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Published on: September 20, 2019
Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic
Chrystelle Sola1,2, Cecilia Menacé3, Sophie Bringuier3
1From the Pediatric Anesthesia Unit, Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier University, Montpellier, France.
Insights
Ultrasound-guided transversus abdominis plane (TAP) block with levobupivacaine provides effective pain relief in children undergoing abdominal surgery. Both high volume/low concentration and low volume/high concentration regimens showed similar analgesic effects and low toxicity risks.
Area of Science:
- Regional anesthesia
- Pediatric pain management
- Pharmacokinetics
Background:
- Transversus abdominis plane (TAP) block is a common regional anesthesia for abdominal procedures.
- Limited evidence exists on optimal local anesthetic regimens and toxicity risks in children.
- This study aimed to compare analgesic effects and pharmacokinetics of levobupivacaine in pediatric TAP blocks.
Purpose of the Study:
- To compare the analgesic efficacy of two different levobupivacaine concentrations for ultrasound-guided TAP block in children.
- To investigate the pharmacokinetic profile of levobupivacaine in children receiving TAP block.
- To assess the safety and systemic toxicity risks associated with these regimens.
Main Methods:
- Prospective randomized study involving children for day-case inguinal surgery.
- Children received TAP block with 0.4 mg·kg levobupivacaine via high volume/low concentration (HVLC) or low volume/high concentration (LVHC).
- Primary outcome: need for opioid rescue analgesia; secondary outcome: pharmacokinetic analysis.
Main Results:
- 65 children analyzed; 71% required no opioid analgesia.
- No significant difference in opioid rescue analgesia between LVHC (35%) and HVLC (23%) groups (P = .26).
- Comparable levobupivacaine pharmacokinetic profiles and concentrations well below toxic thresholds were observed in both groups.
Conclusions:
- TAP block with levobupivacaine (0.4 mg·kg) offers comparable postoperative pain control in children regardless of HVLC or LVHC administration.
- Both regimens are associated with a very low risk of local anesthetic systemic toxicity in pediatric patients.
Background:
The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children.
Methods:
This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed.
Results:
Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds.
Conclusions:
In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.
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