Evaluation of postoperative pain scores following ultrasound guided transversus abdominis plane block versus local infiltration following day surgery laparoscopic cholecystectomy-retrospective study

The Effect of Various Combinations of Peripheral Nerve Blocks on Postoperative Pain in Laparoscopic Cholecystectomy: A Comparative Prospective Study

Objectives

Most patients who undergo laparoscopic cholecystectomy (LC) experience moderate to severe pain in the first 24 hours after surgery. The transversus abdominal plane (TAP) is currently used for post-LC analgesia. Posterior, subcostal, or rectus sheath TAP blocks are the conventional approaches used. The aim of the current study was to compare the efficacy of combinations of various peripheral blocks on pain intensity and the use of pain killers, shortly after LC.

Methods

This was a prospective, double-blind study, in which 200 patients who were about to undergo a LC procedure were recruited and randomized into 4 groups: patients receiving one of the following: TAP block alone, subcostal Tap block alone, subcostal TAP block with a TAP block, or subcostal TAP with a rectus sheath block. The intensity of pain (VAS score) and the use of painkillers were monitored in the recovery unit and in the department for up to 24 hours after surgery.

Results

Pain levels decreased with time from 3.6 ± 3.2 at 30 minutes to 0.9 ± 2.0 at 24 hours after the surgery. Nevertheless, no difference between the various block types groups was noted. The percentage of patients who consumed analgesic medications decreased over time, from 83% at 30 to 21% at 24 hours after surgery. The mean/median number of medications consumed by each of the patients was lower among the patients who received a combination of 2 blocks compared to those who received a single one (mean/median of 2.7/3 and 2.8/3 for the TAP or subcostal TAP blocks, respectively; 2.5/2 and 2.3/2 for the subcostal TAP + TAP or subcostal TAP + rectus sheath blocks, respectively).

Conclusion

A combination of peripheral nerve blocks reduced the use of analgesic consumption during the 24 hours after LC surgery, compared to standalone blocks.

Comparison of Clonidine with Bupivaicaine vs Plain Bupivaicaine in Transversus Abdominis Plane (TAP) Block in Women Undergoing Cesarean Delivery Under Spinal Anesthesia: Randomized Clinical Trial

Introduction

Transversus abdominis plane (TAP) block is a technique of regional anesthesia, introduced by Rafi in 2001. Various additives have been added to prolong the duration of effect of TAP block. We conducted this study to see if addition of clonidine to bupivacaine significantly increases the duration of effect of TAP block.

Materials and Methods

This randomized, parallel group, placebo controlled double blind clinical trial was conducted on 100 healthy participants (ASAII) undergoing LSCS under Spinal anesthesia (SA) from Jan 2021 to July 2021 after consent of Institutional Ethics Committee. Women with contraindications to spinal anesthesia, allergy to any of the drugs or not-suitable for cesarean under SA were excluded. After written informed consent, eligible participants were randomly allocated into two groups using computer generated random number tables using serially numbered opaque sealed envelopes. 48 out of 50 participants in group A (Bupivacaine) were given TAP block with 20 ml of 0.25% bupivacaine bilaterally. 2 women were excluded because of conversion to General Anesthesia. Similarly, 47 out of 50 participants in Group B (Bupivacaine + Clonidine) were given TAP block with 20 ml of 0.25% bupivacaine plus 1.0 mcg/kg clonidine bilaterally after completion of surgery using 18 G Tuohy needle. Separate person used to fill the drugs for block. Participants were assessed for duration of analgesic effect of TAP block measured as the time to request for additional analgesia. Additional analgesic requirement was noted. Participants were assessed for side effects of clonidine like hypotension, bradycardia, sedation and dryness of mouth. Overall patient satisfaction was also noted. Data was analysed using Graphpad Prism 9, using Student's t-test for primary outcome and Mann-Whitney U test for secondary outcomes.

Results

The mean 'duration of analgesic effect with TAP block' was 6.34 (SD1.26) hrs for 'Bupivacaine' group and 10.56 (SD2.12) hrs for 'Bupivacaine + Clonidine' group. None of the patients developed hypotension or bradycardia. 25% participants in Bupivacaine only group and 40.42% in Bupivacaine + Clonidine group were sedated (P < 0.05). 20.8% in 'Bupivacaine' group and 51.06% in 'Bupivacaine + Clonidine' group had dryness of mouth (P < 0.001). Patient satisfaction was equal in both the groups.

Conclusion

Addition of clonidine to bupivacaine in the dose of 1 mcg/kg significantly increases the duration of analgesic effect of TAP block, decreases analgesic usage without significant increase in side effects.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Efficacy and safety of different doses of ropivacaine for laparoscopy-assisted infiltration analgesia in patients undergoing laparoscopic cholecystectomy: A prospective randomized control trial

BACKGROUND

Wound infiltration analgesia provides effective postoperative pain control in patients undergoing laparoscopic cholecystectomy (LC). However, the efficacy and safety of wound infiltration with different doses of ropivacaine is not well defined. This study investigated the analgesic effects and pharmacokinetic profile of varying concentrations of ropivacaine at port sites under laparoscopy assistance.

METHODS

In this randomized, double-blinded study, 132 patients were assigned to 4 groups: Group H: in which patients were infiltrated with 0.75% ropivacaine; Group M: 0.5% ropivacaine; Group L: 0.2% ropivacaine; and Group C: 0.9% normal saline only. The primary outcome was pain intensity estimated using numeric rating scale (NRS) at discharging from PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration. Secondary outcomes included plasma concentrations of ropivacaine at 30 minutes after wound infiltration, rescue analgesia requirements after surgery, perioperative vital signs changes, and side effects.

RESULTS

The NRS in Group C was significantly higher at rest, and when coughing upon leaving PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration (P < .05) and rescue analgesic consumption was significantly higher. Notably, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). Intra-operative consumption of sevoflurane and remifentanil, HR at skin incision and MAP at skin incision, as well as 5 minutes after skin incision were significantly higher in Group C than in the other 3 groups (P < .01). In contrast, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). The concentration of ropivacaine at 30 minutes after infiltration in Group H was significantly higher than that of Group L and Group M (P < .05). No significant differences were observed in the occurrence of side effects among the 4 groups (P > .05).

CONCLUSIONS

Laparoscopy-assisted wound infiltration with ropivacaine successfully decreases pain intensity in patients undergoing LC regardless of the doses used. Infiltration with higher doses results in higher plasma concentrations, but below the systematic toxicity threshold.

Perioperative factors that contribute to postoperative pain and/or nausea and vomiting in ambulatory laparoscopic surgery

INTRODUCTION

Both postoperative pain and postoperative nausea and vomiting are major factors that determine the time and quality of recovery in laparoscopic surgery.

OBJECTIVE

To determine the perioperative factors that contribute to the appearance of postoperative pain and postoperative nausea and vomiting in outpatient laparoscopic surgery.

MATERIAL AND METHODS

A prospective study was conducted on a cohort of 297 patients undergoing laparoscopic ambulatory surgery. A record was made of preoperative factors (usual medication, anaesthetic risk, etc.), intraoperative (surgical and anaesthetic times, drugs, CO₂ pressure, etc.), and postoperative factors (major and minor complications, recovery times, etc.). As dependent variables, the postoperative symptoms considered were, nausea, vomiting, and/or postoperative pain.

RESULTS

Considering as a combined variable the occurrence of níusea, vomiting or moderate/severe pain (4 or more points on a visual analogue scale), one or more of these symptoms occurred in 58.7% of the patients (95% CI: 52.8-64.4). Using a logistic regression, the variables associated with the appearance of symptoms were: female gender (OR: 3.4), waiting time over 45minutes prior to surgery (OR: 4.9) and no anti-emetic prophylaxis (OR: 12.2).

CONCLUSIONS

In patients undergoing ambulatory laparoscopic surgery, one in 4had postoperative nausea and vomiting, and approximately half of moderate-intensity pain before discharge. Considering the overall the occurrence of pain and/or postoperative níusea and vomiting, these symptoms affect more than half of the patients being operated on, and are more frequent in women and in those who have to wait to access the operating room.

Transversus Abdominis Plane Block: Comparison of Efficacy of Varying Doses of Clonidine Combined with Levobupivacaine - A Double-Blind Randomized Trail

Background:

Transversus abdominis plane block (TAP) has an evolving role in postoperative analgesia following laparoscopic-assisted vaginal hysterectomy (LAVH).

Aims:

This study was carried out to evaluate 75 μg and 150 μg of clonidine added to 0.25% levobupivacaine, with regard to the duration of analgesia. Our study also sought to assess the hemodynamic effects, sedation, and adverse effects.

Settings and Design:

This was a prospective, randomized, double-blinded, comparative study.

Methods:

A total number of 80 patients undergoing elective LAVH surgery under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group LC75 – 29 ml of 0.25% levobupivacaine plus 75 μg of clonidine diluted in 1 ml of normal saline (total 30 ml) and Group LC150 – 29 ml of 0.25% levobupivacaine plus 150 μg of clonidine diluted in 1 ml of normal saline (total 30 ml). Duration of analgesia was the primary outcome. Hemodynamic variables, sedation score, and adverse effects were secondary outcomes.

Statistical Analysis:

The data were analyzed with Student's t-test and Chi-square test.

Results:

The duration of analgesia was significantly prolonged in Group LC150 (609.18 ± 6.59 vs. 410.52 ± 7.18 min; P = 0.001). The visual analog scale score in patients who received clonidine 150 μg Group LC150 as an adjunct was significantly lower than who received 75 μg Group LC75. Significantly higher sedation score was observed in Group LC150. The incidence of bradycardia was also significant between two groups. Significantly fewer patients in Group LC150 required rescue analgesia.

Conclusion:

The 150 μg dose of clonidine in TAP block prolongs the duration of analgesia but with higher incidence of sedation.

Ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy: comparison of efficacy of bupivacaine and levobupivacaine on postoperative pain control

Background and objective

The use of transversus abdominis plane block with different local anesthetics is considered as a part of multimodal analgesia regimen in laparoscopic cholecystectomy patients. However no studies have been published comparing bupivacaine and levobupivacaine for transversus abdominis plane block. We aimed to compare bupivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

Methods

Fifty patients (ASA I/II), undergoing laparoscopic cholecystectomy were randomly allocated into two groups. Following anesthesia induction, ultrasound-guided bilateral transversus abdominis plane block was performed with 30 mL of bupivacaine 0.25% in Group B (n = 25) and 30 mL of levobupivacaine 0.25% in Group L (n = 25) for each side. The level of pain was evaluated using 10 cm visual analog scale (VAS) at rest and during coughing 1, 5, 15, 30 min and 1, 2, 4, 6, 12 and 24 h after the operation. When visual analogue scale > 3, the patients received IV tenoxicam 20 mg. If visual analogue scale remained >3, they received IV. tramadol 1 mg.kg⁻¹. In case of inadequate analgesia, a rescue analgesic was given. The analgesic requirement, time to first analgesic requirement was recorded.

Results

Visual analogue scale levels showed no difference except first and fifth minutes postoperatively where VAS was higher in Group L (p < 0.05). Analgesic requirement was similar in both groups. Time to first analgesic requirement was shorter in Group L (4.35 ± 6.92 min vs. 34.91 ± 86.26 min, p = 0.013).

Conclusions

Bupivacaine and levobupivacaine showed similar efficacy at TAP block in patients undergoing laparoscopic cholecystectomy.

[Ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy: comparison of efficacy of bupivacaine and levobupivacaine on postoperative pain control]

BACKGROUND AND OBJECTIVE

The use of transversus abdominis plane block with different local anesthetics is considered as a part of multimodal analgesia regimen in laparoscopic cholecystectomy patients. However no studies have been published comparing bupivacaine and levobupivacaine for transversus abdominis plane block. We aimed to compare bupivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

METHODS

Fifty patients (ASA I/II), undergoing laparoscopic cholecystectomy were randomly allocated into two groups. Following anesthesia induction, ultrasound-guided bilateral transversus abdominis plane block was performed with 30mL of bupivacaine 0.25% in Group B (n=25) and 30mL of levobupivacaine 0.25% in Group L (n=25) for each side. The level of pain was evaluated using 10cm visual analog scale (VAS) at rest and during coughing 1, 5, 15, 30min and 1, 2, 4, 6, 12 and 24h after the operation. When visual analogue scale>3, the patients received IV tenoxicam 20mg. If visual analogue scale remained >3, they received IV. tramadol 1mg.kg^-1. In case of inadequate analgesia, a rescue analgesic was given. The analgesic requirement, time to first analgesic requirement was recorded.

RESULTS

Visual analogue scale levels showed no difference except first and fifth minutes postoperatively where VAS was higher in Group L (p<0.05). Analgesic requirement was similar in both groups. Time to first analgesic requirement was shorter in Group L (4.35±6.92min vs. 34.91±86.26min, p=0.013).

CONCLUSIONS

Bupivacaine and levobupivacaine showed similar efficacy at TAP block in patients undergoing laparoscopic cholecystectomy.

Comparison of ultrasound-guided bilateral subcostal transversus abdominis plane block and port-site infiltration with bupivacaine in laparoscopic cholecystectomy

Background and Aims:

Many patients experience moderate-to-severe pain after laparoscopic cholecystectomy. We aimed to compare the efficacy of ultrasound-guided bilateral subcostal transversus abdominis plane (TAP) block with port-site infiltration for post-operative analgesia after laparoscopic cholecystectomy.

Methods:

Patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were divided into two groups of 40 each to receive ultrasound-guided bilateral subcostal TAP block (T) with 0.25% bupivacaine 20 ml each side or port-site infiltration with 0.5% bupivacaine 5 ml each at 4 ports (I) at the end of the surgery before extubation. All patients received paracetamol 1 g intravenous 8^th hourly. Tramadol 1 mg/kg intravenous bolus and diclofenac 1 mg/kg intravenous infusion were used as the first- and second-line rescue analgesics when Numerical Rating Scale (NRS) ≥4, or when the patient complained of pain. NRS at 1, 2, 3, 6, 12 and 24 h after surgery, time to first analgesic request and total dose of analgesics in 24 h were recorded. Chi-square test and independent t-test were used to compare qualitative and quantitative data, respectively.

Results:

Time to first analgesic (mean±SD) in Group I and Group T was 292.7 ± 67.03 and 510.3 ± 154.55 min and mean tramadol required was141.8 ± 60.01 mg and 48.69 ± 36.14 mg, respectively (P = 0.001 for both). Mean NRS at 2, 3, 6, 12 and 24 h was significantly lower in Group T.

Conclusion:

Ultrasound-guided bilateral subcostal TAP block provides superior post-operative analgesia after laparoscopic cholecystectomy compared to port-site infiltration.