- Email: [email protected]
Itching to do a TAP block?
468
Correspondence
The postpartum period was complicated by the patient’s underlying muscle weakness which impaired mobility but this gradually improved and she was discharged six days postpartum. The use of succinylcholine in patients with denervated muscle is controversial. Denervation leads to increased expression (up-regulation) of fetal nicotinic neuromuscular acetylcholine receptors (nAChR) in the muscle or at neuromuscular junctions potentially causing increased potassium release and hyperkalaemia following administration of succinylcholine. It has been recommended not to use succinylcholine for 24– 48 h after the insult or prior to 1–2 years or more after the injury,1 the amount of potassium release depending upon the relative increase in fetal nAChR expression. The risk of hyperkalaemia probably persists until nAChR expression returns to normal but it is unknown exactly how long succinylcholine should be avoided after each type and degree of injury. In light of this, it was felt prudent to avoid the use of succinylcholine for both the subsequent suture removal and for future delivery should a general anaesthetic be required. Several cases of TM have been reported following both neuraxial techniques and general anaesthesia although a direct causal relationship has not been shown. We identified only seven cases of parturients with TM in the literature, four with pre-existing TM,2–4 and three with acute-onset TM during pregnancy.5–7 Two patients with pre-existing TM were offered epidural analgesia for labour, but one declined and proceeded to have a vaginal delivery, and the other had elective caesarean delivery under general anaesthesia. The remaining two had vaginal deliveries without epidural analgesia. The three acute-onset TM parturients had caesarean deliveries, one with general, and one with epidural anaesthesia. The mode of anaesthesia for the third patient was not recorded. TM may occur as a single episode or behave similarly to multiple sclerosis (MS) as a relapsing disease with good, partial or no recovery of sensory or motor function and current thinking is that epidurals do not precipitate a relapse of MS. As local anaesthetic drugs are neurotoxic,8 and the demyelinated fibres of TM and MS may be more susceptible to neurotoxicity, we decided it would be better to avoid spinal anaesthesia as the cerebrospinal fluid local anaesthetic concentrations are higher. We avoided lidocaine as it is known to be more neurotoxic than bupivacaine. Given the similarities of TM and MS, we considered the risk of precipitating a TM relapse with epidural anaesthesia was minimal.
S. Thomas, S. Massey, J. Douglas, L. Magee, M. Rosengarten Department of Anesthesia,
BC Women’s Hospital, Vancouver, British Columbia, Canada E-mail addresses: [email protected]
References 1. Martyn JAJ, Richtsfeld M. Succinylcholine-induced hyperkalaemia in acquired pathological states. Anesthesiology 2006;104: 158–69. 2. Young BK, Katz M, Klein S. Pregnancy after spinal cord injury: altered maternal and fetal response to labour. Obstet Gynecol 1983;62:59–63. 3. Berghella V, Spector T, Trauffer P, Johnson A. Pregnancy in patients with pre-existing transverse myelitis. Obstet Gynecol 1996;87:809–12. 4. May AE, Fombon FN, Francis S. UK registry of high-risk obstetric anaesthesia: report on neurological disease. Int J Obstet Anesth 2008;17:31–6. 5. Marabani M, Zoma A, Hadley D, Sturrock RD. Transverse myelitis occurring during pregnancy in a patient with systemic lupus erythematosis. Anaesthesia 1989;48:160–2. 6. Gunaydin B, Akcali D, Alkan M. Epidural anaesthesia for caesarean section in a patient with Devic’s Syndrome. Anaesthesia 2001;56:562–7. 7. Walsh P, Grange C, Beale N. Anaesthetic management of an obstetric patient with idiopathic acute transverse myelitis. Int J Obstet Anesth 2010;19:98–101. 8. Johnson ME. Neurotoxicity of lidocaine: implications for spinal anaesthesia and neuroprotection. J Neurosurg Anesthesiol 2004;16: 80–3. 0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.06.006
Itching to do a TAP block? Pruritus is a common side effect of neuraxial opioids which can be severe, distressing and resistant to treatment. We report the case of a woman who had a history of severe pruritus following previous caesarean sections in whom we successfully used a transversus abdominis plane (TAP) block to eliminate the need for long-acting opioids following her third caesarean section. A 22-year-old, 80 kg, G3P2 woman, presented at 38 weeks of gestation for her third elective caesarean section. Both previous operations had been performed under regional anaesthesia using intrathecal opioids and on each occasion she complained of severe pruritus. She stated that the itch had started intraoperatively and was so severe that the excoriations to her hands and face produced bleeding. This effect lasted for almost 15 h. We therefore decided to offer her an opioid-free spinal anaesthetic, followed by a TAP block and intravenous fentanyl patient-controlled analgesia (PCA). Bilateral TAP blocks were performed at the completion of surgery using the landmark technique via the lumbar trian-
Correspondence gle of Petit.1 A total of 30 ml 0.125% levobupivacaine was injected on each side. She remained pain-free for her entire postoperative course as assessed by a numerical pain rating score of zero throughout. The PCA remained unused. She was ambulant to the shower 5 h after surgery and was discharged home 24 h later. She received only paracetamol and diclofenac during her admission and reported no itching. Pregnant women are particularly susceptible to pruritus following neuraxial opioids with an incidence of greater than 70%.2 This may be an effect of oestrogen on opioid receptors. Pruritus usually occurs 3–7 h after morphine injection. From the site of administration, itch tends to spread rostrally to the trunk and then to the face, particularly the nose and around the eyes. The intensity may be such that it can interfere with a mother’s sleep and ability to breastfeed as well as leading to skin excoriation. Symptoms are difficult to control and often do not respond to therapy. In 2001 Kjellberg and Tramer published a systematic review of 22 trials of pharmacological treatment of opioid-induced pruritus.3 Drugs investigated included propofol, intralipid, clonidine, prednisolone, ondansetron, hydroxyzine and many l-receptor antagonists. The review concluded that naloxone, naltrexone, nalbuphine and droperidol were efficacious in the prevention of opioid-induced pruritus but there was a lack of valid data on the efficacy of interventions for the treatment of established pruritus. Several other studies and reviews have shown the efficacy of ondansetron compared with placebo.4 Abdominal field blocks have been used for several decades to provide analgesia following abdominal surgery. They were highly unpredictable, however, due to lack of clear landmarks, varied needle position and lack of knowledge of local anaesthetic spread. In 2001, Rafi improved success of the blocks with a blind landmark technique via the lumbar triangle of Petit.1 More recently ultrasound-guided techniques have been described in an attempt to improve efficacy and safety.5 Two recent trials have investigated the use of TAP blocks after caesarean delivery. They have shown a reduction of 40–70% in morphine requirements during the first 48 h postoperatively.6,7 Sedation scores and nausea scores were also reduced. Alternative analgesic strategies for avoiding use of long-acting neuraxial opioids include use of combined spinal-epidural (CSE) anaesthesia followed by patientcontrolled epidural analgesia (PCEA), intravenous PCA, intramuscular opioids or oral morphine. However, these techniques still have the potential to induce pruritus. R. Isaacs, M. Turner Department of Anaesthetics, Royal Gwent Hospital, Newport, UK E-mail addresses: [email protected]
469
References 1. Rafi A. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001;56:1024–6. 2. Szarvas S, Harman D, Murphy D. Neuraxial opioid-induced pruritus: a review. J Clin Anesth 2003;15:234–9. 3. Kjellberg F, Tramer MR. Pharmacological control of opioidsinduced pruritis: a quantitative systematic review of randomized trials. Eur J Anaesthesiol 2001;18:346–57. 4. Bonnet MP, Marret E, Josserand J, Mercier FJ. Effect of prophylactic 5-HT3 receptor antagonist on pruritus induced by neuraxial opioids: a quantitative systematic review. Br J Anaesth 2008;101:311–9. 5. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616–7. 6. McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186–91. 7. Belavy D, Cowlishaw PJ, Howes M, Phillips F. Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery. Br J Anaesth 2009;103:726–30.
0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.05.003
Texting while birthing ‘‘I feel a lot of pressure now. . . Alana is about to be born’’ is what our patient texted to her mother as the obstetrician was delivering her child by cesarean delivery (Fig. 1). New advances and technology are always making their way into our work environment. Photos during delivery to remember the birth of a newborn have always been popular, but digital photography has expanded the scope of what can be achieved during
Fig. 1 very.
Texting at the moment of birth during cesarean deli-
Correspondence
The postpartum period was complicated by the patient’s underlying muscle weakness which impaired mobility but this gradually improved and she was discharged six days postpartum. The use of succinylcholine in patients with denervated muscle is controversial. Denervation leads to increased expression (up-regulation) of fetal nicotinic neuromuscular acetylcholine receptors (nAChR) in the muscle or at neuromuscular junctions potentially causing increased potassium release and hyperkalaemia following administration of succinylcholine. It has been recommended not to use succinylcholine for 24– 48 h after the insult or prior to 1–2 years or more after the injury,1 the amount of potassium release depending upon the relative increase in fetal nAChR expression. The risk of hyperkalaemia probably persists until nAChR expression returns to normal but it is unknown exactly how long succinylcholine should be avoided after each type and degree of injury. In light of this, it was felt prudent to avoid the use of succinylcholine for both the subsequent suture removal and for future delivery should a general anaesthetic be required. Several cases of TM have been reported following both neuraxial techniques and general anaesthesia although a direct causal relationship has not been shown. We identified only seven cases of parturients with TM in the literature, four with pre-existing TM,2–4 and three with acute-onset TM during pregnancy.5–7 Two patients with pre-existing TM were offered epidural analgesia for labour, but one declined and proceeded to have a vaginal delivery, and the other had elective caesarean delivery under general anaesthesia. The remaining two had vaginal deliveries without epidural analgesia. The three acute-onset TM parturients had caesarean deliveries, one with general, and one with epidural anaesthesia. The mode of anaesthesia for the third patient was not recorded. TM may occur as a single episode or behave similarly to multiple sclerosis (MS) as a relapsing disease with good, partial or no recovery of sensory or motor function and current thinking is that epidurals do not precipitate a relapse of MS. As local anaesthetic drugs are neurotoxic,8 and the demyelinated fibres of TM and MS may be more susceptible to neurotoxicity, we decided it would be better to avoid spinal anaesthesia as the cerebrospinal fluid local anaesthetic concentrations are higher. We avoided lidocaine as it is known to be more neurotoxic than bupivacaine. Given the similarities of TM and MS, we considered the risk of precipitating a TM relapse with epidural anaesthesia was minimal.
S. Thomas, S. Massey, J. Douglas, L. Magee, M. Rosengarten Department of Anesthesia,
BC Women’s Hospital, Vancouver, British Columbia, Canada E-mail addresses: [email protected]
References 1. Martyn JAJ, Richtsfeld M. Succinylcholine-induced hyperkalaemia in acquired pathological states. Anesthesiology 2006;104: 158–69. 2. Young BK, Katz M, Klein S. Pregnancy after spinal cord injury: altered maternal and fetal response to labour. Obstet Gynecol 1983;62:59–63. 3. Berghella V, Spector T, Trauffer P, Johnson A. Pregnancy in patients with pre-existing transverse myelitis. Obstet Gynecol 1996;87:809–12. 4. May AE, Fombon FN, Francis S. UK registry of high-risk obstetric anaesthesia: report on neurological disease. Int J Obstet Anesth 2008;17:31–6. 5. Marabani M, Zoma A, Hadley D, Sturrock RD. Transverse myelitis occurring during pregnancy in a patient with systemic lupus erythematosis. Anaesthesia 1989;48:160–2. 6. Gunaydin B, Akcali D, Alkan M. Epidural anaesthesia for caesarean section in a patient with Devic’s Syndrome. Anaesthesia 2001;56:562–7. 7. Walsh P, Grange C, Beale N. Anaesthetic management of an obstetric patient with idiopathic acute transverse myelitis. Int J Obstet Anesth 2010;19:98–101. 8. Johnson ME. Neurotoxicity of lidocaine: implications for spinal anaesthesia and neuroprotection. J Neurosurg Anesthesiol 2004;16: 80–3. 0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.06.006
Itching to do a TAP block? Pruritus is a common side effect of neuraxial opioids which can be severe, distressing and resistant to treatment. We report the case of a woman who had a history of severe pruritus following previous caesarean sections in whom we successfully used a transversus abdominis plane (TAP) block to eliminate the need for long-acting opioids following her third caesarean section. A 22-year-old, 80 kg, G3P2 woman, presented at 38 weeks of gestation for her third elective caesarean section. Both previous operations had been performed under regional anaesthesia using intrathecal opioids and on each occasion she complained of severe pruritus. She stated that the itch had started intraoperatively and was so severe that the excoriations to her hands and face produced bleeding. This effect lasted for almost 15 h. We therefore decided to offer her an opioid-free spinal anaesthetic, followed by a TAP block and intravenous fentanyl patient-controlled analgesia (PCA). Bilateral TAP blocks were performed at the completion of surgery using the landmark technique via the lumbar trian-
Correspondence gle of Petit.1 A total of 30 ml 0.125% levobupivacaine was injected on each side. She remained pain-free for her entire postoperative course as assessed by a numerical pain rating score of zero throughout. The PCA remained unused. She was ambulant to the shower 5 h after surgery and was discharged home 24 h later. She received only paracetamol and diclofenac during her admission and reported no itching. Pregnant women are particularly susceptible to pruritus following neuraxial opioids with an incidence of greater than 70%.2 This may be an effect of oestrogen on opioid receptors. Pruritus usually occurs 3–7 h after morphine injection. From the site of administration, itch tends to spread rostrally to the trunk and then to the face, particularly the nose and around the eyes. The intensity may be such that it can interfere with a mother’s sleep and ability to breastfeed as well as leading to skin excoriation. Symptoms are difficult to control and often do not respond to therapy. In 2001 Kjellberg and Tramer published a systematic review of 22 trials of pharmacological treatment of opioid-induced pruritus.3 Drugs investigated included propofol, intralipid, clonidine, prednisolone, ondansetron, hydroxyzine and many l-receptor antagonists. The review concluded that naloxone, naltrexone, nalbuphine and droperidol were efficacious in the prevention of opioid-induced pruritus but there was a lack of valid data on the efficacy of interventions for the treatment of established pruritus. Several other studies and reviews have shown the efficacy of ondansetron compared with placebo.4 Abdominal field blocks have been used for several decades to provide analgesia following abdominal surgery. They were highly unpredictable, however, due to lack of clear landmarks, varied needle position and lack of knowledge of local anaesthetic spread. In 2001, Rafi improved success of the blocks with a blind landmark technique via the lumbar triangle of Petit.1 More recently ultrasound-guided techniques have been described in an attempt to improve efficacy and safety.5 Two recent trials have investigated the use of TAP blocks after caesarean delivery. They have shown a reduction of 40–70% in morphine requirements during the first 48 h postoperatively.6,7 Sedation scores and nausea scores were also reduced. Alternative analgesic strategies for avoiding use of long-acting neuraxial opioids include use of combined spinal-epidural (CSE) anaesthesia followed by patientcontrolled epidural analgesia (PCEA), intravenous PCA, intramuscular opioids or oral morphine. However, these techniques still have the potential to induce pruritus. R. Isaacs, M. Turner Department of Anaesthetics, Royal Gwent Hospital, Newport, UK E-mail addresses: [email protected]
469
References 1. Rafi A. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001;56:1024–6. 2. Szarvas S, Harman D, Murphy D. Neuraxial opioid-induced pruritus: a review. J Clin Anesth 2003;15:234–9. 3. Kjellberg F, Tramer MR. Pharmacological control of opioidsinduced pruritis: a quantitative systematic review of randomized trials. Eur J Anaesthesiol 2001;18:346–57. 4. Bonnet MP, Marret E, Josserand J, Mercier FJ. Effect of prophylactic 5-HT3 receptor antagonist on pruritus induced by neuraxial opioids: a quantitative systematic review. Br J Anaesth 2008;101:311–9. 5. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616–7. 6. McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186–91. 7. Belavy D, Cowlishaw PJ, Howes M, Phillips F. Ultrasound-guided transversus abdominis plane block for analgesia after caesarean delivery. Br J Anaesth 2009;103:726–30.
0959-289X/$ - see front matter c 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2010.05.003
Texting while birthing ‘‘I feel a lot of pressure now. . . Alana is about to be born’’ is what our patient texted to her mother as the obstetrician was delivering her child by cesarean delivery (Fig. 1). New advances and technology are always making their way into our work environment. Photos during delivery to remember the birth of a newborn have always been popular, but digital photography has expanded the scope of what can be achieved during
Fig. 1 very.
Texting at the moment of birth during cesarean deli-