Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial

Patients' expectations, experience and acceptability of postoperative analgesia: a nested qualitative study within a randomised controlled trial comparing rectus sheath catheter and thoracic epidural analgesia

Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.

Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs

Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.

OUP accepted manuscript

Background

Rectus sheath catheter analgesia (RSCA) and thoracic epidural analgesia (TEA) are both used for analgesia following laparotomy. The aim was to compare the analgesic effectiveness of RSCA with TEA after laparotomy for elective colorectal and urological surgery.

Methods

Patients undergoing elective midline laparotomy were randomized in a non-blinded fashion to receive RSCA or TEA for postoperative analgesia at a single UK teaching hospital. The primary quantitative outcome measure was dynamic pain score at 24 h after surgery. A nested qualitative study (reported elsewhere) explored the dual primary outcome of patient experience and acceptability. Secondary outcome measures included rest and movement pain scores over 72 h, functional analgesia, analgesia satisfaction, opiate consumption, functional recovery, morbidity, safety, and cost-effectiveness.

Results

A total of 131 patients were randomized: 66 in the RSCA group and 65 in the TEA group. The median (interquartile range; i.q.r.) dynamic pain score at 24 h was significantly lower after TEA than RSCA (33 (11–60) versus 50.5 (24.50–77.25); P = 0.018). Resting pain score at 72 h was significantly lower after RSCA (4.5 (0.25–13.75) versus 12.5 (2–13); P = 0.019). Opiate consumption on postoperative day 3 (median (i.q.r.) morphine equivalent 17 (10–30) mg versus 40 (13.25–88.50) mg; P = 0.038), hypotension, or vasopressor dependency (29.7 versus 49.2 per cent; P = 0.023) and weight gain to day 3 (median (i.q.r.) 0 (−1–2) kg versus 1 (0–3) kg; P = 0.046) were all significantly greater after TEA, compared with RSCA. There were no significant differences between groups in other secondary outcomes, although more participants experienced serious adverse events after TEA compared with RSCA, which was also the more cost-effective.

Conclusions

TEA provided superior initial postoperative analgesia but only for the first 24 h. By 72 hours RSCA provides superior analgesia, is associated with a lower incidence of unwanted effects, and may be more cost-effective.

Rectus sheath catheter analgesia versus standard care following major abdominal surgery: An observational study of 911 patients

BACKGROUND

It is unknown whether rectus sheath catheter (RSC) continuous infusion of local anaesthetic is superior to standard post-operative opiate analgesia following major abdominal surgery. Previous audit in our Trust had suggested RSC was very effective and reduced opiate analgesia use. We aimed to see if this was maintained as the technique became more widespread comparing clinical outcomes and post-operative opiate analgesia requirements between patients who had RSCs and those that did not following major abdominal surgery over a 32-month period.

METHODS

A retrospective observational study investigated patients who had major abdominal surgery at a single centre in the UK between January 2018 and August 2020. Placement of RSCs was at the discretion of the surgical team according to their own personal choice. All patients having the procedure in both an elective and non-elective setting have been included in this study, including patients requiring higher level care after emergency surgery. Clinical outcomes and post-operative opiate analgesia requirements (oral and intravenous) were analysed using multivariate logistic regression models adjusting for American Association of Anesthesiologists (ASA) grade and type of surgery (emergency vs elective and open vs laparoscopic).

RESULTS

There were 911 patients; 276/911 (30.3%) RSC and 635/911 (69.7%) non-RSC. Median age was 64 (52-74) years; 51.6% were male. In the adjusted models, RSC was associated with a reduced likelihood of serious complications (OR 0.49 (95% CI 0.33, 0.72); p < 0.001) and lower length of stay in ICU (OR 0.95 (95% CI 0.91, 0.99); p = 0.029). RSC was not associated with reduced post-operative opiate analgesia use. There were 3/276 (1.1%) adverse events following RSC placement during the period of data collection.

CONCLUSIONS

Clinical outcomes may be superior for patients following major abdominal surgery when RSCs are placed for post-operative analgesia but uncertainty remains. This paper highlights the difficulty with retrospective non-selected data in answering this question. High quality prospective randomised data are required to determine the effects on clinical outcomes and post-operative opiate analgesia requirements.

Rectus sheath block and emergency midline laparotomy at a hospital in Ethiopia: A prospective observational study

BACKGROUND

Midline laparotomy is associated with severe postoperative pain. Literature showed controversial results regarding the efficacy of the rectus sheath block.

METHODS

This is a prospective cohort study that recruits 30 patients in the rectus sheath block (RSB) group and 30 patients in the multimodal analgesia (MMA) group who underwent emergency midline laparotomy. The RSB was performed by an experienced anesthetist using a land-mark technique. Independent t-test and Mann-Whitney-U test were used for numeric data while Chi-Square or Fisher exact test was used for categorical variables. P-values < 0.05 were considered as statistically significant.

RESULTS

The numeric rating scale score at the recovery was significantly reduced in an RSB group with a p-value of 0.039. Postoperative numeric rating scale scores at 3rd, 6th, 12th, and 24th hours were statistically significantly lower in the RSB group. Postoperative tramadol consumption in 24 h was significantly lower with a p-value of 0.0001 for the rectus sheath group.

CONCLUSIONS

For midline laparotomy, adding a bilateral rectus sheath block at the end of the operation might be an effective postoperative analgesia option.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study

OBJECTIVES

Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.

METHODS

We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.

RESULTS

Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.

CONCLUSIONS

ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Intravenous Dexmedetomidine Combined with Ultrasound-Guided Rectus Sheath Block for Open Gastrectomy: a Prospective Randomized Trial

PURPOSE

To compare the incidences of positive hemodynamic response (HR > 100 beats min^-1 or SBP > 160 mmHg) during abdominal exploration and moderate pain after surgery, when using dexmedetomidine infusion and rectus sheath block.

METHODS

One hundred patients undergoing open gastrectomy were randomized to receive rectus sheath block with ropivacaine (Group B, n = 25), initial loading dose of 0.6 μg kg^-1 dexmedetomidine, followed by a continuous infusion of 0.2 μg kg^-1 h^-1 throughout surgery (Group D, n = 25), both rectus sheath block and dexmedetomidine (Group BD, n = 25), or neither rectus sheath block nor dexmedetomidine (Group C, n = 25). General anesthesia techniques were standardized. HR, SBP, and positive hemodynamic response at peritoneum incision (T_PI), 5 min (T_AE-5), 10 min (T_AE-10), and 15 min (T_AE-15) after the start of abdominal exploration, and incidences of moderate postoperative pain were recorded.

RESULTS

Positive hemodynamic responses during abdominal exploration were more common in Groups B (82%) and C (74%) than in Groups D (14%) and BD (9%) (all P = 0.000). HR and SBP were lower in Groups D and BD, compared with those in Groups C and B (all P < 0.05). Compared with T_PI, HR and SBP increased significantly in Groups B and C during abdominal exploration (all P < 0.05)_, but not in Group BD (except HR at T_AE-15). The incidences of moderate pain in Groups B and BD were noticeably lower than in Groups C and D at 1 h, 2 h, and 6 h after surgery (all P < 0.0083).

CONCLUSION

Dexmedetomidine infusion combined with rectus sheath block provided more hemodynamic stability during abdominal exploration and better analgesia after surgery.

Analgesic effectiveness of rectus sheath block during open gastrectomy: A prospective double-blinded randomized controlled clinical trial

BACKGROUND

Despite recent advances in gastric cancer surgery, open gastrectomy is often needed to treat gastric cancer. Due to the large incision in the abdomen, the amount of opioid required during surgery increases and postoperative pain becomes worse. It is well known that postoperative pain has a negative impact on the patient's immune system. Herein, we performed an ultrasound-guided bilateral rectus sheath block (RSB) in patients undergoing open gastrectomy under general anesthesia and analyzed the analgesic effectiveness of RSB in open gastrectomy.

METHODS

A total of 46 patients scheduled for open gastrectomy were randomly divided into 2 groups: Group A (n = 21) consisted of patients who received an RSB using 40 mL of 0.375% ropivacaine under ultrasound guidance and Group B (n = 20) consisted of patients who received an RSB using 40 mL of normal saline. An electronic injection pump was connected to each patient for patient-controlled analgesia (PCA) immediately after the skin closure. The amount of remifentanil required during the surgery was analyzed. After using PCA, data on the use of PCA bolus dose were extracted and analyzed using Excel.

RESULTS

Group A used significantly less remifentanil (1021.4 ± 172.0 μg) than group B (1415.0 ± 330.6 μg; P = .03). The number of PCA bolus dose provided to the patients after surgery was significantly lower in group A (1 h: 1.14 ± 0.9, 2 h: 0.85 ± 0.7) than in group B (1 h: 1.85 ± 0.7, 2 h: 1.45 ± 1.0) until 2 hours after the surgery (1 h, P = .008; 2 h, P = .03), but after 3 hours, there were no significant differences between the 2 groups.

CONCLUSIONS

If ultrasound-guided bilateral RSB with 40 mL of 0.35% ropivacaine is performed precisely in patients undergoing open gastrectomy, the requirement for remifentanil during surgery can be reduced. In addition, it significantly reduces the use of PCA bolus dose for acute postoperative pain within 2 hours after surgery.

Managing epidural catheters in critical care beds: An observation analysis in the Republic of Ireland

In certain hospitals, epidural analgesia is restricted to critical care beds. Due to critical care bed strain, it is likely that many patients are unable to avail of epidural analgesia. The aims of the study were to retrospectively review the number of patients admitted to critical care beds for epidural analgesia over a two-year period 2015–16, to determine the duration of epidural analgesia, to identify the average critical care bed occupancy during this period, to get updated information on the implementation of acute pain service in the Republic of Ireland and the availability of ward-based epidural analgesia. One hundred and sixty patients had a midline laparotomy, 40 of which had an epidural (25%). Forty-two patients were admitted to a critical care bed for epidural analgesia. Aside from epidural analgesia, 12% had other indications for ICU admission. Median duration epidural analgesia was 1.64 days (IQR 0.98–2.14 days). ICU bed occupancy rates were 88.7% in 2015 and 85.1% in 2016. Acute pain service and ward-based epidural analgesia were available in 46 and 42% of hospitals, respectively. Restricting epidural use to a critical care setting is likely to result in reduced access to epidural analgesia. The implementation of acute pain service and availability of ward-based epidural analgesia in the Republic of Ireland are suboptimal.

The Analgesic Efficiency of Ultrasound-Guided Rectus Sheath Analgesia Compared with Low Thoracic Epidural Analgesia After Elective Abdominal Surgery with a Midline Incision: A Prospective Randomized Controlled Trial

BACKGROUND

Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy.

METHODS

Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs.

RESULTS

While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27 - 39 mg), 95% confidence interval (28.63 - 37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45 - 57 mg), 95% CI (47.4 - 54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups.

CONCLUSIONS

Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.

A Comparative Study for Post Operative Analgesia in the Emergency Laparotomies: Thoracic Epidural Ropivacaine with Nalbuphine and Ropivacaine with Butorphanol

BACKGROUND

Adequate postoperative pain therapy for emergency abdominal surgeries is important far beyond the perioperative period because sensitization to painful stimuli can cause postoperative morbidity. A prospective, double-blind, randomized study was carried out to compare the quality of postoperative analgesia and side-effect profile between epidurally administered butorphanol and nalbuphine as an adjuvant to 0.2% ropivacaine.

MATERIALS AND METHODS

A total of eighty patients, 43 men and 37 women between the age of 18 and 65 years of American Society of Anesthesiologists (ASA) Class I E and II E, who underwent intestinal perforation repair surgery were randomly allocated into two groups ropivacaine with butorphanol (RB) and ropivacaine with nalbuphine (RN), comprising of 40 patients each. Group RB received 0.2% ropivacaine containing 2 mg butorphanol while Group RN received 0.2% ropivacaine containing 10 mg nalbuphine through thoracic epidural catheter. Quality of analgesia, cardiorespiratory parameters, side-effects, and the need of rescue intravenous analgesia were observed.

RESULTS

The demographic profile and ASA Class were comparable between the groups. RN group had good quality of analgesia and stable cardiorespiratory parameters for the initial 6 h of postoperative period, after which they were comparable in both groups. Furthermore, the need of rescue analgesia was higher (20%) in the RB group during the first 6 h. The side-effect profile was comparable with a little higher incidence of nausea in both groups.

CONCLUSION

Thoracic epidurally administered ropivacaine with nalbuphine is more effective than ropivacaine with butorphanol for immediate postoperative pain relief in patients undergoing emergency exploratory laparotomy.

Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery

Introduction Rectus sheath catheters (RSCs) are increasingly being used to provide postoperative analgesia following laparotomy for colorectal surgery. Little is known about their efficacy in comparison with epidural infusion analgesia (EIA). They are potentially better as they avoid the recognised complications associated with EIA. This study compares these two methods of analgesia. Outcomes include average pain scores, time to mobilisation and length of stay. Methods This was a 33-month single centre observational study including all patients undergoing elective open or laparoscopic-converted-to-open colorectal resection for both benign and malignant disease. Patients received either EIA or RSCs. Data were collected prospectively and analysed retrospectively. Results A total of 95 patients were identified. Indications for surgery, operation and complications were recorded. The mean time to mobilisation was significantly shorter in patients who had RSCs compared with EIA patients (2.4 vs 3.5 days, p<0.05). There was no difference in postoperative pain scores or length of stay. Conclusions RSCs provide equivalent analgesia to EIA and avoid the recognised potential complications of EIA. They are associated with a shorter time to mobilisation. Their use should be adopted more widely.