Hernandez Maria A, Vecchione Tricia, Boretsky Karen
Department of Anesthesia, Perioperative & Pain Medicine, Boston Children's Hospital - Harvard Medical School, Boston, MA, USA.
Paediatr Anaesth. 2017 Mar;27(3):300-304. doi: 10.1111/pan.13034. Epub 2017 Jan 18.
Several techniques for the transversus abdominis plane (TAP) block have been described. The extent of sensory changes using an ultrasound-guided posterior TAP block (pTAP) remains unclear in pediatric patients. The primary aim of this study was to report the extent of sensory changes achieved with pTAP; specifically the highest thoracic dermatome anesthetized. Secondary outcomes were pain scores (PS), opioid consumption, and complications.
We retrospectively reviewed the medical records of patients less than 21 years of age undergoing abdominal surgery with a unilateral or bilateral pTAP(s) for postoperative analgesia. The local anesthetic was placed posterior to the termination of the transversus abdominis muscle where the thoracolumbar fascia overrides the quadratus lumborum muscle. The extent of sensory changes, pain scores, and opioid consumption were analyzed.
A total of 10 patients (15 pTAP blocks) met the inclusion criteria. The mean (sd; range) age and weight were 15 years (5 years; range 7-20 years) and 57 kg (21 kg; 27-97 kg), respectively. The cephalad dermatome levels achieved were: T7 in 6/15 (40%); T8 in 10/15 (67%); and T9 in 14/15 (93%). An inferior dermatome level of T12/L1 and sensory extension from midaxillary line to the midline was documented in 15/15 blocks. The mean intraoperative and postanesthesia care unit (PACU) opioid consumption in morphine equivalents were 0.34 mg·kg (sd = 0.12 mg·kg ) and 0.04 mg·kg (sd = 0.05 mg·kg ), respectively. PACU pain scores were mild (<4) in 60%, moderate (4-7) in 30%, and severe (>7) in 10% of patients. No complications were reported.
The current uncertainty regarding sensory blockade limits the clinical application of TAP blocks. While the midaxillary approach results in unpredictable sensory changes of the abdomen, we reliably achieved sensory changes up to a T9 level in 93% of the blocks.
In this small series of patients, we demonstrate a high technical success rate of achieving cutaneous analgesia to the abdominal wall. These results should encourage clinical studies of the efficacy of this block for abdominal surgery in pediatric patients.
已经描述了几种腹横肌平面（TAP）阻滞技术。在儿科患者中，使用超声引导下后路TAP阻滞（pTAP）后的感觉变化范围尚不清楚。本研究的主要目的是报告pTAP实现的感觉变化范围；具体而言，是最高麻醉的胸段皮节。次要结果是疼痛评分（PS）、阿片类药物消耗量和并发症。
我们回顾性分析了年龄小于21岁、接受单侧或双侧pTAP用于术后镇痛的腹部手术患者的病历。局部麻醉药注射在腹横肌终止处的后方，即胸腰筋膜覆盖腰方肌的位置。分析感觉变化范围、疼痛评分和阿片类药物消耗量。
共有10例患者（15次pTAP阻滞）符合纳入标准。平均（标准差；范围）年龄和体重分别为15岁（5岁；范围7 - 20岁）和57千克（21千克；27 - 97千克）。达到的头侧皮节水平为：T7在6/15（40%）；T8在10/15（67%）；T9在14/15（93%）。15/15次阻滞均记录到T12/L1的尾侧皮节水平以及从中腋线到中线的感觉延伸。术中及麻醉后恢复室（PACU）吗啡当量的平均阿片类药物消耗量分别为0.34毫克·千克（标准差 = 0.12毫克·千克）和0.04毫克·千克（标准差 = 0.05毫克·千克）。PACU中，60%的患者疼痛评分为轻度（<4），30%为中度（4 - 7），10%为重度（>7）。未报告并发症。
目前关于感觉阻滞的不确定性限制了TAP阻滞的临床应用。虽然腋中线入路导致腹部感觉变化不可预测，但我们在93%的阻滞中可靠地实现了高达T9水平的感觉变化。
在这一小系列患者中，我们证明了腹壁皮肤镇痛的技术成功率很高。这些结果应鼓励对该阻滞在儿科患者腹部手术中的疗效进行临床研究。
