Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study

Abstract

Background: We explored the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received intravenous patient-controlled analgesia (IV-PCA), rectus sheath bupivacaine block (RSB), or intrathecal morphine with bupivacaine block (ITMB). Methods: This was a prospective, observational clinical trial. Patients were divided into three groups: IV-PCA (n = 30), RSB (n = 30), and ITMB (n = 30). Peak pain scores at rest and with coughing, cumulative IV-PCA drug consumption, the need for IV rescue opioids, and Quality of Recovery-15 (QoR-15) questionnaire scores collected on POD 1 were compared among the groups.Results: The preoperative and intraoperative findings were comparable among the groups; the ITMB group required the least remifentanil of all groups. During POD 1, the ITMB group reported lower levels of pain at rest and with coughing, compared with the other two groups. During POD 1, incidences of severe pain at rest (10.0% vs. 23.3% vs. 40.0%) and with coughing (16.7% vs. 36.7% vs. 66.7%) were the lowest in the ITMB group compared with the RSB and IV-PCA groups, respectively. After adjustment for age, body mass index, diabetes mellitus, hypertension, and intraoperative remifentanil infusion, severe pain at rest was 0.167-fold less common in the ITMB group than in the IV-PCA group, while pain with coughing was 0.1-fold lower in the ITMB group and 0.306-fold lower in the RSB group, compared with the IV-PCA group. The ITMB group required lower cumulative IV-PCA drug infusions and less IV rescue opioids, while exhibiting a better QoR-15 global score, compared with the other two groups. Complications (nausea and pruritus) were significantly more common in the ITMB group than in the other two groups; however, we noted no ITMB- or RSB-related anesthetic complications (respiratory depression, post-dural headache, nerve injury, or puncture site hematoma or infection), and all patients were assessed as Clavien-Dindo grade I or II during the hospital stay.Conclusion: Although ITMB induced complications of nausea and pruritus, this analgesic technique provided appropriate pain relief that enhanced patient perception related to early postoperative recovery.Trial registration: Clinical Research Information Service, Republic of Korea, (approval number: KCT0005040) on May 20, 2020https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=15943&sLeft=2&ltype=my&rtype=my

Complications and Technical Consideration of Ultrasound-Guided Rectus Sheath Blocks: A Retrospective Analysis of 4033 Patients

“…17,18 However, others also described the inplane approach from a medial-to-lateral direction. [13][14][15][16] As the anterior cutaneous branches enter the rectus sheath at its lateral border, the local anesthetic administered should be reached at the lateral edge of the rectus sheath to ensure complete block. Because there was no study investigating whether the analgesic effect of RSB is different depending on needle direction, a medial-to-lateral approach was determined in this study so that all injectates could be located at the lateral edge of the rectus sheath.…”

“…12 Furthermore, the needle was inserted medially to laterally using the in-plane method in this study since depositing local anesthetic on the lateral edge of the posterior rectus sheath is necessary for achieving an adequate block. [13][14][15][16] However, this method can differ from other methods using a blunt needle 14 or lateral-to-medial approach. 17,18 Once the needle tip was visually positioned in the plane between the lateral side of the rectus abdominis muscle and the posterior rectus sheath, 15-20 mL of 0.375% ropivacaine per side was administered to the patient, ensuring no blood regurgitation using the negative aspiration test.…”