González’’ University Hospital at the Autonomous University of Nuevo León, Monterrey, Mexico Received19March2015;accepted23July2015 Availableonline9October2015 KEYWORDS Painmanagement; B
Trang 1Medicina Universitaria.2015;17(69):203 -206
www.elsevier.es/rmuanl
ORIGINAL ARTICLE
D Adame-Coronel∗, G.E Mu˜ noz-Maldonado, J.Á Rodríguez-Brise˜ no
General Surgery Service at the ‘‘Dr José E González’’ University Hospital at the Autonomous University of Nuevo León,
Monterrey, Mexico
Received19March2015;accepted23July2015
Availableonline9October2015
KEYWORDS
Painmanagement;
Bupivacaine;
Anesthesiaand
analgesia;
Ultrasound;
Transverseabdominis
plane;
Laparoscopic
cholecystectomy
Abstract
Objective: UseandevaluatetheUS-TAPBLOCK(UltrasoundTransverseAbdominisPlaneBlock) for themanagementofpostoperativepaininpatientssubmittedtoambulatorylaparoscopic cholecystectomy at the General Surgery service of the ‘‘Dr José E González’’ University Hospital
Materials and methods: Clinical trial, experimental, transversal, comparative, prospective, blind study with24patients 12patients inthe‘‘control’’ group,wherepain wasmanaged withintravenousadministrationofketorolac30mg,and12patientsinthe‘‘cases’’groupusing US-TAPBLOCKwithbupivacaine0.5%forpaincontrol.Weevaluatedthepainlevelusingthe VisualAnalogScale(VAS)at1/2/4/6hpostoperatively.Wheneverthepatientspresentedsevere pain(VAS>6),tramadol50mgwasadministeredintravenouslyasarescuedrug
Results:Gallbladderdiseasewasmorefrequentinthefemalegender(87.5%),between40 -49 yearsold(37.5%),themajoritywereoverweight(54.1%).Thepredominanthistopathological diagnosiswascholecystolithiasis(38%).Weobservednodifferencebetweenthelevelsof post-operativepaininthecomparedgroups.Theuseofrescuedrugswaslowerinthecasegroup
(p=0.035)
Conclusions: TheUS-TAPBLOCKisaneffectiveanalgesictechnique,comparabletothestandard forpainmanagementusedatourhospital,anddecreasestheuseofrescueanalgesics
©2015UniversidadAut´onomadeNuevoLe´on.PublishedbyMassonDoymaM´exicoS.A.Thisis
anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/)
夽 SpecialthankstoDr.NeriA.ÁlvarezVillalobos,MedicalStatisticsSupport CoordinatorattheResearchDepartmentoftheSchoolof
Medicine at the Autonomous University of Nuevo León.
∗Correspondingauthorat:ServiciodeCirugíaGeneral,HospitalUniversitario‘‘Dr.JoséEleuterioGonzález’’,UniversidadAutónomade
Nuevo León Av Francisco I Madero y Av Gonzalitos s/n, colonia Mitras Centro, C.P 64460 Monterrey, NL, Mexico Tel.: +52 01 81 82596525.
E-mail address:dadameuanl@gmail.com (D Adame-Coronel).
http://dx.doi.org/10.1016/j.rmu.2015.07.002
1665-5796/© 2015 Universidad Aut´ onoma de Nuevo Le´ on Published by Masson Doyma M´ exico S.A This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Trang 2204 D.Adame-Coroneletal.
Introduction
Benign biliary pathologies are a topic of interest for the
medicalcommunity,sincetheyarefrequentlydiagnosedin
healthinstitutions.Cholelithiasisandcholecystitisarethe
ones withthehighest incidence Overa million cases are
diagnosedannually,mainlyaffectingtheadultpopulation,
andmorepredominantlyinfemales
InMexico, cholelithiasisprevalence is8.5% inmenand
20.5% in women.1 This has required the development of
surgicaltechniquesandanalgesiawhichallowbetter
medi-cal attention and patient recovery At the ‘‘Dr José E
González’’ University Hospital, the surgical technique of
choiceisambulatorylaparoscopiccholecystectomy,whichis
currentlyacceptedworldwideasthefirstchoiceofapproach
for gallbladder removal,2 which is similar to what
medi-calliteraturereports,reducingsurgicaltime3andproviding
a lesser sensation of pain for the patient An ideal
post-surgical management of pain requires a multimodal and
multidisciplinary approach with a combination of
thera-peuticmaneuversactingat multiple levelsofthe nervous
systemthatinterferewiththedifferentmechanismsof
per-ceptionand painpropagation.4 Current painmanagement
of patients who require this procedure as treatment for
theirmedical condition at the General Surgery service of
thishealthinstitutionconsistsoftheadministrationof
non-steroidalanti-inflamatorydrugs(NSAIDs)intravenously,such
asketorolacat30mg,and/oropioidsliketramadolat50mg,
whenthepainissevere
Localorregionalanesthesiaplaysamajorrolein
post-surgicalpainmanagement.Techniqueshavebeendescribed
and performed which can be considered an alternative
in pain management, such as the TAP-BLOCK (Transverse
AbdominisPlaneblock),whichconsistsofidentifyinga
neu-rovascular plane in the anterolateral abdominal muscles
andinjecting a localanesthetic.5 It is considered tobea
relativelynewtechnique,which wasdescribedin 2001by
A.N Rafi,6 who qualified it asa novel focus in the field
ofabdominalblockage,allowingcontrolof pain.Itis
per-formedthroughtheanatomicalregiondubbedthe‘‘Petit’s
triangle’’,the anesthetic drugs aredeposited in-between
theinternal obliquemuscleandthe abdominaltransverse
muscle,blockingthe T7 -12intercostalnerves, the
iliohy-pogastricandilioinguinalnervesandthecutaneousbranches
oftheL1 -L3dorsalbranch.7
The most commonly prescribed local anesthetic is
bupivacaine,8whichbelongstothelong-termamino-amida
family, provides a superior pain control than opioids and
isusedcommonlyin postoperativeperiodsfor infiltrative,
regionalandneuraxialblockade.4
Because the TAP-BLOCK is a blind technique, it can
causeinappropriate blockades However,the introduction
of ultrasound has allowed the block to be made with
great precision,9 and creating the US-TAP BLOCK
(Ultra-SoundguidedTransverseAbdominisPlaneblock),whichhas
minimizederrorsintheblockade,duetothereal-time
visu-alization of the abdominal planes Previous studies have
reportedtheuseoftheUS-TAPBLOCKtechniqueinpatients
submittedforalaparoscopiccholecystectomy,usinggroups
at differentconcentrations of levobupivacaine(B0.25and
B0.5) as an analgesic, and showing a decrease of pain
whichwasevaluatedwithavisualscaleat20/30/60minand 6/12/24hafterthesurgeryingroups treatedwiththe US-TAPBLOCKandthosewhodidnotundergotheprodedure.10 Duetothefactthatthepostoperativepainwhichresults fromlaparoscopicproceduresintheabdominalplaneis mod-erate to severe, and that at the ‘‘Dr José E González’’ University Hospital there is no precedent for the use of alternatives for postoperative pain control, our study’s objective wastouse the US-TAP BLOCK asan alternative techniquetoanalgesiain patientssubmittedfor a laparo-scopic cholecystectomyandcompareit againsttheuse of conventionalanalgesics.Itisaquickandsimpletechnique which can beperformed onpatients of an advanced age These characteristics make it applicableto theclinic and thepopulationofourhospitalwouldbenefitinitsentirety
This wasaclinical, transversal,comparative,prospective, and blind study, carried out in the Ambulatory Surgery area of the Department of General Surgery of the ‘‘Dr José E González’’ University Hospital of the School of Medicine of theAutonomousUniversity of NuevoLeón(or UANL,byitsSpanishacronym).Thestudywasreviewedand approvedbytheinstitution’sEthicsCommittee.Duringthe periodofJanuary -Februaryof2015,werecruitedvolunteer patientsover18yearsofage,maleorfemale,whowerenot pregnant,diagnosedwithcholelithiasisorcholecystitis,with
aprevioussignedconsentform,whorequiredalaparoscopic cholecystectomyastreatment.We excludedpatientswith alterations in their blood coagulation,patients who were allergictolocalanesthetics(bupivacaine)andpatientswith dermalinjuriesintheblockadezone
Patientparticipationconsistedofselectingaclosedand sealedenvelopeinthepresenceofawitnessandthedoctor
on duty, which couldeither containthe word ‘‘control’’, which madereferencetopostoperative painmanagement viaintravenousketorolacat30mgs,or‘‘cases’’whichmade referencetothesoleapplicationofaUS-TAPBLOCK, inject-ing bupivacaine as a local anesthetic for pain control Each grouphad 12patients, andeach patientcountedon the security that whichever procedure theyselected was intended tocontrol postoperative pain Only the surgeon wasawareoftheproceduretowhicheachenvelopereferred to
Withthe ‘‘cases’’group, the US-TAP BLOCK technique was applied under general anesthesia immediately after the surgery The external obliquemuscleand the abdom-inal transversal muscle were located using Philips HD3 ultrasoundsequipment(Philips,Canada),allowingthe intro-duction ofa 21G,100mm needle(Stimuplex® A,B.Braun, Germany)intotheplaneattheleveloftheanterioraxillary line, following itscourse until itwasplaced between the internal obliqueandabdominaltransversemuscles, where the anesthetic (bupivacaine) was deposited at a concen-tration of 0.5%, at a dosage of2mg/kg, maximaldose of
175mg,equivalentto35ml(17.5mloneachside),followed
byabolusof0.5ccsofsalinesolutionat0.9%
Bothgroupswereevaluatedat1,2,4and6htofollow theirpostoperativeevolution,andtheirdegreeofpainwas evaluatedwiththeVisualAnalogScale(VAS),where0means
Trang 3US-TAPBLOCK 205
Table 1 Socio-demographicdata
Controlgroup
n=12
CasesGroup
n=12
NS = Not significant.
Table 2 ResultsofpainevaluatedbytheVisualAnalogScale
VAS1haverage(SD) VAS2haverage(SD) VAS4haverage(SD) VAS6haverage(SD) Controlgroup
n=12
Casesgroup
n=12
SD = Standard deviation; NS = Not significant.
nopain,1 -3meanslightpain,4 -6meansmoderatepainand
7 -10isseverepain
Tramadolata50mgdosiswasadministeredintravenously
asarescuedrugtopatientswho,duringtheirpostoperative
evaluation,presentedseverepain(VAS±7)
Clinicaldataofthepatients,andthedataobtainedwith
the VAS, were introduced into a database with Excel for
Windows7 HomePremium and statisticallyanalyzed with
the SPSS v.20.0 statistics program, adescriptive analysis
wasusedwiththequantitativevariablesandthequalitative
variableswereexpressedasproportions
Wecomparedthedataonthelevelofpainbetweenthe
groups using the student’s t-test. The need to apply
res-cueanalgesicsduringtheobservationperiodwascompared
usingx2andp<0.05wasdeterminedtosignifyastatistically
significantdifference
Results
The total population studied was 24 patients The
socio-demographicparametersanalyzedweregender,age,height,
weight and body mass index 87.5% of the patients were
femalewithanagebetween40and49yearsandoverweight,
withabodymassindex(BMI)greater than25.The results
bygrouparereportedinTable1
The average time spent in surgery was 60min for the
control group and 70min for thecases group No patient
required the use of drainage and there were no mishaps
orcomplicationsduringtheprocedures(surgeryand
treat-ment).Thehistopathologicaldiagnosisofthesurgicalpieces
reported that 38% were cases of cholecystolithiasis, 33%
chroniccholecystitisandlithiasis,17%chroniccholecystitis
withcholesterolosis and lithiasis, 8% chronic cholecystitis
and4% chronic cholecystitisaggravatedby cholesterolosis
andlithiasis
UsingPearson’sChi-squaredtest,wedidnotfinda
sta-tisticallysignificantdifferencewhencomparingthevalues
oftheVAStakenat1/2/4/6hpostoperativelybetweenthe
patientsparticipatinginthecontrolgroupandthoseinthe casesgroup,findingvaluesofp>0.05(Table2)
Another parameter which wasevaluated to determine
ifthe proposedtechniquefor postoperativeanalgesiawas effectivewastheuseofrescuedrugs,whichwere adminis-teredtopatientswhentheVASvaluewasequaltoorgreater than7atthetimeoftheirevaluation.Ofthetotalnumber
ofpatients, 62.5%didnot requiretheuse ofrescue anal-gesics,againstthe37.5%thatdidrequiretheadministration
ofTramadol
Weobservedthatalargernumberofpatientsinthe con-trolgrouprequiredtheadministrationofrescueanalgesics, withastatisticallysignificantdifference(Table3)
Discussion
The US-TAPBLOCK has demonstrateda reductionin post-operative pain and the dependence on analgesics after abdominalandgynecological surgery,11 when it isused as
apartofaregimenofmultimodalanalgesics
ThefindingsofourstudyreportthattheUS-TAPBLOCK techniquehasshownitselftobeeffective inpaincontrol Althoughitsefficacywasonlycomparableandnotsuperior
toconventional methods,thetwoprocedurescanbe con-sideredeffectivethroughtheVASpainreportsthatshowed lightpainatthedifferenthoursoftheevaluation
The characteristics of the patients participating inour study show that, in our field,the femalegender is more
Table 3 Patientswhoreceivedrescuedrugs(Tramadol)
Controlgroup
n=12
7(58.3%) 5(41.7%) Casesgroup
n=12
2(16.7%) 10(83.3%)
Trang 4206 D.Adame-Coroneletal oftenaffectedbyadiagnosisofbiliarydisease.Compared
tootherstudieslikethatofRaYSetal.,10ourpopulationdid
notdiffermuchintheBMIthattheypresentedatthetime
of thesurgical procedure, themajority wereoverweight
Regardingtheaverage ageofourpatients(43.17±18.46),
itwassimilartothepopulationofthecontrolgroupinour
study(43.4±12.4),anddifferedinourcasesgroup,which
wascomposedofpatientsaround26yearsold
Whencomparedwithotherpublishedstudiesontheuse
oftheUS-TAPBLOCKinabdominalsurgicalprocedures,we
foundthatthevaluesreportedinthepainevaluation,
apply-ingthe technique withdifferent concentrations andlocal
anesthetics,did notdiffermuchbetween thecontroland
casesgroups.Forexample,MunGyuetal.12usedthe
block-adeinthetotalextraperitonealplastyforthemanagement
ofinguinalhernias,usingropivacaineat0.375%,andfound
that,at 4h, the values of the numericalpain scale were
3.11±2.00inthecontrolgroupand2.61±1.56intheTAP
group.Ourstudyreportsanevaluationofpainatthesame
postoperative time, values similar to 3.08 in the control
groupand2.25inthecasesgroup
Niraj,etal.,13inhisstudytoevaluatetheefficacyofthe
US-TAPBLOCK analgesiain patients submittedtoan open
appendectomyusingbupivacaineat0.5%andevaluatingthe
painthroughaVASat30minand24h,foundthatthepain
valuesatrestwerereducedsignificantlyaftertheblock.The
samestudyalsorevealedthatthestandardgrouprequired
significantlymorerescueantiemeticsthantheTAPgroup
Themajorityofpublishedstudiesusedtheapplicationof
theanestheticinasingledose,buttherearestudieswhich
reporttheblockadeinacontinualmanner,whichalsoshow
thatpostoperativepainwaslessintheTAPgroup,butwitha
greateremphasisonthefirstandsecondpostoperativeday
atrestandinmotion.15
Regardingtheuseofrescueanalgesics,whencomparing
thegroupsofpatients,wefoundanimportantdecreasein
theuseof tramadolafterthesurgicalprocedure(p0.035)
inthe casesgroup (US-TAPBLOCK), thesame asreported
by other studies like the one by Sharma, et al.,14 which
reportedadecreaseintheuseoftramadol24hafterthe
sur-gicalprocedure.KadamRaoetal.,15inastudywhichused
theblockadeapplicationinacontinuousmanner, reported
theuseofrescueanalgesicsintwogroups(controlandTAP)
intherecoveryunit;TheTAPgroupusedsignificantlyless
Wedidn’tfoundanyrestrictionsintheapplicationof
US-TAPBLOCK.Therewerenomishapsorcomplicationsduring
theperformanceoftheprocedures.Wecouldmentionthat
thecostofimplementingthistechniqueasapostoperative
alternative rises because, more surgical time is required
alongwiththeacquisitionofbupivacaine
We can conclude that the US-TAP BLOCK, in our field,
offersalesseruseofrescueanalgesicsaftertheprocedure
whencomparedtothenormalmanagementofpostoperative
analgesics
Theauthorshavenoconflictsofinteresttodeclare
Funding
The resources financed come from the General Surgery Service at the‘‘Dr José E González’’University Hospital
attheAutonomousUniversityofNuevoLeón
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