Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis.

INTRODUCTION: Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge. METHODS: We retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge. RESULTS: Total narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047). CONCLUSION: Preincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery. RETROSPECTIVE COMPARATIVE STUDY: LEVEL III EVIDENCE.

In children undergoing umbilical hernia repair is rectus sheath block effective at reducing post-operative pain? Best evidence topic (bet).

A best evidence topic was constructed according to a structured protocol. The question addressed was: In children undergoing umbilical hernia repair is a rectus sheath block (RSB) better than local anaesthetic infiltration of the surgical site, at reducing post-operative pain? From a total of 34 papers, three studies provided the best available evidence on this topic. One randomised clinical trial showed RSB had a better analgesic effect in the immediate post-operative period. In another randomised trial opioid consumption in the peri-operative period was found to be significantly lower in patients administered RSB. These improvements in pain and analgesia consumption need to be balanced against the expertise, training, equipment required, time implications and complications of performing a RSB.

Abdominal wall trigger point case study.

Myofascial trigger points (TrPs) are posited to be an element in the etiology of both musculoskeletal and visceral pain. However, the recognition of TrPs as a causative factor in a patient's pain presentation varies amongst physicians and therapists. When myofascial pain syndrome is responsible for a patient's condition and is not recognized by the patient's medical advisors, the patient may be put through a plethora of testing procedures to find the cause of the patient's pain, and prescribed medications in an effort to treat the patient's symptoms. The case review presented here involves a patient with severe anterior abdominal pain, with a history of Crohn's disease, who experienced a long and difficult medical process before a diagnosis of myofascial pain syndrome was made.

Comparative neuromuscular blocking potency of pipecuronium and pancuronium.

The effects of pipecuronium bromide (Pi.) and pancuronium bromide (Pa.) on the contractile response of rat-phrenic nerve diaphragm and frog's musculus rectus abdominis preparation were studied. Pi. and Pa. were found to have a dose-dependent reduction in the contractile response of the tested preparation. Trials were made to estimate the potency of Pi. in a comparison with Pa. In this respect Pi. exhibited a more potent effect than Pa. The duration of action is about twice as long as that of Pa. in equieffective doses. Neostigmine rapidly and completely antagonises the neuromuscular blockade caused by Pi. and Pa.