Effects of Ultrasonography-Guided Plan Blocks (ESP&OSTAP) on Perioperative Analgesia in Laparoscopic Hysterectomies
Phase: NA
Conditions: Pain, Postoperative
Sponsor: Balikesir University

THE EFFECTS OF PLANNING BLOCKS (ESP&OSTAP) APPLIED WITH ULTRASOUND ON
PERIOPERATIVE ANALGESIA IN LAPAROSCOPIC HYSTERECTOMIES
INTRODUCTION
Hysterectomy is the most common major intervention in gynecology after cesarean section.
Among the indications are myoma uteri, abnormal uterine bleeding, cervical intraepithelial neoplasia
chronic pelvic pain, desensus uterine, operated breast cancer, and endometrial considered
hyperplasia. Hysterectomy today It can be done abdominal , vaginal and laparoscopic.¹ Laparoscopic
Hysterectomy (LH) has several advantages and disadvantages over other forms of hysterectomy .
Shorter recovery time, less wound infection, shorter hospital stay, and less need for postoperative
analgesia can be counted among the advantages. Prolongation of the operation time and urinary the
increased risk of complications constitutes its disadvantages.²
Pain management after laparoscopic operations is of critical importance. In case of poor
management of postoperative pain, pulmonary diseases such as atelectasis and pneumonia , which
increase morbidity and mortality after anesthesia and surgery, complications , cardiac dysfunctions
due to increased workload of the heart, gastrointestinal gastrointestinal disturbances such as nausea-
vomiting
dysfunctions,
urinary
retention,
immunosuppression,
anxiety,
depression,
and
neuroendocrine system dysfunctions.³
Postoperative pain management can be done with different methods depending on the location of
the surgical field, the type of surgical procedure, the patient's analgesia needs and patient preference.
These methods include oral, intravenous or intramuscular medication and nerve blocks. The "balanced
analgesia" method is used to minimize the side effects of opioids used in analgesic therapy such as
respiratory depression, nausea-vomiting, lethargy, constipation , itching and to increase the analgesic
effect.⁴ With this method, opioids , non-opioid analgesics or peripheral nerve-field blocks are used.
side effects are minimized and optimum analgesia is provided .
Transversus, one of the abdominal field blocks abdominis plane (TAP) block was first described by
Rafi in 2001.⁶ Hebbard et al. stated in 2007 that ultrasound (US)-guided TAP block can be applied more
effectively and reliably.⁷ This block can be performed with antero-lateral , posterior and oblique It can
be done subcostal with three different approaches. TAP block has been shown to reduce postoperative
pain after hysterectomy , cesarean section, and colorectal surgery.⁸
Erector spina plan (ESP) block was first described by Forero et al. in 2016 on a patient with chronic
neuropathic pain.⁹ The basic technique is performed paraspinally under US guidance . It is used for
postoperative analgesia in breast, thoracic surgeries, hernia repair, dorsal colon, abdomen and hip
surgery .
In this study, total laparoscopic US-guided erector in hysterectomy surgeries spina plan (ESP) block and
oblique subcostal transversus We aimed to compare the effect of abdominis plan (OSTAP) block
applications on perioperative pain control.
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METHODS AND MATERIALS
Patients between the ages of 18-65, ASA I-II, BMI ≤30 kg/m2 who will undergo elective surgery under
general anesthesia, with voluntary consent will be included in the study . Local anesthetic patients with
allergy , coagulopathy , infection at the block application site and mental deficiency and for whom the
surgical plan has been changed ( complicated / open surgery) will be excluded from the study.
Numerical rating scale (NRS: Numeric ) for the evaluation of patient-controlled analgesia (PCA) and
pain intensity before the operation in the patients included in the study. Rating Scale ) will be given.
Demographic data of the patients will be recorded.
Anesthesia Application:
After the intravenous (IV) route is provided with a 20 G cannula in the preoperative preparation room,
10 mL /kg of balanced crystalloid fluid infusion will be started. 0.03 mg/kg midazolam will be
administered for premedication . Standard monitoring (ECG, heart rate, non- invasive blood pressure ,
SPO2 , temperature) and neuromuscular monitoring will be implemented. The input value of these
parameters will be saved before induction. Records will be taken at 5-minute intervals until the end of
the operation. For anesthesia induction, 2 mg/kg propofol and 1μg/kg remifentanil will be
administered as an IV bolus within 60 seconds . Maintenance of analgesia 0.05-0.25 μg /kg/ min
remifentanil provided by infusion . Muscle relaxation will be provided with IV 0.6 mg/kg rocuronium .
He will be intubated orotracheally when his train of four rate (TOFR) response is zero . ( Neuromuscular
In case of blocker requirement, IV 0.1 mg/kg rocuronium will be additionally administered.) Anesthesia
maintenance 0.5 L/ min fresh gas flow, oxygen concentration between 40-45 inspiratory oxygen levels,
minimum alveolarIt will be administered with sevoflurane at a concentration (MAK) of 1.0 . mechanical
ventilation It will be done in volume controlled mode with ETCO 2 between 35-40 mmHg .
Randomly divided into two groups after induction .
Group I : Erector The group to which Spina Plan Block (ESP) will be applied
Group II : Oblique subcostal transversus The group to which the Abdominis Plan Block (OSTAP) will be
applied
In the study, anesthesia induction and plan blocks will be performed by the same anesthesiologist.
Intraoperative and postoperative data recording and patient evaluation will be done by two separate
anesthesiologists.
ESP Block Application :
Post-induction lateral US ( Sonosite M-Turbo) machine, linear 6-13 mHz , in accordance with the rules of
asepsis-antisepsis in the decubitus position probe approximately 3 cm lateral to the T9 spinous
process. The hyperechoic shadow of the transverse process and the erector will be placed in the
sagittal plane and with an in- plane approach. After identifying the spinae muscle (ESM) 22 G, 80 mm
Stimuplex ® Ultra 360® (B.Braun , Melsungen , Germany) needle, erector It will be inserted in the
cephalocaudal direction to gently contact the T9 spinous process over the spinae . 1-2 mL after
negative pressure aspiration between the transverse process and ECM local by injecting anesthetic,
after observing its cephalocaudal spread, a total of 20 mL 0.25 mg/ mL bupivacaine will be given by
intermittent aspiration every 4-5 mL . The same procedure will be applied to the other side.
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OSTAP Block Application:
In the supine position after induction, US (Sonosite M-Turbo) machine, linear 6-13 mHz, in accordance
with the rules of asepsis-antisepsis probe in anterior axillary line, anterosuperior to xiphoid rectus by
placing it on the subcostal lower edge between the iliac crest abdominis and transversus abdominis
muscles will be imaged. Then 22 G, 80 mm Stimuplex® Ultra 360® (B.Braun , Melsungen , Germany)
needle rectus It is directed in- plane from 2-3 cm medial of the abdominis muscle , transversus
abdominis and rectus 1-2 mL with negative pressure aspiration between the abdominis muscles local
anesthetic will be injected. After local anesthetic spillover is observed, a total of 20 mL 0.25 mg/ mL
bupivacaine will be given by intermittent aspiration every 4-5 mL . The same procedure will be applied to
the other side.
Surgical incision will be made 15 minutes after block applications . Patients will undergo standard
surgical procedures. The patients will be operated in the 45⁰ trendelenburg position and the
pneumoperitoneum pressure is 10-12 mmHg . In case of (±) 15% change in the hemodynamic
parameters of the patient from the baseline values, remifentanil The infusion dose will be increased or
decreased at the specified intervals and the amount consumed intraoperatively at the end of the
operation will be recorded. It will be defined as hypotension when the systolic arterial pressure
decreases by 30% from the baseline value. Before treatment, 250 mL 0.9 % NaCl will be infused quickly .
If there is no response, 10 mg of ephedrine will be given IV. When bradycardia occurs (heart rate <50
beats/ min) IV 0.5 mg of atropine will be administered. The time from the skin incision to the end of the
surgical procedure will be recorded as "Operation Time ".
Sevoflurane flow and remifentanil 15 minutes before the end of the operation infusion will be
terminated. 50 mg dexketoprofen was given to the patients. trometamol IV and 1 g paracetamol IV
infusion will be administered. At the end of the operation, the fresh gas flow will be increased to 8 L/
min . neuromuscular 4 mg/kg sugammadex IV will be administered to end the blockade . When the
TOFR is 0.9, he will be extubated and transferred to the postoperative recovery unit (PACU). The time
between termination of sevoflurane flow and extubation will be recorded as " Extubation time" , and
the time between anesthesia induction and extubation will be recorded as "Anesthesia Time ".
Patient-controlled analgesia (PCA) and morphine infusion will be administered to both groups of
patients in the PACU .
Morphine protocol : It will be prepared as 1 mg/ mL with 5 mL Morphine Sulphate (50mg) + 45 mL
physiological saline . It will be administered as an intermittent bolus of 1 mg, without basal infusion ,
with a 20-minute lock-in time.
Postoperative pain intensity, sedation level and nausea-vomiting score at rest and in motion will be
evaluated at 0, 2, 4, 6, 12 and 24 hours by an anesthesiologist who is not familiar with the study groups.
The severity of pain will be evaluated with NRS at rest and in motion (0: No pain 1 2 3 4 5 6 7 8 9 10:
Unbearable pain) If NRS≥4, dexketoprofen as a rescue analgesic Trometamol 50 mg IV will be
administered.
"Observer's Alertness and Sedation Evaluation Scale" for monitoring the sedation level of the patient
Observer's assessment of the Alertness / Sedation (OAA/S) will be used.
Nausea will be measured with 4 categorical scoring systems (No nausea: 0, Mild: 1, Moderate: 2,
Severe: 3) For the treatment of nausea-vomiting, 4mg ondansetron will be administered IV. modified
Patients with an Aldrete score of ≥9 will be discharged to the ward. The time elapsed between the
patient's admission to the PACU and discharge to the service will be recorded as " Recovery Time ".
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RESOURCES
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JH.
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of
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627a
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NRS ( Numeric Rating Scale- Numerical Pain Rating Scale)
0
one
2
3
4
5
6
7
8
9
10
No pain Mild Pain Moderate Severe Pain Very Severe Pain
0: No pain
10: Unbearable pain
OAA/S (Observer's Alertness and Sedation Rating Scale)
Does not respond even when squeezing trapezius muscle
Responds when squeezing trapezius muscle
Responds to light shaking or shaking
Responds when you repeat his name in a loud voice
Responds sleepily when called by name in normal tone
Responds when called by name in normal tone
0 points
1 point
2 points
3 points
4 points
5 points
SCORING OF NAUSEA-VOMITING
NO
LIGHT
MIDDLE
SERIOUS
1.0
0 points
1 point
2 points
3 points
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modified Aldrete Scoring
Activity(Order/Move)
Respiratory
Circulation
Consciousness
O 2 saturation
4 extremities
2 extremities
0 extremities
Deep breathing and comfortable coughing
Dyspnea , superficially limited breathing
apneic
blood pressure ± 20 mmHg preanesthetic period
Blood pressure ± 20-50 mmHg preanesthetic period
Blood pressure ±50 mmHg preanesthetic period
fully awake
Waking up by calling
No answer
>92% at room air
O2 inhalation required for 90% SpO2
< 90% with O 2 support
2 points
1 point
0 points
2 points
1 point
0 points
2 points
1 point
0 points
2 points
1 point
0 points
2 points
1 point
0 points
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