• Domitille Dereu, Georges L Savoldelli, Yannick Mercier, Christophe Combescure, Stanislas Mathivon, and Benno Rehberg.
• From the Department of Anaesthesia, Geneva University Hospitals, Geneva 14 (DD, GLS, SM, BR), Department of Anaesthesia, Jura Hospital, Delémont (YM) and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva 14, Switzerland (CH).
• Eur J Anaesthesiol. 2019 Aug 1; 36 (8): 575-582.

BackgroundIntrathecal morphine (ITM) is a widely used technique for postcaesarean section analgesia but entails a high risk of postoperative nausea and vomiting (PONV). The transversus abdominis plane (TAP) block is an alternative.ObjectiveWe tested the hypothesis that a TAP block including clonidine reduces the incidence of PONV after caesarean section when compared with ITM.DesignA randomised, controlled, double-blinded study.SettingGeneva University Hospitals, Switzerland, from October 2013 to February 2017.PatientsA total of 182 patients undergoing elective caesarean section were studied. Reasons for noninclusion were complicated pregnancy, contraindication to spinal anaesthesia or TAP block, extreme weight or height, allergy to any medication or previous median abdominal incision.InterventionsPatients were allocated randomly to one of two groups (quadruple blinded): 100 μg of morphine added to the spinal local anaesthetic or a bilateral TAP block with 20 ml of ropivacaine 0.375% + 75 μg of clonidine on each side.Main Outcome MeasuresThe primary outcome measure was the total number of patients presenting with PONV at 24 h. Secondary aims were to compare other adverse effects (pruritus, respiratory depression, hypotension, bradycardia, sedation), analgesic efficacy and the quality of postoperative recovery.ResultsAt 24 h, there was no significant difference between ITM and TAP groups in the total number of patients presenting with PONV: 17/92 patients (18.5%, 95% confidence interval 11.1 to 27.9) and 27/88 patients (30.7%, 95% confidence interval 21.3 to 41.4) in TAP and ITM groups, respectively (P = 0.065). Pain scores at 6 h and cumulative morphine consumption at 24 h were lower in the ITM group (P < 0.0001 for morphine consumption at 24 h). The incidence of hypotension was higher in the TAP group (54.3 vs. 29.2%, P = 0.0006). Maternal satisfaction was high and not different between groups.ConclusionA TAP block with clonidine and local anaesthetic does not reduce significantly the incidence of PONV compared with ITM. We confirm the superiority of ITM on acute postcaesarean section analgesia compared with a TAP block, even with clonidine as an adjunct.Trial RegistrationClinicalTrials.gov identifier: NCT01931215.

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