Comparison of postoperative analgesia and opioid requirement with thoracic epidural vs. continuous rectus sheath infusion in midline incision laparotomies under general anaesthesia – A prospective randomised controlled study

Abstract

Background and Aims: To assess and compare the effect of bilateral continuous rectus sheath infusion (CRSB) for postoperative analgesia with continuous thoracic epidural infusion (TEA) in patients undergoing midline incision laparotomies. Methods: A prospective, randomised study involving sixty patients with Indian Society of Anesthesiologists (ASA) grade I to III, planned for elective laparotomy were enrolled for the study. Patients were randomly allocated into two groups. In the TEA group, an epidural was sited before induction of general anaesthesia (GA), whereas in the CRSB group, bilateral ultrasound-guided RSB catheters were placed at the end of the surgical procedure, before extubation. Both groups received continuous 0.2% Ropivacaine infusion for postoperative analgesia. They were followed for two post-operative days (POD), for the opioid requirement and post-operative pain at rest, coughing, and moving. Age and body mass index (BMI) were compared using independent t -test and visual analogue scale (VAS) scores were compared by the Mann–Whitney test between the two groups. Opioid consumption, gender, and type of surgery were compared using the Chi-Square test. Statistical analysis was done using Statistical Package for Social Sciences (SPSS 21.0). Results: Opioid consumption in both groups was comparable, for the first two post-operative days with no statistically significant difference. Pain scores were comparable among the groups at all times except postoperative day (POD) 0 (4 h and 12 h postop) and POD 2 (8 AM and 12 PM), where lower pain scores were observed in CRSB Group. Conclusions: As a part of the multimodal analgesia technique, CRSB offers a reliable, safe, and effective alternative to TEA.

Comparison of the effectiveness of thoracic epidural and rectus sheath catheter as analgesic modalities following laparotomy: A systematic review and meta-analysis

“…However, in the recent randomised control studies, Gupta et al (2020) have suggested there was no significant difference in PRN opioid requirements between RSCs and TEs, though they did find the time until initial opioid request was significantly longer in the TEs cohort. Furthermore, Yassin et al (2017) found a lower cumulative opioid requirement over the first 72 hours in the cohort who received TEs.…”

“…The optimal analgesia choice between RSCs and TEs is still widely debated and both modalities are still utilised (Gupta et al 2020). The aim of this meta-analysis and systematic review is to compare the analgesic effects and side effects profile of TE and RSC in the setting of emergency or elective laparotomy.…”

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

“…Three of the RCTs compared RSB to general anaesthetic alone, saline use in identically placed catheters or rescue analgesia: in all, RSB associated with significantly better pain relief and opioid consumption 31–33. The remaining four RCTs and all four retrospective studies compared RSB to TEA 34–41. Apart from two RCTs that showed higher postoperative opioid consumption in RSB,34 37 and one who highlighted less pain on POD 1 but higher pain scores and more morphine consumption on POD 3 in TEA,36 these studies did not observe major differences in postoperative opioid consumption, pain scores, patient satisfaction, LOS or side effects 35–41.…”

“…Another anterior abdominal-wall anaesthetic block is the posterior rectus-sheath block (RSB), which targets the anterior nervous branches of the same dermatomes as TAP (T6 to L1) to anaesthetise the medial abdominal quadrants 30. It is much less well studied than TAP: when limiting the studies to those in the last decade due to changes in clinical practices, the literature reveals seven RCTs31–37 and four retrospective cohort studies38–41 (table 1). Only two of these RCTs included more than 100 patients: Tueki et al 37 and the TERSC study (Krige et al ),36 with, respectively, 50 and 65 patients in each arm.…”

Opioid-free anaesthesia: The conundrum and the solutions

“…[ 1 2 ] Restricting opioid use in anaesthesia has shown variable effectiveness in different surgeries and patient population. [ 3 4 5 6 ] Whereas on one hand, the opioid consumption is reduced intraoperatively, effective nociception and reduction in postoperative opioid consumption is still under investigation with OFA/OSA. [ 7 ] Number of alternate analgesics and analgesic adjuncts are usually employed to replace or reduce perioperative opioids.…”