Continuous oblique subcostal transversus abdominis plane block: an alternative for pain management after upper abdominal surgery in children

SIR—Continuous epidural analgesia is the most common regional anesthetic method performed for pain management after major upper abdominal surgery in children. However, central neuraxial block is sometimes contraindicated. The classical posterior approach for TAP block produces reliable analgesia below the umbilicus (1). Recently, an oblique subcostal approach of transversus abdominis plane (TAP) block has been described (2). This single injection technique has been proposed for pain control after abdominal surgery above the umbilicus in children (3). Here, we reported first use of continuous TAP block with insertion of a catheter via the subcostal approach under ultrasound guidance in a child. A 4-year-old child weighing 15 kg underwent a portosystemic shunt, 3 years after liver transplantation for congenital biliary atresia complicated by venous portal thrombosis. Because heparin was necessary at the end of the surgery, epidural anesthesia was not performed. General anesthesia was induced and maintained with sevoflurane and remifentanil. After left subcostal nonmidline abdominal incision, surgery was performed uneventfully. Before the end of the surgery, the children received paracetamol (15 mgÆkg) and morphine (0.15 mgÆkg). After skin closure, a left unilateral TAP catheter was placed under ultrasound guidance using sterile technique, with a high frequency 13-6 MHz linear ultrasound probe (SonoSite Micromax; SonoSite Inc., Bothwell, WA, USA) directed parallel to the costal margin. The Tuohy needle (Plexolong Nanoline 18 G · 50 mm; Pajunk, Geisingen, Germany) was inserted via an in-plane approach. When the tip was visualized in the fascia dividing the transversus abdominis and the internal oblique muscles, a 0.25% levobupicacaine bolus of 7.5 ml (0.5 mlÆkg) was administered, and a catheter was inserted 1 cm under ultrasound guidance (Figure 1). The patient denied pain in the immediate postoperative period. A multimodal analgesia was initiated in the postanesthesia care unit and regular pain assessment was made every 4 h using the FLACC scale. Intravenous administration of paracetamol (15 mgÆkg per 6 h) was started. The patient received also 0.125% levobupivacaine continuous infusion at a rate of 1.5 mlÆh via the TAP catheter. Intravenous nalbuphine (0.15 mgÆkg per 4 h) was added as rescue if FLACC > 4/10. Based on this drug regimen, analgesia was assessed as inadequate over the first twelve postoperative hours and the child received two injections of nalbuphine. For this reason, addition of 1.5 ml boluses of 0.125% levobupivacaine through the TAP catheter with lockout interval of 1 h were prescribed, in addition to background infusion of 1.5 mlÆh. In the subsequent 36 h, the child did not receive any other additional analgesic, and maximal pain score recorded was 3/10 on the FLACC scoring system. The TAP catheter was removed 48 h after the end of surgery. There is only one case report reporting the placement of TAP block catheters using the posterior approach in two children (4). Although the insertion of a catheter via the oblique subcostal approach for continuous TAP block has been proposed in adults (1), we describe the first use of this approach in a child.