A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

Background

Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery.

Methods

Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events.

Results

There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787).

Conclusion

Our observations found both interventions had an overall similar efficacy.

Trial registration

The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

Comparison of ultrasound-guided transmuscular quadratus lumborum block catheter technique with surgical pre-peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85 years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20 ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5 ml.h^-1 , continued up to 48 h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48 h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p = 0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p = 0.036) and satisfaction scores on days 1 and 30 (p = 0.004, p = 0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

The effect of sevoflurane on the transmural dispersion of repolarisation in patients with type 2 diabetes mellitus: a prospective observational study

The 'torsadogenic' property of a drug is linked to its ability to increase the transmural dispersion of repolarisation, represented by the interval between the peak of, and the end of, the T-wave (Tp-e interval) in an electrocardiogram. Reports have consistently shown that sevoflurane does not increase the Tp-e interval. Type 2 diabetes is a risk factor for increased QTc (rate-corrected QT interval), QTcd (rate-corrected QTc dispersion: difference between the maximum and the minimum QTc interval), and Tp-e, as well as the rate-corrected Tp-e (Tp-e/QTc ratio). The study aimed to ascertain whether sevoflurane increased the Tp-e interval and Tp-e/QTc ratio in patients with diabetes, thereby increasing their risk of torsades. We enrolled 35 female patients; 17 with type 2 diabetes and 18 controls undergoing non-laparoscopic surgery under sevoflurane anaesthesia. The Tp-e interval, Tp-e/QTc ratio, QTc and QTcd were recorded after intubation, 5, 10, 30 and 60 minutes into the anaesthetic, and were compared between the groups. No significant increase in the Tp-e interval or Tp-e/QTc was observed between or within the groups (a 13 ms increase was considered significant). In the control group, the QTc was significantly increased from baseline immediately after intubation (449 versus 414 ms, <i>P</i> <0.001); at 5 minutes (434 versus 414 ms, <i>P</i>=0.01); at 10 minutes (444 versus 414 ms, <i>P</i>=0.002); at 30 minutes (439 versus 414 ms, <i>P</i>=0.001) and at 60 minutes (442 versus 414 ms; <i>P</i> <0.001) (a 20 ms increase was considered significant). No significant increase in QTc was observed in the diabetic group. There were no between or within group differences observed for QTcd. Our findings suggest that sevoflurane does not have a significant predictable pro-arrhythmic effect in type 2 diabetic patients in the absence of other factors affecting ventricular repolarisation.

'Speaking valve' aspiration in a laryngectomy patient

Tracheo-oesophageal speech using a one-way speaking valve is a common mode of speech rehabilitation for laryngectomy patients. Aspiration of this device can cause significant airway obstruction and pose anaesthetic and surgical challenges during its retrieval. In this case report, we describe our management of a patient who had had a laryngectomy who aspirated his speaking valve through his stoma. Emergency retrieval of the valve was performed, during which difficulties were encountered, first in obtaining an adequate seal for pre-oxygenation, and second in maintaining adequate oxygen saturation. We discuss some innovative techniques that could be used to address these issues.

Relative efficiency of two warming devices during laparoscopic cholecystectomy

Intraoperative hypothermia is a known consequence of general anaesthesia. Forced air warming devices are commonly used to prevent hypothermia in anaesthesia, but there are limited data on the use of radiant warming devices. Previous trials comparing the efficacy of forced air and radiant warming devices have reported discordant results. The current study evaluated the efficacy of these devices during elective laparoscopic cholecystectomy, where surgery was expected to last > 60 minutes. Twenty-nine patients were randomised to either a forced air warming device (Warm-touch; group 1, n = 15) or a radiant warming device applied to the face (Sun-touch; group 2, n = 14). All fluids were given via a standardised fluid warmer set at 41 degrees C. Oesophageal temperature was measured every 15 minutes until the end of the procedure. Between-group, over-time temperatures and interaction were analysed using a linear mixed model. Statistical significance was ascribed at P < or = 0.05. The median (range) time of surgery was 90 (60 to 180) minutes. Mean (SD) oesophageal temperatures in the Warm-touch and Sun-touch groups were at 15 minutes 36.2 (0.30) degrees C and 36.2 (0.57) degrees C, and at 90 minutes 36.2 (0.44) degrees C and 35.9 (0.29) degrees C respectively. There was no statistically significant temperature difference between groups (P = 0.69) or over time (P = 0.61), and no interaction between time and treatment group (P = 0.97). Postoperative headache was recorded in four Sun-touch and no Warm-touch patients (P = 0.04). No difference in the efficacy of the Sun-touch warming device compared with the Warm-touch was demonstrated. Operational-mode side-effects may limit the use of the Sun-touch device.