Surgeon-Assisted Continuous Transversus Abdominis Plane Block a Feasible Option for Perioperative Pain Relief in Pediatric Surgical Patients with Spinal Deformities.

Sir,

Transversus abdominis plane (TAP) block's role in the pediatric population is extended for various surgeries such as herniotomy, laparoscopy, appendicectomy, laparotomy, and colostomy formation.[1] It works out as a viable alternative to the neuraxial blocks in situations where it is contraindicated such as coagulopathies, spinal deformities, and spinal surgeries.

After obtaining written informed consent from the parents, we present a case of a 12-year-old female child weighing 35 kg, a known case of Klippel Feil syndrome with diagnosed left ectopic kidney and right pelvic ureteric junction obstruction planned for right pyeloplasty. Preoperative examination revealed scoliosis of cervical spine and dorsal spine with spina bifida at C3–C4 with fused cervical bodies from C4 to C7 and springer shoulder. The patient was counseled with parents for difficult airway. On arrival in operating room, standard monitoring (electrocardiogram, noninvasive blood pressure, pulse oximetery, and end-tidal CO2) ensued. Awake, fiber-optic intubation was successfully attempted after blocking the superior laryngeal nerve bilaterally with 1 ml each of 2% lignocaine below the greater cornu of the hyoid bone and recurrent laryngeal nerve with 5 ml of 4% lignocaine after piercing the cricothyroid membrane in the midline with confirmed aspiration of the air in the syringe. Successful awake intubation was confirmed with end-tidal CO2 trace on the capnograph. General anesthesia was administered with intravenous injection of fentanyl 2 μ/kg, propofol 2 mg/kg, and injection atracurium 0.5 mg/kg.

Maintenance of anesthesia was done with oxygen, nitrous oxide, and sevoflurane. At the end of surgery for prolonged postoperative pain relief, surgeons created the plane between internal oblique (IO) and transversus abdominis (TA) muscle by blunt dissection at the initial incision site and an epidural catheter (20G, Portex) was tunneled for about 8 cm between the fascial planes with help of 19 G epidural needle (Portex) and was secured at the skin [Figure 1a and b]. After extubation, continuous infusion through the truncal catheter was started at the rate of 0.2 ml/kg/h of 0.1% ropivacaine for 48 h. The patient was monitored in the ward and Visual Analogue Scale (VAS) rated pain every 2 h for first 6 h and then every 4 h till 24 h, and on all occasions, the VAS never exceeded three on a continuum line of 10. In addition to this, injection paracetamol (15 mg/kg) was administered eight hourly for 48 h.

Figure 1

(a) Surgeon-assisted transversus abdominis plane block with transversus abdominis plane catheter tunneled in the plane between internal oblique and transversus abdominis muscle. (b) Transversus abdominis plane catheter secured at the skin site and connected to a filter for continuous infusion

Safety of TAP block has already been established in the literature with incidence of complications not exceeding 0.3%.[2] Pyeloplasty surgery with flank incision is one of the most common pediatric surgeries being performed and is associated with the considerable amount of postoperative pain due to the tissue handling, cutting, and retraction. It is imperative to provide continuous postoperative pain relief to facilitate early mobility, recovery, and limiting the morbidity.

Situations where the neuraxial blocks are contraindicated like in our case where the spinal deformities were present, TAP block is an excellent option for multimodal analgesia.[1] EI Fawy and EI Gendy in their study concluded that unilateral TAP block provides superior analgesia when compared with the caudal block in children who underwent pyeloplasty.[3] For continuous postoperative analgesia, we modified the surgeon-assisted TAP block technique as described by Araco et al.[4] where instead of the bolus of local anesthetic solution, we tunneled a 20 G epidural catheter between IO and TA plane and commenced the continuous infusion of ropivacaine with the elastomeric pump. Bakshi et al. have used similar technique of continuous TAP block in a pediatric laparotomy patient with the prolonged postoperative pain relief.[5] To conclude, surgeon-assisted TAP block is a technique for postoperative pain relief, which can be used where ultrasound is not available in a “resource-constrained setting.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.