Reducing Postoperative Opioid Consumption by Adding an Ultrasound-Guided Rectus Sheath Block to Multimodal Analgesia for Abdominal Cancer Surgery With Midline Incision

Abstract

Background:Many multimodal analgesia techniques have been tried to provide adequate analgesia for midline incisions extending above and below the umbilicus aiming at limiting the perioperative use of morphine thus limiting side effects. Ultrasound (US) guidance made the anesthesiologist reconsider old techniques for wider clinical use. The rectus sheath block (RSB) is a useful technique under-utilized in the adult population.Objectives:Our study examined the efficacy of a preemptive single-injection rectus sheath block in providing better early postoperative pain scores compared to general anesthesia alone.Patients and Methods:Sixty patients were recruited in this randomized controlled trial. These patients were divided into two groups: RSB group had an RSB after induction of anesthesia and before surgical incision, and GA (general anesthesia) group had general anesthesia alone. Both groups were compared for verbal analogue scale (VAS) score, opioid consumption and hemodynamic variables in the post-anesthesia care unit (PACU). Analgesic requirements in surgical wards were recorded in postoperative days (POD) 0, 1 and 2.Results:The median VAS score was significantly lower in RSB group compared with GA group in all 5 time points in the PACU (P ˂ 0.05). Also PACU morphine consumption was lower in RSB group than GA group patients (95% confidence interval [CI] of the difference in means between groups, −4.59 to −2.23 mg). Morphine consumption was also less in the first 2 postoperative days (POD0 and POD1).Conclusions:Ultrasound-guided rectus sheath block is an easy technique to learn. This technique, when it is used with general anesthesia, will be more effective in reducing pain scores and opioid consumption compared with general anesthesia alone.

Ultrasound-guided truncal blocks for perioperative analgesia

“…Study reports have also demonstrated that this block provides effective pain control in surgeries involving midline incisions [60,61]. The rectus sheath block can be used in combination with the TAP block for pain relief over a wider area in surgeries involving the anterior abdominal wall [57,62].…”

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

“…Bilateral single injection ultrasound‐guided rectus sheath blocks (UGRBs) are used for postoperative analgesia after midline abdominal incisions from the xyphoid superiorly, to the pubic symphysis inferiorly . To ensure adequate blockade of multiple branches of intercostal nerves , the spread of anesthetic should match the length of the incision .…”

“…Bilateral single injection ultrasound-guided rectus sheath blocks (UGRBs) are used for postoperative analgesia after midline abdominal incisions from the xyphoid superiorly, to the pubic symphysis inferiorly. [1][2][3][4][5][6][7][8][9] To ensure adequate blockade of multiple branches of intercostal nerves, the spread of anesthetic should match the length of the incision. Knowledge of the local anesthetic spread can help to determine the optimal site at which the local anesthetic via single injection should be administered, along with the volume of local anesthetic required to achieve the desired spread in the posterior rectus sheath.…”

Analgesic Benefits of Ultrasound-Guided Thoraco-Abdominal Wall Peripheral Nerve Blocks

“…Bashandy et al randomized 60 patients who were undergoing midline laparotomies for radical cancer resections to receive RSB with general anesthesia or general anesthesia alone [61]. Not only were pain scores significantly lower in the RSB group postoperatively, but also morphine consumption was less and consequently patients developed fewer side effects like respiratory depression, excessive sedation and postoperative nausea and vomiting [61].…”

“…Bashandy et al randomized 60 patients who were undergoing midline laparotomies for radical cancer resections to receive RSB with general anesthesia or general anesthesia alone [61]. Not only were pain scores significantly lower in the RSB group postoperatively, but also morphine consumption was less and consequently patients developed fewer side effects like respiratory depression, excessive sedation and postoperative nausea and vomiting [61]. In a retrospective case review of 98 patients undergoing major gynecologic surgery for benign or malignant disease, patients who received a rectus sheath block performed by the surgeons intraoperatively had lower pain scores on waking, required less morphine postoperatively, had their patient controlled analgesia (PCA) discontinued sooner, and went home earlier than patients receiving standard subcutaneous infiltration of the wound [62].…”