BACKGROUND:

The analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery.

METHODS:

Sixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3mg/kg), low-dose ropivacaine (1.5mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10-12mg, fentanyl 10μg and morphine 150μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48h and at 6 and 12weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction.

RESULTS:

There were no differences between groups in the primary outcome. Mean ± SD pain scores (0-10) with movement at 24h were: high-dose ropivacaine 3.6±1.5, low-dose ropivacaine 4.6±2.1 and placebo 4.1±1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6h were lower in the high-dose group 2.0±1.8 compared to the low-dose 3.4±2.7 and placebo groups 4.2±2.0 (P=0.009). Pain scores at 12h were also lower in the high-dose group 2.2±2.0 compared to the low-dose group 4.1±2.7 and placebo group 4.0±1.3 (P=0.011). There was no difference in other outcomes between groups.

CONCLUSIONS:

Neither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12h after cesarean delivery.

The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

There has been interest in using high inspired oxygen concentrations to reduce surgical site infections in the obstetric population. Previous meta-analyses looking at the effect of high-concentration oxygen in other surgical populations have reported conflicting results. However, no meta-analysis has been performed on women undergoing cesarean section, who are generally a healthier population and thus may have different outcomes. The aim of this study was to complete a meta-analysis comparing high (>60%) and low (<40%) inspired concentrations of oxygen and determine the risk of surgical site infections in patients undergoing cesarean section.A full systematic review and meta-analysis were completed. Two independent literature searches were conducted using electronic databases, bibliographies and sources of gray literature to identify appropriate randomized controlled studies. These studies were assessed for quality and the results were pooled.Five studies, with a total of 1966 patients, were included in the review. There was no evidence that the perioperative use of high concentrations of oxygen reduced surgical site infections in this group (risk ratio 1.12, 95% confidence interval 0.86-1.46, P=0.40). The meta-analysis has an overall moderate GRADE.There is no evidence to suggest a difference in risk of surgical site infection by administration of high inspired oxygen concentrations among women undergoing cesarean section. Future studies with better adherence to the intervention may affect the results of this analysis.

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 μg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.