If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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E-letters: Electronic letters published:
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Re: Transversus abdominis plane blocks: a correction and a suggestion
- Abdelazeem Eldawlatly (12 October 2009)
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Re: Ultrsound guided TAP block -continous catheter technique in abdominal surgery.
- Abdelazeem Eldawlatly (2 October 2009)
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Re: Ultrasound-guided transversus abdominis plane block... is it still a new technique?
- Abdelazeem Eldawlatly (28 September 2009)
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Ultrsound guided TAP block -continous catheter technique in abdominal surgery.
- vasanth rao kadam (27 July 2009)
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Transversus abdominis plane blocks: a correction and a suggestion
- Rachel K Perry (16 July 2009)
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Ultrasound-guided transversus abdominis plane block... is it still a new technique?
- Karim MUKHTAR, Shiv Singh (7 May 2009)
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Abdelazeem Eldawlatly, Professor of Anesthesia College of Medicine, King Saud University, Riyadh, KSA
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Dear Editor I read with interest the letter sent by Rachel K. Perry as a comment on my recently published article on TAP block in laparosopic surgery. I wish to thank Dr.Perry for drawing my attention to the error found in the abstract which contradict with the full text. What is true is what is written in the full text which stated that: “Patients in Group A (TAP) received significantly less intraoperative sufentanil and postoperative morphine compared with those in Group B (without TAP).” I wish to thank Dr.Perry for her note an apologize for the reades for this error. Conflict of Interest:None declared |
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Abdelazeem Eldawlatly, Professor of Anestheia, College of medicine, King Saud University, Riyadh, saudi Arabia
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Dear Editor I read with interest the response to my recently published article on TAP block which was sent by Dr. Vasanth Rao Kadam. I found his reply very interesting using continuous TAP block for postoperative analgesia for the first 72 hr following abdominal surgery. I wonder about the dose of ropivacaine used by the author, how it was calculated?. Whether it was based on pharmacokinetic study or not. I believe, as I concluded in my paper, pharmacokinetic studies are reqired to calculate the proper dose of local anesthetic. Further studies are needed to estimate the dose used for continuous infusion technique. Conflict of Interest:None declared |
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Abdelazeem Eldawlatly, Professor of Anesthesia
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Dear Editor I read Dr Mukhtar's letter with interest.I agree with him that the technique of ultrasound TAP block has been described earlier, however its use in laparoscopic cholecystectomy was not reported. I also agree that scores for pain and nausea and vomiting assessment would be appropriate for our study. However, we meant to publish our initial results about the eficacy of TAP block in laparoscopic surgery and, soon and with large sample size, we will provide a new article for possible publication addressing the issues raised by Dr Mukhtar. We have mentioned that the aneshesiologist who performed general anaesthesia was blinded to the establishment of TAP block. Thus he/she didnt know the contents of the syringe used whether it was local anesthetic or saline. I would like to thank Dr Mukhtar again for his comments and I believe that further studies are needed to evaluate optimal volumes for ultrasound-guided TAP block and pharmacokinetic data. Conflict of Interest:None declared |
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vasanth rao kadam, anaesthetist senior consultant, senior lecturer at university of adelaide
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Editor-In the June issue El Dawlatly et al have described the use of ultrasound guided bilateral transversus abdominis plane (TAP) block as an adjunct to conventional systemic analgesia following laparoscopic cholecystectomy¹ . They concluded that the ultrasound guided approach to this block enabled exact placement of the local anaesthetic and that this resulted in a significant decrease in intraoperative and postoperative opioid requirements. I am able to report a similar conclusion, using a continuous infusion technique via ultrasound guided TAP catheters for upper abdominal surgery. In this study 20 patients undergoing upper abdominal surgery were enrolled. The general anaesthetic technique was standardised using Propofol, Rocuronium , Sevoflurane and fentanyl upto 500mcg . Postoperative analgesia was provided by fentanyl PCA and paracetamol 1g 6 hourly IV in both Non TAP group (n=10) and in TAP group (n=10). The TAP group additionally had bilateral Portex epidural catheters placed in the Transverse abdominal plane using an ultrasound guided approach with a bolus dose of 15 ml ropivacaine 5mg/ml followed by an infusion of ropivacaine 2mg/ml at a rate of 8 – 10 ml per hour per side. Infusions were maintained for 72 hours. Outcomes recorded were pain scores, (measured on a Numerical Rating Scale NRS) and fentanyl use at 1-hour post op and on days 1 – 3 following surgery. The number of vomiting episodes was also recorded. Findings: There were no differences in age, sex or ASA status between the groups. The `at rest’ pain scores at 1 hr and on post op days 1 – 3 are as follows. (* indicates a significant difference at the P<0.05 level or less using 2 tailed T test.) Pain Scores (NRS) TAP group ±/- S.E. NON TAP Group ±/- S.E. 1 h 1.6 ± 0.7 1.2 ± 0.4 Day 1 1.7 ± 0.6 3.1 ± 0.7 Day 2 1.0 ± 0.5 2.6 ± 0.6* Day 3 1.0 ± 0.5 2.4 ± 0.9 Pain Scores on coughing Pain Scores (NRS) TAP group ±/- S.E. NON TAP Group ±/- S.E. 1 h 2.8 ± 1.0 3.3 ± 0.9 Day 1 2.9 ± 0.8 6.0 ± 0.8* Day 2 3.0 ± 0.8 6.5 ± 0.8* Day 3 3.2 ± 0.9 3.6 ± 1.0 Fentanyl Requirements in mcg at 1 hr and on post op days 1 – 3 are as follows. (* indicates a significant difference at the P<0.05 level or less using 2 tailed T test.) Fentanyl TAP Group±/- S.E NON TAP Group±/- S.E 1 h 78 ± 29 203 ± 42* Day 1 664 ± 134 1237 ± 145* Day 2 799 ± 257 1345 ± 257 Day 3 509 ± 161 661 ± 257 Although the number of patients in this study is small, the data show a decrease in the pain scores and fentanyl requirements as a consequence of using the ultra sound guided TAP blocks and postoperative infusions. Like El Dawatley I found the anatomical structures best visualised sonographically in the anterior axillary line between the iliac crest and the 12th rib. For this reason I used this site to insert the catheters. While El Dawatley had the opportunity to perform the blocks 15 minutes before surgery, I was obliged to site the catheters postoperatively. This ensured avoidance of the incision area and wound dressings. I found that subcutaneous tunnelling of the catheters away from the wound site was a useful technique and this helped to limit any leakage of local anaesthetic. In all patients, 10 cm of catheter was advanced into the TAP, although experience gained during this study suggests that 15 cm might be more appropriate in obese patients. A single shot TAP block was successfully used by McDonnell² but this is the first controlled study of ultrasound guided TAP block using a postoperative catheter technique for upper abdominal incisions. I found the blocks easy to perform and catheter placements straightforward. I believe the results are promising and that this technique may have a place when epidural analgesia is contra indicated. 1.A.A.El-Dawlatly, A.Turkistan,S.C.Kettner, A.-M. Machata, M.B.Delvi, A. Thallaj, S.Kapral and P. Marhofer. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth (2009) 102:763-767. 2. McDonnell JG, O'Donnell B, Curley G, et al. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg (2007) 104:193–7. Dr V.Rao Kadam. The Queen Elizabeth hospital, SA. Australia. Vasanth.rao@health.sa.gov.au Fax 0061 8 82227065 Conflict of Interest:None declared |
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Rachel K Perry, LAT ST3 Anaesthesia Torbay Hospital, Devon
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Editor - El-Dawlatly et al report a well designed prospective, double -blind randomised controlled trial investigating the use of ultrasound guided transversus abdominis plane (TAP) blocks for laparoscopic cholecystectomy (1). It is unfortunate that the abstract contradicts the full text. Although the study showed a substantial reduction in perioperative opioid consumption in Group A who had received TAP blocks, the abstract states the opposite. Specifically, the abstract reads “Patients in Group A received significantly more intraoperative sufentanil and postoperative morphine compared with those in Group B.” Although the full report correctly presents the advantage of reduced analgesic use, a casual reading of the abstract might suggest the reverse to be true and needs correcting for future literature searches. The report is right to conclude that further research is needed to determine the optimal site for TAP block needle insertion under ultrasound guidance and the volume of local anaesthetic (LA) infiltrated. As a trainee I have used TAP blocks for the last six months but have encountered resistance from some surgical and anaesthetic colleagues towards their use. These colleagues cite potential disadvantages including “failed blocks” and haematoma formation in the abdominal wall from the TAP injections. The use of ultrasound should help to address these concerns by improving analgesic quality and safety. My colleagues also argue that TAP blocks have not been shown to be superior to the current best practice of multimodal analgesia with local and intraperitoneal infiltration of LA(2), but have the previously stated disadvantages. This could be researched with a three arm randomised controlled trial of patients under general anaesthesia comparing LA infiltration alone, TAP block alone, and LA infiltration plus a TAP block. All groups would also receive Paracetamol, a non-steroidal anti – inflammatory and an opioid titrated to effect. Outcome measurements should include pain scores as well as levels of analgesic consumption and side effects experienced. I suggest that his would give more translational results than comparing TAP blocks with opioid analgesia alone and would provide the evidence needed to justify a change in practice. 1 El-Dawlatly AA , Turkistani A, Kettner SC, Machata A-M, Delvi M B, Thallaj A, Kapral S and Marhofer P. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaes 2009: 102:763 – 7 2 Gupta A. Local anaesthesia for pain relief after laparoscopic cholecystectomy-a systematic review. Best Pract Res Clin Anaesthesiol 2005 ;19(2):275-92 Conflict of Interest:None declared |
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Karim MUKHTAR, Regional Anaesthesia Fellow Department of Anaesthesia, Royal Liverpool and Broadgreen University Hospitals, Shiv Singh
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Dear Editor- We read the article by El-Dawlatly et al with great interest. We were very surprised that they have branded their ultrasound-guided technique of performing the transversus abdominis plane (TAP) block as "a new technique". As mentioned in their study, the block has been described using ultrasound guidance in several reports(1,2) and a cadaveric study(3). We have certainly described the exact approach for laparoscopic surgery in our case series(4). There are also a few omissions we would like to highlight.We expected to find a comparison of pain scores at different times between both groups in the postoperative period which is a good indicator of the quality of the analgesia provided . There was also no mention of the impact the reduction in morphine consumption had on the side effects associated with this particular surgery and augmented by the use of opioids, such as nausea and vomiting . Our experience with the use of TAP blocks for laparoscopic cholecystectomy shows comparable opioid-sparing effects although in our institution, 2 of the ports used by the surgeons are placed in the supraumbilical region which necessitates an additional subcostal injection to provide adequate analgesia. 1. Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg (2008) 106:674–5. 2. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care (2007) 35:616–7. 3. Tran TMN, Ivanusic JJ, Hebbard P, et al. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study. Br J Anaesth 2009; 102(1): 123-73. 4. Mukhtar K, Singh S. Transversus abdominis plane block for laparoscopic surgery. Br J Anaesth 2009; 102(1):143-4 Conflict of Interest:None declared |
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