Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery

Shona Charlton; Allan M Cyna; Philippa Middleton; James D Griffiths

doi:10.1002/14651858.CD007705.pub2

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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 1 Morphine requirement, mean (mg).

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Analysis 1.2

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 2 Time to first morphine request (mins), mean.

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Study	TAP (landmark)	Placebo	P‐value
Carney 2008	45 (26‐116): n = 24	12.5 (0‐23): n = 26	p ≤ 0.001

Analysis 1.3

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 3 Time to first morphine request (mins), median, IQR.

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Analysis 1.4

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 4 Incidence of sedation.

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Study	Timing, post‐operative	TAP block (landmark)	no TAP block	p‐value
TAP v no TAP
McDonnell 2007	2 hours	0.5 (1, 1.5 IQR): n = 16	1 (1, 1.5 IQR): n = 16	not significant
McDonnell 2007	24 hours	0 (0, 0 IQR): n = 16	0 (0, 0 IQR): n = 16	not significant
TAP v TAP placebo
Griffiths 2010	2 hours	2 (range 1 to 4): n = 32	2 (range 1 to 3): n = 33	0.44
Griffiths 2010	24 hours	1 (range 1 to 3): n = 32	1 (range 1 to 3): n = 33	0.83

Analysis 1.5

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 5 Sedation scores (median, IQR or range).

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Analysis 1.6

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 6 Incidence of PONV.

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Study	Timing, postoperative	TAP block	no TAP block	p value
Niraj 2009	30 mins	0 (0, 0): n = 24	0 (0, 1): n = 23	< 0.05
Niraj 2009	24 hours	0 (0, 0); n = 24	0 (0, 1): n = 23	ns

Analysis 1.7

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 7 PONV scores (median, IQR).

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Study	timing	TAP block	No TAP block	p value
Griffiths 2010	2 hours	0 (0 to 3); n = 32	0 (0 to 3): n = 33	0.43
Griffiths 2010	24 hours	0 (0 to 3): n = 32	1.5 (0 to 2): n = 33	0.51

Analysis 1.8

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 8 Nausea (median, range).

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Study	Timing	TAP block	No TAP block	p‐value
Griffiths 2010	2 hours	0 (0 to 2): n = 32	0 (0):n = 33	0.20
Griffiths 2010	24 hours	0 (0 to 1) :n = 32	0 (0 to 2):n = 33	0.61

Analysis 1.9

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 9 Vomiting (median, range).

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Study	Timing	TAP block	No TAP block	p‐value
Griffiths 2010	2 hours	0 (0 to 2): n = 32	0 (0 to 2): n = 33	0.50
Griffiths 2010	24 hours	0 (0 to 2): n = 32	0 (0 to 1): n = 33	1.00

Analysis 1.10

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 10 Pruritus (median, range).

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Study	Timing, post‐operative	TAP block	Standard care	p‐value
McDonnell 2007	2 hours	0 (0,1): n = 16	2 (2, 2): n = 16	P ≤ 0.001
McDonnell 2007	24 hours	1 (0,1): n = 16	1 (1, 2): n = 16	not significant

Analysis 1.11

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 11 Pain severity (median, IQR).

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Analysis 1.12

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 12 Pain at rest, VAS (cm).

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Study	Timing, post‐operative	TAP block	no TAP block	P‐value
Carney 2008	2 hours	3 (0.5‐4): n = 24	4 (3‐6.75): n = 26
Carney 2008	4 hours	2 (0.5‐4): n=24	5 (3.25‐6): n = 26	p ≤ 0.001
Carney 2008	6 hours	2 (0‐3.5): n = 24	4 (2‐5): n = 26	p ≤ 0.01
Carney 2008	12 hours	2 (0‐3): n = 24	3 (2‐4.75): n = 26	p ≤ 0.01
Carney 2008	24 hours	1 (0‐2.25): n = 24	3 (2‐4): n = 26	p ≤ 0.05
Carney 2008	36 hours	1 (0‐2): n = 24	3 (2‐4): n = 26	p ≤ 0.001
Carney 2008	48 hours	0 (0‐2): n = 24	2 (0‐2): n = 26
Niraj 2009	30 mins	2 (1.5‐3.2): n = 24	5 (3.5‐8): n = 23	p < 0.001
Niraj 2009	24 hours	2 (1‐2.8): n = 24	4 (2.5‐6) : n = 23	p < 0.001
Niraj 2009
Niraj 2009
Niraj 2009
Niraj 2009
Niraj 2009

Analysis 1.13

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 13 Pain at rest VAS, (median, IQR).

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Analysis 1.14

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 14 Pain on coughing, VAS (cm).

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Study	Timing, post‐operative	TAP block	no TAP block	p‐value
Niraj 2009	30 mins	4.5 (3‐5.3): n = 24	8.5 (7.5‐10): n = 23	p < 0.001
Niraj 2009	24 hours	5.2 (4‐6.2): n = 24	8 (7‐8.5): n = 23	p < 0.001

Analysis 1.15

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 15 Pain on coughing VAS, (median, IQR).

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Analysis 1.16

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 16 Need for additional intraoperative opioid.

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Analysis 1.17

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 17 Intraoperative analgesia requirement.

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Analysis 1.18

Comparison 1 TAP block versus no TAP block/TAP placebo, Outcome 18 Satisfaction, VAS (cm).

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Analysis 2.1

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 1 Morphine requirement, mean (mg/kg).

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Study	timing	rectus sheath block	no rectus sheath block	p‐value
Padmanabhan 2007	first 24 hours	19.4 (n = 19)	21.4 (n =21)	0.535
Padmanabhan 2007	second 24 hours	30.5 (n = 19)	25.3 (n = 21)	0.464

Analysis 2.2

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 2 Morphine requirement, mean (mg, range).

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Analysis 2.3

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 3 Need for intramuscular analgesia.

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Analysis 2.4

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 4 Incidence of sedation.

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Analysis 2.5

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 5 Nausea requiring treatment.

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Analysis 2.6

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 6 Number of patients pain‐free post‐op.

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Study	Timing, post‐operative	Rectus sheath block (n = 22)	No rectus sheath block (GA) (n = 24)	p‐value
Smith 1988	1 hour	0.7 (0 to 4.1)	7.1 (3.1 to 8.4)	< 0.005
Smith 1988	6 hours	0.4 (1.6 to 6.4)	4.3 (1.6 to 6.4)	< 0.005
Smith 1988	10 hours	1.6 (0 to 2.3)	3.2 (1.4 to 5.5)	< 0.05

Analysis 2.7

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 7 Pain scores, mean (range).

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Analysis 2.8

Comparison 2 Rectus sheath block versus no rectus sheath block, Outcome 8 Parental dissatisfaction.

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Comparison 1. TAP block versus no TAP block/TAP placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Morphine requirement, mean (mg) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 at 2 hours (TAP v no TAP)	1	42	Mean Difference (IV, Random, 95% CI)	‐1.4 [‐1.92, ‐0.88]
1.2 at 2 hours (TAP v TAP placebo)	1	65	Mean Difference (IV, Random, 95% CI)	3.90 [‐0.47, 8.27]
1.3 at 24 hours (all)	5	236	Mean Difference (IV, Random, 95% CI)	‐21.94 [‐37.91, ‐5.96]
1.4 at 24 hours (TAP v no TAP)	3	121	Mean Difference (IV, Random, 95% CI)	‐30.68 [‐57.88, ‐3.47]
1.5 at 24 hours (TAP v TAP placebo)	2	115	Mean Difference (IV, Random, 95% CI)	‐8.99 [‐29.03, 11.05]
1.6 at 48 hours (TAP v TAP placebo)	1	50	Mean Difference (IV, Random, 95% CI)	‐28.50 [‐38.92, ‐18.08]
2 Time to first morphine request (mins), mean Show forest plot	1	32	Mean Difference (IV, Random, 95% CI)	133.1 [76.77, 189.43]

3 Time to first morphine request (mins), median, IQR Show forest plot			Other data	No numeric data

4 Incidence of sedation Show forest plot	1	50	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.33, 1.11]

5 Sedation scores (median, IQR or range) Show forest plot			Other data	No numeric data

5.1 TAP v no TAP			Other data	No numeric data
5.2 TAP v TAP placebo			Other data	No numeric data
6 Incidence of PONV Show forest plot	2	82	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.31, 1.79]

7 PONV scores (median, IQR) Show forest plot			Other data	No numeric data

8 Nausea (median, range) Show forest plot			Other data	No numeric data

9 Vomiting (median, range) Show forest plot			Other data	No numeric data

10 Pruritus (median, range) Show forest plot			Other data	No numeric data

11 Pain severity (median, IQR) Show forest plot			Other data	No numeric data

12 Pain at rest, VAS (cm) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

13 Pain at rest VAS, (median, IQR) Show forest plot			Other data	No numeric data

14 Pain on coughing, VAS (cm) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

15 Pain on coughing VAS, (median, IQR) Show forest plot			Other data	No numeric data

16 Need for additional intraoperative opioid Show forest plot	1	42	Risk Ratio (M‐H, Random, 95% CI)	0.26 [0.12, 0.53]

17 Intraoperative analgesia requirement Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

18 Satisfaction, VAS (cm) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

Comparison 1. TAP block versus no TAP block/TAP placebo

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Comparison 2. Rectus sheath block versus no rectus sheath block

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Morphine requirement, mean (mg/kg) Show forest plot	1	13	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.09, 0.09]

2 Morphine requirement, mean (mg, range) Show forest plot			Other data	No numeric data

3 Need for intramuscular analgesia Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 at 1 hour	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.07, 0.57]
3.2 at 6 hours	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.14, 0.68]
3.3 at 10 hours	1	46	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.14, 0.68]
4 Incidence of sedation Show forest plot	1	13	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.68, 2.44]

5 Nausea requiring treatment Show forest plot	1	13	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.01, 6.07]

6 Number of patients pain‐free post‐op Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 at 1 hour	1	46	Risk Ratio (M‐H, Random, 95% CI)	42.39 [2.71, 662.72]
6.2 at 6 hours	1	46	Risk Ratio (M‐H, Random, 95% CI)	44.57 [2.86, 695.49]
6.3 at 10 hours	1	46	Risk Ratio (M‐H, Random, 95% CI)	8.18 [2.11, 31.79]
7 Pain scores, mean (range) Show forest plot			Other data	No numeric data

8 Parental dissatisfaction Show forest plot	1	13	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Rectus sheath block versus no rectus sheath block

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