Sir,
Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) was defined by Tulgar et al.[1] for postoperative analgesia in abdominal surgeries. In this modified technique, local anesthetic given at the lower surface of the chondrium provides a wide blockage area that includes T5 and T11-12 dermatomal levels because the applied Local anaesthetic (LA) also passes the linea semilunaris.[2] This block has been widely used for abdominal surgery both in adult and pediatric patients.[3-5] However, its use has not been explored for thoracotomy surgery. We describe here a case series of five pediatric patients undergoing left or right thoracotomy, with ultrasound-guided M-TAPA block.
The study was approved by the departmental research committee and a written informed consent was taken from all the patient’s parents/legal guardians.
All patients between the age group of 10–12 years were given ultrasound-guided M-TAPA block after induction of general anesthesia. It was performed with the patient in the supine position via a 22-gauge, 50-mm length insulated facet-type needle (B Braun Sonoplex, Germany). The costochondral angle of 10th rib was identified in the sagittal plane using a linear transducer and the lower aspect of the chondrium was used as the landmark [Figure 1a]. A total of 7.5 mL of 0.25% levobupivacaine was administered at the lower end of the chondrium on the side of surgery between the internal oblique and transversus abdominis in the transversus abdominis plane [Figure 1b and 1c]. The patients received intravenous paracetamol 15 mg/kg body weight intraoperatively. The intraoperative course was uneventful in all patients. After the completion of the surgery, patients were observed for 2 h in post-anesthesia care unit and 12 h in the pediatric surgery ward. The pain was rated on an 11-point rating by numerical rating scale (NRS), and patients were asked to circle the number between 0 and 10 (0 no pain and 10 worst pain). If NRS score was above 4, rescue analgesic was intravenous fentanyl 1 mcg/kg. In the postoperative period, the mean time for first rescue analgesia was 7.2 ± 0.392 h. The median NRS score at assessed time points till 12 h postoperatively was below 4 in all subjects.
Figure 1.
(a) Ultrasound image of M-TAPA in-plane technique; (b) Point of injection of local anesthetic; (c) Local anesthetic injected in the required plane. CC, Costal cartilage; EOM, external oblique muscle; IOM, internal oblique muscle; TAM, transversus abdominis muscle
Aikawa et al. in their study reported that injecting 25 mL of 0.25% ropivacaine for M-TAPA in patients posted for gynecological surgery, achieved the highest sensory level of T7 (T5-T8) in the anterior and T9 (T7-10) in the lateral area. This extensive coverage is explained by the fact that deposited LA also crosses the linea semilunaris at this level.[1] They stipulated that the sensory level achieved by this block was compatible with segmental analgesia required for thoracotomy (T5-T9).[3] Therefore, there is a possibility that this block can be utilized for alleviating pain due to thoracotomy.
The added advantages of the procedure were the ease of identification of structures for the block performance and that there was no need for lateral positioning during the procedure.
The necessity for research to reveal the spread of local anesthetics and its mechanism is there. Furthermore, clinical trials are needed to substantiate our findings.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Tulgar S, Selvi O, Thomas DT, Deveci U, Özer Z. Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) provides effective analgesia in abdominal surgery and is a choice for opioid sparing anesthesia. J Clin Anesth. 2019;55:109. doi: 10.1016/j.jclinane.2019.01.003. [DOI] [PubMed] [Google Scholar]
- 2.Ciftci B, Alici HA, Ansen G, Sakul BU, Tulgar S. Cadaveric investigation of the spread of the thoracoabdominal nerve block using the perichondral and modified perichondral approaches. Korean J Anesthesiol. 2022;75:357–9. doi: 10.4097/kja.22137. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Aikawa K, Tanaka N, Morimoto Y. Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) provides a sufficient postoperative analgesia for laparoscopic sleeve gastrectomy. J Clin Anesth. 2020;59:44–5. doi: 10.1016/j.jclinane.2019.06.020. [DOI] [PubMed] [Google Scholar]
- 4.Tanaka N, Suzuka T, Kadoya Y, Okamoto N, Sato M, Kawanishi H, et al. Efficacy of modified thoracoabdominal nerves block through perichondrial approach in open gynecological surgery: A prospective observational pilot study and a cadaveric evaluation. BMC Anesthesiol. 2022;22:107. doi: 10.1186/s12871-022-01652-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bilge A, Başaran B, Et T, Korkusuz M, Yarımoğlu R, Toprak H, et al. Ultrasound-guided bilateral modified-thoracoabdominal nerve block through a perichondrial approach (M-TAPA) in patients undergoing laparoscopic cholecystectomy: A randomized double-blind controlled trial. BMC Anesthesiol. 2022;22:329. doi: 10.1186/s12871-022-01866-4. [DOI] [PMC free article] [PubMed] [Google Scholar]