Comparison of analgesic effectiveness between nefopam and propacetamol in living kidney donors following rectus sheath block after hand-assisted living donor nephrectomy: a prospective, randomized controlled trial.

BACKGROUND: Nefopam and propacetamol are the most commonly used analgesics in postoperative multimodal analgesic regimens. Distinct mechanisms are involved in each drug's anti-nociceptive effects. No studies have compared pain relief efficacy between the two drugs in patients undergoing transplantation surgery. Here, we investigated whether the administration of nefopam or propacetamol to healthy living kidney donors who underwent rectus sheath block (RSB) for parietal pain could reduce the subsequent opioid dose necessary to produce adequate analgesia. METHODS: This prospective, randomized controlled trial included 72 donors undergoing elective hand-assisted living donor nephrectomy into two groups: propacetamol (n = 36) and nefopam (n = 36). Intraoperative RSB was performed in all enrolled donors. The primary outcome was the total volume of intravenous opioid-based patient-controlled analgesia (PCA) used on postoperative day 1 (POD 1). Additionally, the Numeric Rating Scale scores for flank (visceral) and umbilicus (parietal) pain at rest and during coughing were compared, and the Korean adaptation of the Quality of Recovery-15 Questionnaire (QoR-15 K) was evaluated on POD 1. RESULTS: Both groups had similar preoperative and intraoperative characteristics. On POD 1, the total amount of PCA infusion was significantly lower in the nefopam group than in the propacetamol group (44.5 ± 19.3 mL vs. 70.2 ± 29.0 mL; p < 0.001). This group also reported lower pain scores at the flank and umbilical sites and required fewer rescue doses of fentanyl in the post-anesthesia care unit. However, pain scores and fentanyl consumption in the ward were comparable between groups. The QoR-15 K scores were similar between groups; there were substantial improvements in breathing, pain severity, and anxiety/depression levels in the nefopam group. The incidences of postoperative complications, including sweating and tachycardia, were similar between groups. CONCLUSION: Compared with propacetamol, nefopam provides a greater analgesic effect for visceral pain and enhances the effects of blocks that reduce the opioid requirement in living kidney donors with parietal pain managed by RSB. TRIAL REGISTRATION: The trial was registered prior to patient enrollment in the clinical trial database using the Clinical Research Information Service (registration no. KCT0007351 , Date of registration 03/06/2022).

Analgesic effect of ultrasound-guided transversus abdominis plane block with or without rectus sheath block in laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Ultrasound-guided transversus abdominis plane (TAP) block is commonly used for pain control in laparoscopic cholecystectomy. However, significant pain persists, affecting patient recovery and sleep quality on the day of surgery. We compared the analgesic effect of ultrasound-guided TAP block with or without rectus sheath (RS) block in patients undergoing laparoscopic cholecystectomy using the visual analog scale (VAS) scores. METHODS: The study was registered before patient enrollment at the Clinical Research Information Service (registration number: KCT0006468, 19/08/2021). 88 American Society of Anesthesiologist physical status I-III patients undergoing laparoscopic cholecystectomy were divided into two groups. RS-TAP group received right lateral and right subcostal TAP block, and RS block with 0.2% ropivacaine (30 mL); Bi-TAP group received bilateral and right subcostal TAP block with same amount of ropivacaine. The primary outcome was visual analogue scale (VAS) for 48 h postoperatively. Secondary outcomes included the use of rescue analgesics, cumulative intravenous patient-controlled analgesia (IV-PCA) consumption, patient satisfaction, sleep quality, and incidence of adverse events. RESULTS: There was no significant difference in VAS score between two groups for 48 h postoperatively. We found no difference between the groups in any of the secondary outcomes: the use of rescue analgesics, consumption of IV-PCA, patient satisfaction with postoperative pain control, sleep quality, and the incidence of postoperative adverse events. CONCLUSION: Both RS-TAP and Bi-TAP blocks provided clinically acceptable pain control in patients undergoing laparoscopic cholecystectomy, although there was no significant difference between two combination blocks in postoperative analgesia or sleep quality.

Combined rectus sheath block with transverse abdominis plane block by one puncture for analgesia after laparoscopic upper abdominal surgery: a randomized controlled prospective study.

BACKGROUND: Rectus sheath block (RSB) and transversus abdominis plane block (TAPB) have been shown to reduce opioid consumption and decrease postoperative pain scores in abdominal surgeries. However, there are no reports about the one-puncture technique of RSB combined with TAPB for perioperative pain management during laparoscopic upper abdominal surgery. METHODS: A total of 58 patients were randomly assigned to the control group (C), the TAP group (T), and the one-puncture technique of RSB combined with TAPB group (RT). The patients in group C did not receive any regional block. The patients in group T received ultrasound-guided subcostal TAPB with 30 mL of 0.33% ropivacaine on each side. The patients in the RT group received a combination of RSB and TAPB with 15 mL of 0.33% ropivacaine in each plane by one puncture technique. All patients received postoperative patient-controlled intravenous analgesia (PCIA) after surgeries. The range of blocks was recorded 20 min after the completion of the regional block. The postoperative opioid consumption, pain scores, and recovery data were recorded, including the incidence of emergence agitation (EA), the times of first exhaust and off-bed activity, the incidence of postoperative nausea and vomiting, dizziness. RESULTS: The range of the one-puncture technique in group RT covered all areas of surgical incisions. The visual analogue scale (VAS) score of the RT group is significantly lower at rest and during coughing compared to groups T and C at 4, 8, 12, and 24 h after surgery, respectively (P < 0.05). The consumption of sufentanil and the number of postoperative compressions of the analgesic pumps at 24 and 48 h in the RT group are significantly lower than those in groups T and C (P < 0.05). The incidence of EA in the RT group is significantly lower than that in groups T and C (P < 0.05). CONCLUSION: The one-puncture technique of RSB combined with TAPB provides effective postoperative analgesia for laparoscopic upper abdominal surgery, reduces the incidence of EA during PACU, and promotes early recovery. TRIAL REGISTRATION: ChiCTR, ChiCTR2300067271. Registered 3 Jan 2023, http://www.chictr.org.cn .

Impact of Intraoperative Nefopam on Postoperative Pain, Opioid Use, and Recovery Quality with Parietal Pain Block in Single-Port Robotic Cholecystectomy: A Prospective Randomized Controlled Trial.

Background and Objectives: This study explored how nefopam, a non-opioid analgesic in a multimodal regimen, impacts postoperative pain, opioid use, and recovery quality in single-port robot-assisted laparoscopic cholecystectomy (RALC) patients with a parietal pain block, addressing challenges in postoperative pain management. Materials and Methods: Forty patients scheduled for elective single-port RALC were enrolled and randomized to receive either nefopam or normal saline intravenously. Parietal pain relief was provided through a rectus sheath block (RSB). Postoperative pain was assessed using a numeric rating scale (NRS) in the right upper quadrant (RUQ) of the abdomen, at the umbilicus, and at the shoulder. Opioid consumption and recovery quality, measured using the QoR-15K questionnaire, were also recorded. Results: The 40 patients had a mean age of 48.3 years and an average body mass index (BMI) of 26.2 kg/m2. There were no significant differences in the pre- or intraoperative variables between groups. Patients receiving nefopam reported significantly lower RUQ pain scores compared to the controls, while the umbilicus and shoulder pain scores were similar. Rescue fentanyl requirements were lower in the nefopam group in both the PACU and ward. The QoR-15K questionnaire scores for nausea and vomiting were better in the nefopam group, but the overall recovery quality scores were comparable between the groups. Conclusions: Nefopam reduces RUQ pain and opioid use post-single-port RALC with a parietal pain block without markedly boosting RSB's effect on umbilicus or shoulder pain. It may also better manage postoperative nausea and vomiting, underscoring its role in analgesia strategies for this surgery.

A randomized controlled trial investigating rectus sheath catheters following radical cystectomy.

OBJECTIVE: To evaluate whether rectus sheath catheter (RSC) insertion may be an alternative to thoracic epidural (TE). PATIENTS AND METHODS: In a non-blinded, single-centre, non-inferiority study, patients undergoing open radical cystectomy were randomized 1:1 to receive either a TE or surgically placed RSC. The primary endpoint was cumulative opiate use (median oral morphine equivalent [OME]) in the first 72 h postoperatively. Secondary outcomes included visual analogue scale pain scores, measures of postoperative recovery including mobility and time to regular diet, and complications. RESULTS: Ninety-seven patients were randomized (51 TE, 46 RSC). The median OME was 103 (77.5-132.5) mg in the TE arm and 161.75 (117.5-187.5) mg in the RSC arm. A Mann-Whitney U-test confirmed non-inferiority of RSC to TE at a threshold of 15 mg OME (P = 0.002). When comparing pain scores for the first three postoperative days, an early difference was observed that favoured the TE group during post-anaesthesia care unit stay, which was lost after postoperative day 1. Patient satisfaction with analgesia on the third postoperative day was similar in the two arms (P = 0.47). There were no statistically significant differences between arms with respect to the other secondary outcomes. CONCLUSIONS: The outcomes from this prospective randomized trial demonstrated non-inferiority of RSC insertion compared to TE with respect to 72-h opiate use. Patient satisfaction with pain control on postoperative day 3 was the same for each group.

Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis: outcomes of a dedicated anesthesia and surgery protocol.

BACKGROUND: Patients requiring percutaneous endoscopic gastrostomy (PEG) for amyotrophic lateral sclerosis (ALS) related dysphagia represent a clinical challenge. Diminished pulmonary function and aspiration risks can lead to anesthesia-related complications, and gastric displacement from hemidiaphragm elevation may preclude safe gastric access. This study reports the efficacy and outcomes of a dedicated anesthesia/surgery management protocol for ALS patients undergoing PEG. METHODS: In 2013, a PEG placement protocol for ALS patients was developed emphasizing efficient pre-operative evaluation, rapidly metabolized anesthetic agents, and minimization of opioid use. Outcomes were analyzed retrospectively. Preoperative weight loss, pulmonary function tests, total analgesia, procedural time, and 90-day morbidity and mortality were recorded. RESULTS: From 2013-2019, 67 ALS patients (mean age 65.3 years, 52.2% female) received a PEG under the protocol. Mean percentage weight loss 6 months before PEG was 9.3 ± 5.1% with 38.8% of patients meeting criteria for severe malnutrition. Mean anesthesia time (propofol induction to anesthesia emergence) was 34.5 ± 10.8 min and mean operative time (endoscope insertion to dressing placement) was 16.4 ± 8.2 min. Regional anesthesia with liposomal bupivacaine was performed in 76.1%. All attempts at PEG placement were successful. With a mean follow-up of 6.1 ± 6.8 months, all PEGs were functional and there were no surgical site complications. Thirty-day readmission rate was 7.0% and 90-day mortality was 22.4% (46.7% occurring within 30 days). Mean time from surgery to death was 8.8 ± 7.8 months. CONCLUSIONS: Protocols for optimizing PEG may help overcome challenges present in the ALS patient population. Despite patient comorbidities, protocol implementation and dedicated team members resulted in a high procedural success rate and low complication rate. Further study is warranted to optimize the timing of PEG placement in relation to ALS disease progression and determine the utility of regional anesthesia during PEG placement.

Cardiovascular changes, laboratory findings and pain scores in calves undergoing ultrasonography-guided bilateral rectus sheath block before herniorrhaphy: a prospective randomized clinical trial.

BACKGROUND: The study aimed to assess the clinical utility of a multiparametric approach to measure the impact of bilateral ultrasound-guided rectus sheath blocks (RSB) on heart rate, serum cortisol concentrations, and pain in calves undergoing herniorraphy. Fourteen calves were randomly assigned to receive either the RSB (RSB group, n = 7, injected with 0.3 mL/kg of bupivacaine 0.25% and 0.15 µg/kg of dexmedetomidine per side) or a sham injection (CG group, n = 7, injected with an equivalent volume of sterile saline solution). Monitoring included (i) continuous Holter recording from 120 min pre-surgery to 120 min post-surgery; (ii) serum cortisol concentration (SC) at -150 min pre-surgery (baseline), induction time, skin incision, end of surgical procedure (EP-t), and then 30 min, 45 min, 60 min, 120 min, 360 min after recovery; (iii) UNESP-Botucatu pain evaluation at -150 min pre-surgery and 30 min, 45 min, 60 min, 120 min, 240 min, 360 min after recovery. RESULTS: A significant difference in the heart rate was observed within the RSB group, in the time frame between 120 min to induction compared to the time frame between induction to EP-t period. The SC concentration was significantly higher in the CG at the skin incision. Calves in the RSB group recorded significantly lower pain scores at 45 min, 60 min, 120 and 240 min after recovery. CONCLUSIONS: The study demonstrated that monitoring heart rate and serum cortisol concentrations effectively quantified the effects of RSB during surgery. At the same time, the UNESP-Botucatu pain scale identified effects post-surgery when the calves regained consciousness. Overall, ultrasound-guided RSB appeared to enhance the well-being of calves undergoing herniorrhaphy.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review.

PURPOSE OF REVIEW: The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain. RECENT FINDINGS: Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

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.

Transversus abdominis plane (TAP) block for pain management of rectus sheath hematoma in the emergency department (ED).

Peripheral nerve blocks for pain management have historically been discussed in anesthesiology literature but, until recently, have not been considered in emergency medicine contexts. Transversus abdominis plane (TAP) blocks, in particular, have recently been explored in the emergency department for pain control in acute appendicitis but are potentially helpful for managing abdominal pain of other etiologies. One such pathology is rectus sheath hematomas, where conservative management is often necessary as curative treatments often pose more significant risks than are necessary. We report the case of a 57-year-old female presenting to the emergency department with severe abdominal pain following vigorous exercise. She was found to have a large rectus sheath hematoma on computed tomography. An ultrasound-guided transversus abdominis plane block was performed in the emergency department, and the patient had complete resolution of her pain.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience.

PURPOSE: To retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH). MATERIALS AND METHODS: Retrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed. RESULTS: Pre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms. CONCLUSION: Embolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

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.

Spontaneous rectus sheath hematoma associated with apixaban in an elderly gentleman with chronic obstructive airway disease - a case report.

BACKGROUND: Rectus sheath hematoma (RSH) is a relatively uncommon cause of acute abdominal pain and can be mistaken as other surgical causes of acute abdomen. A diagnosis requires high index of suspicion especially in susceptible patients, for example, in patients on anticoagulation. While anticoagulation is the commonest risk factor for RSH, direct-acting oral anticoagulants have only been very recently implicated as a potential cause with fewer than ten cases reported in the literature. CASE PRESENTATION: An 82-year-old Chinese man with chronic obstructive airway disease, ischemic heart disease, heart failure and atrial fibrillation on apixaban presenting with acute onset of lower abdominal pain. Physical examination showed peritoneal signs with tenderness and guarding over the lower quadrants with hypotension. Computed tomography (CT) of the abdomen confirmed a large rectus sheath hematoma (RSH) without active extravasation. He was given fluid resuscitation and was managed successfully with supportive treatment and cessation of apixaban. A follow-up CT two months later showed resolving hematoma and aspirin was resumed primarily for ischemic heart disease. The patient tolerated anti-platelet therapy without recurrence of RSH. The risk factors, treatment options, prognosis and issue related to anticoagulation resumption after an episode of RSH are discussed. Reported cases of RSH associated with direct-acting oral anticoagulants are reviewed. CONCLUSIONS: Direct-acting oral anticoagulant-associated rectus sheath hematoma is rare. With increasing use of direct-acting oral anticoagulants in multiple clinical settings, clinicians should remain vigilant of this potentially life-threatening bleeding complication when a patient presents with acute abdominal pain. Conservative treatment with cessation of anti-coagulant and supportive transfusion remains the mainstay of treatment.

Stapled fascial suture: ex vivo modeling and clinical implications.

BACKGROUND: Recently, in the field of abdominal wall repair surgery, some minimally invasive procedures introduced the use of staplers to provide a retromuscular prosthetic repair. However, to the knowledge of the authors, there are little data in the literature about the outcomes of stapled sutures adoption for midline reconstruction. This study aims to investigate the biomechanics of stapled sutures, simple (stapled), or oversewn (hybrid), in comparison with handsewn suture. From the results obtained, we tried to draw indications for their use in a clinical context. METHODS: Human cadaver fascia lata specimens, sutured (handsewn, stapled, or hybrid) or not, underwent tensile tests. The data on strength (maximal stress), ultimate strain (deformability), Young's modulus (rigidity), and dissipated specific energy (ability to absorb mechanical energy up to the breaking point) were recorded for each type of specimens and analyzed. RESULTS: Stapled and hybrid suture showed a significantly higher strength (handsewn 0.83 MPa, stapled 2.10 MPa, hybrid 2.68 MPa) and a trend toward a lower ultimate strain as compared to manual sutures (handsewn 344%, stapled 249%, hybrid 280%). Stapled and hybrid sutures had fourfold higher Young's modulus as compared to handsewn sutures (handsewn 1.779 MPa, stapled 7.374 MPa, hybrid 6.964 MPa). Handsewn and hybrid sutures showed significantly higher dissipated specific energy (handsewn 0.99 mJ-mm3, stapled 0.73 mJ-mm3, hybrid 1.35 mJ-mm3). CONCLUSION: Stapled sutures can resist high loads, but are less deformable and rigid than handsewn suture. This suggests a safer employment in case of small defects or diastasis (< W1 in accord to EHS classification), where the presumed tissutal displacement is minimal. Oversewing a stapled suture improves its efficiency, becoming crucial in case of larger defects (> W1 in accord to EHS classification) where the expected tissutal displacement is maximal. Hybrid sutures seem to be a good compromise.

Awake cardiac surgery using the novel pectoralis-intercostal-rectus sheath (PIRS) plane block and subxiphoid approach.

BACKGROUND: Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION: We report the case of a 75-year-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a pectoralis-intercostal rectus sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 h for postoperative pain management without others pain relievers. CONCLUSION: Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.

Transversus thoracic plane block and rectus sheath block for left ventricular assist device implantation via full median sternotomy: A case report.

BACKGROUND: Traditionally, pain management after left ventricular assist device (LVAD) implantation via median sternotomy have been based on intravenous opioids but, in the era of enhanced recovery after surgery, a multimodal opioid-sparing analgesia could represent a valid alternative reducing opioids related side effects. CASE REPORT: We described the successfully use of an opioid-sparing regimen for pain management after LVAD implantation via median sternotomy based on two ultrasound-guided fascial plane wall blocks. Bilateral ultrasound-guided transversus thoracic plane block was performed to manage sternotomy pain; additionally, unilateral left ultrasound-guided rectus sheath block was performed to provide somatic pain relief for left abdominal wall structures superficial to the peritoneum within which the LVAD driveline was inserted. The patient was extubated on Day 1 and good quality analgesia (numerical rating scale <3) was obtained, without using nonsteroidal antiinflammatory drugs or opioids. The patient was discharged from Intensive Care Unit on Day 3 and during hospitalization (lasted 24 days) there was no need for rescue analgesia administration.

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.

Evaluation of contrast-enhanced ultrasonography with Sonazoid® in visualization of local anesthetic distribution in rectus sheath block: a prospective, clinical study.

PURPOSE: Clear visualization of ultrasound (US) images is crucial for successful US-guided nerve block. However, accurate determination of local anesthetic (LA) distribution from US images remains difficult. Sonazoid®, which comprises perflubutane microbubbles, is used to diagnose hepatic and breast tumors. This study aimed to investigate the visibility of Sonazoid® in perioperative US-guided nerve block. METHODS: We performed rectus sheath block (RSB) in patients scheduled for laparoscopic abdominal surgery (n = 10). 10 mL of a mixture containing equal amounts of 0.75% ropivacaine and iohexol with the addition of Sonazoid® diluted 100-fold was administered. We investigated the correlation and agreement between Sonazoid® and iohexol distributions. The brightness of the solution and tissues was calculated: a grayscale value between 0 (dark) and 255 (bright) was measured in all pixels of the region of interest. Adverse events were also investigated. RESULTS: Sonazoid® was clearly visualized and distinguished from the surrounding tissues both during and after RSB. The spread of Sonazoid® and iohexol was significantly correlated (spearman's ρ = 0.53, p = 0.0004). Bland-Altman analyses revealed significant mean difference between two methods (15.6 mm; 95% confidence interval [CI]: 10.6, 20.6; standard deviation (SD) 15.65; p < 0.0001). Limits of agreement were - 14.94 to 46.24 mm. Sonazoid® significantly increased the mean grayscale values at the posterior rectus sheath (93.7 vs. 201.9, p < 0.0001). There were no complications. CONCLUSION: Sonazoid diluted 100-fold® was clearly visualized real-time, and the enhancement was sustained and measurable after RSB. Sonazoid® could potentially be used for the contrast agent of US-guided nerve block.

Efficacy and Safety Profile of Rectus Sheath Block in Adult Laparoscopic Surgery: A Meta-analysis.

BACKGROUND: Rectus sheath block (RSB) has been increasingly used for pain management after laparoscopic procedures but with a conflicting data on its analgesic efficacy. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of RSB in adults undergoing laparoscopic surgery. METHODS: A systematic literature search of the PubMed, Embase, CINAHL, and Cochrane Library databases was conducted from inception through October 1, 2020, to identify trials comparing RSB with a control group in laparoscopic surgery. The primary outcome was rest pain scores at 0-2 h postoperatively. Secondary outcomes included pain scores at rest at 10-12 and 24 h postoperatively, pain scores on movement at 0-2, 10-12, and 24 h postoperatively, 24- and 48-h opioid consumption, opioid-related side effects, and RSB-associated adverse events. RESULTS: Nine trials with 698 patients were included. RSB was associated with significantly lower rest pain scores at 0-2 h postoperatively (standardized mean difference -1.83, 95% confidence interval [-2.70, -0.96], P < 0.001, I2 = 95%) than control. Furthermore, RSB significantly reduced pain scores at rest at 10-12 h postoperatively and on movement at 0-2 h postoperatively, 24-h opioid consumption, and opioid-related side effects. Other secondary outcomes were similar between groups. Preoperative RSB provided better pain control compared with postoperative block administration. None of the studies reported local or systemic complications related to RSB. CONCLUSIONS: In the setting of laparoscopic surgery, RSB improves pain control for up to 12 h postoperatively and reduces opioid consumption, without major reported adverse events.

Effect of ultrasound-guided transversus abdominis plane block with rectus sheath block on patients undergoing laparoscopy-assisted radical resection of rectal cancer: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Many patients complain of pain following laparoscopic surgery. Clinicians have used ultrasound-guided posterior transversus abdominis plane block (TAPB) and rectus sheath block (RSB) for multimodal analgesia after surgery. We investigated the analgesic effects of US-guided posterior TAPB with RSB on postoperative pain following laparoscopy-assisted radical resection of early-stage rectal cancer. METHODS: Seventy-eight adults scheduled for laparoscopy-assisted radical resection of rectal cancer were enrolled in this double-blind placebo-controlled trial. Patients were randomized into 3 groups: the TR Group underwent US-guided bilateral posterior TAPB (40 mL 0.33% ropivacaine) with RSB (20 mL 0.33% ropivacaine); the T Group underwent US-guided bilateral posterior TAPB alone; and the Control Group received saline alone. All patients also had access to patient-controlled intravenous analgesia (PCIA) with sufentanil. The primary outcome was postoperative sufentanil consumption at 0-24, 24-48, and 48-72 h. The secondary outcomes were postoperative pain intensity and functional activity score at rest and while coughing for the same three time periods, intraoperative medication dosage, use of rescue analgesia, recovery parameters, and adverse effects. RESULTS: The three groups had no significant differences in baseline demographic and perioperative data, use of intraoperative medications, recovery parameters, and adverse effects. The TR group had significantly lower postoperative use of PCIA and rescue analgesic than in the other two groups (P < 0.05), but the Control Group and T Group had no significant differences in these outcomes. CONCLUSIONS: Postoperative US-guided posterior TAPB with RSB reduced postoperative opioid use in patients following laparoscopy-assisted radical resection of rectal cancer. TRIAL REGISTRATION: The trial was registered with chictr.org (ChiCTR2000029326) on January 25, 2020.