Effect of Ultrasound Guided Rectus Sheath Block on Postoperative Analgesia after Laparotomy with Transverse Incision in Children

Year 2015, , 534 - 541, 30.09.2015

Aydın Halefoğlu Ersel Güleç , Zehra Hatipoğlu Dilek Özcengiz

https://doi.org/10.17826/cutf.75186

Abstract

Purpose: Rectus sheath block have been used for postoperative pain control in adult patients undergoing abdominal surgery. To investigate the effect of the ultrasound guided rectus sheath block (RSB) with levobupivacaine on both intraoperative sevoflurane consumption and postoperative analgesia after laparotomy with transverse incision in children. Material and Methods: Forty patients with ASA I-II physical status, aged 3-7 years and undergoing laparotomy with transverse incision were randomly allocated into two groups. Patients were administered general anesthesia and before the beginning of surgery ultrasound guided RSB with 0.2 mL/kg, 0.25% of levobupivacaine and thirty minutes before the surgery the loading dose of morphine of 0.1 mg/kg intravenously were received in group RSB and group M, respectively. Analgesic drug pump with 0.01 mg/kg bolus doses of morphine and 30 minutes lockout interval was set up postoperatively in both groups. Concentrations (%) and consumed amounts (mL/h) of sevoflurane during the surgery and systolic and diastolic blood pressure, heart rate, and peripheral oxygen saturation values were recorded both intraoperative and postoperative period in each groups. Analgesic consumption with postoperative analgesic drug pump, FLACC pain scores, sedation level, nausea, vomiting, supplemental analgesic requirement and side effects were also recorded. Results: Demographic data and hemodynamic parameters were similar in both groups excepting that systolic arterial pressure values were reduced in group RSB than in group M. Inhaled concentration and consumed amounts of sevoflurane were decreased in group RSB compared with group M. Averages of consumptions of sevoflurane were 18.7±2.1 mL/h and 21.5 ±2.9 mL/h in group RSB and group M, respectively (p<0.001). Postoperative FLACC scores, sedation scores, and morphine consumption for 24 hours were lower in group RSB than in group M (p<0.001). Three patients had nausea in group M, however no nausea and vomiting was observed in group RSB and any patients did not need supplemental analgesia postoperatively. Conclusions: Ultrasound guided RSB is superior to intravenous morphine according to intraoperative anesthetic gas consumption and postoperative pain control in children undergoing abdominal surgery using transverse incision.

Keywords

Children, laparotomy, levobupivacaine, postoperative pain, rectus sheath block, ultrasound

Transvers Insizyonla Laparotomi Uygulanan Çocuklarda Ultrason Kılavuzluğunda Rektus Kılıf Bloğunun Postoperatif Analjezi Üzerine Etkisi

Abstract

Amaç: Rektus kılıf bloğu abdominal cerrahi geçirecek olan erişkin hastalarda postoperatif ağrı kontrolünde kullanılmaktadır. Çalışmamızda levobupivakain ile ultrason kılavuzluğunda rektus kılıf bloğunun çocuklarda transvers insizyon ile uygulanan laparatomide intraoperatif anestezik gaz tüketimi ve postoperatif analjezi üzerine etkisini araştırmayı amaçladık. Materyal ve Metod: Çalışmamızda 3-7 yaşları arasında ve fizik durumu ASA I-II olan transvers insizyon ile laparatomi uygulanacak 40 çocuk hasta rastlantısal olarak iki gruba yerleştirildi. Hastaların tamamına genel anestezi uygulandı. Grup RSB’ deki hastalara cerrahi başlamadan hemen önce 0,2 ml/kg, %0,25 levobupivakain ile ultrason kılavuzluğunda rektus kılıf bloğu uygulandı. Grup M’deki hastalara da cerrahi bitmeden 30 dakika önce intravenöz yolla 0,1 mg/kg morfin uygulandı. Tüm hastalara postoperatif dönemde 0,01 mg/kg morfin bolus doz ve 30 dakika kilit süresi olan bir analjezik ilaç pompası kuruldu. İntraoperatif kullanılan sevofluran konsantrasyonları ve tüketilen miktarları, hemodinamik değişkenler, periferik oksijen satürasyonlar kaydedildi. Postoperatif dönemde morfin tüketim miktarı, FLACC ağrı skorları, sedasyon seviyeleri, yan etkiler ve ek analjezik tüketimleri de kaydedildi. Bulgular: Demografik veriler ve hemodinamik değişkenler her iki grupta birbirine benzerdi. Ancak sistolik arter basınçları grup RSB’de grup M’ye göre anlamlı olarak daha düşüktü. Kullanılan sevofluran konsantrasyon seviyeleri ve tüketilen miktarları grup RSB’de grup M’ye göre anlamlı olarak düşüktü. Ortalama sevofluran tüketim miktarları grup RSB’de 18,7±2,1 ml/saat iken grup M’de 21,5 ±2,9 ml/saat idi (p<0.001). 24 saat boyunca postoperatif FLACC skorları, sedasyon skorları ve morfin tüketim miktarları grup RSB’de grup M’ye göre anlamlı düşüktü (p<0.001). Grup M’de 3 hastada bulantı görüldü bununla birlikte grup RSB’de hiçbir hastada bulantı veya kusma görülmedi. Hiçbir hastada postoperatif ek analjezik gereksinimi gözlenmedi. Sonuç: Ultrason kılavuzluğunda rektus kılıf bloğu, transvers insizyon uygulanan abdominal cerrahi geçiren çocuklarda intraoperatif anestezik gaz tüketimi ve postoperatif ağrı kontrolü yönünden intravenöz morfine göre daha üstündür.

Keywords

Çocuk, laparotomi, levobupivakain, postoperatif ağrı, rektus kılıf bloğu, ultrason

References

• Wong I, St John-Green C, Walker SM. Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children. Pediatr Anesth. 2013;23:475-95.
• Engelhardt T, Steel E, Johnston G, Veitch DY. Tramadol for pain relief in children undergoing tonsillectomy: a comparison with morphine. Pediatr Anesth. 2003;13:249-52.
• Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, et al. Postoperative pain. Pediatr Anesth. 2008;18:36-63.
• Gelfand HJ, Ouanes JP, Lesley MR, Ko PS, Murphy JD, Sumida SM, et al. Analgesic efficacy of ultrasound-guided regional anesthesia: a meta- analysis. J Clin Anesth. 2011;23:90-6.
• Isaac LA, McEwen J, Hayes JA, Crawford MW. A pilot study of the rectus sheath block for pain control after umbilical hernia repair. Paediatr Anaesth. 2006;16:406-9.
• Wada M, Kitayama M, Hashimoto H, Kudo T, Kudo M, Takada N, et al. Brief reports: plasma ropivacaine concentrations after ultrasound-guided rectus sheath block in patients undergoing lower abdominal surgery. Anesth Analg. 2012;114:230-2.
• Gurnaney HG, Maxwell LG, Kraemer FW, Goebel T, Nance ML, Ganesh A. Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair. Br J Anaesth. 2011;107:790-5.
• Ivani G, De Negri P, Lonnqvist PA, L'Erario M, Mossetti V, Difilippo A, et al. Caudal anesthesia for minor pediatric surgery: a prospective randomized comparison of ropivacaine 0.2% vs levobupivacaine 0.2%. Pediatr Anesth. 2005;15:491-4.
• Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23:293-7.
• Bhalla T, Sawardekar A, Dewhirst E, Jagannathan N, Tobias JD. Ultrasound-guided trunk and core blocks in infants and children. J Anesth. 2013;27:109- 23.
• Finnerty O, Carney J, McDonnell JG. Trunk blocks for abdominal surgery. Anaesthesia. 2010; 65:76-83.
• Dingeman RS, Barus LM, Chung HK, Clendenin DJ, Lee CS, Tracy S, et al. Ultrasonography-guided bilateral rectus sheath block vs local anesthetic infiltration after pediatric umbilical hernia repair: a prospective randomized clinical trial. JAMA surg. 2013;148:707-13.
• Willschke H, Bosenberg A, Marhofer P, Johnston S, Kettner SC, Wanzel O, et al. Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique. Br J Anaesth. 2006;97:244-9.
• Breschan C, Jost R, Stettner H, Feigl G, Semmelrock S, Graf G, et al. Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series. Pediatr Anesth. 2013;23:1199-204.
• Fredrickson MJ, Abeysekera Randomized study of the effect of local anesthetic volume and concentration on the duration of peripheral nerve blockade. Reg Anesth Pain Med. 2012;37:495-501. A, White R.
• Dolan J, Lucie P, Geary T, Smith M, Kenny GN. The rectus sheath block: accuracy of local anesthetic placement by trainee anesthesiologists using loss of resistance or ultrasound guidance. Reg Anesth Pain Med. 2009;34:247-50.
• de Jose Maria B, Gotzens V, Mabrok M. Ultrasound-guided umbilical nerve block in children: a brief description of a new approach. Pediatr Anesth. 2007;17:44-50.
• Sandeman DJ, Bennett M, Dilley AV, Perczuk A, Lim S, abdominis appendicectomy randomized trial. Br J Anaesth. 2011;106:882-6. prospective children: in a
• Ozalevli M, Unlugenc H, Tuncer U, Gunes Y, Ozcengiz D. Comparison of morphine and tramadol by patient-controlled analgesia for postoperative analgesia after tonsillectomy in children. Pediatr Anesth. 2005;15:979-84.
• Doyle E, Mottart KJ, Marshall C, Morton NS. Comparison of different bolus doses of morphine for patient-controlled analgesia in children. Br J Anaesth. 1994;72:160-3.
• Doyle E, Harper I, Morton NS. Patient-controlled analgesia with low dose background infusions after lower abdominal surgery in children. Br J Anaesth. 1993;71:818-22.
• Morton NS, O'Brien K. Analgesic efficacy of paracetamol and diclofenac in children receiving PCA morphine. Br J Anaesth. 1999;82:715-7. PubMed PMID: 10536549.
• Newman B, McCarthy L, Thomas PW, May P, Layzell M, Horn K. A comparison of pre-operative nerve stimulator-guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture. Anaesthesia. 2013;68:899- 903.
• Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy postoperative pain management: a meta-analysis. Anesth Analg. 2005;100:757-73, table of contents.
• Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence-based medicine: ultrasound guidance for truncal blocks. Reg Anesth Pain Med. 2010;35:36-42.