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• W2113679916 abstract "The transversus abdominis plane (TAP) block is a field block that provides postoperative analgesia for abdominal surgery. Its analgesic utility after Caesarean delivery (CD) remains controversial. This systematic review and meta-analysis examines whether TAP block can reduce i.v. morphine consumption in the first 24 h after CD. The authors retrieved randomized controlled trials comparing TAP block with placebo in CD. Postoperative i.v. morphine consumption during the first 24 h was selected as a primary outcome. Pain scores and both maternal and neonatal opioid-related side-effects were secondary outcomes. Where possible, meta-analytic techniques and random effects modelling were used to combine data. Trials were stratified based on whether or not spinal morphine was used as part of the analgesic regimen. Five trials including 312 patients were identified. TAP block reduced the mean 24 h i.v. morphine consumption by 24 mg [95% confidence interval (CI) −39.65 to −7.78] when spinal morphine was not used. TAP block also reduced visual analogue scale pain scores (10 cm line where 0 cm, no pain, and 10 cm, worst pain) by 0.8 cm (95% CI −1.53 to −0.05, P=0.01), and decreased the incidence of opioid-related side-effects. The differences in primary and secondary outcomes were not significant when spinal morphine was used. TAP block provides superior analgesia compared with placebo and can reduce the first 24 h morphine consumption in the setting of a multimodal analgesic regimen that excludes spinal morphine. TAP block can provide effective analgesia when spinal morphine is contraindicated or not used. The transversus abdominis plane (TAP) block is a field block that provides postoperative analgesia for abdominal surgery. Its analgesic utility after Caesarean delivery (CD) remains controversial. This systematic review and meta-analysis examines whether TAP block can reduce i.v. morphine consumption in the first 24 h after CD. The authors retrieved randomized controlled trials comparing TAP block with placebo in CD. Postoperative i.v. morphine consumption during the first 24 h was selected as a primary outcome. Pain scores and both maternal and neonatal opioid-related side-effects were secondary outcomes. Where possible, meta-analytic techniques and random effects modelling were used to combine data. Trials were stratified based on whether or not spinal morphine was used as part of the analgesic regimen. Five trials including 312 patients were identified. TAP block reduced the mean 24 h i.v. morphine consumption by 24 mg [95% confidence interval (CI) −39.65 to −7.78] when spinal morphine was not used. TAP block also reduced visual analogue scale pain scores (10 cm line where 0 cm, no pain, and 10 cm, worst pain) by 0.8 cm (95% CI −1.53 to −0.05, P=0.01), and decreased the incidence of opioid-related side-effects. The differences in primary and secondary outcomes were not significant when spinal morphine was used. TAP block provides superior analgesia compared with placebo and can reduce the first 24 h morphine consumption in the setting of a multimodal analgesic regimen that excludes spinal morphine. TAP block can provide effective analgesia when spinal morphine is contraindicated or not used. Editor’s key points•The utility of transversus abdominis plane (TAP) block in Caesarean delivery was assessed by analysing results of previous studies.•TAP block reduced i.v. morphine consumption and pain scores in the first day after surgery.•TAP block can provide effective analgesia after Caesarean delivery when intrathecal morphine has not been used. •The utility of transversus abdominis plane (TAP) block in Caesarean delivery was assessed by analysing results of previous studies.•TAP block reduced i.v. morphine consumption and pain scores in the first day after surgery.•TAP block can provide effective analgesia after Caesarean delivery when intrathecal morphine has not been used. Inadequate postoperative pain relief after Caesarean delivery (CD) can negatively impact ambulation, breastfeeding, and even maternal bonding,1Leung A Postoperative pain management in obstetric anesthesia—new challenges and solutions.J Clin Anesth. 2004; 16: 57-65Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar while effective analgesia improves the amount of breastfeeding and infant weight gain.2Hirose M Hara Y Hosokawa T Tanaka Y The effect of postoperative analgesia with continuous epidural bupivacaine after cesarean section on the amount of breast feeding and infant weight gain.Anesth Analg. 1996; 82: 1166-1169PubMed Google Scholar Neuraxial anaesthesia has become the anaesthetic technique of choice in CD because of its safety and reduction in maternal mortality.3Hawkins JL Koonin LM Palmer SK Gibbs CP Anesthesia-related deaths during obstetric delivery in the united states, 1979–1990.Anesthesiology. 1997; 86: 277-284Crossref PubMed Scopus (605) Google Scholar The transversus abdominis plane (TAP) block, a field block4Rafi AN Abdominal field block: a new approach via the lumbar triangle.Anaesthesia. 2001; 56: 1024-1026Crossref PubMed Scopus (498) Google Scholar whose analgesic efficacy in several abdominal surgeries has been confirmed,5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar, 6Niraj G Searle A Mathews M et al.Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing open appendicectomy.Br J Anaesth. 2009; 103: 601-605Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar, 7El-Dawlatly AA Turkistani A Kettner SC et al.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: 763-767Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar has also been proposed for postoperative analgesia in parturients undergoing elective CD under spinal anaesthesia.8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar However, the analgesic utility of TAP block remains controversial; some trials comparing it with placebo reported significant advantages,8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar while others found no analgesic benefit.10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Reviews examining the analgesic effects of TAP block in various surgeries have not provided definitive answers regarding the specific role of TAP block in CD. A Cochrane review examining the efficacy of TAP block in abdominal surgeries excluded CD.12Charlton S Cyna AM Middleton P Griffiths JD Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery.Cochrane Database Syst Rev. 2010; 12: 007705Google Scholar A recent meta-analysis supporting TAP block for its effective pain relief included only one trial in the setting of CD.13Siddiqui MRS Sajid MS Uncles DR Cheek L Baig MK A meta-analysis on the clinical effectiveness of transversus abdominis plane block.J Clin Anesth. 2011; 23: 7-14Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar A 2012 qualitative systematic review14Abdallah FW Brull R Transversus abdominis plane block: a systematic review.Reg Anesth Pain Med. 2012; 37: 193Crossref PubMed Scopus (176) Google Scholar examined the role of TAP block across all abdominal surgeries and raised questions about its role in the setting of multimodal analgesia but stopped short of conducting any further analysis specific to CD. The purpose of this systematic review was to determine whether or not TAP block is effective in providing pain relief after CD. The primary outcome was morphine consumption in the first 24 h, an important issue for the breastfeeding woman. The authors followed the PRISMA15Moher D Liberati A Tetzlaff J Altman DG PRISMA GroupPreferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.Int J Surg. 2010; 8: 336-341Abstract Full Text Full Text PDF PubMed Scopus (7263) Google Scholar recommendations in preparing this review. We searched the literature for randomized controlled trials (RCTs) that compared TAP block with placebo in patients undergoing elective CD under spinal anaesthesia. We included trials that used both ultrasound and landmark guidance for the single-shot TAP block technique. RCTs were retrieved from the US National Library of Medicine database, MEDLINE; the Excerpta Medica database, EMBASE; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; and Latin American and Caribbean Health Sciences Literature, LILACS databases. The search terms TAP, TAP block, transversus abdominis, transverse abdominis, transversus abdominis plane block, transversus abdominis block, transverse abdominis plane block, transverse abdominis block, Caesarean, and C section were used in combination with the medical subject headings nerve block/abdomen/abdominal cavity/abdominal wall/abdominal muscles, and Caesarean Section (January 2007–February 2012). In addition, we searched the bibliographies of relevant reviews and identified RCTs that fulfilled the inclusion criteria. We also searched for and reviewed published abstracts of anaesthesiology meetings that were held during the period 2007–2012 by the American Society of Anesthesiologists, the American Society of Regional Anesthesia, the Society of Obstetric Anesthesia and Perinatology, the European Society of Anaesthesiology, and the European Society of Regional Anaesthesia. Finally, we sought unpublished data at ‘clinicaltrials.gov’ as a measure of publication bias. No language restriction was used. The final list of qualifying studies was derived by consensus among the three authors. Excluded trials are listed in the Appendix. Quality of the reviewed trials was assessed independently by two of the authors (F.W.A. and C.B.M.) using the Cochrane Risk of Bias tool.16Higgins JPT The Cochrane collaboration’s tool for assessing risk of bias in randomised trials.Br Med J (Clin Res Ed.). 2011; 343: d5928Crossref PubMed Scopus (18849) Google Scholar A final score was assigned for each trial by consensus. I.V. morphine consumption during the first 24 h after CD was defined as a primary outcome. Rest and dynamic pain visual analogue scale (VAS) scores (10 cm unmarked line in which 0 cm, no pain, and 10 cm, worst pain imaginable) at 24 h and maternal opioid-related side-effects (sedation, pruritus, nausea, and vomiting), patient satisfaction, and block-related complications were designated as secondary outcomes. A standardized data collection form was used for outcome data extraction. Data were recorded independently by two of the authors (F.W.A., C.B.M.) to avoid transcription errors; discrepancies were resolved by re-inspection of the original data. The data were then entered into the statistical program (by C.B.M.) and rechecked (by F.W.A.). When possible, meta-analytic techniques (Revman 5.1, Cochrane Library, Oxford, UK) were used to combine the data. Random effect modelling was used in analysing continuous and dichotomous outcomes. The standardized mean difference and 95% confidence interval (CI) were calculated for continuous outcomes; while odds ratio (OR) and 95% CI were calculated for dichotomous outcomes. Differences were considered statistically significant when the 95% CI did not include 0. The I2 statistic was used to assess heterogeneity.17Higgins JPT Quantifying heterogeneity in a meta-analysis.Stat Med. 2002; 21: 1539-1558Crossref PubMed Scopus (21740) Google Scholar As the analgesic efficacy of spinal morphine in postoperative pain control is well recognized,18Dahl JB Jeppesen IS Jrgensen H Wetterslev J Miniche S Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.Anesthesiology. 1999; 91: 1919-1927Crossref PubMed Scopus (276) Google Scholar, 19Gwirtz KH Young JV Byers RS et al.The safety and efficacy of intrathecal opioid analgesia for acute postoperative pain: seven years’ experience with 5969 surgical patients at Indiana University Hospital.Anesth Analg. 1999; 88: 599-604PubMed Google Scholar, 20Gadsden J Hart S Santos A Post-cesarean delivery analgesia.Anesth Analg. 2005; 101: S62-S69Crossref PubMed Scopus (147) Google Scholar we hypothesized—a priori—that it constitutes a co-intervention that would generate significant heterogeneity among the pooled trial results. We therefore performed subgroup analysis according to administration of intrathecal morphine (ITM), where (SM−) referred to the group of RCTs where spinal morphine was not used, while (SM+) referred to the group of RCTs where spinal morphine was used. Search results, including retrieved, excluded, and reviewed RCTs, are summarized by a flowchart in Figure 1. We found five trials5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar, 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar, 10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar, 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar with a total of 312 patients that met the inclusion criteria. The trials reviewed included one11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar where TAP block and placebo were compared in the presence and absence of spinal morphine, resulting in two distinct comparisons. Table 1 summarizes trial characteristics and the outcomes sought in each of the reviewed trials. The methodological quality of the included studies and the risk of bias are described in Table 2; Table 3 defines the analgesic regimens used in the reviewed trials. In addition to the published studies, we found five unpublished studies at ‘clinicaltrials.gov’ comprising 438 patients who potentially meet the inclusion criteria but were still in the recruitment phase.Table 1Trial characteristics and reported outcomes. ITM, intrathecal morphine; TAP, transversus abdominis planeStudynGroups (n)Primary outcomeRest pain scoresDynamic pain scoresOpioid consumptionTime to first analgesic requestOpioid-related adverse effectsPatient satisfactionBlock-related complicationsChronic painMcDonnell and colleagues8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar521. TAP block (25)Opioid consumption•••••2. Sham block (25)Belavy and colleagues5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar501. TAP block (23)Opioid consumption•••••••2. Sham block (24)Costello and colleagues10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar1001. TAP block (49)Dynamic pain scores••••••2. Sham block (47)Baaj and colleagues9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar401. TAP block (19)Opioid consumption••••••2. Sham block (20)McMorrow and colleagues11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar801. TAP block+ITM (20)Dynamic pain scores•••••2. Sham TAP+ITM (20)3. TAP block (20)4. Sham block (20) Open table in a new tab Table 2Risk of bias. Each study risk of bias was assessed using the Cochrane Collaboration tool16Higgins JPT The Cochrane collaboration’s tool for assessing risk of bias in randomised trials.Br Med J (Clin Res Ed.). 2011; 343: d5928Crossref PubMed Scopus (18849) Google Scholar as Low (low risk of bias), High (high risk of bias), or Unclear for each question-based entryStudyAdequate sequence generationAllocation concealmentBlinding of participants and personnelBlinding of outcome assessmentIncomplete data addressedFree of selective reportingMcDonnell and colleagues8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google ScholarLowLowLowLowLowLowBelavy and colleagues5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google ScholarLowUnclearLowLowLowLowCostello and colleagues10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google ScholarLowUnclearUnclearLowLowLowBaaj and colleagues9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google ScholarUnclearUnclearLowLowLowLowMcMorrow and colleagues11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google ScholarUnclearLowLowLowLowLow Open table in a new tab Table 3Analgesic regimens used in included trials. *Volume refers to injection per side. I.V. PCA, i.v. patient-controlled analgesiaStudySurgical analgesiaSupplemental postoperative analgesiaTAP blockLocalizationBlock solution*McDonnell and colleagues8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google ScholarSpinal+intrathecal: 25 µg fentanyl1 dose rectal diclofenac, 1 dose rectal acetaminophen, then i.v. PCA morphine, oral acetaminophen, rectal diclofenacAnatomical1.5 mg kg−1 0.75% ropivacaine to a total dose of 150 mgBelavy and colleagues5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google ScholarSpinal+intrathecal: 15 µg fentanyl1 dose rectal acetaminophen, 1 dose rectal diclofenac, then i.v. PCA morphine, oral acetaminophen, oral ibuprofenUltrasound20 ml 0.5% ropivacaineCostello and colleagues10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google ScholarSpinal+intrathecal: 10 µg fentanyl, 100 µg morphine1 dose i.v. ketorolac, 1 dose rectal acetaminophen, then i.v. morphine, oral diclofenac, oral acetaminophenUltrasound20 ml 0.375% ropivacaineBaaj and colleagues9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google ScholarSpinal+intrathecal: 20 µg fentanylI.V. PCA morphineUltrasound20 ml 0.25% bupivacaineMcMorrow and colleagues11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google ScholarSpinal+intrathecal: 10 µg fentanyl, 100 µg morphine1 dose rectal acetaminophen, 1 dose rectal diclofenac, then i.v. PCA morphine, oral acetaminophen, rectal diclofenacAnatomical1 mg kg−1 0.375% bupivacaine Open table in a new tab Postoperative i.v. morphine consumption during the first 24 h in each study and pooled consumption are shown in Figure 2. When spinal morphine is excluded from the multimodal analgesic regimen (SM−), we found that TAP block, compared with placebo, reduced the mean 24 h i.v. morphine consumption by 24 mg (95% CI −39.65 to −7.78). This statistically significant reduction (P=0.004) favours TAP block. When both groups received spinal morphine (SM+), TAP block did not significantly reduce morphine consumption (mean difference 2 mg, 95% CI −3.47 to 7.46, P=0.47). The pooled morphine consumption of the SM+ and SM− subgroups was lower by 15 mg (95% CI −33.10 to 2.56) in patients receiving TAP block, although this lacked statistical significance (P=0.09). Heterogeneity among the studies in the SM− subgroup and in the pooled studies was significant (I2=0.94 and 0.97, respectively, P<0.00001). The 24 h rest VAS scores for individual and pooled studies are shown in Figure 3. Compared with placebo in the (SM−) setting, TAP block reduced 24 h rest VAS scores by 0.8 cm (95% CI −1.53 to −0.05, P=0.01). The difference was not significant in the SM+ group (0.3 cm, 95% CI −0.42 to 0.97, P=0.08). The pooled difference favoured TAP block but was not statistically significant (P=0.39). Heterogeneity was significant in both SM− and SM+ subgroups (I2=0.72; P=0.01 and I2=0.67; P=0.08, respectively). Figure 4 shows the 24 h dynamic VAS scores for individual and pooled studies. Difference between the groups were not statistically significant for either the SM− or the SM+ studies. The reviewed trials were inconsistent in reporting opioid-related side-effects. Four trials reported the incidence of postoperative nausea and vomiting (PONV);5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar while three reported the incidence of sedation,5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar and another two reported the incidence of pruritus.5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The inconsistency in reporting these outcomes and the heterogeneity of assessment when these outcomes were reported precludes quantitative analysis. Qualitative analysis of trials in the (SM−) subgroup showed that all of the trials5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar that assessed the incidence of PONV reported reduced incidence in patients who received TAP block. Furthermore, one8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar of the three5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 8McDonnell J Curley G Carney J et al.The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2008; 106: 186-191Crossref PubMed Scopus (446) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar trials that assessed sedation showed reduced incidence with TAP block, while two5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar showed no difference. As for pruritus, one trial5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar showed no difference, while another11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar showed reduced incidence with TAP block. Opioid-related side-effects assessment in the (SM+) group was performed in only one trial; the incidence of pruritus favoured TAP block, while the incidence of PONV favoured control group.11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Neonatal opioid-related side-effects of TAP block such as somnolence and difficulty with breastfeeding were not studied in any of the trials. There was no reported difference in the incidence of chronic pain in the single trial that assessed this outcome.10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar TAP block resulted in improved patient satisfaction in two trials5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar and reduced satisfaction in one.11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Three of the trials5Belavy D Cowlishaw PJ Howes M Phillips F Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery.Br J Anaesth. 2009; 103: 726-730Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar 9Baaj J Alsatli R Majaj H Babay Z Thallaj A Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia—a double-blind, placebo-controlled, randomized study.Middle East J Anaesthesiol. 2010; 20: 821-826PubMed Google Scholar 10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar reviewed examined block-related complications, but none was reported. This review suggests that TAP block constitutes an effective analgesic option capable of reducing 24 h opioid consumption, 24 h rest pain scores, and PONV in parturients undergoing CD who receive a multimodal analgesic regimen that excludes ITM. While the improvement in pain scores was modest and not clinically relevant, the difference in i.v. morphine consumption was robust and clinically significant. These differences are not significant in the presence of ITM. It should be noted that heterogeneity in baseline morphine consumption among the studies might have significantly contributed to the difference between the (SM+) and (SM−) groups. There were insufficient data to conclude that TAP affects the incidence of other opioid-related side-effects such as sedation or pruritus. Reduction in opioid analgesics is generally desirable in CD and more so when spinal morphine is not used. Although opioid analgesics can be taken safely by lactating women, some opioids can result in significant exposures and toxicity in infants,21Ito S Lee A Drug excretion into breast milk—overview.Adv Drug Deliv Rev. 2003; 55: 617-627Crossref PubMed Scopus (124) Google Scholar including the risk of neurobehavioural depression in the breastfed newborn.22Wittels B Glosten B Faure EA et al.Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates.Anesth Analg. 1997; 85: 600-606Crossref PubMed Google Scholar Future research is needed to examine the ability of TAP block to reduce opioid metabolites in infant plasma. As a component of spinal anaesthesia, the superiority of post-Caesarean analgesia produced by long-acting spinal opioids over their systemic counterparts18Dahl JB Jeppesen IS Jrgensen H Wetterslev J Miniche S Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.Anesthesiology. 1999; 91: 1919-1927Crossref PubMed Scopus (276) Google Scholar 19Gwirtz KH Young JV Byers RS et al.The safety and efficacy of intrathecal opioid analgesia for acute postoperative pain: seven years’ experience with 5969 surgical patients at Indiana University Hospital.Anesth Analg. 1999; 88: 599-604PubMed Google Scholar makes them an integral part of multimodal analgesic regimens.20Gadsden J Hart S Santos A Post-cesarean delivery analgesia.Anesth Analg. 2005; 101: S62-S69Crossref PubMed Scopus (147) Google Scholar 23McDonnell NJ Keating ML Muchatuta NA Pavy TJG Paech MJ Analgesia after caesarean delivery.Anaesth Intensive Care. 2009; 37: 539-551Crossref PubMed Google Scholar 24Pan P Post cesarean delivery pain management: multimodal approach.Int J Obstet Anesth. 2006; 15: 185-188Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Since neuraxial anaesthesia has been established as the best modality for CD, it has become difficult to justify excluding a small dose of ITM,25Gehling M Tryba M Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis.Anaesthesia. 2009; 64: 643-651Crossref PubMed Scopus (178) Google Scholar given the superior analgesia it produces, the prolonged duration of this analgesia,26Chadwick HS Ready LB Intrathecal and epidural morphine sulfate for post-cesarean analgesia—a clinical comparison.Anesthesiology. 1988; 68: 925-929Crossref PubMed Scopus (95) Google Scholar, 27Gehling MHG Luesebrink T Kulka PJ Tryba M The effective duration of analgesia after intrathecal morphine in patients without additional opioid analgesia: a randomized double-blind multicentre study on orthopaedic patients.Eur J Anaesthesiol. 2009; 26: 683-688Crossref PubMed Scopus (34) Google Scholar, 28Meylan N Elia N Lysakowski C Tramr MR Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials.Br J Anaesth. 2009; 102: 156-167Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar and its ability to treat both somatic20Gadsden J Hart S Santos A Post-cesarean delivery analgesia.Anesth Analg. 2005; 101: S62-S69Crossref PubMed Scopus (147) Google Scholar and visceral29Omote K Kawamata M Iwasaki H Namiki A Effects of morphine on neuronal and behavioural responses to visceral and somatic nociception at the level of spinal cord.Acta Anaesthesiol Scand. 1994; 38: 514-517Crossref PubMed Scopus (24) Google Scholar, 30Scott PV Bowen FE Cartwright P et al.Intrathecal morphine as sole analgesic during labour.Br Med J. 1980; 281: 351-353Crossref PubMed Scopus (68) Google Scholar, 31Tong C Conklin D Eisenach J A pain model after gynecologic surgery: the effect of intrathecal and systemic morphine.Anesth Analg. 2006; 103: 1288-1293Crossref PubMed Scopus (13) Google Scholar components of pain. The absence of definitive analgesic advantages of TAP block when added to multimodal analgesic regimens inclusive of ITM,10Costello J Moore A Wieczorek P Macarthur A Balki M Carvalho JCA The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.Reg Anesth Pain Med. 2009; 34: 586-589Crossref PubMed Scopus (132) Google Scholar 11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar and its inferiority, as a substitute to ITM demonstrated in three recent trials,11McMorrow RCN Ni Mhuircheartaigh RJ Ahmed KA et al.Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.Br J Anaesth. 2011; 106: 706-712Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar 32Kanazi G Aouad M Abdallah F et al.The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial.Anesth Analg. 2010; 111: 475-481Crossref PubMed Scopus (122) Google Scholar 33Loane HH A randomized controlled trial comparing intrathecal morphine with transversus abdominis plane block for post-cesarean delivery analgesia.Int J Obstet Anesth. 2012; 21: 112-118Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar suggest a potential role of TAP block as part of the post-Caesarean multimodal analgesic regimen in practice settings that do not use long-acting intrathecal opioids or when their use is either not feasible or contraindicated. There is also recent evidence to suggest that TAP block might be beneficial for patients undergoing CD under general anaesthesia.34Eslamian LL Transversus abdominis plane block reduces postoperative pain intensity and analgesic consumption in elective cesarean delivery under general anesthesia.J Anesth. 2012; 26: 334-338Crossref PubMed Scopus (66) Google Scholar 35Tan TT Teoh WH Woo DC Ocampo CE Shah MK Sia AT A randomised trial of the analgesic efficacy of ultrasound-guided transversus abdominis plane block after caesarean delivery under general anaesthesia.Eur J Anaesthesiol. 2012; 29: 88-94Crossref PubMed Scopus (64) Google Scholar Although not studied, TAP block might be useful when other components of multimodal analgesia such as non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated. Patients with conditions such as hypersensitivity to NSAIDs, renal impairment, concomitant use of nephrotoxic drugs, or a history of peptic ulcer disease might benefit from TAP block as a practical alternative for pain relief. This review is limited by the small size of included studies and the significant heterogeneity in reporting the primary and secondary outcomes. Our sample comprised 312 patients; however, there are five unpublished trials with 438 patients reported at ‘clinicaltrials.gov’ for which we have no data. This represents a significant risk of publication bias (Appendix). Also, some important outcomes were missing in all trials reviewed, such as differentiation between visceral and somatic pain, effect of TAP block on breastfeeding, and its effect on the incidence of chronic pain after CD. Further limitations include differences in TAP block technique and doses of local anaesthetics used. In the absence of dose-ranging studies that assess the impact of various volumes and concentrations of local anaesthetics on post-Caesarean analgesia produced by TAP block, and since the studies reviewed did not assess patients for the presence of sensory block, we cannot ascertain the success of TAP blocks performed. Additionally, our choice to combine ultrasound-guided and landmark-guided TAP blocks might be challenged by recent evidence that indicates differences between the two techniques. Anatomically guided TAP blocks performed in the triangle of Petit can produce prolonged analgesia, and theoretically less morphine consumption, compared with their ultrasound-guided counterparts,14Abdallah FW Brull R Transversus abdominis plane block: a systematic review.Reg Anesth Pain Med. 2012; 37: 193Crossref PubMed Scopus (176) Google Scholar an observation that can be attributed to paravertebral spread.36Carney J Finnerty O Rauf J Bergin D Laffey J Mc Donnell J Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks.Anaesthesia. 2011; 66: 1023-1030Crossref PubMed Scopus (212) Google Scholar There is evidence to suggest that only a small fraction of landmark-guided blocks deposit local anaesthetics in the correct anatomical plane,37McDermott G Korba E Mata U et al.Should we stop doing blind transversus abdominis plane blocks?.Br J Anaesth. 2012; 108: 499-502Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar thus rendering their analgesic efficacy questionable. Finally, the authors wish to underscore the ethical concern that arises from potential harm associated with the use of invasive placebo38McGuirk S Fahy C Costi D Cyna AM Use of invasive placebos in research on local anaesthetic interventions.Anaesthesia. 2011; 66: 84-91Crossref PubMed Scopus (56) Google Scholar 39Jarman J Marks N Fahy CJ Costi D Cyna AM Anaesthetists’ risk assessment of placebo nerve block studies using the SHAM (serious harm and morbidity) scale.Anaesthesia. 2012; 67: 361-366Crossref PubMed Scopus (15) Google Scholar in the reviewed trials. Patients in the control groups in all five trials received a saline injection in the TAP, a practice classified as Grade 4 on the scale of serious harm and morbidity (SHAM) as it might predispose parturients to risks similar to those associated with local anaesthetic injection.40Lancaster P Chadwick M Liver trauma secondary to ultrasound-guided transversus abdominis plane block.Br J Anaesth. 2010; 104: 509-510Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar 41Farooq M Carey M A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block.Reg Anesth Pain Med. 2008; 33: 274-275Crossref PubMed Google Scholar In summary, TAP block constitutes an effective analgesic option for postoperative analgesia after CD performed under spinal anaesthesia when spinal morphine is not used. There is currently no evidence that the TAP block is of benefit when ITM has been administered. None declared." @default.
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