Evaluation of efficacy of bupivacaine and bupivacaine plus clonidine in transversus abdominis plane (TAP) block for postoperative analgesia: a prospective, randomized, double blind, comparative study
DOI:
https://doi.org/10.18203/2320-6012.ijrms20174602Keywords:
Bupivacine, Clonidine, Lower abdominal surgeries, Transverse abdominis plane blockAbstract
Background: Pain is the commonest symptom encountered postoperatively and hence multimodal analgesia is tried to overcome it. In this study, we have compared bupivacaine and bupivacaine plus clonidine in transversus abdominis plane (TAP) block for postoperative analgesia in patients undergoing lower abdominal surgeries under spinal anaesthesia.
Methods: Sixty ASA I and II patients in the age range of 18-60 years undergoing various lower abdominal surgeries were randomly divided into two groups, who were operated after giving spinal block using 2.5 ml of 0.5% hyperbaric bupivacine and 25ug of fentanyl. At the end of surgical procedure tranversus abdominis plane (TAP) block was given by giving 25 ml of injection bupivacaine 0.25% in group I and 25 ml of 0.25% of bupivacaine with 1 ug.kg-1 of clonidine in group II. Quality of analgesia was assessed by visual analogue scale (VAS), categorical pain scoring system and frequency of rescue analgesia given and duration was assessed with the time at which first rescue analgesia was given. Side effects of clonidine such as sedation, bradycardia and hypotension were also noted. The hemodynamic parameters like heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were noted for both the groups.
Results: Demographic characteristics like age, weight, sex, ASA class and type of surgeries were comparable in both groups. SBP, DBP and HR were less in group II than in group I and was statistically significant (p-value<0.05). The overall mean VAS score in group I was 3.03 ± 1.57 and group II was 1.72 ± 1.02 with p-value of 0.0005 and hence better quality of analgesia in group II. Categorical pain scoring system also showed statistically better scores in group II than group I. The duration of analgesia which was calculated by mean time for first rescue analgesia in group I was 6.38 ± 2.56 hours and group II was 14.23 ± 4.63 hours with a p-value of <0.0001 and the difference was statistically significant. The mean number of doses of rescue analgesia in group I for the first 24 hours was 1.37 ± 0.89 and in group II was 0.60 ± 0.62 with a p-value of 0.0003 and the difference was statistically significant. Group II patients showed more sedation scores than group I patients (p-value <0.05). None of the patients had any episode of bradycardia or hypotension.
Conclusions: Addition of clonidine 1 ug.kg-1 to 25 ml of 0.25% bupivacaine compared to 25 ml of 0.25% bupivacaine alone in tranverse abdominis plane (TAP) block improves quality of analgesia, increases duration of postoperative analgesia and decreases postoperative analgesic requirements with minimal side effects.
References
Garimella V, Cellini C. Postoperative Pain Control. Clin Colon Rectal Surg. 2003;26:191-6.
Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev. 2010;(12):CD007705.
McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus Abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg. 2007;104:193-7.
McDonnell J, O’ Donnell B, Tuite D, Farrell T, Power C. The regional abdominal field infiltration (R.A.F.I.) technique: computerized tomographic and anatomical identification of a novel approach to the transversus abdominis neuro-vascular fascial plane Anesthesiol. 2004;101:A899.
Rafi A. Abdominal field block: a new approach via the lumbar triangle. Anaesth. 2001;56:1024-6.
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intens Care. 2007;35:616-7.
Mishra M, Mishra SP. Transversusabdominis plane block: The new horizon for postoperative analgesia following abdominal surgery. Egypt J Anaesth. 2016;32:243-7.
M. RS. Siddiqui MS. Sajid DR. Uncles L. Cheek, and Baig MK, “A meta-analysis on the clinical effectiveness of transversus abdominis plane block,” Journal of Clinical Anesth. 2011;23(1):7-14.
Zafar N, Davies R, Greenslade GL, Dixon AR. The evolution of analgesia in an 'accelerated' recovery programme for resectional laparoscopic colorectal surgery with anastomosis. Colorectal Dis. 2010;12(2):119-24.
Brady RR, Ventham NT, Roberts DM, Graham C, Daniel T. Open transversus abdominis plane block and analgesic requirements in patients following right hemicolectomy. Ann R Coll Surg Engl. 2012;94(5):327-30.
Conaghan P, Maxwell-Armstrong C, Bedforth N. Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections. Surg Endosc. 2010;24(10):2480-4.
Abdallah FW, Halpern SH, Margarido CB. Transversus Abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia. A systematic review and meta-analysis. Br J Anaesth. 2012;109:679-87.
Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27:117-26.
Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), Verbal Descriptive Scale(VDS), Visual Analog Scale (VAS), and West Haven-Yale Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum. 2003;49:S96-104.
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol. 1990;17:1022-4.
Rana S, Verma RK, Singh J, Chaudhary SK, Chandel A. Magnesium sulphate as an adjuvant to bupivacaine in ultrasound-guided transversus abdominis plane block in patients scheduled for total abdominal hysterectomy under subarachnoid block. Indian J Anaesth. 2016;60(3):174-9.
Young MJ, Gorlin AW, Modest VE, Quraishi SA. Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract. 2012:731645.
Farragher RA, Laffey JG. Postoperative pain management following cesarean section. In: Shorten G, Carr D, Harmon D, Puig MM, Browne J. editors. Postoperative Pain Management: An Evidence-Based Guide to Practice. 1st ed. Philadelphia, PA: Saunders Elsevier; 2006:225-38.
Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005;1:CD004088.
Fotiadis RJ, Badvie S, Weston MD, Allen-Mersh TG. Epidural analgesia in gastrointestinal surgery. Br J Surg. 2004;91:828-41.
Eisenach JC, De Kock M, Klimscha W. á2-Adrenergic Agonists for Regional Anesthesia: A Clinical Review of Clonidine (1984-1995). Anesth. 1996;85:655-74.
Yaksh TL. Pharmacology of spinal adrenergic systems which modulate spinal nociceptive processing. Pharmacol Biochem Behav. 1985;22: 845-58.
Al-Ghanem SM, Massad IM, Al-Mustafa MM, Al-Zaben KR, Qudaisat IY, Qatawneh AM, et al. Effect of Adding Dexmedetomidine versus Fentanyl to Intrathecal Bupivacaine on Spinal Block Characteristics in Gynecological Procedures: A Double Blind Controlled Study. Am J Appl Sci. 2009;6:882-7.
Jain G, Chauhan D, Chauhan G, Upadhyaya RM, Comparison between Dexmedetomidine and Clonidine as an Adjuvant to Spinal Anesthesia in Abdominal Hysterectomy, Internat J Sci Res. 2015;4(1):2386-89.
Kanazi GE, Aouad MT, Jabbour-Khoury SI, Al Jazzar, Alameddine MM, Al-Yaman R, et al. Effect of low-dose Dexmedetomidine or Clonidine on the characteristics of Bupivacaine spinal block. Acta Anaesth Scand. 2006;50:222-7.
Cucchiaro G, Ganesh A. The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children. Anesthesia Analges. 2007; 104(3):532-7.
Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: A meta-analysis of randomized trials. Anesth. 2009;111:406-15.
Elia N, Culebras X, Mazza C, Schiffer E, Tramèr MR. Clonidine as an adjuvant to intrathecal local anesthetics for surgery: Systematic review of randomized trials. Reg Anesth Pain Med. 2008;33:159-67.
Casati A, Magistris L, Beccaria P, Cappelleri G, Aldegheri G, Fanelli G. Improving postoperative analgesia after axillary brachial plexus anesthesia with 0.75% ropivacaine. A double-blind evaluation of adding clonidine. Minerva Anestesiol. 2001;67:407-12.
Danelli G, Nuzzi M, Salcuni PF, Caberti L, Berti M, Rossini E, et al. Does clonidine 50 microg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study. J Clin Anesth. 2006;18:585-8.
El Saied AH, Steyn MP, Ansermino JM. Clonidine prolongs the effect of ropivacaine for axillary brachial plexus blockade. Can J Anaesth. 2000;47:962-7.
Griffiths JD, Le NV, Grant S, Bjorksten A, Hebbard P, Royse C. Symptomatic local anaesthetic toxicity and plasma ropivacaine concentrations after transversus abdominis plane block for Caesarean section. Br J Anaesth. 2013;110:996-1000.
Singh R, Kumar N, Jain A, Joy S. Addition of clonidine to bupivacaine in transversus abdominis plane block prolongs postoperative analgesia after cesarean section. J Anaesthesiol Clin Pharmacol. 2016;32:501-4.
Bollag L, Richebe P, Siaulys M, Ortner CM, Gofeld M, Landau R. Effect of transversus abdominis plane block with and without clonidine on post-cesarean delivery wound hyperalgesia and pain. Reg Anesth Pain Med. 2012;37(5):508-14.
