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summary
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The incidence of systemic local anesthetic toxicity showed different risk profiles at different injection sites. In order of decreasing incidence of systemic toxicity events:
1. Paravertebral – OR 3.62 [95% CI, 1.33–7.86]
2. Upper limb — OR 1.75 [95% CI, 0.93–2.99]
3. Lower limb — OR 0.24 [95% CI, 0.05–0.71]
4. Trunk — 0.00 [95% CI, 0–0.94]
Of the 25,336 peripheral nerve blocks in the study, there were only 22 episodes of local anesthetic toxicity. 12 events occurred in the 20,401 PNBs performed with ultrasound guidance and 10 events in the 4,745 blocks performed without ultrasound.
Barrington MJ Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013 Jul 1; 38 (4): 289-99.
  Daniel Jolley
pearl
1
The use of ultrasound for peripheral nerve blockade reduces the incidence of systemic local anesthetic toxicity by at least 65%, possibly 80%.
Barrington MJ Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013 Jul 1; 38 (4): 289-99.
  Daniel Jolley
comment
1
Important to note that the 9 studies included for meta-analysis (524 patients in total) were quite heterogenous: 7 performed under spinal anaesthesia and 2 under general; TAP performed using anatomical landmarks in 3 and ultrasound in 6; spinals used various doses of fentanyl and/or morphine; and the TAP blocks used ropivacaine (4), bupivacaine (4) or levobupivacaine (1). Post-operative analgesic regimes also varied.
Thus these findings should be cautiously applied to your local setting.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012 Aug 1; 59 (8): 766-78.
  Daniel Jolley
pearl
1
In patients not receiving intrathecal morphine, TAP block after caesarean section reduced opioid use at 6, 12 and 24 hours, along with nausea at 12h.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012 Aug 1; 59 (8): 766-78.
  Daniel Jolley
pearl
1
Intermittent intraperitoneal lidocaine at 50 mg/h reduces post-operative morphine consumption by almost 50% after open abdominal hysterectomy.
Perniola A, Magnuson A, Axelsson K et al. Intraperitoneal Local Anesthetics Have Predominant Local Analgesic Effect: A Randomized, Double-blind Study. Anesthesiology. 2014 Aug 1;121(2):352-61.
  Daniel Jolley
pearl
0
Intermittent intraperitoneal lidocaine at 50mg/h during open abdominal hysterectomy exerts analgesic effects via local mechanisms rather than central.
Perniola A, Magnuson A, Axelsson K et al. Intraperitoneal Local Anesthetics Have Predominant Local Analgesic Effect: A Randomized, Double-blind Study. Anesthesiology. 2014 Aug 1;121(2):352-61.
  Daniel Jolley
pearl
1
Dexamethasone provides effective PONV prophylaxis (NNT 3.7). There is however no benefit of an 8 to 10 mg IV dose over a lower 4 to 5 mg dose.
De GS, Castro-Alves LJ, Ahmad S et al. Dexamethasone to prevent postoperative nausea and vomiting: an updated meta-analysis of randomized controlled trials. Anesth. Analg. 2013 Jan 1;116(1):58-74.
  Daniel Jolley
summary
1
Meta-analysis of 10 RCTs totalling 633 subjects showed that while pain at rest following laparoscopic surgery was reduced by transverse abdominis plane block, early (0-4 h) pain was only moderately reduced (-2.4 cm) and late pain (24 hours) minimally reduced (-1.3 cm). Pain with movement was not significantly different between TAP blocks and controls.
De GS, Castro-Alves LJ, Nader A et al. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth. Analg. 2014 Feb 1;118(2):454-63.
  Daniel Jolley
pearl
1
TAP block reduced early and late pain at rest after laparoscopic surgery, though not pain with movement.
De GS, Castro-Alves LJ, Nader A et al. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth. Analg. 2014 Feb 1;118(2):454-63.
  Daniel Jolley
pearl
1
TAP block reduces pain severity, morphine consumption and opioid side effects after caesarean section when intrathecal morphine is not used.
Abdallah FW, Halpern SH, Margarido CB. Transversus abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis. Br J Anaesth. 2012 Nov 1;109(5):679-87.
  Daniel Jolley