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A Case Series Describing an Important Role for Transversus Abdominis Plane Blocks for Rescue Analgesia After Cesarean Delivery
Abstract Number: T-40
Abstract Type: Case Report/Case Series
Introduction: The role of transversus abdominis plane (TAP) blocks for cesarean delivery (CD) analgesia is uncertain. Previous studies have focused on TAP blocks administered at the end of surgery prior to the offset of spinal anesthesia, and report limited additional analgesic benefit in patients receiving intrathecal (IT) morphine (1,2). We present a series of three cases where TAP blocks were used as rescue analgesia in patients who had severe post-CD pain despite receiving IT morphine.
Case Summaries: The patients received our institutions standard CD spinal anesthetic (IT 12 mg bupivacaine, 10 mcg fentanyl and 200 mcg morphine). For all three, NSAIDs were withheld for bleeding concerns. All the patients experienced severe pain in PACU after surgery. Bilateral TAP blocks were performed under ultrasound guidance, and 20 ml of 0.375% ropivacaine with 1:400,00 epinephrine was deposited bilaterally. All three patients got significant pain relief that lasted 10-19 hours, facilitated neonatal interaction and allowed timely PACU discharge.
Case 1: A 31-year-old G1P2 with gestational diabetes and obesity underwent an uncomplicated repeat CD under spinal epidural anesthesia. Sixty minutes after her 54 min surgery she complained of 9/10 incisional pain unresponsive to: oral 10 mg oxycodone with 650 mg acetaminophen, 1 mg IV hydromorphone, and 4 mg IV morphine. Within 20 min of the TAP block, her pain decreased from a 9 to a 2/10, and the next request for analgesia was 12 hrs and 15 min later.
Case 2: A 34-year-old G2P1 underwent an uncomplicated repeat CD under spinal anesthesia. She complained of 10/10 incisional pain once her spinal blockade had resolved. The pain did not significantly improve despite: 5 mg oxycodone with 325 mg acetaminophen po, 100 mcg IV fentanyl, 2 mg IV morphine and 2 mg IV hydromorphone. Her pain decreased from 10 to a 3/10 within 18 min of the TAP block, and her next request for pain medication was 10 hrs and 18 min later.
Case 3: A 39-year-old G2P1 with history of a previous colectomy underwent a repeat CD under spinal anesthesia. Surgery was uncomplicated and lasted 56 min. The patient reported 9/10 incision pain in PACU unresponsive to: 50 mcg IV fentanyl and 2 mg IV hydromorphone. Her pain score decreased from a 9 to a 2/10 after the TAP block and pain relief lasted 19 hrs and 52 min.
Conclusion: Although the role of routine, preemptive TAP block for CD in patients that receive IT morphine is uncertain, these cases show that rescue TAP blocks have a valuable role. TAP blocks reduced the need for escalating IV opioid doses and associated opioid-related maternal and breastfeeding neonatal side effects. Rescue TAP blocks should be considered in post-CD patients as described above where routine care does not provide adequate pain relief, NSAIDs are contraindicated or withheld, or for early breakthrough pain after offset of spinal anesthesia.
1. Reg Anesth Pain Med 2009; 34:586–9
2. Anesth Analg 2008; 106:186–91