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Ultrasound-Guided Transversus Abdominis Plane Block Versus Ilioinguinal/Iliohypogastric Block in Intraoperative Anesthesia and Analgesia in Pediatric Patients: A Randomized Controlled Study

AUTHORS

Ilke Kupeli 1 , * , Sara Salcan 2

AUTHORS INFORMATION

1 Anesthesiology and Reanimation Department, Erzincan University, Erzincan, Turkey

2 Public Health Department, Erzincan Universıty, Erzincan, Turkey

How to Cite: Kupeli I, Salcan S. Ultrasound-Guided Transversus Abdominis Plane Block Versus Ilioinguinal/Iliohypogastric Block in Intraoperative Anesthesia and Analgesia in Pediatric Patients: A Randomized Controlled Study, Iran Red Crescent Med J. 2018 ; 20(4):e65163. doi: 10.5812/ircmj.65163.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 20 (4); e65163
Published Online: July 29, 2018
Article Type: Research Article
Received: December 15, 2017
Revised: February 6, 2018
Accepted: April 3, 2018
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Abstract

Background: Regional techniques both reduce opioid requirements and provide quality pain control in patients, especially in pediatrics.

Objectives: The aim of this study was to compare the contributions of ilioinguinal/iliohypogastric (II/IH) block and transversus abdominis plane (TAP) block combined with sedation to intraoperative anesthesia and analgesia in pediatric surgery.

Methods: In this randomized controlled study, 100 patients aged 2 - 6 years were enrolled and divided into five groups: TAP block with ketamine; II/IH block with ketamine; TAP block with Sevoflurane; II/IH block with Sevoflurane; and the control group with Sevoflurane alone. Hemodynamics (mean arterial pressure (MAP) and heart rate (HR)), depth of anesthesia, Sevoflurane usage, pain score, number of children who needed analgesia, and the time to start rescue analgesia of all patients were recorded.

Results: There was no significant difference between the study groups, in HR and MAP during operations (P > 0.05). The amount of Sevoflurane used in the group supported with both blocks decreased significantly compared to the control group (P < 0.001). In the groups where the block was added until the 6th hour in the postoperative period, there were lower HR and MAP (P < 0.05). Pain scores were high in the first six hours in the control group (P < 0.05). There was a longer duration of analgesia in the ketamine + TAP group and the Ketamine + II/IH block group (P < 0.001) in comparison to others. A higher analgesic need was found in the control group (P < 0.05).

Conclusions: This study revealed that transversus abdominis plane or ilioinguinal/iliohypogastric regional blocks could have same intraoperative/ postoperative effects regarding hemodynamics and intraoperative analgesia in lower abdominal pediatric surgery. Anesthesia can be maintained using sedative medicines only.

Keywords

Anesthesia Analgesia Block Iliohypogastric lioinguinal Pediatric Surgery Transversus Abdominis Plane Ultrasound-Guided

Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

Regional anesthesia and analgesia techniques are frequently used to provide pain control in pediatric surgical practices. Regional techniques reduce both opioid requirements and provide quality pain control in patients (1).

Ilioinguinal/Iliohypogastric (II/IH), when nerve blocks are applied with mild general anesthesia, provide ipsilateral analgesia in the inguinal area surgeries (e.g., inguinal hernia, orchiopexy, and varicocele) (2). In the study by Yang et al. (3), it was emphasized that ultrasound-guided II/IH extended the time of postoperative analgesia, reduced the amount of local anesthetic required, and accelerated postoperative recovery.

Transversus abdominis plane (TAP) block is one of the abdominal site blocks used in both anesthesia and postoperative acute pain treatment in surgeries of the lower abdominal region (4). Ramzy Shaaban (5) determined that TAP block application provided a better analgesia than the wound site infiltration in the children to whom appendectomy was applied and in this study, the time of the first analgesic need was significantly longer in the TAP group (6.4 ± 1.5 hours) and the dose and number of rescue analgesics were significantly lower.

Both block methods have been applied so far to provide postoperative analgesia, especially in pediatric cases and in combination with general anesthesia, and there are rare case reports in terms of performing the operation with blocks only (6, 7). Likewise, in the PRAN study by Polaner et al. (8), 95% of the 14917 blocks were performed under general anesthesia. In a study by Tekelioglu et al. (7), it was emphasized that TAP block supported by sedation without giving general anesthesia provide an opportunity for both an effective and reliable surgery and long-term postoperative pain control.

The purpose of the present study was to compare the contributions of TAP block and II/IH block combined with sedation in pediatric surgery to intraoperative anesthesia and analgesia without general anesthesia.

2. Methods

This study approved by the ethics committee of Erzincan University, Turkey (09/07), and registered in the clinical trial registration website (ClinicalTrials.gov) with the registration number of NCT02991053. Written informed consent was obtained from the parents of the study patients.

This randomized controlled trial conducted at a university hospital in the pediatric surgery operating room in 2017. Hundred pediatric patients aged 2 - 6 years undergoing elective lower abdominal surgery were enrolled. Five patients were excluded from the study because fentanyl was administered in repeated doses. The cases were candidates for inguinal hernia repair, orchiopexy, and appendectomy. The exclusion criteria were psychiatric disease, the weight of > 40 kg, cardiac-pulmonary-neurological diseases, bleeding problems, infections or wound scars in the injection site, and known allergies to local anesthetics.

2.1. Preoperative Management

All patients transferred to the operating room with established vascular access and received intravenous premedication with 0.1 mg/kg midazolam, ten minutes before the surgery. Hemodynamic values, including mean arterial pressure (MAP) and heart rate (HR), were recorded preoperatively in all patients.

2.2. Intraoperative Management

Anesthesia induction was performed with 2 mg/kg ketamine (Ketalar, Pfizer, Istanbul, Turkey) and 0.01 mg/kg Atropine (Atropin Sülfat, Osel, Istanbul, Turkey), intravenously. Patients were randomly assigned to groups using simple block randomization. All nerve blocks and operations performed by the same anesthetist and surgeon.

Group 1: Transversus abdominis plane (TAP) block was performed with 0.4 mL/kg Bupivacaine 0.25% (Marcaine, AstraZeneca, Istanbul, Turkey) and the anesthesia was maintained with only Ketamine (Ketamine + TAP group).

Group 2: The laryngeal mask airway (LMA) was inserted under Sevoflurane anesthesia and anesthesia maintained by two MAC Sevoflurane (Sevorane Likid, Abdi Ibrahim, Istanbul, Turkey) and oxygen/air mixture. TAP block was performed with 0.4 mL/kg Bupivacaine 0.25% (LMA + Sevoflurane + TAP group)

Group 3: The II/IH block was done with 0.4 mL/kg Bupivacaine 0.25%, and the anesthesia maintenance was provided with only Ketamine (Ketamine + II/IH group)

Group 4: The LMA was inserted and anesthesia maintained by 2 MAC Sevoflurane and oxygen/air mixture. II/IH block was performed with 0.4 mL/kg bupivacaine 0.25% (LMA + Sevoflurane + II/IH group)

Group 5 (control group): LMA was inserted and anesthesia maintenance was provided with the mixture of 2 MAC Sevoflurane, and oxygen/air mixture and no block was applied (Sevoflurane group). Intravenous Paracetamol was used to control postoperative pain (Parol, Atabay, Istanbul, Turkey).

Both blocks were applied as previously mentioned (9). High-frequency linear probes (SonoSite M-Turbo, Sonosite, USA) were used in all blocks. The ultrasound device was calibrated every morning.

All surgeries except for the 5th group, which did not receive the block, were started 20 minutes after the block. HR = 100 - 130 beats/min, BIS = 60 - 80, and MAP = 80 - 120 mmHg were considered as normal values. At the time of surgery, 1 mcg/kg IV Fentanyl was administered when there was movement in the patient or if the heart rate increased by 20% or more from baseline. Patients requiring additional doses of fentanyl within three minutes were excluded from the study. Anesthesia depth was assessed with bispectral index (BIS) and kept between 60 and 80. During the surgery, HR, SpO2, MAP, BIS measurements, the amount of Sevoflurane used, and the dose of Ketamine were recorded at 5-minute intervals.

2.3. Postoperative Management

The postoperative pain was assessed with modified children’s hospital of Eastern Ontario pain scale (CHEOPS) and objective pain scale (OPS) for 12 hours. The time of CHEOPS ≥ 6 or OPS ≥ 5 was recorded, and rescue analgesia was performed with 15 mg/kg dose of IV Paracetamol at that time (1). 15 mg/kg of Paracetamol was applied to all the patients every 8 hours. If Paracetamol was ineffective, ibuprofen would be administered at 20 - 30 mg/kg.

Pain scores via CHEOPS and OPS and hemodynamic changes were followed- up and patients’ need for analgesics at the time of first analgesia, nausea, and vomiting were recorded. Rescue analgesia and nausea/vomiting status were evaluated as either present or absent.

There was one observer in this study that was a pediatric surgeon.

The primary purpose of the study was to investigate the contribution of both regional anesthesia techniques to intraoperative anesthesia and analgesia and postoperative analgesia.

2.4. Statistical Analysis

We are primarily interested in the precise estimates of acceptability, as well as outcome variability that will aid in the planning of a larger, sufficiently powered efficient trial. A sample size of 20 per group will allow us to be relatively precise in our conclusions regarding the acceptability of outcomes. In the power analysis, it was determined that a total of 100 patients should be included with α = 0.05, and the power of 85%.

Normal distribution and analysis of variance were assessed using the Kolmogorov-Smirnov test, Skewness-Kurtosis, and histogram. Numerical data are presented as the mean and standard deviation and categorical data as the number. The Chi-square test was used to compare categorical data between the groups. The Mann-Whitney U test was used to compare the mean values between two groups, and the Kruskal-Wallis test was used to compare three or more groups. Tukey’s honest significant difference or non-parametric comparison tests were used in multiple comparisons. All the data were analyzed using IBM SPSS statistical package for Windows version 20 (IBM Corp., Armonk, NY, USA). A P value of < 0.05 was considered statistically significant.

3. Results

3.1. Descriptive and Preoperative Data

A total of hundred children included in this study, 55 boys and 45 girls, with a mean age of 3.9 ± 1.2 years. There was no significant difference in age, gender, preoperative BIS, HR, MAP, and SpO2 values between the study groups (P > 0.05) (Table 1).

Table 1. Descriptive and Preoperative Dataa
VariblesKetamine + II/IH GroupLMA + II/IH GroupKetamine + TAP GroupLMA + TAP GroupControl GroupTotalP Valueb
Sex> 0.05
Boy111210111155
Girl98109945
Patient number, No.2020202020100
Age, y4 ±1.43.9 ± 1.64.4 ±1.13.7 ± 1.23.9 ± 1.0> 0.05
Preop BIS85.00 ±4.286.30 ± 4.085.0 ± 3.685.0 ± 3.387.05 ± 2.9> 0.05
Preop HR (min)114.55±17.8122.0 ± 15.9113.3 ± 14.7121.5 ± 14.3122.05 ± 10.0> 0.05
Preop MAP (mmHg)95.50 ± 15.0101.10 ± 12.894.5 ± 13.4102.3 ± 13.2103.95 ± 13.0> 0.05

Abbreviations: II/IH, Ilioinguinal/Iliohypogastric; Preop (BIS, HR, MAP), preoperative bispectral index, heart rate, mean arterial pressure; TAP, transversus abdominis plane.

aChi-Square tests.

bP < 0.05 was considered significant.

3.2. Intraoperative Data

In the between-group comparison of intraoperative values, it was determined that there was a difference between MAP values in the first 10 minutes after the block. After the 15th minute, heart rate was observed to be significantly different compared to the start of surgery (P < 0.05). It is observed that heart rates were higher but the means of arterial pressure were lower in the control group (Table 2).

Table 2. Intraoperative Dataa
TimeKetamine + II/IH GroupLMA + II/IH GroupKetamine + TAP GroupLMA + TAP GroupControl GroupP Value
0 (Start time)
HR117.3 ± 15.6123.6 ± 13.2113.8 ± 15.4122.0 ± 15.2122.5 ± 10.70.154
MAP94.5 ± 14.697.6 ± 12.793.9 ± 12.599.2 ± 12.082.0 ± 3.8< 0.001b
After 5 min
HR121.6 ± 12.0125.1 ± 11.8117.5±15.2123.2±15.9123.2 ± 9.70.441
MAP93.7 ± 10.898.6 ± 8.694.3 ± 10.299.4 ± 8.384.7 ± 5.9< 0.001b
After 10 min
HR114.2 ± 13.8119.9 ± 12.6111.8 ± 15.4119.3 ± 15.7122.7 ± 11.00.090
MAP92.9 ± 9.998.8 ± 5.994.2 ± 10.296.0 ± 9.185.8 ± 6.2< 0.001b
After 15 min
HR108.6 ± 10.8114.3 ± 10.3107.2 ± 12.0114.8 ± 12.3121.5 ± 9.9< 0.001b
MAP88.8 ± 8.493.6 ± 6.890.6 ± 9.392.3 ± 6.884.7 ± 5.2< 0.003b
After 20 min
HR108.0 ± 11.1113.5 ± 11.4105.5±12.7109.3 ± 12.9121.7 ± 10.1< 0.001b
MAP85.5 ± 8.587.7 ± 9.188.0 ± 9.587.6 ± 9.782.2 ± 4.40.042b
Skin incision
HR106.6 ± 14.3110.9 ± 13.8109.3 ± 11.3107.8±11.9124.3 ± 7.7< 0.001b
MAP90.6 ± 13.294.5 ± 15.692.6 ± 12.992.7 ± 14.286.4 ± 6.10.038b
After 10 min
HR108.8 ± 15.7113.8 ± 16.6107.4±14.1108.6±14.4123.4 ± 7.60.003b
MAP85.3 ± 8.687.0 ± 10.089.1 ± 10.487.7 ± 11.285.0 ± 2.90.593
After 20 min
HR107.5 ± 12.8111.8 ± 13.6105.2 ± 13.1105.2 ± 11.9119.7 ± 9.7< 0.001b
MAP88.0 ± 12.587.1 ± 12.189.2 ± 11.887.4 ± 11.585.3 ± 2.70.846
After 30 min
HR105.9 ± 15.2110.3 ±16.4104.3 ± 14.6103.3 ± 14.3120.7 ± 10.3< 0.001b
MAP88.6 ± 13.485.4 ± 12.189.9 ± 13.286.7 ± 12.185.2 ± 5.10.660
Sevoflurane, mL/h012 ± 0.308 ± 0.319 ± 0.3< 0.001b
Ketamine, mg67.2 ± 28.762.5 ± 22.30.563

Abbreviations: HR, heart rate (min); MAP, mean arterial pressure (mmHg).

aOne way ANOVA.

bThe mean difference is significant at the 0.05 level.

When the cause of the difference between the groups was investigated, similar intra-operative values were found with both anesthesia methods with the application of both II/IH block and TAP block, but there was a significant difference between these four groups and the control group. This difference was due to the control group (Table 3).

Table 3. Comparison of P Values Between Groupsa
Ketamine + II/IH and LMA + II/IH GroupControl Group and Ketamine + II/IH GroupLMA + II/IH and Control GroupKetamine + TAP and LMA + TAPControl Group and Ketamine + TAPLMA + TAP and Control GroupKetamine + II/IH and Ketamine TAPLMA + II/IH and LMA + TAP
0 Starting time
HR0.1610.2460.8070.0710.0560.9120.4870.726
MAP0.408< 0.001b< 0.001b0.1620.002b< 0.001b0.8900.695
After 5 min
HR0.4030.7020.6490.1740.1740.9780.3500.672
MAP0.0870.002b< 0.001b0.075< 0.001b< 0.001b0.8590.767
After 10 min
HR0.2000.0550.5170.0900.044b0.4330.6000.895
MAP0.029b0.010b< 0.000b0.5050.002b< 0.000b0.6870.249
After 15 min
HR0.109< 0.001b0.044b0.035b< 0.001b0.0580.7020.901
MAP0.046b0.088< 0.001b0.4760.014b0.002b0.5180.567
After 20 min
HR0.138< 0.001b0.030b0.314< 0.000b< 0.001b0.5210.279
MAP0.4160.2300.046b0.8970.035b0.048b0.3890.987
After skin incision
HR0.269< 0.001b< 0.001b0.705< 0.001b< 0.001b0.5210.706
MAP0.3410.3110.041b0.9900.1310.1280.6240.298
After 10 min
HR0.260< 0.001b0.035b0.780< 0.001b< 0.001b0.7690.298
MAP0.5590.9040.4820.6310.1560.3460.2190.837
After 20 min
HR0.2740.002b0.045b0.990< 0.000b< 0.000b0.5870.112
MAP0.7930.4400.6100.5900.2570.5500.6460.937
After 30 min
HR0.3340.002b0.024b0.826< 0.001b< 0.000b0.7290.156
MAP0.3940.3650.9570.3860.2090.6940.7590.747
Sevoflurane< 0.001b< 0.001b< 0.001b< 0.001b0.127
Ketamine0.563

Abbreviations: HR, heart rate (min); MAP, mean arterial pressure (mmHg).

aMultiple comparison, student’s t test, Mann-Whitney U test.

bThe mean difference is significant at the 0.05 level.

In the comparison of TAP block and II/IH block, similar hemodynamic values were found in both groups in terms of HR and MAP during surgeries. When the amount of intraoperative anesthetic use was considered, the amount of Sevoflurane decreased significantly in the block groups compared to the control group (P < 0.01). However, when the use of ketamine was examined, it was found that even though there was less ketamine need in the group in which TAP block was added, this difference was not significant (P > 0.05) (Table 4).

Table 4. Intraoperative Comparison of Transversus Abdominis Plane Block, with Ilioinguinal/Iliohypogastric Blocka
Ketamine + II/IH and Ketamine + TAPP ValueLMA + II/IH and LMA + TAPP Value
0 min
HR117.3 ± 15.6113.8 ± 15.40.487123.6 ± 13.2122.0 ± 15.20.726
MAP94.5 ± 14.693.9 ± 12.50.89097.6 ± 12.799.2 ± 12.00.695
After 5 min
HR121.6 ± 12.0117.5 ± 15.20.350125.1 ± 11.8123.2 ± 15.90.672
MAP93.7 ± 10.894.3 ± 10.20.85998.6 ± 8.699.4 ± 8.30.767
After 10 min
HR114.2 ± 13.8111.8 ± 15.40.600119.9 ± 12.6119.3 ± 15.70.895
MAP92.9 ± 9.994.2 ± 10.20.68798.8 ± 5.996.0 ± 9.10.249
After 15 min
HR108.6 ± 10.8107.2 ± 12.00.702114.3 ± 10.3114.8 ± 12.30.901
MAP88.8 ± 8.490.6 ± 9.30.51893.6 ± 6.892.3 ± 6.80.567
After 20 min
HR108.0 ± 11.1105.5 ± 12.70.521113.5 ± 11.4109.3 ± 12.90.279
MAP85.5 ± 8.588.0 ± 9.50.38987.7 ± 9.187.6 ± 9.70.987
Skin incision
HR106.6 ± 14.3109.3 ± 11.30.521110.9 ± 13.8107.8 ± 11.90.706
MAP90.6 ± 13.292.6 ± 12.90.62494.5 ± 15.692.7 ± 14.20.298
After 10 min
HR108.8 ± 15.7107.4 ± 14.10.769113.8 ± 16.6108.6 ± 14.40.298
MAP85.3 ± 8.689.1 ± 10.40.21987.0 ± 10.087.7 ± 11.20.837
After 20 min
HR107.5 ±12.8105.2 ± 13.10.587111.8 ±13.6105.2 ± 11.90.112
MAP88.0 ± 12.589.2 ± 11.80.64687.1 ± 12.187.4 ± 11.50.937
After 30 min
HR105.9 ± 15.2104.3 ± 14.60.729110.3 ±16.4103.3 ± 14.30.156
MAP88.6 ± 13.489.9 ± 13.20.75985.4 ± 12.186.7 ± 12.10.747
Sevoflurane, mL0012 ± 0.38 ± 0.30.127
Ketamine, mg67.2 ± 28.762.5 ± 22.30.563

Abbreviations: HR, heart rate (min); MAP, mean arterial pressure (mmHg).

aStudent’s t-test and Mann-Whitney U test.

3.3. Postoperative Data

There was a significant difference between the groups in the postoperative values. Hemodynamic indexes (HR and MAP) were higher in the control group at all follow-up hours. However, it was more significant in the first six hours (P < 0.05). The hemodynamic changes that occurred in the Sevoflurane group after the first six hours were not statistically significant (P > 0.05).

Based on there were significant differences in the CHEOPS and OPS values at first, 2nd, 4th, and sixth postoperative hours regardless of group discrimination (Table 5).

Table 5. Postoperative Dataa
Ketamine + II/IH BlockLma + II/IH BlockKetamine + TAP BlockLMA + TAP BlockLMA + Sevoflurane (Control)P Value
PACU 0 min
HR106.7 ± 16.9111.1 ± 17.5103.6 ± 16.5106.4 ± 17.6122.2 ± 14.60.006b
MAP85.3 ± 11.579.0 ± 10.887.2 ± 12.784.7 ± 13.289.6 ± 4.30.042b
CHEOPS1.1 ± 0.40.7 ± 0.51.1 ± 0.61.0 ± 0.63.9 ± 2.2< 0.000b
OPS0.10± 0.30.1 ± 0.40.4 ± 0.60.3± 0.73.8 ± 2.4< 0.000b
PACU after 30 min
HR109.3 ± 13.2113.3 ± 15.1107.8 ± 13.0109.6 ± 14.7122.7 ±11.30.005b
MAP85.5 ± 13.984.5 ± 10.791.4 ± 14.287.2 ± 14.087.5 ± 6.10.458
CHEOPS0.8 ± 0.50.8 ± 0.70.9 ± 0.80.9 ± 0.73.8 ± 1.4< 0.000b
OPS0.5 ± 1.00.7 ± 1.00.5 ± 0.80.6 ± 1.03.7 ± 1.4< 0.000b
PACU after 60 min
HR110.7 ±14.4113.3 ± 15.6108.1 ± 13.3110.3 ± 13.9121.4 ± 11.10.030b
MAP87.3 ± 10.688.3 ± 8.591.1 ± 11.192.2 ± 10.487.2 ± 6.20.334
CHEOPS1.6 ± 1.21.7 ± 1.21.5 ± 1.11.6 ± 1.33.2 ± 1.0< 0.000b
OPS1.8 ± 1.82.3 ± 1.71.8 ± 1.52.0 ± 1.93.4 ± 1.50.031b
PACU after 2 h
HR107.6 ± 15.3115.7 ±14.8108.0 ± 12.6112.4 ± 13.7121.9 ± 9.80.006b
MAP86.6 ± 11.785.3 ± 6.889.5 ± 13.587.8 ± 12.386.4 ± 7.10.777
CHEOPS2.3 ± 2.62.7 ± 2.52.2 ± 2.32.5 ± 2.83.9 ± 1.90.003b
OPS2.2 ± 2.73.1 ± 2.52.6 ± 2.32.7 ± 2.63.7 ± 2.20.060
PACU after 3 h
HR107.9 ± 14.9114.4 ± 15.4106.8 ± 13.3107.9 ± 13.3118.9 ± 9.90.022b
MAP86.4 ± 10.685.4 ± 7.088.0 ± 12.089.2 ± 11.385.7 ± 4.40.682
CHEOPS1.7 ± 1.82.6 ± 1.91.8 ± 1.52.1 ± 1.92.5 ± 1.20.411
OPS1.8 ± 1.82.6 ± 2.01.8 ± 1.42.0 ± 1.92.1 ± 1.20.553
PACU after 4 h
HR107.5 ± 13.3112.7 ± 15.5107.1 ± 13.2107.3 ± 12.7120.6 ± 8.70.004b
MAP84.3 ± 10.383.5 ± 6.387.0 ± 10.884.1 ± 10.686.2 ± 5.50.706
CHEOPS0.95 ± 0.91.7 ± 1.01.7 ± 1.01.6 ± 1.02.5 ± 1.20.026
OPS1.3 ± 1.22.0 ± 1.11.8 ± 1.11.8 ± 1.12.9 ± 1.60.005b
PACU after 6 h
HR108.6 ± 15.2115.6 ± 15.9109.2 ± 15.3110.2 ± 14.9123.6 ±12.20.009b
MAP87.3 ± 9.886.1 ± 6.790.4 ± 9.791.1 ± 9.489.9 ± 4.50.261
CHEOPS1.7 ± 1.52.5 ± 2.12.1 ± 1.62.4 ± 1.93.6 ± 1.90.022b
OPS1.4 ± 1.82.2 ± 1.52.0 ± 2.02.1 ± 1.84.0 ± 2.5< 0.001b
PACU after 8 h
HR110.4 ± 17.0115.8 ± 17.2108.6 ± 16.2112.8 ± 17.8122.5 ± 12.60.071
MAP91.0 ± 9.985.3 ± 8.690.8 ± 11.689.0 ± 11.487.7 ± 5.30.326
CHEOPS3.9 ± 1.34.1 ± 1.23.6 ± 1.53.7 ± 1.43.6 ± 0.90.714
OPS4.0 ± 1.33.8 ± 1.13.8 ± 1.33.8 ± 1.53.6 ± 0.80.945
PACU after 12 h
HR109.5 ± 17.2114.6 ± 17.0111.5 ± 14.3114.0 ± 15.2119.6 ± 9.90.274
MAP84.4 ± 11.281.5 ± 8.590.2 ± 12.488.6 ± 13.185.3 ± 4.80.078
CHEOPS2.2 ± 2.01.7 ± 0.92.7 ± 1.91.9 ± 1.52.4 ± 0.50.252
OPS2.2 ± 2.11.7 ± 1.52.9 ± 2.02.2 ± 1.82.4 ± 0.50.297
Analgesia time, h6.1 ± 3.54.7 ± 2.06.2 ± 3.44.9 ± 3.02.1 ± 1.7< 0.000b
Rescue analgesia, No.6/205/206/206/2012/200.021b
Nausea and vomiting0/200/200/200/208/20< 0.000b

Abbreviation: MAP, mean arterial pressure; CHEOPS, children’s hospital of Eastern Ontario pain scale; HR, heart rate (min); MAP, mean arterial pressure (mmHg).

aOne-way ANOVA, Mann-Whitney U test.

bThe mean difference is significant at the 0.05 level.

The amounts of heart rate, CHEOPS, and OPS values were significantly higher in the first six hours in the control group (P < 0.05). The values were similar in the block groups.

When the duration of analgesia was evaluated, it was detected that analgesia was needed at 6.2 hours in the ketamine + TAP block group, at 4.9 hours in the Ketamine + II/IH block group, at 4.7 hours in the LMA + II/IH block group, and at 2.1 hours in the control group and this was found to be statistically significant (P < 0.001) (Table 5).

In addition, the supplemental analgesia needed in the early period in six patients in the block groups while the analgesia need was observed in 12 patients in the control group. Nausea and vomiting were observed only in the control group (Table 4).

Concerning the duration of analgesia and the number of rescue analgesia, the lowest analgesia duration, and the highest analgesia need were observed in the control group (P < 0.05) (Tables 5 - 6).

Table 6. Comparison of P Values Between Groups in Postoperative Periodsa
Ketamine + II/IH and LMA + II/IHLMA + Sevoflurane (Control) and Ketamine + II/IHLMA + II/IH and LMA + Sevoflurane (Control)Ketamine + TAP and LMA + TAPLMA + Sevoflurane (Control) and Ketamine + TAPLma + TAP and LMA + Sevoflurane (Control)Ketamine + II/IH and Ketamine TAPLMA + II/IH and LMA + TAP
PACU 0 min
HR0.4010.004b0.039b0.604< 0.001b0.004b0.5670.399
MAP0.0720.2200.003b0.4750.4930.1630.6240.141
CHEOPS0.338< 0.001b< 0.001b0.891< 0.001b< 0.001b0.9990.135
OPS0.999< 0.001b< 0.001b0.793< 0.001b< 0.001b0.0840.305
PACU after 30 min
HR0.3590.002b0.030b0.675< 0.001b0.003b0.7110.438
CHEOPS0.999< 0.001b< 0.001b0.999< 0.001b< 0.001b0.6610.677
OPS0.569< 0.001b< 0.001b0.776< 0.001b< 0.001b0.8640.885
PACU after 60 min
HR0.5450.016b0.0680.6070.003b0.013b0.5570.526
CHEOPS0.795< 0.001b< 0.001b0.795< 0.001b< 0.001b0.7960.810
OPS0.4200.006b0.0510.6540.005b0.017b0.9280.673
PACU after 2 h
HR0.061< 0.001b0.1480.3080.002b0.028b0.9280.470
CHEOPS0.5630.0360.1250.6990.031b0.0740.9490.813
PACU after 3 h
HR0.1330.012b0.2970.7980.006b0.012b0.8070.164
PACU after 4 h
HR0.2020.002b0.0560.961< 0.001b0.002b0.9340.237
CHEOPS0.021b< 0.001b0.021b0.8850.014b0.010b0.0250.766
OPS0.086< 0.001b0.038b0.9020.011b0.008b0.1970.496
PACU after 6 h
HR0.1410.002b0.0910.8310.003b0.005b0.9020.281
CHEOPS0.152< 0.001b0.0650.6110.012b0.044b0.3780.878
OPS0.2390.002b0.004b0.8750.002b0.003b0.3390.929
Analgesia
P0.125< 0.001b0.005b0.154< 0.001b0.003b0.9290.808
Rescue analgesia
P0.7380.047b0.021b0.9990.047b0.047b0.9990.731
Nausea and vomiting
P0.999< 0.001b< 0.001b0.999< 0.001b< 0.001b

aMultiple Comparison, Student’s t-test, Mann-Whitney U test.

bThe mean difference is significant at the 0.05 level.

In the postoperative comparisons of the two blocks, there was no significant difference between the groups in terms of HR, MAP, CHEOPS, OPS values, and the number of rescue analgesia. When the duration of analgesia was examined, it was determined that the TAP block have a relatively longer action period, but this was not statistically significant (Table 7). In addition, nausea and vomiting were not observed in the groups to which block was added.

Table 7. Postoperative Comparison of TAP Block with II/IH Blocka
Ketamine + II/IH and Ketamine + TAPP ValueLMA + II/IH and LMA + TAPP Value
PACU 0 min
HR106.7 ± 16.9103.6 ± 16.50.567111.1 ± 17.5106.4 ± 17.60.399
MAP85.3 ± 11.587.2 ± 12.70.62479.0 ± 10.884.7 ± 13.20.141
CHEOPS1.1 ± 0.41.1 ± 0.60.9990.7 ± 0.51.0 ± 0.60.135
OPS0.1± 0.30.4 ± 0.60.0840.1 ± 0.40.3± 0.70.305
PACU 30 min
HR109.3 ± 13.2107.8 ± 13.00.711113.3 ± 15.1109.6 ± 14.70.438
CHEOPS0.8 ± 0.50.9 ± 0.80.6610.8 ± 0.70.9 ± 0.70.677
OPS0.5 ± 1.00.5 ± 0.80.8640.7 ± 1.00.6 ± 1.00.885
PACU 60 min
HR110.7 ±14.4108.1 ± 13.30.557113.3 ± 15.6110.3 ± 13.90.526
CHEOPS1.6 ± 1.21.5 ± 1.10.7961.7 ± 1.21.6 ± 1.30.810
OPS1.8 ± 1.81.8 ± 1.50.9282.3 ± 1.72.0 ± 1.90.673
PACU 2 h
HR107.6 ± 15.3108.0 ± 12.60.928115.7 ±14.8112.4 ± 13.70.470
CHEOPS2.3 ± 2.62.2 ± 2.30.9492.7 ± 2.52.5 ± 2.80.813
PACU 3 h
HR107.9 ± 14.9106.8 ± 13.30.807114.4 ± 15.4107.9 ± 13.30.164
PACU 4 h
HR107.5 ± 13.3107.1 ± 13.20.934112.7 ± 15.5107.3 ± 12.70.237
CHEOPS0.9 ± 0.91.7 ± 1.00.0251.7 ± 1.01.6 ± 1.00.766
OPS1.3 ± 1.21.8 ± 1.10.1972.0 ± 1.11.8 ± 1.10.496
PACU 6 h
HR108.6 ± 15.2109.2 ± 15.30.902115.6 ± 15.9110.2 ± 14.90.281
CHEOPS1.7 ± 1.52.1 ± 1.60.3782.5 ± 2.12.4 ± 1.90.878
OPS1.4 ± 1.82.0 ± 2.00.3392.2± 1.52.1 ± 1.80.929
Analgesia
P6.1 ± 3.56.2 ± 3.40.9294.7 ± 2.04.9 ± 3.00.808
Rescue analgesia
P6/206/200.9995/206/200.731
Nausea-vomiting
P0000

aStudent’s t-test, Mann-Whitney U test.

4. Discussion

In the present study, the effect of two regional anesthesia techniques on the intraoperative anesthetic use and intraoperative analgesia in pediatric lower abdominal surgery was evaluated. The superiority of perioperative effects of Transversus abdominis plane or ilioinguinal/iliohypogastric blocks, to which general anesthesia (Sevoflurane) or sedation (ketamine) was added, could not be shown. Anesthesia maintenance in these surgeries can be performed with mild sedation added to the regional blocks.

Regional anesthesia techniques have been shown to reduce perioperative stress response (10). As in the present study, even though there was no intraoperative comparison of two regional methods, some studies in the literature have reported that better intraoperative hemodynamics were achieved in the groups to which block was applied and reduced the use of intraoperative Sevoflurane (1, 7, 11). On the other hand, in the present study, similar hemodynamic values were found in both groups in terms of HR and MAP at all intraoperative hours in comparisons with the TAP block and II/IH block. In the control group, HR and MAP values were higher. When the amount of intraoperative anesthetic use was examined, the Sevoflurane use in the block groups decreased significantly. The ketamine need in the group with TAP block was less than others; however, this difference was not statistically significant. This was associated with the fact that regional techniques, regardless of being TAP block or II/IH block, decrease the response to surgical stimulation and thus decrease the anesthetic need.

For postoperative pain control in children, regional analgesia is preferred more often because it is easier to apply and does not require additional equipment and care (12). There are many studies in the literature comparing postoperative analgesia with two blocks in pediatric patients, but the results are contradictory (9, 13-16). While the TAP block is associated with longer analgesia time, lower pain scores, and less analgesic need in some studies (13-15), it is argued in some studies that II/IH block is preferred in the postoperative period (9, 16, 17). In the meta-analysis of Wang et al. (18) in 2016, it was emphasized that ultrasound-guided II/IH nerve or TAP blocks reduce the need for analgesia during surgery and reduce the pain scores significantly. Similarly, in the study of Okur et al. (19), it was determined that in the groups with a block, the pain scores were lower, the duration of analgesia was longer, and the need for rescue analgesia was less. In the present study, no difference was found between the two regional anesthesia methods in terms of postoperative hemodynamics, pain scores, analgesia duration, the number of people requiring analgesia, and nausea and vomiting rates. The prominent detail is the painless duration elapsed between the Ketamine + block groups and LMA + Sevoflurane + block groups. When ketamine was added to the blocks, the duration of the analgesia increased by two hours. This effect was associated with the anti-hyperalgesic effect of ketamine, a part of multimodal analgesia (20).

The present study has some strong points. Our study reminds us that a mild sedation-assisted TAP or II/IH block may be preferred in some surgical procedures alone to avoid possible adverse effects of general anesthesia in children. The reliability was improved by using two different methods for the evaluation of postoperative pain. The cases were managed by the same anesthetist and the same surgeon to exclude the differences in practice. Our study had no missing value.

The present study has some weak points. This single-center study cannot be generalized. Further work is needed to make generalizations. We could not consider and assess the postoperative agitation effect of Sevoflurane (21). Third, our follow-up time was limited to 12 hours since the primary purpose of the present study was intraoperative anesthesia and analgesia. Longer follow-up periods can more clearly determine the postoperative effects of the two blocks.

4.1. Conclusion

In this study, investigating the effect of two regional anesthesia techniques on the intraoperative anesthetic use and intraoperative analgesia in pediatric lower abdominal surgery. The perioperative effects of transversus abdominis plane or ilioinguinal/iliohypogastric blocks to which general anesthesia (Sevoflurane) or sedation (ketamine) was added and have not any superiority to others. However, it was thought that they caused a better preoperative process compared to the control group without a block. Therefore, both block methods can be preferred as a part of general anesthesia or sedation, children can be protected from the side effects of general anesthesia, and better patient and family satisfaction can be achieved with a longer painless postoperative period.

Footnote

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