Rectus sheath and transversus abdominis plane blocks in children: a systematic review and meta-analysis of randomized trials

[Old and New Regional Anesthesia Procedures Under Review - Abdomen to Toe]

Ultrasound (US) technology has significantly expanded the spectrum of regional anesthesiological procedures in recent years. Abdominal wall blocks are becoming an increasingly integral part of a multimodal postoperative pain concept after abdominal surgery, gynecological or urological interventions. Thoracic epidural analgesia remains the gold standard for extensive surgery. The requirement for rapid postoperative mobilization and discharge after lower extremity surgery has led to the abandonment of neuroaxial or plexus blocks in favor of selective, peripheral blocks such as the PENG block or adductor canal block. The following article is intended to show the reader the change in the use of regional anesthesiological procedures for abdominal wall and lower extremity blocks using selected blockages.

Investigation into the clinical performance of rectus sheath block in reducing postoperative pain following surgical intervention: A systematic review and meta-analysis of randomised controlled trials

Background and Aims

Rectus sheath block (RSB) is an effective postoperative pain control technique in abdominal surgical procedures. This systematic review evaluated the efficacy and outcome data of patients undergoing RSB compared to the standard of care in both laparoscopic and open surgical procedures.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO ID: CRD42022372596). The search was restricted to randomised controlled trials (RCTs) comparing RSB effectiveness on postoperative pain to any standard general anaesthesia technique (control). We systematically explored PubMed, Medline, Central, Scopus and Web of Science for RCTs from inception to September 2023. The primary outcome was the evaluation of pain scores at rest 0-2, 10-12 and 12-24 h postoperatively. The secondary outcome was the analysis of postoperative intravenous (IV) morphine equivalent consumption at 24-h. A risk-of-bias tool for randomised trials (ROB 2.0, Cochrane, Copenhagen, Denmark) assessment and Grades of Recommendation, Assessment, Development and Evaluation (GRADE, Cochrane, Copenhagen, Denmark) analysis was conducted to evaluate the quality of the RCTs.

Results

Twenty RCTs involving 708 participants who received RSB intervention and 713 who received alternative analgesic care were included. RSB pain scores were significantly lower than control at 0-2 h (P < 0.001) and 10-12 h (P < 0.001) postoperatively. No significant effect was observed at 24 h (P = 0.11). RSB performance compared to control in 24-h IV morphine equivalency in milligrams was significantly lower (P < 0.001).

Conclusion

RSB implementation was associated with reduced postoperative pain scores and decreased opioid consumption in IV morphine equivalency up to 24 h following surgical intervention.

Perioperative Regional Anesthesia Pain Outcomes in Children: A Retrospective Study of 3160 Regional Anesthetics in Routine Practice

OBJECTIVE

Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice.

METHODS

Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients 18 years or below undergoing orthopedic, urologic, or general surgeries with and without RA from May 2014 to September 2021 were categorized as single shot, catheter based, or no block. Outcomes included intraoperative opioid exposure and dose, preincision anesthesia time, postanesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables.

RESULTS

A total of 11,292 procedures with 3160 RAs were included. Compared with no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (ie, while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours postop, no difference in opioid use from 24 to 36 hours, and a higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption.

DISCUSSION

Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.

Postoperative Pain Management in Children Undergoing Laparoscopic Appendectomy: A Scoping Review

Laparoscopic appendectomy (LA) is one of the most commonly performed surgical procedures in children and is associated with extreme postoperative discomfort due to peritoneal inflammation and infection. The main objective of this study was to investigate the effects of postoperative pain (POP) in children after laparoscopic appendectomy. Articles describing or evaluating the control of POP in children with LA were considered eligible. All available literature such as randomized controls, prospective controls, retrospective as well as clinical studies were considered. A comprehensive search was performed in PubMed, Medline, Embase, Cochrane Library, Clinical trials.gov, and Google scholar. The initial search took place on 23 April 2021, and was updated on 24 August 2021. There were no language or date restrictions. Each of the included articles was evaluated separately by two independent reviewers. Additional papers were found by searching the reference lists of eligible studies. Eighteen papers were considered. All papers, and many of them used different methods to treat POP in children undergoing LA, such as lidocaine infusion, different analgesic approaches, ultrasound-guided transverse abdominis blockade (UGTAP), ultrasound-guided quadratus lumborum blockade (UGQLB), and comparison of open appendectomy (OA) with local anesthetics in relation to POP management in children. Laparoscopic appendectomy is the surgical procedure preferred by clinicians compared with open appendectomy in children. A multimodal analgesic approach is optimal and efficient surgical techniques such as UGBRSB, UGQLB, and UGTAP block might significantly impact POP in children except that there are contraindications. Dexmedetomidine proved to be an effective adjuvant that can enhance the effect of local anesthetics. The lack of a sufficient number of studies may be a factor affecting our confidence in the results of this study. Therefore, further evidence-based randomized control trials with a large sample size are needed to provide clarity.

Analgesic efficacy of ultrasound-guided bilateral transversus abdominis plane block in children: retrospective analysis of 97 cases

BACKGROUND

Transversus abdominis plane (TAP) block is a method for postoperative pain management. Studies on children are gradually increasing. The aim of this retrospective study was to evaluate effectiveness of TAP block on pain control, its side effects, and parental satisfaction levels in children.

METHODS

Study included patients operated between January 2019 and December 2020 in Gazi University Faculty of Medicine. Total of 97 patients (35 girls, 62 boys) between 5 and 18 years who had an ultrasound guided TAP block for lower abdominal or inguinal surgery were examined retrospectively. TAP block application time, hemodynamic variables, postoperative pain scores, postoperative analgesic requirement, sex, surgical history and satisfaction levels were evaluated.

RESULTS

: The average application time of TAP block was 9.48 ± 3.4 and the time between TAP block and surgical incision was 12.06 ± 6.1 min. Pain scores in postanesthesia care unit (PACU) and at the postoperative first hour decreased as the time between TAP block and surgical incision increased (p < 0.05). Girls have higher pain scores at PACU than boys (p < 0.05). Previous surgical history increased postoperative 1st hour pain scores (OR: 13.8; 95% CI 1.7-113.3; p = 0.01). There was a significant negative correlation between pain scores at PACU, postoperative 1st, 2nd, 4th, 6th, 12th and satisfaction levels (r = -0.45, r = -0.56, r = -0.60, r = -0.54, r = -0.52, r = -0,43, respectively, p < 0.05).

DISCUSSION

Ultrasound-guided TAP blocks can be performed safely in children in lower abdominal surgeries. However, the efficacy of TAP block on late term postoperative pain scores is limited. Time interval between the TAP block and the incision, sex, and pain memory, as well as other factors that may improve the quality of TAP block should be considered.

Transversus abdominis plane block with different bupivacaine concentrations in children undergoing unilateral inguinal hernia repair: a single-blind randomized clinical trial

BACKGROUND

Current knowledge on the ideal local anesthetic concentration for the ultrasound-guided transversus abdominis plane block (TAPB) in pediatrics is scarce. The purpose of this study is to compare the efficacy of US-guided TAPB at two different concentrations of bupivacaine in pediatrics undergoing unilateral inguinal hernia repair.

METHODS

After random allocation, 74 children aged 1-8 were randomized to receive US-guided TAPB by using 1 mg.kg^- 1 bupivacaine as either 0,25% (0,4 ml.kg^- 1) (Group 1) or 0,125% (0,8 ml.kg^- 1) (Group 2) concentration. All blocks were performed under general anesthesia, immediately after the induction, unilaterally with a lateral approach. All subjects received intravenous 15 mg/kg paracetamol 0.15 mg/kg dexamethasone and 0.1 mg/kg ondansetron intraoperatively. The primary outcome was the efficacy which is assessed by postoperative FLACC behavioral pain assessment score at 15', 30', 45', 1 h, 2 h, 6 h, and 24 h. The secondary outcomes were to assess the total dose of rescue analgesic consumption, length of hospital stay, the incidence of side effects, complications and satisfaction levels of the patients' parents and the surgeons.

RESULTS

Sixty-four children were recruited for the study. Postoperative pain scores were equal between the two groups. There was no need for a rescue analgesic in any group after the postoperative 6^thhour. No local or systemic complication or side effect related to anesthesia or surgery was reported.

CONCLUSION

TAPB using 1 mg.kg^- 1 bupivacaine administered as either high volume/low concentration or low volume/high concentration was providing both adequate analgesia and no side effects.

TRIAL REGISTRATION

This trial was retrospectively registered at Clinicaltrals.gov , NCT04202367 .

Comparison of rectus sheath block and local anesthetic for analgesia in pediatric umbilical hernia repair: A systematic review and meta-analysis

BACKGROUND

Pediatric umbilical hernia repair could cause considerable postoperative discomfort. This study aimed to compare the analgesia between rectus sheath block and local anesthetic infiltration in child pediatric umbilical hernia repair.

METHODS

The relevant randomized controlled trials were searched from PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases from its inception to October 2020. The random-effects model was used for meta-analysis.

RESULTS

Four randomized controlled trials were included in the meta-analysis. The 4 studies were published between 2006 and 2017, with sample sizes ranging from 13 to 52 and a total of 143 individuals across the 4 studies. The Jadad scores of the 4 included studies ranged from 4 to 5, and all 4 studies were considered high quality based on quality assessment. There was no difference in analgesic effect at 10 minutes (standardized mean difference [SMD] = -0.19; 95% confidence interval [CI] = -1.52 to 1.16; P = .78), 30 minutes (SMD = -0.37; 95% CI = -1.53 to 0.78; P = .52), 1 hour (SMD = -0.73; 95% CI = -2.00 to 0.53; P = .26) after surgery. Besides, there was no significant difference in postoperative nausea (risk ratio = 0.95; 95% CI = 0.18 to 5.02; P = .95) and postoperative morphine use in morphine equivalents (mean difference = -0.95; 95% CI = -0.06 to 0.01; P = .12).

CONCLUSION

Rectus sheath block and local anesthetic are effective methods for analgesia in pediatric umbilical hernia repair.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Mechanisms of action of fascial plane blocks: a narrative review

BACKGROUND

Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks.

OBJECTIVES

This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research.

FINDINGS

There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain.

CONCLUSION

Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

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.

Comparison of Analgesic Efficacy of Ultrasound-Guided Transversus Abdominus Plane Block and Caudal Block for Inguinal Hernia Repair in Pediatric Population: A Single-Blinded, Randomized Controlled Study

Background:

Caudal analgesia was a widely practiced regional anesthesia technique in pediatric population. Transversus abdominus plane block (TAP) block has recently emerged as a promising analgesic method in pediatric lower abdominal surgeries.

Aim:

This study aimed to compare the analgesic efficacy of ultrasound-guided TAP block and caudal block.

Setting:

This study was conducted in the department of anesthesiology of a tertiary care teaching hospital.

Design:

This was a prospective, single-blinded, randomized controlled study.

Materials and Methods:

Sixty-two children of American Society of Anesthesiologists Class I and II undergoing inguinal hernia repair received TAP block at a dose of 0.5 ml.kg^{− 1} of 0.25% bupivacaine (Group A) or caudal block at a dose of 1 ml.kg^{− 1} of 0.25% bupivacaine (Group B) after randomization. The children were analyzed by comparing the post operative pain scores and duration of analgesia. Statistical analysis was done with IBM SPSS software 23 version. Unpaired sample t-test and Mann–Whitney U-test were used to compare the means of continuous variables. Fisher's exact test/Chi-square test was used to find the association between categorical variables.

Results:

Both groups were comparable in terms of age, gender, weight, and surgery duration. Duration of analgesia was longer in TAP block group compared to that of caudal analgesia (12.93 ± 2.91 h vs. 6.52 ± 1.67 P < 0.001). The postoperative pain scores were comparable up to 6 h and at 24 h. Pain scores at 12 h and 18 h were significantly higher in caudal analgesia group compared to that of TAP block group.

Conclusion:

Children who received TAP block had prolonged duration of analgesia and lower pain scores compared to those who received caudal analgesia.

[Peripheral truncal blocks-Overview and assessment]

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.

The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis

Objective

Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients.

Methods

The studies comparing TAP-block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis.

Results

We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47-21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47-1.22) but not statistically significant.

Conclusion

Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].

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.

Anesthetic management of a child with congenital Steiner syndrome scheduled for laparoscopic bilateral orchidopexy

Congenital Steinert syndrome is a severe form of myotonic dystrophy, characterized by general hypotonia, facial diplegia, respiratory difficulty and sucking and swallowing problems presented since birth. This syndrome has an estimated incidence of 1 per 10.000 births. Mortality is close to 50% during the neonatal period. It represents a challenge for the anesthesiologist due to the great variety of intraoperative and postoperative adverse events, given by both the evolution of the disease and the susceptibility to the vast majority of the anesthetic agents. A report of a 3-year-old boy with congenital myotonic dystrophy is presented, scheduled for laparoscopic bilateral orchidopexy, performed under general anesthesia without muscular relaxation, combined with ecoguide bilateral TAP block.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries

Background and Aims:

The purpose of this study was to compare the analgesic efficacy of ultrasonography-guided transversus abdominis plane (TAP) blocks with local port site infiltration in children undergoing laparoscopic surgeries.

Methods:

After ethics committee approval and informed consent, 92 children aged 2–12 years posted for laparoscopic surgeries were randomly divided into Group T and Group L. Port site infiltration was performed in Group L by the surgeon at the time of port placement and end of surgery with 0.4mL/kg of 0.25% bupivacaine. Bilateral TAP block was performed in Group T after induction of anaesthesia, under ultrasonographic guidance with a Logiq E7 GE portable ultrasound unit and a linear 5–10 MHz probe. A 22G hypodermic needle and 0.4 mL/kg of 0.25% bupivacaine were used on each side for the TAP block. The parameters recorded were intraoperative haemodynamics, opioid requirements, postoperative pain scores and the need for rescue analgesia in the first 6 h postoperatively.

Results:

The median (interquartile range) pain scores were significantly lower in the TAP block group than the local infiltration group at 10 min [2 (0–2.5) vs 2 (3–4); P = 0.011], 30 min [1.5 (0–3) vs 3 (2–5);P < 0.001], 1 h [1.5 (0–2) vs 2 (2–3);P < 0.001] and 2 h [2 (0–2) vs 2 (1.5–2.5); P = 0.010] postoperatively. The need for intraoperative opioids and rescue analgesia was also significantly lower in the TAP block group (P < 0.001).

Conclusion:

TAP block is superior to local infiltration for intra- and immediate postoperative analgesia in paediatric laparoscopic surgeries.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

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.

Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes

Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.

Epidural analgesia in a paediatric teaching hospital: Trends, developments, and a brief review of literature

Introduction:

Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital.

Methods:

Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital. Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants used, as well as postoperative infusion rates, were then analysed retrospectively.

Results:

There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in preference of LAs and adjuvant drugs toward safer alternatives.

Conclusion:

Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls.

Development of a novel technique for bilateral rectus sheath nerve blocks under laparoscopic-guidance

BACKGROUND

Bilateral rectus sheath blocks have proven to be superior to local anesthetic infiltration for umbilical incisions and have been gaining popularity for the treatment of perioperative pain in children. We aim to develop a technique of surgeon performed rectus sheath blocks under laparoscopic-guidance alone.

METHODS

In phase I, we observed the laparoscopic appearance of a rectus sheath block. The pain management team performed an ultrasound-guided rectus sheath nerve block as we visualized the posterior rectus sheath with the laparoscope. In phase II, after completion of the laparoscopic procedure, we performed a rectus sheath nerve block. Ultrasound was used to identify where the local anesthetic had been injected.

RESULTS

Nineteen patients were included in this study, accounting for 38 rectus sheath blocks. In phase I, we observed with the laparoscope the delivery of ten ultrasound-guided rectus sheath blocks. In phase II, 28 laparoscopic-guided rectus sheath blocks were completed with immediate ultrasound confirmation of correct placement.

CONCLUSIONS

We have demonstrated that the rectus sheath nerve block can be performed reliably under laparoscopic-guidance alone. The efficacy of the laparoscopic-guided nerve block compared to the ultrasound-guided approach will need further study in a prospective, randomized trial.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

3.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

BACKGROUND

Regional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair.

METHODS

A single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong-Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay.

RESULTS

Fifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar.

CONCLUSION

Following umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted.

TYPE OF STUDY

Randomized controlled trial.

LEVEL OF EVIDENCE

Level I.

A history of the treatment of appendicitis in children: lessons learned

During the latter half of the 19th century, surgeons increasingly reported performing appendicectomies. Fitz from Harvard, Groves from Canada and Tait from Britain all recorded successful removal of the appendix. McBurney described the point of maximal tenderness in classic appendicitis and also the muscle-splitting incision centred on this point. Priority is given to McArthur in describing the lateral muscle-splitting incision. The direction of the cutaneous incision was later modified by Elliott and Lanz. Incisions that healed well were essential to recovery. Appendicectomy became a 'fashionable' operation after the London surgeon, Treves, removed the appendix of King Edward VII. Through the 20th century, the mortality from appendicitis fell notably with the advent of sulphonamide and penicillin, improvements in fluid therapy and safer anaesthesia. By 1990, diagnostic delay was the main cause of death. Semm performed the first laparoscopic appendicectomy in 1990, roundly criticized at the time for what is now a routine procedure. We view contemporary debates on the indications for appendicectomy, the best approach and how to optimize recovery in the light of the history of this intriguing disease.