Reducing postoperative opioid consumption by adding an ultrasound-guided rectus sheath block to multimodal analgesia for abdominal cancer surgery with midline incision

Postoperative analgesic effectiveness of ultrasound-guided bilateral erector spinae plane block vs. rectus sheath block for midline abdominal surgery in a low- and middle-income country: a randomised controlled trial

INTRODUCTION

The use of erector spinae plane block and rectus sheath block for postoperative analgesia in midline abdominal procedures is becoming more common. However, the most effective and appropriate method remains unclear. We aimed to compare the postoperative analgesic effecacy of ultrasound-guided bilateral erector spinae plane blocks with rectus sheath blocks for midline abdominal surgery in a low- and middle-income country.

METHODS

We allocated randomly 72 patients aged 18-65 y undergoing midline abdominal surgery to an erector spinae plane block (n = 36) or a rectus sheath block (n = 36) utilising a prospective, parallel study design. Patients, care providers and outcome assessors were blinded to the interventions. The primary outcome measures were total postoperative analgesia consumption, postoperative pain severity and time to first rescue analgesic administration. Secondary outcomes included the incidence of postoperative complications and adverse events.

RESULTS

Of 78 patients assessed for eligibility, six were excluded, leaving 72 for analysis. Patients allocated to erector spinae plane block had a lower mean (SD) postoperative opioid consumption compared with those allocated to rectus sheath block (3.5 (8.7) morphine milligram equivalents vs. 8.2 (2.8) morphine milligram equivalents, respectively; p = 0.003). Time to first analgesic request was greater in patients allocated to erector spinae plane block compared with those allocated to rectus sheath block (mean (95%CI) 16 (13-17) h vs. 12 (11-13) h, respectively; p < 0.001). There were no block-related complications in either group.

DISCUSSION

Erector spinae plane blocks are more effective than rectus sheath blocks for the management of postoperative pain following midline abdominal surgery. Integration of erector spinae plane blocks into multimodal opioid-sparing analgesic strategies after midline abdominal surgeries may promote enhanced patient recovery in low-and middle-income countries.

Evaluation of preoperative rectus sheath block with bupivacaine for analgesia in cats undergoing ovariohysterectomy: a cadaveric and randomized clinical study

OBJECTIVE

Phase 1: to determine the feasibility of desensitizing ventral branches of spinal nerves within the rectus sheath using an ultrasound-guided rectus sheath block (USRSB). Phase 2: to determine the effect of preoperative USRSB on intraoperative responses to surgical stimulation and postoperative pain.

STUDY DESIGN

Cadaveric study and prospective, randomized, blinded, parallel-arm clinical trial.

ANIMALS

A group of five cat cadavers and 37 shelter-owned cats undergoing ovariohysterectomy.

METHODS

Phase 1: anatomical dissection was performed on one uninjected cadaver. Abdominal walls were dissected in four cadavers (eight hemiabdomens) following bilateral USRSB using 1:1 new methylene blue and 0.5% bupivacaine (0.8 mL kg-1 total). Phase 2: preoperative bilateral USRSB was performed with 0.8 mL kg-1 of 0.25% bupivacaine (RSB) or equivalent volume of 0.9% saline (CONTROL). Intraoperative systolic arterial blood pressure (SAP), heart rate (HR), respiratory rate (fR) and vaporizer setting (vap%) were recorded before skin incision, during celiotomy and abdominal wall closure. In recovery, cats were administered robenacoxib (2 mg kg-1; CONTROL) or 0.9% saline (0.1 mL kg-1; RSB) subcutaneously. Postoperative pain was evaluated for 6 hours using the Glasgow Composite Measure Pain Scale.

RESULTS

Phase 1: spinal nerves T9-L3 were identified within the rectus sheath, and stained in 0%, 40%, 63%, 75%, 100%, 88%, 50% and 13% of hemiabdomens, respectively. Phase 2: 37 cats were included (RSB, n = 17; CONTROL, n = 20). Intraoperatively, SAP, HR and fR were not significantly different between groups. Vap% was significantly lower in RSB during celiotomy (p = 0.036) and closure (p = 0.044). Postoperatively, RSB cats were 5.3 times (95% CI 1.8-8.3) more likely to require rescue analgesia than CONTROL cats.

CONCLUSIONS AND CLINICAL RELEVANCE

During surgery, USRSB with bupivacaine offered minor benefits and provided markedly less postoperative analgesia than robenacoxib, indicating that relying on USRSB provides insufficient postoperative analgesia for ovariohysterectomy in cats.

Applying enhanced recovery principles to emergency laparotomy in penetrating abdominal trauma: a case-matched study

PURPOSE

The implementation of enhanced recovery after surgery programs (ERPs) has significantly improved outcomes within various surgical specialties. However, the suitability of ERPs in trauma surgery remains unclear. This study aimed to (1) design and implement an ERP for trauma laparotomy patients; (2) assess its safety, feasibility, and efficacy; and (3) compare the outcomes of the proposed ERP with conventional practices.

METHODS

This case-matched study prospectively enrolled hemodynamically stable patients undergoing emergency laparotomy after penetrating trauma. Patients receiving the proposed ERP were compared to historical controls who had received conventional treatment from two to eight years prior to protocol implementation. Cases were matched for age, sex, injury mechanism, extra-abdominal injuries, and trauma scores. Assessment of intervention effects were modelled using regression analysis for outcome measures, including length of hospital stay (LOS), postoperative complications, and functional recovery parameters.

RESULTS

Thirty-six consecutive patients were enrolled in the proposed ERP and matched to their 36 historical counterparts, totaling 72 participants. A statistically significant decrease in LOS, representing a 39% improvement in average LOS was observed. There was no difference in the incidence of postoperative complications. Opioid consumption was considerably lower in the ERP group (p < 0.010). Time to resumption of oral liquid and solid intake, as well as to the removal of nasogastric tubes, urinary catheters, and abdominal drains was significantly earlier among ERP patients (p < 0.001).

CONCLUSION

The implementation of a standardized ERP for the perioperative care of penetrating abdominal trauma patients yielded a significant reduction in LOS without increasing postoperative complications. These findings demonstrate that ERPs principles can be safely applied to selected trauma patients.

Comparison of the effectiveness of thoracic epidural and rectus sheath catheter as analgesic modalities following laparotomy: A systematic review and meta-analysis

BACKGROUND

Rectus sheath catheters are used as an analgesic alternative to thoracic epidural. The aim of this meta-analysis is to compare the analgesic effects and side effects of thoracic epidural and rectus sheath catheter in the setting of emergency or elective laparotomy.

MATERIALS AND METHODS

A systematic review of the Cochrane library, Embase, PubMed and Medline was conducted. Papers that directly compared thoracic epidurals and rectus sheath catheters following laparotomy were identified. Literature published between 2001 and 2021 were included. Data were extracted on the following postoperative outcomes: additional analgesic requirements, pain scores, hypotension and ambulation. A random effects meta-analysis model was used to compare additional opioid requirements between thoracic epidural and rectus sheath catheter.

RESULTS

Eight publications were included from five countries. This comprised 484 patients, with 120 patients being extracted from randomised trials. Thoracic epidural reduced the requirement for additional intravenous analgesia compared with rectus sheath catheters (p = 0.004). Despite this, both analgesic techniques were equivalent with regard to reported pain scores. Furthermore, rectus sheath catheters have a lower rate of postoperative hypotension and allow for earlier ambulation compared with thoracic epidural.

CONCLUSIONS

The literature suggests that rectus sheath catheters provide similar analgesic effect to thoracic epidurals, but rectus sheath catheters have a favourable side effect profile.

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates early refeeding and mobilisation. Thoracic epidural analgesia (TEA) was long the gold standard for locoregional anaesthesia in anterior abdominal wall surgery. However, newer wall-block techniques such as rectus-sheath block (RSB) may be preferable because they are less invasive and may provide equivalent analgesia with fewer side effects. Since the evidence base remains limited, the Quality Of Recovery enhanced by REctus sheat CATHeter (QoR-RECT-CATH) randomised controlled trial (RCT) was designed to assess whether RSB elicits better postoperative rehabilitation than TEA after laparotomy.

METHODS AND ANALYSIS

This open-label parallel-arm 1:1-allocated RCT will determine whether RSB is superior to TEA in 110 patients undergoing scheduled midline laparotomy in terms of postoperative rehabilitation quality. The setting is a regional French hospital that provides opioid-free anaesthesia for all laparotomies within an ERAS programme. Recruited patients will be ≥18 years, scheduled to undergo laparotomy, have American Society of Anesthesiologists (ASA) score 1-4 and lack contraindications to ropivacaine/TEA. TEA-allocated patients will receive an epidural catheter before surgery while RSB-allocated patients will receive rectus sheath catheters after surgery. All other pre/peri/postoperative procedures will be identical, including multimodal postoperative analgesia provided according to our standard of care. Primary objective is a change in total Quality-of-Recovery-15 French-language (QoR-15F) score on postoperative day (POD) 2 relative to baseline. QoR-15F is a patient-reported outcome measure that is commonly used to measure ERAS outcomes. The 15 secondary objectives include postoperative pain scores, opioid consumption, functional recovery measures and adverse events.

ETHICS AND DISSEMINATION

The French Ethics Committee (Sud-Ouest et Outre-Mer I Ethical Committee) gave approval. Subjects are recruited after providing written consent after receiving the information provided by the investigator. The results of this study will be made public through peer-reviewed publication and, if possible, conference publications.

TRIAL REGISTRATION NUMBER

NCT04985695.

Antinociceptive effects of bupivacaine injected within the internal abdominis rectus sheath in standing healthy horses

OBJECTIVE

To evaluate a regional anesthetic technique for blocking the abdominal midline in horses.

STUDY DESIGN

Anatomical description and prospective, crossover, placebo-controlled, blinded study.

ANIMALS

Adult horses; two cadavers, six healthy animals.

METHODS

In stage 1, 0.5% methylene blue with 0.25% bupivacaine (0.5 mL kg-1) was injected using ultrasonography into the internal rectus abdominis sheath (RAS) of two cadavers with a one-point or two-point technique. The dye spread was described after the dissection of the abdomens. In stage 2, each horse was injected with 1 mL kg-1 of 0.9% NaCl (treatment PT) or 0.2% bupivacaine (treatment BT) using a two-point technique. The abdominal midline mechanical nociceptive threshold (MNT) was measured with a 1 mm blunted probe tip and results analyzed with mixed-effect anova. Signs of pelvic limb weakness were recorded.

RESULTS

The cadaver dissections showed staining of the ventral branches from the eleventh thoracic (T11) to the second lumbar (L2) nerve with the one-point technique and T9-L2 with the two-point technique. Baseline MNTs were, mean ± standard deviation, 12.6 ± 1.6 N and 12.4 ± 2.4 N in treatments PT and BT, respectively. MNT increased to 18.9 ± 5.8 N (p = 0.010) at 30 minutes, and MNT was between 9.4 ± 2.0 and 15.3 ± 3.4 N from 1 to 8 hours (p > 0.521) in treatment PT. MNTs in treatment BT were 21.1 ± 5.9 to 25.0 ± 0.1 N from 30 minutes to 8 hours (p < 0.001). MNTs after the RAS injections were higher in treatment BT than PT (p = 0.007). No pelvic limb weakness was observed.

CONCLUSIONS AND CLINICAL RELEVANCE

Antinociception of at least 8 hours without pelvic limb weakness was observed in the abdominal midline in standing horses after the RAS block. Further investigations are necessary to evaluate suitability for ventral celiotomies.

Analgesic efficacy of Clonidine as an adjuvant in ultrasound-guided rectus sheath block for midline incisional hernia repair - A randomized double-blind controlled trial

Background and Aims

Clonidine as an adjuvant has not been evaluated in rectus sheath block (RSB) for postoperative pain management in incisional hernia repair. The study aims to evaluate clonidine as an adjuvant in single-shot RSB along with general anesthesia (GA).

Material and Methods

This randomized, double-blind controlled study was conducted following IEC-Human approval and written informed consent from 30 patients of either sex, aged 16 to 60 years, ASA physical status I or II undergoing midline incisional hernia repair under GA. All patients received ultrasound-guided bilateral RSB following administration of GA. The subjects enrolled in the study were randomly allocated to receive either normal saline 1 mL (group B) or clonidine 1 μg/kg diluted to 1 mL with normal saline (group BC) as adjuvant along with 9 mL bupivacaine hydrochloride 0.25%. Inj. tramadol 1 mg/kg was administered for rescue analgesia. The primary outcome was the time to first request for analgesia, and secondary outcomes were total consumption of rescue analgesic over 24 h, numerical rating score (NRS), patients' satisfaction, hemodynamics, and side effects. Unpaired t-test and Chi-square test were used.

Results

On intergroup analysis, the mean time to first request for analgesia (in min) was significantly higher in group BC i.e., [9.60 (± 5.23) vs 5.33 (± 3.53); (P < 0.034]; whereas, the mean rescue analgesic consumption in 24 h (in mg) was higher in group B i.e., [(88.00 ± 60.97) vs (46.00 ± 48.08)]; (P < 0.045)]. Hemodynamic parameters i.e., mean blood pressure and heart rate were comparable between the two groups, and there were no side effects.

Conclusion

Clonidine as an adjuvant in single-shot ultasonography (USG)-guided RSB along with GA is efficacious for postoperative pain management following midline incisional hernia repair.

Comparison of Postoperative Analgesic Efficacy of Ultrasound-Guided Bilateral Rectus Sheath Block With That of Local Anaesthetic Infiltration in Patients Undergoing Emergency Midline Laparotomy Surgeries: A Randomised Controlled Trial

Purpose Rectus sheath block (RSB) is increasingly utilised as a part of multimodal analgesia in laparotomy surgeries. We proposed this study to compare the analgesic efficacy of ultrasound-guided bilateral RSB with local anaesthetic (LA) infiltration. The primary outcome was the visual analogue scale (VAS) at rest and cough. The secondary outcomes were the postoperative morphine consumption, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV) and patient satisfaction score. Methods In our prospective, single-centre, randomised clinical trial, we enrolled a total of 100 patients undergoing emergency midline laparotomy surgeries. They were randomly allocated into two groups and were administered either LA infiltration (group L, n=50) or ultrasound-guided bilateral RSB (group R, n=50) with 15-20 ml of 0.25% bupivacaine end operatively. The categorical and ordinal variables were analysed using Chi-square/ Fisher's exact test. The continuous and discrete variables were analysed using Mann-Whitney/independent Student t-test. Results The median VAS scores in the postoperative period were significantly lower with RSB when compared with LA. Statistically significant differences in median VAS scores were noticed at one hour (P<0.001), four hours (P=0.001), eight hours (P<0.001), and 12 hours (P=0.014) at rest, and at one hour (P<0.001), four hours (P<0.001) and eight hours (P<0.001) during cough. The median morphine consumption was less with RSB (P<0.001). The time to first rescue analgesia was prolonged with RSB (P<0.001). The incidence of PONV was significantly lower with RSB (P=0.027). Conclusion Bilateral ultrasound-guided RSB provides extended postoperative analgesia at rest and cough for patients undergoing emergency laparotomy surgeries when compared with LA infiltration. There was a significant reduction in morphine consumption, incidence of PONV, and prolonged time to first rescue analgesia with RSB.

Utility of the transversus abdominis plane and rectus sheath blocks in patients undergoing anterior lumbar interbody fusions

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery.

PURPOSE

Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control.

STUDY DESIGN/SETTING

Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital.

PATIENT SAMPLE

Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021.

OUTCOME MEASURES

Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room.

METHODS

Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups.

RESULTS

The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups.

CONCLUSIONS

The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Minimal effective dose of ultrasound-guided rectus sheath block to reduce oral analgesic requirement after ambulatory laparoscopic tubal resection: a randomized controlled superiority trial

Background

The effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection.

Methods

A prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented.

Results

A total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [−0.26, 0.71], p = 0.368 and 0.33 [−0.16, 0.81], p = 0.184, respectively).

Conclusion

A dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection.

Trial registration

Thaiclinicaltrials.orgTCTR20150921002. Registered on 18 September 2015

Description of an ultrasound-guided rectus sheath block injection technique and the spread of dye in calf cadavers

OBJECTIVES

To describe an ultrasound-guided rectus sheath (RS) block technique in calves with injections of methylene blue and assess the extent of injectate spread and nerve staining in calf cadavers.

STUDY DESIGN

Prospective, experimental, blinded cadaveric study.

ANIMALS

A total of 16 calf cadavers weighing 30.7 ± 7.1 kg.

METHODS

Using an ultrasound-guided, in-plane technique, each cadaver was injected with both a low (LV; 0.25 mL kg-1) and high (HV; 0.5 mL kg-1) volume of methylene blue dye. Volumes were randomly assigned to the left or right hemiabdomen. Ultrasound imaging was scored based on landmarks and needle visualization, and duration to perform injections were assessed. Dissections were performed immediately after injections. Staining of ventral branches of spinal nerves and the extent of dye spread were recorded by an anatomist unaware of treatment allocation.

RESULTS

The number of nerves stained in treatments LV and HV were 2.3 ± 1.7 and 4.4 ± 1.3, respectively (p = 0.0001). Branches of thoracic nerves T7-13 and lumbar nerves L1-2 were completely stained 6.3%, 6.3%, 31.3%, 62.5%, 56.3%, 37.5%, 31.3%, 6.3% and 0%, respectively, in treatment LV and 0%, 12.5%, 50%, 93.8%, 100%, 93.8%, 62.5%, 25% and 6.3%, respectively, in treatment HV. Ultrasound imaging was scored excellent in most cadavers and needle visualization deemed excellent in all injections. The mean duration to perform RS injections in both treatments was 2 (range, 1-6) minutes.

CONCLUSIONS AND CLINICAL RELEVANCE

Nerve staining results from treatment HV suggest that this RS injection technique could be clinically useful in ventral midline surgical procedures, including umbilical procedures, in calves. This study supports future clinical trials in calves.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis.

METHODS

We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system.

RESULTS

Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr.

CONCLUSIONS

Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr.

TRIAL REGISTRATION

PROSPERO (CRD42021238916); registered 25 February 2021.

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.

Comparison of the analgesic effects continuous epidural anesthesia and continuous rectus sheath block in patients undergoing gynecological cancer surgery: a non-inferiority randomized control trial

PURPOSE

We investigated the non-inferiority of continuous rectus sheath block to continuous epidural anesthesia for postoperative analgesia of gynecological cancer patients.

METHODS

One hundred ASA-PS 1-2 patients via a median incision up to 5 cm above the navel were randomized into a continuous epidural anesthesia (CEA) group and a continuous rectus sheath block (CRSB) group. Following surgery, they have controlled with intravenous patient-controlled analgesia (IV-PCA) as basal postoperative analgesia. For patients in the CEA group were administered 0.25% levobupivacaine at 5 mg/h. Patients in the CRSB group, catheters were inserted on both sides of the posterior rectus sheath after surgery. They received 0.25% levobupivacaine on both sides at 7.5 mg/h. To determine whether CRSB is non-inferior to CEA in postoperative treatment, pain at rest and movement was assessed using the Numerical Rating Scale (NRS). The non-inferiority margin of NRS difference between CRSB and CEA was set at 1.3 difference in means. The primary outcome was non-inferiority comparisons of NRS at rest/at movement after surgery, while the secondary outcome included the frequency of requesting IV-PCA and rescue drugs.

RESULTS

NRS at rest in the CRSB group was not inferior to that in the CEA group. On the other hand, the NRS at movement at 4, 6, 8, 12 h following surgery in the CRSB group was inferior to CEA. There was no difference in the frequency of requesting IV-PCA and rescue drugs.

CONCLUSIONS

CRSB showed the non-inferiority to CEA for postoperative analgesia at rest, while CRSB was not non-inferior to CEA at movement in gynecological cancer patients. CRSB would be a substitute when CEA is contraindicated as a component of postoperative multimodal analgesia.

European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

Serratus intercostal interfascial plane block in supraumbilical surgery: a prospective randomized comparison

BACKGROUND

Upper abdominal wall surgical incisions may lead to a severe postoperative pain. Therefore, adequate analgesia is important. Here we investigate whether the low serratus-intercostal interfascial plane block (SIPB) achieves an effective analgesia, considering opioids consumption, pain control and recovery quality in upper abdominal surgeries.

METHODS

This blinded, randomized controlled study was conducted on 102 patients undergoing open upper abdominal wall surgery under general anesthesia. All patients who received serratus-intercostal plane block at the eighth rib as analgesic technique were included in SIPB group and in control group those who received continuous intravenous morphine analgesia. Pain scores in numeric verbal scale (NVS) and opioids consumption at 0, 6, 12, 24 and 48 hours postoperatively were assessed. The quality of the postoperative recovery was evaluated using the QoR-15 questionnaire at 24 hours.

RESULTS

This study showed lower postoperative opioid consumption at 24 hours (P<0.0001; 4.17 mg vs. 41.52 mg of morphine) and better pain control (P<0.005) with mean pain scores (NVS 1.8±1.5 vs. 4.8±1.6) in group 0 (SIPB). The global QoR-15 scores 24 hours postoperatively were higher (better quality) in the SIPB group (122 vs. 100).

CONCLUSIONS

The low serratus-intercostal interfascial plane block (SIPB) provides efficient analgesia leading to a saving of opioids and improvement of the recovery quality in patients undergoing upper abdominal wall surgeries.

The Postoperative Analgesic Effect of Ultrasound-Guided Bilateral Transversus Abdominis Plane Combined with Rectus Sheath Blocks in Laparoscopic Hepatectomy: A Randomized Controlled Study

Background

Our aim was to investigate the postoperative analgesic effect of ultrasound (US)-guided bilateral transversus abdominis plane (TAP) blocks combined with rectus sheath blocks (RSBs) in laparoscopic hepatectomy.

Patients and Methods

A total of 126 patients were allocated into two groups for analysis. Group 1 (n = 63) did not receive any local anesthetics. Group 2 (n = 63) received US-guided bilateral TAP blocks and RSBs using 20 mL 0.25% ropivacaine in each block. Postoperative pain scores, the dose of intraoperative remifentanil, 24 h consumption of oxycodone, adverse events such as postoperative dizziness, nausea and vomiting, and the length of postoperative hospital stay were recorded.

Results

In the postanesthesia care unit, patients in group 2 had significantly lower pain visual analog scale (VAS) scores at rest than those in group 1 (P < 0.001). The VAS scores both at rest and during movement were significantly lower in group 2 than in group 1 at 2, 4 and 6 h postoperatively (all P < 0.001). There was no difference in VAS scores between the two groups at rest 24 h postoperatively (P = 0.477). However, the VAS score during movement at 24 h in group 2 was significantly lower than that in group 1 (P < 0.001). No significant differences in the incidence of adverse events or the dose of intraoperative remifentanil were observed between the two groups (all P > 0.05). Patients in group 2 had a significantly lower 24 h consumption of oxycodone than patients in group 1 (P < 0.001). The mean length of postoperative hospital stay of group 2 was shorter than that of group 1 (P = 0.032).

Conclusion

US-guided bilateral TAP blocks combined with RSBs provide effective postoperative analgesia for laparoscopic hepatectomy, and they could shorten the postoperative hospital stay without increasing the incidence of adverse events from opioids.

Comparison of postoperative analgesia and opioid requirement with thoracic epidural vs. continuous rectus sheath infusion in midline incision laparotomies under general anaesthesia - A prospective randomised controlled study

Background and Aims:

To assess and compare the effect of bilateral continuous rectus sheath infusion (CRSB) for postoperative analgesia with continuous thoracic epidural infusion (TEA) in patients undergoing midline incision laparotomies.

Methods:

A prospective, randomised study involving sixty patients with Indian Society of Anesthesiologists (ASA) grade I to III, planned for elective laparotomy were enrolled for the study. Patients were randomly allocated into two groups. In the TEA group, an epidural was sited before induction of general anaesthesia (GA), whereas in the CRSB group, bilateral ultrasound-guided RSB catheters were placed at the end of the surgical procedure, before extubation. Both groups received continuous 0.2% Ropivacaine infusion for postoperative analgesia. They were followed for two post-operative days (POD), for the opioid requirement and post-operative pain at rest, coughing, and moving. Age and body mass index (BMI) were compared using independent t-test and visual analogue scale (VAS) scores were compared by the Mann–Whitney test between the two groups. Opioid consumption, gender, and type of surgery were compared using the Chi-Square test. Statistical analysis was done using Statistical Package for Social Sciences (SPSS 21.0).

Results:

Opioid consumption in both groups was comparable, for the first two post-operative days with no statistically significant difference. Pain scores were comparable among the groups at all times except postoperative day (POD) 0 (4 h and 12 h postop) and POD 2 (8 AM and 12 PM), where lower pain scores were observed in CRSB Group.

Conclusions:

As a part of the multimodal analgesia technique, CRSB offers a reliable, safe, and effective alternative to TEA.

The impact of ultrasound-guided bilateral rectus sheath block in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy - a retrospective study

Background

Rectus sheath block (RSB) is known to attenuate postoperative pain and reduce perioperative opioid consumption. Thus, a retrospective study was performed to examine the effects of bilateral rectus sheath block (BRSB) in cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

A total of 178 patients undergoing CRS/HIPEC at our hospital were included. Patient information and anaesthesia-related indicators were collected from the electronic medical record (EMR) system. All subjects were divided into the following two groups: the G group (general anaesthesia) and the GR group (RSB combined with general anaesthesia). Patients in the GR group received 0.375% ropivacaine for BRSB before surgery. The primary outcomes included the total amount of remifentanil and rocuronium, the total consumption of dezocine after surgery, the visual analogue scale (VAS) score and the patient-controlled intravenous analgesia (PCIA) input dose at 1 h (T6), 6 h (T7), 12 h (T8), 24 h (T9) and 48 h (T10) after surgery. Other outcomes were also recorded, such as patient demographic data, the intraoperative heart rate (HR) and mean arterial pressure (MAP), and postoperative complications.

Results

Compared with the G group, the GR group showed a shorter time to tracheal extubation (P < 0.05), a decreased total amount of remifentanil and rocuronium (P < 0.05), and a reduced VAS score, PCIA input dose and number of PCIA boluses at 1 h, 6 h and 12 h after surgery (P < 0.05). However, at 24 h and 48 h after surgery, there were no differences in the VAS score of pain at rest or during motion between the two groups (P > 0.05). Moreover, the incidence of hypertension, emergence agitation, delayed recovery, hypercapnia, and nausea and vomiting was lower in the GR group than in the G group (P < 0.05). There were no differences in the changes in MAP and HR during the surgery between the two groups (P > 0.05). No complications associated with nerve block occurred.

Conclusion

BRSB could provide short-term postoperative analgesia, reduce perioperative opioid consumption and reduce the incidence of postoperative complications. It is an effective and safe procedure in CRS/HIPEC.

Ultrasound-guided rectus sheath block: an anatomic study in dog cadavers

OBJECTIVES

To describe the ultrasound-guided rectus sheath block technique and the anatomical spread of two volumes of methylene blue injection in dog cadavers.

STUDY DESIGN

Blinded, prospective, experimental cadaveric study.

ANIMALS

A total of eight dog cadavers weighing 8.9 ± 1.6 kg.

METHODS

Ultrasound-guided rectus sheath injections were performed bilaterally 1 cm cranial to the umbilicus using 0.25 mL kg^-1 (low volume; LV) and 0.50 mL kg^-1 (high volume; HV) of 0.5% methylene blue dye. A total of 16 hemiabdomens were injected. The ultrasound image quality of the muscular and fascial plane landmarks and needle visualization were scored using a standardized scale. Cadavers were dissected to determine the distribution of the dye and to assess staining of ventral branches of the spinal nerves.

RESULTS

Fewer ventral spinal nerve branches were stained in the LV group than in the HV group, at 2.00 ± 0 and 2.90 ± 0.83, respectively (p < 0.01). Ventral branches of thoracic (T) and lumbar (L) spinal nerves (T10, T11, T12, T13 and L1) were stained 25%, 100%, 75%, 25% and 0% of the time in LV group and 12.5%, 87.5%, 100.0%, 75.0% and 13.0% in HV group. A lesser extent of cranial-caudal dye distribution was observed in the LV group than in the HV group (7.1 ± 1.8 cm and 9.2 ± 1.8 cm, respectively; p = 0.03). There was no significant difference in medial-lateral spread of dye, number of test doses or ultrasound image quality scores between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

The results of this study suggest that, on an anatomical basis, this easily performed block has the potential to provide effective abdominal wall analgesia for the ventral midline. This study supports the potential of the rectus sheath block for abdominal procedures, and further investigations on its clinical efficacy are warranted.

Single injection ultrasound-guided rectus sheath blocks for children: Distribution of injected anesthetic

BACKGROUND

Single injection ultrasound-guided rectus sheath blocks are used for postoperative analgesia after midline abdominal incisions, but the ultrasonographic spread of medication posterior to the rectus muscle has not been investigated.

AIMS

The primary goal of this study was to determine the ultrasound-measured medication spread superiorly and inferiorly after single injection ultrasound-guided rectus sheath blocks and to calculate the incidence of cases with spread up to the subcostal margin and below of umbilicus. The secondary goals were to correlate the spread with the volume of medication administered and with the patient's age, weight, height, sex, and body mass index.

METHODS

Pediatric patients who underwent single injection ultrasound-guided rectus sheath blocks and underwent data collection of ultrasonographic information on medication spread along the plane of the posterior rectus sheath were identified retrospectively from an acute pain service database at UPMC Children's Hospital of Pittsburgh.

RESULTS

Sixty-eight children, 10.2 ± 4.2 (mean ± SD) years old, 41.7 ± 17.9 kg, 140 ± 24.6 cm, had complete data collection. Mean injected volume of ropivacaine was 8.3 ± 2.8 mL (right) and 8.2 ± 2.8 mL (left). The average spread was measured as 3.9 ± 1.4 cm (right) and 3.4 ± 1.3 cm (left) cranial to the umbilicus, and 1.5 ± 1.6 cm (right) and 1.6 ± 1.4 cm (left) caudal to the umbilicus. Complete spread up to the level of the subcostal margin was observed in 52.9% (n = 36; right) and 36.8% (n = 25; left) of cases. The spread correlated closely with the volume of injected ropivacaine (right: 0.556, P < 0.001; left: 0.541, P < 0.001). The spread below umbilicus was 70.6% (n = 48, right) and 80.9% (n = 55, left). There was a positive strong correlation (P < 0.001) between total medication spread and age (right: 0.608; left: 0.538), weight (right: 0.600; left: 0.540), and height (right: 0.593; left: 0.526).

CONCLUSION

After single injection ultrasound-guided rectus sheath blocks, incomplete cephalocaudal medication spread can be expected within the posterior rectus sheath.

The rising tide of opioid use and abuse: the role of the anesthesiologist

Opioid use has risen dramatically in the past three decades. In the USA, opioid overdose has become a leading cause of unintentional death, surpassing motor vehicle accidents. A patient's first exposure to opioids may be during the perioperative period, a time where anesthesiologists have a significant role in pain management. Almost all patients in the USA receive opioids during a surgical encounter. Opioids have many undesirable side effects, including potential for misuse, or opioid use disorder. Anesthesiologists and surgeons employ several methods to decrease unnecessary opioid use, opioid-related adverse events, and side effects in the perioperative period. Multimodal analgesia, enhanced recovery pathways, and regional anesthesia are key tools as we work towards optimal opioid stewardship and the ideal of effective analgesia without undesirable sequelae.

Preoperative versus postoperative ultrasound-guided rectus sheath block for improving pain, sleep quality and cytokine levels in patients with open midline incisions undergoing transabdominal gynecological surgery: a randomized-controlled trial

Background

Nerve block is usually performed before surgery because it inhibits reflection of the skin incision and reduces the amount of intraoperative anesthetic used. We hypothesized that performing rectus sheath block (RSB) after surgery would result in a longer duration of the analgesic effects and have a subtle influence on sleep time after surgery but that it would not decrease the perioperative cytokine levels of patients undergoing gynecological surgery.

Methods

A randomized, double-blinded, controlled trial was conducted from October 2015 to June 2016. Seventy-seven patients undergoing elective transabdominal gynecological surgery were randomly assigned to the following two groups: a general anesthesia group who received 0.5% ropivacaine hydrochloride RSB preoperatively and saline RSB postoperatively, and another group who received the opposite sequence. The objective of the trial was to evaluate the postoperative pain, sleep and changes in cytokine levels of patients during the postoperative 48 h.

Results

A total of 61 female patients (mean age: 50 years; range: 24–65 years) were included in the final study sample. There was no significant difference in the pain, consumption of oxycodone, or time to first administration of patient-controlled intravenous analgesia between the two groups. The postoperative sleep stages N2 and N3 were increased by 52.9 and 29.1 min per patient, respectively, in the preoperative RSB group compared with those in the postoperative group. The preoperative IL-6 concentration in the preoperative RSB group was lower than that in the same group at the end of surgery and 24 h postoperatively.

Conclusions

We concluded that preoperative RSB might preserve postoperative sleep by inhibiting the increase of IL-6 without shortening the analgesia time compared with postoperative RSB in female patients undergoing elective midline incision transabdominal gynecological surgery.

Trial registration

ClinicalTrials.gov, NCT02477098, registered on 15 June 2015.

A prospective, randomized, open label, controlled study investigating the efficiency and safety of 3 different methods of rectus sheath block analgesia following midline laparotomy

BACKGROUND

There is a controversy regarding the efficacy of rectus sheath block (RSB). The aim of the present study was to evaluate analgesic efficacy and safety of three different methods of RSB in postoperative pain management after midline laparotomy.

METHODS

A prospective, randomized, controlled, open-label clinical trial with 4 parallel groups was conducted in a tertiary care hospital in Finland. A total of 57 patients undergoing midline laparotomy were randomized to the control group (n = 12) or to 1 of the 3 active RSB analgesia groups: single-dose (n = 16), repeated-doses (n = 12), or continuous infusion (n = 17). Opioid consumption with iv-patient-controlled analgesia pump was recorded, and pain scores and patients' satisfaction were surveyed on an 11-point numeric rating scale for the first 48 postoperative h. Plasma concentrations of oxycodone and levobupivacaine were analyzed. All adverse events during the hospital stay were recorded.

RESULTS

Oxycodone consumption was less during the first 12 h in the repeated-doses and in the continuous infusion groups (P = .07) and in numerical values up to 48 h in the repeated-doses group. Plasma oxycodone concentrations were similar in all 4 groups. Pain scores were lower in the repeated-doses group when coughing during the first 4 h (P = .048 vs. control group), and at rest on the first postoperative morning (P = .034 vs. the other 3 groups) and at 24 h (P = .006 vs. the single-dose group). All plasma concentrations of levobupivacaine were safe. The patients' satisfaction was better in the repeated-doses group compared with the control group (P = .025). No serious or unexpected adverse events were reported.

CONCLUSIONS

RSB analgesia with repeated-doses seems to have opioid sparing efficacy, and it may enhance pain relief and patients' satisfaction after midline laparotomy.

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.

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.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

The Effect of Multimodal Analgesia on Intraoperative Morphine Requirement in Lumbar Spine Surgeries

BACKGROUND

Lumbar spine surgery demands intense analgesia. Preemptive multimodal analgesia (MMA) is a novel approach to attenuate the stress response to surgical stimulus.

AIMS

The aim of the study was to assess the intraoperative morphine consumption in patients undergoing lumbar spine surgery.

PATIENTS AND METHODS

A randomized, prospective, double-blind study involving 42 patients belonging to the American Society of Anesthesiologists Class I and II scheduled to undergo elective lumbar spine surgery were allocated into two groups of 21 each. Group A (study group) received injection diclofenac sodium, paracetamol, clonidine, and skin infiltration with bupivacaine adrenaline and Group B (control group) received paracetamol and skin infiltration with saline adrenaline. Preemptive analgesia was practiced in both the groups. Intraoperative morphine consumption was documented.

STATISTICAL METHODS

Intraoperative morphine consumption between the two groups was compared using Mann-Whitney U-test. Postextubation sedation score between the two groups was compared using Chi-square test and presented as number and percentage. P < 5% was considered statistically significant.

RESULTS

Intraoperative morphine consumption was significantly low in the study group (P < 0.001). Postextubation sedation score was comparable between the two groups.

CONCLUSION

Preemptive MMA has demonstrated significant morphine sparing effect intraoperatively in patients undergoing lumbar spine surgeries.

Rectus sheath block for postoperative analgesia in patients with mesenteric vascular occlusion undergoing laparotomy: A randomized single-blinded study

Background:

Acute mesenteric ischemia is a life-threatening vascular emergency that requires early diagnosis, immediate anticoagulation, and intervention to restore mesenteric blood flow adequately.

Aims:

To investigate the effect of rectus sheath block (RSB) for postoperative analgesia in patients with mesenteric vascular occlusion.

Settings and Design:

Forty patients with mesenteric vascular occlusion, American Society of Anesthesiologists physical status I or II or III, scheduled for laparotomy were enrolled in this study.

Subjects and Methods:

Patients were randomized into two groups; control group (C Group) and rectus block group (RB Group). In both groups, general anesthesia was induced fentanyl 1 μg/kg with sleeping dose of propofol and 0.15 mg/kg cisatracurium. Then, anesthesia was maintained with sevoflurane in oxygen 100%. In RB Group, under aseptic condition, RSB guided by ultrasound was performed. Surgery is then continued and intravenous fentanyl patient-controlled analgesia pump started. Postoperative pain, sedation, and opioid side effects were assessed.

Statistical Analysis Used:

Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA).

Results:

Patients in the RB Group consumed statistically significant less opioid in comparison to control group either intraoperatively or postoperatively. Mean pain scores were statistically significant less in RB Group than in the control group at 2, 4, and 6 h postoperatively. Sedation score, incidence of nausea and vomiting were statistically significant less in the RB Group in comparison to control group. More patients’ satisfaction was reported in the RB Group.

Conclusions:

Ultrasound-guided RSB resulted in postoperative reduction of pain scores and opioid consumption compared with general anesthesia alone. Moreover, RSB was associated with better patient satisfaction and less nausea and vomiting.