# Causes of delay in the management of surgical conditions at Tamale Teaching Hospital in Ghana {#article-title-2} Improving access to surgical services and understanding the barriers to receiving timely care are necessary to save lives. The aim of this study was to assess delays among patients in

( Anaesthesia . 2019;74:167–173) Worldwide, cesarean section is the most frequently performed major surgery. However, most research regarding anesthesia and postoperative analgesia for cesarean section has been performed in high-income countries that have extensive health care resources. In comparison, low-income and middle-income countries have markedly fewer resources for health care in general and postoperative nursing care specifically. This study was performed to compare analgesic outcomes after cesarean section. At a hospital in Southwestern Uganda where this study was undertaken, most of the basic postoperative nursing care after cesarean section is provided by family or friends of the patient. The current study was performed to compare outcomes when intrathecal morphine or transversus abdominis plane (TAP) block was used to provide postcesarean pain control in a resource-limited setting.

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

BACKGROUND:Transversus abdominis plane (TAP) block provides 12-24 h of analgesia to the parietal peritoneum and abdominal wall, and are best used combined with oral or intravenous medications. Despite ease of use, a large margin of safety, and a high success rate, TAP blocks remain under used in settings where patients could most benefit from their use. Previous studies have used oral or intravenous narcotics for supplementation. However, the efficacy of TAP blocks in low-resourced settings where patients do not have dependable access to these medications is unknown. This study examines TAP block analgesic efficacy after caesarean section in a poorly resourced setting. We compared the post-operative status of 170 women with self-administered paracetamol-diclofenac with or without TAP blocks. We hypothesised that the block would decrease pain at 8 h, 16 h, and 24 h at rest, with coughing and upon standing.METHODS:Between Oct 31, and Dec 28, 2013, 180 women were enrolled and randomly assigned to receive either TAP or sham blocks after caesarean section. Bi-institutional (Mbarara Regional Referral Hospital and Massachusetts General Hospital) institutional review board approval was obtained for this single-centre study. After informed written consent, patients received TAP or sham blocks after caesarian section. Inclusion criteria for enrolment were: age 18 years or older, weight at least 50 kg, no allergies to study medications, otherwise healthy (American Society of Anesthesiologists classification status I or II), and having undergone elective, urgent, or emergent caesarian section under spinal anaesthesia without sedation. Under ultrasound guidance, 20-25 mL of 0·25% bupivacaine (epinephrine 1:400 000) were injected near the triangles-of-Petit. Sham blocks consisted of a transducer with a needleless syringe pressed over each flank. In the post-anaesthesia recovery area, all patients received 1000 mg paracetamol and 50 mg diclofenac, orally, to be continued on an 8-h schedule for 3 days. A skilled (masked) research nurse collected all data. The primary outcomes measured were numerical rating scale at 8 h, 16 h, and 24 h at rest, with coughing, and upon standing. The association between the pain scores at each time and type of treatment (TAP vs sham blocks) was assessed using general linear model with repeated measures. Demographics were compared using the two sample t-test (appendix).FINDINGS:170 patients completed the study; 86 in the sham group and 84 in the study group. Demographics (age, weight, and parity) were similar between both study groups. One participant from the sham group was missing parity information (appendix). Preliminary data analysis showed reduced pain scores at all times, and with all degrees of movement for the TAP group (appendix). The largest reduction in pain was at 8 h (resting 33%, coughing 36%, and standing 44%). With time, the pain scores of the TAP group changed a little, whereas a decreasing trend can be noted in the sham group. No adverse events occurred.INTERPRETATION:This study show a significant improvement in pain scores for obstetric patients receiving a transversus abdominis plane block in comparison to standard of care in a low income, limited resource setting. The use of these blocks shows the use of an easy, inexpensive, and achievable pain control option. Especially in resource-limited areas, this approach could allow for better pain management and a new standard of care for the world's most common operative procedure.FUNDING:Eleanor and Miles Harvard Medical School Shore Fellowship Grant, and Massachusetts General Hospital, DACCPM Faculty Development Grant.

The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. It has a high margin of safety and is technically simple to perform, especially under ultrasound guidance. A growing body of evidence supports the use of TAP blocks for a variety of abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part, this may be related to the limited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of its clinical application. As such, we provide a brief historical perspective on the TAP block, describe relevant anatomy, review current techniques, discuss pharmacologic considerations, and summarize the existing literature regarding its clinical utility with an emphasis on recently published studies that have not been included in other systematic reviews or meta-analyses.