Article, Emergency Medicine

Another use of the ultrasound-guided transversus abdominis plane block in the ED


Another use of the ultrasound-guided transversus abdominis plane block in the ED

To the Editor,

We read with interest the article published by Herring et al [1], describing the interest of the transversus abdominis plane (TAP) block for analgesia in emergency situations.

We describe another interest of the technique. We used the TAP block for a woman with acute hyperalgesic pancreatitis for analgesia in a clinical situation with opiate resistance.

We took care in the emergency department (ED) a 51-year- old patient for an acute pancreatitis. She was hospitalized 1 month before for previous pancreatitis. Her medical history indicated a Harrington implant surgery for a scoliosis in 1977. Initially, she had no clinical complications of the pancreatitis but a CT Balthazar E grade score. She had severe pain. The patient evaluated her pain at 8/10 at the numerical rating scale (NRS). A Multimodal analgesia was started with the association of paracetamol, nefopam, and morphine titration. After 12 mg of morphine, the patient began to present adverse effects of the treatment: drowsiness, bradyp- nea, and desaturation without effective analgesia (NRS, 7/10). We were not able to perform any Neuraxial anesthesia because of her former spine surgery. A bilateral ultrasound-guided subcostal TAP block was realized. We injected 20 mL of ropivacaine 0.5% on each side. It allowed rapid pain control (NRS, 3/10). noninvasive ventilation remained possible. A intravenous patient controllED analgesia (IV-PCA) with morphine was also installed. The patient was transferred to the intensive care unit. Numerical rating scale remained low (b30) during 48 hours. Morphine consumption was 1 mg on day 1 and 3 mg on day 2. The third day, pain came back. The patient needed 8 mg of morphine (PCA), and NRS was 6/10. We decided to realize another TAP block. The patient was discharged on day 5 without serious pain in the medical ward. Pain during acute pancreatitis has to be treated properly.

Italian and Japanese recent guidelines in acute pancreatitis published the dramatic impact of analgesia to control severe persistent abdominal pain in this clinical situation (A-grade recommendation) [2,3]. Morphine in pain treatment for an acute pancreatitis could have negative effect because of its presumed hypertony of the Sphincter of Oddi hypertony [4].

However, a meta-analysis published in 2001 concluded that no studies or evidence exists to indicate that morphine is contraindicated to be used in acute pancreatitis [5]. Anyway, in our case, morphine was ineffective. According to a previous study, an excellent level of analgesia can be expected when Epidural anesthesia is used in case of acute hyperalgesic pancreatitis [6]. In our case report, there was a contraindication to neuraxial anesthesia. That is why we proposed the TAP block. Transversus abdominis plane block was first described in 2001 in a letter by Dr Rafi [7]; the lumbar triangle of Petit is used as a landmark for injecting local anesthetic into the neurovascular plane of the abdominal wall. Over the past years, with the “revolution” of ultrasound in regional anesthesia, there has been a growing interest for the TAP block. The technique realized under ultrasound guidance involves injection of local anesthetic into a plane between internal oblique and transversus abdominis muscles. This plane contains the thoracolumbar nerves from T7 to L1, which supply anterolateral abdominal wall innervation [8].

The Analgesic efficacy of the TAP block has been demonstrated in prospective randomized trials compared with placebo, in different surgical procedures such as abdominal surgery, hysterectomy, retropubic prostatectomy, cesarean section, laparoscopic cholecystectomy, and appen- dicectomy [8]. Catheter insertion is possible to provide boluses as an effective alternative to epidural infusion to provide postoperative analgesia after upper abdominal surgery [9]. The interest of the TAP block for supraumbilical incision allowed us to think about the efficacy of the TAP block for pain linked to acute pancreatitis. In the case of the pancreatitis, we do not have only abdominal wall pain. The TAP block is efficient not only for abdominal wall pain but also for intra-abdominal pain [10]. That is why TAP block can be effective in acute pancreatitis pain [10]. Few complications of the TAP block are described [11].

We did not find recent study or case report presenting the interest of the TAP block for analgesia in acute pancreatitis. Subcostal ultrasound-guided TAP block is a safe and easy technique. Emergency physicians training in sonography can quickly identify relevant structures and perform the block efficiently [1].

It can be used for analgesia in case of hyperalgesic acute pancreatitis. As Herring et al [1], we presented another use of

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Correspondence 627

the ultrasound-guided abdominal nerve block out of the operating theater. Others studies are necessary to evaluate the interest of the TAP block in these indication.

Christian Landy MD David Plancade MD Ingrid Millot MD Nicolas Gagnon MD Julien Nadaud MD Jean-Christophe Favier

Department of Emergency Anesthesiology and Critical Care Legouest Military Teaching Hospital

57000 Metz, France E-mail address: [email protected]



  1. Herring AA, Stone MB, Nagdev AD. Ultrasound-guided Abdominal wall nerve blocks in the ED. Am J Emerg Med 2011; doi:10.1016/ j.ajem.2011.03.008.
  2. Pezzilli R, Zerbi A, Di Carlo V, et al. Practical guidelines for acute pancreatitis. Pancreatology 2010;10(5):523-35.
  3. Takeda K, Takada T, Kawarada Y, et al. JPN guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Surg 2006;13(1):42-7.
  4. Peiro AM, Martinez J, Martinez E, et al. Efficacy and tolerance of metamizole versus morphine for acute pancreatitis pain. Pancreatology 2008;8(1):25-9.
  5. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and Therapeutic implications in treating pancreatitis. Am J Gastroenterol 2001;96(4):1266-72.
  6. Bernhardt A, Kortgen A, Niesel HC, Goertz A. Using epidural anesthesia in patients with acute pancreatitis–prospective study of 121 patients. Anaesthesiol Reanim 2002;27(1):16-22.
  7. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001;56(10):1024-6.
  8. Bonnet F, Berger J, Aveline C. Transversus abdominis plane block: what is its role in postoperative analgesia? Br J Anaesth 2009;103(4):468-70.
  9. Niraj G, Kelkar A, Jeyapalan I, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66(6):465-71.
  10. Beloeil H, Zetlaoui PJ. TAP block and blocks of the abdominal wall. Ann Fr Anesth Reanim 2011;30(2):141-6.
  11. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg 2008;107(5):1758-9.

QT intervalwhat is normal? Comment on Single-dose ziprasidone associated with QT interval prolongation?

To the Editor,

I read with interest the case presented by Witsil et al [1] recently published in the American Journal of Emergency Medicine. They have reported a 47-year-old male patient who had presented to the emergency department (ED) from a

? Conflict of interest statement: None to declare.

detoxification center with suicidal ideation. He had a history of depression and substance abuse (cocaine). His physical examination was unremarkable, except for agitation. His baseline electrocardiogram (ECG) demonstrated a normal sinus rhythm and a QT/QTc of 484/475 milliseconds at a pulse of 58 beats per minute. The patient was given 20 mg intramuscular ziprasidone for agitation. He developed palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. They concluded that performing an ECG before ziprasidone dosing should be considered. It seems that the point that the authors have missed is that the patient has had QT/QTc prolongation since ED presentation [2], the reason of which is not clear. Despite the patient denial, it seems impossible that a patient who had been hospitalized in detoxification center has not been on any medication. Although the patient has not developed Torsade de pointes during the hospital course (even after the administration of ziprasidone), his QT interval considering his heart rate at presentation has made him prone to torsade de pointes based on either the nomogram recently developed for the arrhythmogenic risk assessment of drug-induced QT prolongation or his QTc duration (at baseline, QT was on “at risk” line of the nomogram and QTc was N 450 ms) [3,4]. The authors have suggested to perform an ECG before the administration of ziprasidone while they have interestingly not benefited from ECG performance in their own patient. As the authors themselves have mentioned, ziprasidone is an atypical antipsychotic associated with QTc prolongation even in Therapeutic doses [4-6].

Hossein Sanaei-Zadeh MD Department of Forensic Medicine and Toxicology Tehran University of Medical Sciences

Hazrat Rasoul Akram Hospital 1445613131, Tehran, Iran

E-mail address: [email protected]



  1. Witsil JC, Zell-Kanter M, Mycyk MB. Single-dose ziprasidone associated with QT interval prolongation. Am J Emerg Med 2011. doi:10.1016/j.ajem.2011.03.019.
  2. Goldenberg I, Moss AJ, Zareba W. QT interval: how to measure it and what is “normal”. J Cardiovasc Electrophysiol 2006;17(3):333-6.
  3. Chan A, Isbister GK, Kirkpatrick CM, et al. Drug-induced QT prolongation and Torsades de pointes: evaluation of a QT nomogram. QJM 2007;100(10):609-15.
  4. Al-Khatib SM, LaPointe NM, Kramer JM, et al. What clinicians should know about the QT interval. JAMA 2003;289(16):2120-7.
  5. Taylor D. Ziprasidone in the management of schizophrenia: the QT interval issue in context. CNS Drugs 2003;17(6):423-30.
  6. Klein-Schwartz W, Lofton AL, Benson BE, et al. Prospective observational multi-poison center study of ziprasidone exposures. Clin Toxicol (Phila) 2007;45(7):782-6.

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