external oblique muscle. The posterior border of the triangle is formed by the lateral edge of the latissimusdorsi muscle. The puncture site is just above the iliac crest and just posterior to the midaxillary line within the triangle of petit. After skin disinfection A 24G blunt tipped 50 mm needle was attached with flexible tubing to a syringe filled with the study solution is inserted perpendicular to the skin, and a give or ”pop” is felt when the needle passes through the fascial extensions of the internal oblique muscle. The needle tip is therefore between the fascial layers of the external and internal oblique. Further gentle advancement with a second ”pop” indicates that the needle has advanced into the fascial plane above transversus abdominis and the needle tip is therefore between the fascial layers of the internal oblique and transversus abdominis muscles. In uTAP group A broad linear array probe is used, with an imaging depth of 4-6 cm. After skin disinfection and protection of the ultrasound probe and cable with a sterile ultrasound probe cover, the ultrasound probe is placed transverse to the abdomen (horizontal plane) in the midaxillary line between the costal margin and the iliac crest. Three muscle layers are clearly seen in the image. A 20 G 120 mm blunt ended spinal needle is used. The needle is inserted in a sagital plane approximately 3-4 cm. medial to the ultrasound probe (in-plane technique). The probe is moved slightly anterior to image the skin puncture and superficial course, then gradually posteriorly to the midaxillary line position, following the needle to the correct position in the transversus abdominis plane. A small volume of local anesthetic (1ml) will be injected to open the plane if the 1ml dose appears to be within muscle rather than between them, needle adjustment is required. The local anestheticinjectate appears hypoechoic on ultrasound imaging. When the needle tip is positioned correctly the injectate will be seen on ultrasound to spread out in the plane between the two muscles. In both groups 20ml of 0.25% bupivacaine was injected on each side. After completion of the surgical procedure and block, postoperative analgesia was provided byIV acetaminophen 1 gm and ketorolac 30 mg, then regular oral acetaminophen 1 g four times a day and ketorolac 10 mg three times a day were continued for 24 h after the procedure. If Visual analogue pain score exceed 4, rescue analgesia in the form of intravenous morphine based on morphine titration protocol, 3 mg as a bolus dose which could be repeated every 5 minutes with a maximum dose 40 mg/4 hours.The criteria to stop morphine titration protocol were satisfactory pain control, Patient became sedated (Ramsay sedation scale > 2), Respiratory rate < 12 / min, Oxygen saturation < 95% or development of serious adverse effects (allergy, severe vomiting, hypotension). Morphine consumption and the presence and severity of pain, nausea, vomiting, sedation and pruritus were assessed systematically by an investigator. These assessments were performed in the PACU and at 2, 4, 8, 12, and 24 h after TAP blockade. All patients were asked to give scores for their pain at rest and on movement (knee flexion) and for the degree of nausea at each time point. Pain severity was measured using visual analogue scale (VAS, 10 cm unmarked line in which 0 cm = no pain and 10 cm = worst pain imaginable). Nausea was measured using a categorical scoring system (none = 0; mild = 1; moderate = 2; severe = 3). Nausea was defined as a nausea score >0 at any postoperative time point. Sedation scores were assigned by the investigator using a Ramsay sedation scale(If Awake; Ramsey 1: Anxious, agitated, restless, Ramsey2: Cooperative, oriented, tranquil, Ramsey 3: Responsive to commands only. If Asleep; Ramsey 4: Brisk response to light glabellar tap or loud auditory stimulus, Ramsey 5: Sluggish response to light glabellar tap or loud auditory stimulus) the presence of sedation was defined as a sedation scale > 2 at any postoperative time point. Rescue anti-emetics were offered to any patient who complained of nausea or vomiting. The study ended 24 h after TAP blockade. The primary outcome measure in this study was 24 h morphine consumption. Secondary outcome measures included VAS scores, and side effects associated with morphine consumption. Statistical analyses were performed using a standard statistical program (SPSS version 16). Quantitative data was presented as mean ± Standard deviation, Qualitative data was presented as numbers and percentages, Quantitative data was analysed by using unpaired student t-test, Quantitative data in the same group was analysed by using repeated measure ANOVA test, Qualitative data was analysed by using Chi-square test and Z test, P – Value < 0.05 was considered statistically significant, P – Value < 0.01 was considered statistically highly significant.