Rectus Sheath Block and Coadministration of Intravenous Dexamethasone for Analgesia After Pediatric Laparoscopic Appendectomy - A Pilot Study
Phase: NA
Conditions: Laparoscopic Appendectomy
Sponsor: University of British Columbia

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 1 of 19 
 
 
PROTOCOL 
Rectus Sheath Block and Coadministration of Intravenous Dexamethasone for 
Analgesia after Pediatric Laparoscopic Appendectomy – A Pilot Study 
[H23-03547] 
 
Principal Investigator:  
Dr Prakash Krishnan (prakash.krishnan@cw.bc.ca) 
Department of Anesthesiology, Pharmacology & Therapeutics, 
University of British Columbia  
BC Children’s Hospital Research Institute 
Department of Anesthesia, BC Children’s Hospital  
Vancouver, BC, Canada 
Tel: 604-875-2000 x5616  
Co-investigators:  
 
Dr Rory Blackler (rory.blackler@cw.bc.ca) 
Department of Anesthesia, BC Children’s Hospital  
Vancouver, BC, Canada 
Dr Hannah Piper (hannah.piper@cw.bc.ca)  
Department of General Surgery, BC Children’s Hospital 
Vancouver, BC, Canada 
Primary contact 
 
Steffanie Fisher (steffanie.fisher@cw.bc.ca)  
Pediatric Anesthesia Research Team (PART), BC Children's  
Hospital, 
 
 
 
 
Vancouver, BC, Canada 
 
 
 
 
Tel: 604-875-2000 x1989 
 
 
 
 
 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 2 of 19 
 
1. INTRODUCTION 
One in three pediatric patients who undergo a laparoscopic appendectomy experience 
substantial post-operative pain.1 Post-operative pain often results in the prescription of opioid 
medication that can delay recovery due to its side effects of sedation, respiratory depression, 
nausea, and constipation; all of which can lead to postoperative complications, patient 
dissatisfaction, 
and 
delayed 
discharge.2 
In 
the 
pediatric 
population, 
laparoscopic 
appendectomies result in approximately two-thirds of patients requiring post-operative opioids 
despite the routine use of local anesthetic (LA) infiltration at the incision sites by the surgeon.3 
There is a need to optimize the analgesia management of these patients. Regional anesthetic 
techniques for analgesia in pediatric abdominal surgeries reduce opioid requirements, enhance 
recovery time, and have a proven safety record.4,5,6 Specifically, the rectus sheath block (RSB) is 
a regional technique for pediatric laparoscopic appendectomies.7,8 An RSB specifically delivers LA 
between the rectus muscle and the posterior sheath on either side of the umbilicus to 
anesthetize the intercostal nerves. The randomized control trial (RCT) by Hamill et al. 
demonstrated that RSBs reduced global pain scores in uncomplicated pediatric laparoscopic 
appendectomies as compared to saline infiltration in the anesthetic care unit (ACU), but did not 
significantly reduce 24-hour opioid consumption or reduce the length of ACU stay.7 Similarly, a 
retrospective study by Maloney et al. demonstrated both reduced pain scores and opioid 
consumption in the ACU when an RSB was administered. Despite these promising results, the 
analgesic benefits of an RSB appear to diminish within the first 6 to 8 hours.6 This is not unlike 
other single-shot peripheral nerve blocks, where the duration of analgesic effects is traditionally 
between 8 and 14 hours.9 The use of LA adjuncts, such as dexamethasone, has been shown to 
extend the duration of LA.10 Intravenous (IV) dexamethasone is recommended due to its ability 
to prolong peripheral nerve blocks and its limited side effect profile.9 A Cochrane review 
determined that IV dexamethasone increased block duration by 6.2 hours and reduced 
cumulative 24-hour opioid consumption in comparison to a placebo.11  
Data from a 2021 audit at our institution suggests approximately 25% of laparoscopic 
appendectomy patients had a postoperative pain score of 7 or higher in the ACU and required 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 3 of 19 
 
opioids to control their pain. Furthermore, it is standard to admit all patients who undergo 
laparoscopic appendectomies postoperatively at our institution. This contrasts with pediatric 
hospitals across North America that have transitioned to same-day discharge (SDD) for 
uncomplicated cases. SDD has proven to be a safe, feasible, and cost-effective approach.12,13,14,15 
Many SDD pathways utilize regional anesthetic blocks, such as RSB, to help facilitate discharge16.  
2. STUDY RATIONALE 
The goal of this study is to improve post-operative pain control for pediatric laparoscopic 
appendectomy patients by comparing two methods of anesthetic delivery.  
(1) RSB+dex: an RSB with a coadministration of IV dexamethasone as an LA adjunct, 
administered by the anesthesiologist.   
(2) LA: LA infiltration alone, administered by the surgeon.  
While both (1) RSB+dex and (2) LA are standards of care at BC Children’s Hospital, it is currently 
unclear which is a superior post-operative analgesic option. Furthermore, to our knowledge, no 
study has evaluated the addition of an LA adjunct to an RSB to prolong the analgesia effect in this 
population. We hypothesize that performing (1) RSB+dex will provide superior pain control 
postoperatively compared to (2) LA. To evaluate this hypothesis, we will conduct a pilot study by 
allocating pediatric laparoscopic appendectomy patients to either (1) RSB+dex or (2) LA. 
Postoperative opioid requirements, postoperative pain scores, and parent satisfaction with 
recovery will be assessed. By conducting a pilot study, we plan to  estimate the efficacy of an 
RSB+dex to ensure the study design is optimized prior to engaging with a large, multicenter RCT. 
If an RSB+dex provides superior postoperative analgesia, these results may help guide 
management at our institution for implementing an SDD pathway for pediatric laparoscopic 
appendectomies. The RSB is a basic regional technique due to its simplicity and reliability.17 The 
low cost, minimal risk, and the short amount of time necessary to perform it make the RSB an 
ideal regional anesthetic for widespread implementation.  
 
3. AIM OF STUDY 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 4 of 19 
 
To compare postoperative analgesia between (1) RSB+dex group: an RSB with a coadministration 
of IV dexamethasone as an LA adjunct and (2) LA group: LA infiltration alone by the surgeon in 
pediatric patients undergoing a laparoscopic appendectomy for uncomplicated appendicitis.  
 
4. HYPOTHESIS 
Patients receiving in the (1) RSB+dex group, will have superior analgesia compared to 
patients in the (2) LA group, as evidenced by reduced postoperative opioid consumption and pain 
scores. 
 
5. OUTCOMES  
a. PRIMARY 
i. To determine the total opioid administration from the start of surgery until 
discharge in each group.  
b. SECONDARY 
i. To determine time spent performing the RSB block.  
ii. To determine the time in the ACU for each group.  
iii. To assess the duration of post-procedural hospitalization for each group.  
iv. To assess the parental perspective of patient recovery.  
 
Total opioid administration will be calculated by converting all administered opioids, 
excluding remifentanil, to morphine per kilogram equivalents. The duration of time performing 
RSBs will be recorded by the anesthesia team in the online record within the RSB procedural note. 
Time performing the block will commence post-induction of anesthesia when the anesthesia 
team has secured the airway, and the maintenance stage of anesthesia is initiated. The 
performance of the RSB block will be considered complete at the end of the local anesthetic 
injection. The first post-procedural pain score recorded in ACU will be considered time 0 hours. 
The subsequent pain scores recorded closest to the study time points (i.e., 4 hours, 8 hours, 12 
hours, and 16 hours post-operative) will be used for mean post-operative pain scores. Time in 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 5 of 19 
 
ACU is recorded in the online patient record via post-operative arrival and departure times 
recorded by nursing staff. Average pain scores and non-prescription drug requirements will be 
collected via a post-operative parent survey. No changes to the study outcomes will be made 
after study commencement. See Table 1 below for further details. 
 
 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 6 of 19 
 
Table 1. Study Endpoints 
Clinical Objectives 
Outcome 
Outcome Measure 
Variables 
Hypothesis 
 Analysis 
Primary  
1. Difference in total 
opioid administration 
from start of the surgery 
until discharge 
Mg/kg 
morphine 
equivalents 
 
Continuous: 
Measured by collecting and totaling all 
opioid (excluding remifentanil) 
administrations from intraoperative, ACU, 
and ward records and converting to 
morphine milligram per kilogram 
equivalents. 
Treatment 
group 
 
RSB+dex < LA 
Mean difference 
(95% CI) 
 
Secondary 
2. To determine the 
mean postoperative 
pain score at 12 hours 
for each group  
Visual analog 
pain scores 
Discrete: 
 
Pain: Measured via age-appropriate visual 
analog scales (FACES Pain Scale-Revised 
for age < 12, Numeric Rating Scale for age 
> 12) 
Treatment 
group 
RSB+dex < LA 
Mean difference 
(95% CI) 
 
3. To assess if pain 
scores at 0 hours, 4 
hours, 8 hours, and 16 
hours postoperative 
differ between groups 
Visual analog 
pain scores 
Discrete: 
 
Pain: Measured via age-appropriate visual 
analog scales (FACES Pain Scale-Revised for 
age < 12, Numeric Rating Scale for age > 12) 
Treatment 
group 
RSB+dex < LA 
Mean difference 
(95% CI) 
 
4. Determine the time 
spent performing RSB 
Time (mins) 
recorded by 
anesthesiologist 
Continuous 
Time: measured in minutes  
N/A 
 
N/A 
Mean time 
(mins) 
 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 7 of 19 
 
5. Determine the 
duration of ACU stay 
Time-to-ACU 
discharge 
Continuous 
Time: measured in minutes  
Treatment 
group 
 
 
RSB+dex < LA  
Mean difference 
(95% CI) 
 
6. Determine the 
duration of post-
procedural 
hospitalization  
Time-to-hospital 
discharge 
Time-to-event: 
Event: discharge from hospital 
Time: Duration of time from entering OR 
to hospital discharge in minutes. 
Treatment 
group 
 
 
RSB+dex < LA  
Hazard Ratio 
(95% CI) 
7. Determine the 
parental perspective on 
patient post-operative 
pain 
Numeric analog 
pain scores 
Discrete:  
Pain: Numeric rating scale  
Treatment 
group 
 
RSB+dex < LA 
Mean difference 
(95% CI) 
 
8. Determine which 
non-prescription drugs 
were administered post-
operatively 
Mg/kg 
Continuous: 
Measured by collecting and totaling all 
non-prescription drugs provided by the 
parent to the child post-operatively  
Treatment 
group 
 
RSB+dex < LA 
Mean difference 
(95% CI) 
 
9. Parental satisfaction 
with recovery 
Likert scale 
Discrete 5-point scale 
 
Very unsatisfied 
Unsatisfied 
Neutral 
Satisfied 
Very satisfied 
Treatment 
group 
RSB+dex > LA 
Mean difference 
(95% CI) 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 8 of 19 
 
6. METHODS 
a. Study Design 
This will be a single-center pilot study conducted at British Columbia Children’s Hospital 
(BCCH). The methods will not be modified during the study.  
b. Participant Eligibility 
i. Inclusion Criteria 
• Age 4-18 years old*  
• Diagnosed with acute appendicitis.  
• Undergoing a laparoscopic appendectomy  
ii. Exclusion Criteria 
• Perforated/complicated appendicitis diagnosis 
• Previous abdominal surgery 
• Allergy to bupivacaine or dexamethasone  
• Severe developmental delay preventing patients from using pain scales 
or adequately communicating pain** 
• Patients with Type 1 or 2 diabetes mellitus*** 
• Patients with steroid dependence 
*The pain scale (FACES revised) used for this study has been validated in children as young as 4 
years old. This age range will ensure all eligible patients who can be evaluated using this tool are 
captured in our research. Medications used in this study (bupivacaine and dexamethasone) are 
approved for this age range.  
**The Face. Legs, Activity, Cry, and Consolability (FLACC) Scale may be used to determine pain in 
patients with severe developmental delays. However, we cannot effectively compare FLACC 
scores with the FACE scores used in our study.  
***In some instances, a dose of dexamethasone can increase blood glucose levels for up to 24 
hours post-administration. Some families and surgeons may be hesitant to administer this 
medication to diabetics, as increased blood glucose levels could increase their likelihood of 
perioperative adverse outcomes.  

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 9 of 19 
 
 
Patients will be assessed for study eligibility by research personnel or by care providers 
for after hours cases. If eligibility criteria are met, patients will be randomized into one of two 
groups (RSB+dex or LA). Per current standard of practice at BCCH, the anesthesiologist will 
explain the surgical plan/intervention and any associated risks to the patient during the 
anesthesia consultation, prior to surgery.   
c. Sample Size  
This pilot study is designed primarily to estimate the efficacy of our approach to RSB and 
help guide a future, larger RCT. There are approximately 70-80 cases of uncomplicated 
laparoscopic appendectomies per year. We estimate it will take 7-8 months to reach 32 patients 
for the study if 70% of cases are eligible and consent to participate. Therefore, a convenience 
sample of 16 participants per group (32 patients total) is pragmatic given our local case numbers 
at BCCH. With a significance level of 0.05 and assuming an outcome standard deviation of 0.01 
mg/kg,8 we will have 100% power to detect a minimum difference of 0.02 mg/kg opioid 
administration between groups. With a significance level of 0.05 and assuming an outcome 
standard deviation of 0.15,8 we will have approximately 95% power to detect a minimum 
difference of 0.2 in mean postoperative pain scores between groups.  
d. Randomization 
Patients will be randomized to 1 of 2 groups. The randomization sequence will be 
computer-generated using varying blocks of 2 and 4 randomization. The randomization sequence 
will be concealed from the postoperative care team. Sealed envelopes will be created according 
to the sequence and placed in the BCCH Department of Anesthesia’s Research Office for either 
the anesthesia team or research personnel to obtain and open when a new participant is deemed 
eligible. All randomization and group allocation documents will be kept in the BCCH Department 
of Anesthesia’s Research Office.  
e. Recruitment and Blinding 
All laparoscopic appendectomy cases who are already in the hospital and booked at BCCH 
will be considered as potentially eligible. We will submit a request for  deferred consent under 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 10 of 19 
 
TCPS2 Article 3.7A with our ethics application. No patients (or parents) will be recruited prior to 
surgery. The patient and their parent(s) will be informed by the anesthesiologist that due to their 
surgery type; they will be approached by research staff after surgery. We request the need for 
deferred consent from the Research Ethics Board (REB),  justified according to TCPS2 Article 3.7A 
as it fulfils the following points.  
a. The research involves no more than minimal risk to the participants.  
Both possible interventions are standard of care and are regularly used at BCCH. Participation 
in this study will not pose any additional risk than receiving a laparoscopic appendectomy at BCCH 
already would. Additionally, the patient will not be blinded to their group allocation. 
Anesthesiologists will provide their standard preoperative consult to the patient, where they will 
explain any risks associated with being under anesthesia and where the patient will have the 
opportunity to ask questions. As is standard practice at BCCH, patients will provide surgical and 
anesthetic consent.  
b. The alteration to consent requirements is unlikely to adversely affect the welfare of 
participants.  
The alteration to consent will allow patients and their families consent outside the hospital, 
where they will not face the stress of additional decision in an overwhelming, painful (for the 
patient), and emergent situation. The alteration to consent will allow a more clear and thoughtful 
consideration of consent and participation. Additionally, the alterations are unlikely to adversely 
affect the welfare of study participants because both interventions are standard of care. The 
treatment participants  receive as being part of the study will be no different than the treatment 
they may have received without participating in the study. Following the surgery, participants 
will have the opportunity to decline to consent in the research study.  

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 11 of 19 
 
c. It is impossible or impracticable to carry out the research and to address the research 
question properly, given the research design, if the prior consent of participants is 
required.  
Due to the emergent nature of laparoscopic appendectomies, it is impracticable to recruit a 
representative participant pool without an alteration to consent. Cases done after hours may be 
more severe or painful than cases done during working hours. Deferred consent will avoid bias 
being introduced into the study. Additionally, it is not feasible to have the anesthetic care team 
or health care providers recruit participants.  
d. In the case of a proposed alteration, the precise nature and extent of any proposed 
alteration is defined.  
All laparoscopic appendectomy patients who meet study eligibility criteria at BCCH will be 
randomized to one of two interventions that are standard of care (RSB+dex or LA). The 
anesthesiologist and the participant will not be blinded to their group allocation, allowing the 
anesthesiologist to present the risks associated with the anesthetic intervention to the patient. 
The anesthesiologist will inform the patient that due to their surgery type, a research staff 
member may follow-up with them after their surgery to invite them to participate in a study, at 
which time they could provide or decline consent. Following the surgery (24 to 48 hours post-op) 
a research staff member will call the patient’s parent or guardian to recruit them for the study. 
The parent will then choose to provide informed consent, and the child will choose to assent to 
participate if age appropriate. If the patient chooses to participate, we will collect data from their 
chart and forward a post-discharge parent follow-up survey via REDCap. We will call the patients’ 
parent or guardian up to three times to recruit the patient for the study. If we cannot reach the 
parent or guardian, or if they decline to provide consent, the patient will not be enrolled in the 
study.  

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 12 of 19 
 
e. The plan to provide a debriefing (if any) that may also offer participants the possibility of 
refusing consent and/or withdrawing data and/or human biological materials, shall be in 
accordance with Article 3.7B.  
The patient and their parent will be recruited by phone 24 to 48 hours post-operatively. At 
this point, participants will be given the opportunity to either consent or decline to participate. 
During this phone call, the study will be explained to the patient’s parent and their questions will 
be answered. If they choose to participate, they will be emailed a REDCap e-consent form and a 
link to the parent follow-up survey. If they decline to participate, no data will be gathered from 
their chart. 
Participants will not be blinded to the anesthetic technique the receive, but they will not 
be aware that they were randomized. Therefore, we do not anticipate that the patient’s group 
allocation will bias their post-operative pain scores or post-operative opioid requirements. As per 
our standard practice, ACU nurses will be informed of the total local anesthetic dose 
administered to each participant. Nurses collecting pain scores and assessors completing the data 
collection will be blinded to the patient’s group assignment. We are unable to blind research 
personnel who will be retrospectively collecting data from the BCCH medical record system and 
entering directly into REDCap. However, data analysts will be blinded to group allocation until 
analysis scripts are finalized. 
The intraoperative team will not be blinded to the anesthetic technique used, thus 
unblinding in case of emergency in the operating room is unnecessary. In terms of recovery, both 
patient groups will receive the same single dose administration of the medication (local 
anesthetic bupivacaine) but delivered in different methods. Should an emergency arise, the 
blinded recovery nurse’s management will be the same for either group. The different techniques 
should not differ in terms of local anesthetic absorption or uptake, as the injection sites are in a 
similar area of vascularity.  
f. Study Arms and Anesthetic Protocol 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 13 of 19 
 
There are 2 groups: (1) RSB+dex versus (2) LA. Both interventions are current standards 
of care for appendectomy patients and are used by providers at BC Children’s Hospital. Each 
group will receive up to a maximum of 1 mL/kg total of LA which will ensure the total volume 
calculation for each arm would receive a bupivacaine dose at or below 2.5 mg/kg body weight. 
The anesthesia team will perform the bilateral RSBs using an in-plane ultrasound-guided 
technique with 0.25% bupivacaine with epinephrine 1:200 000 at 0.8 mL/kg (half of total volume 
per side) up to a maximum of 20 mL. The surgical team will then use the remaining 0.2 mL/kg to 
infiltrate the remaining port sites in the RSB+dex group. The LA group will receive the same LA 
(0.25% bupivacaine with epinephrine 1:200 000). Surgeons can inject up to a total dose of 0.8 
mL/kg (maximum 20 mL) at the umbilical port site. The remaining volume of LA (0.2 mL/kg) can 
be infiltrated at each of the incision sites at the discretion of the surgeon. Both study medications 
(bupivacaine and dexamethasone) being used in this study are approved for the age range in this 
study. 
Anesthesiologists can provide intraoperative analgesia such as fentanyl (max 5 mcg/kg), 
morphine (max 0.15 mg/kg), hydromorphone (max 0.02 mg/kg), ketorolac (max 0.5 mg/kg), 
acetaminophen (max 15 mg/kg), dexmedetomidine (max 0.5 mcg/kg) at their clinical discretion, 
to ensure quality of care is maintained and that the varying needs of patients are met. 
Preoperative acetaminophen or ibuprofen given within 4 hours of surgical incision will be 
included in the analysis. No other significant source of LA administration (e.g., lidocaine infusion) 
or ketamine will be permitted. Postoperatively, each participant will receive scheduled 
acetaminophen (20 mg/kg PO q6hr, max 1 g) and ibuprofen (10 mg/kg PO q6hr, max 400 mg) for 
24 hours. Other postoperative analgesic drugs can be administered by ACU and ward nursing 
staff as prescribed. Monitoring and safety measures for each group will follow standard BCCH 
protocols. The anesthetic protocol is all within the standard scope of anesthesia care that is 
normally provided for this patient population, as both these techniques are standard practices of 
care at BC Children’s Hospital. We will be following the standards of care for intraoperative and 
postoperative monitoring that are already in place at BC Children’s Hospital. The potential risks 
of this study are the same risks that apply to every appendectomy case at BC Children’s Hospital. 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 14 of 19 
 
g. Data Collection  
All data, except the parent survey, will be gathered retrospectively from electronic 
medical charts by research assistants and input into REDCap electronic data capture tools.18,19  
See the data collection form for the participant characteristics that will be collected to assess 
group similarity. The parent survey will be conducted via REDCap after the patient is recruited to 
the study.  
h. Implementation  
The primary investigator for this project is Dr. Prakash Krishnan. Dr. Hannah Piper will be 
the lead surgical investigator. All investigators are responsible for initial study conception, 
protocol design, and randomization generation. Consultations with pediatric general surgeons 
and nursing colleagues in the ACU and surgical ward assisted in study design. Before the study 
launch, anesthesia department providers will be briefed on the study protocol, recruitment, data 
collection, and example conduct of RSB blocks (see Appendix Figure 2).  
i. Statistical Method 
Please refer to the outcomes section, table 1 study endpoints, for anticipated data 
analysis. The primary investigators and the department statisticians will perform statistical 
analysis. Descriptive statistics will be used to describe participants’ characteristics. Counts and 
percentages will be presented for categorical variables; means and standard deviations for 
normally distributed continuous variables; and medians and quartiles (Q1 and Q3) for non-
normal continuous variables. Mean differences and corresponding 95% confidence intervals (CI) 
will be reported to capture the differences in treatment group for outcomes (i) mean total opioid 
administration from the start of surgery until 24 hours postoperatively, (ii) pain scores at 0 hours, 
4 hours, 8 hours, 12 hours, and 16 hours post-surgery (iii) duration of time performing RSB, (v) 
duration of time in ACU, and (vii) parental satisfaction using linear regression models. Hazard 
ratios and corresponding 95% CI will be reported to capture the differences in the treatment 
group for time-to-hospital discharge using Cox proportional hazards models. The Likert scale 
scores from the parental survey will be analyzed via a Mann-Whitney test and ordinal logistic 
regression model. 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 15 of 19 
 
j. Knowledge Translation  
Results will be presented at BCCH Department rounds, E2i and UBC Department of 
Anesthesiology, Pharmacology, and Therapeutics Research Days, and at targeted conferences, 
including the International Anesthesia Research Society and the Canadian Pediatric 
Anesthesiology Society’s annual meetings. We will prepare a manuscript(s) for appropriate peer-
reviewed journals. Targeted publications include Pediatric Anesthesia, the Canadian Journal of 
Anesthesia, and the Journal of Pediatric Surgery.  
 
There is an opportunity for the study results to help shape clinical practice at BCCH. The 
most efficacious pathway for postoperative analgesia for laparoscopic appendectomy has yet to 
be determined and variance among our anesthesiologists exists. If one method appears superior, 
this may assist in developing a pathway/guideline for care. Furthermore, the results may suggest 
that a larger RCT is required to accurately conclude if one approach is superior, and if so, this 
could broaden the effect on clinical practice outside of BCCH. 
 
 
 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 16 of 19 
 
7. APPENDIX 
 
 
Figure 1. Example RSB Steps for Anesthesia Providers 
LA Dose 
o 0.25% bupivacaine (with epinephrine 1:200 000) at 0.8 mL/kg  
o Use half of the total volume per side  
 
RSB Steps 
1. Sterile prep and technique 
2. With the patient in a supine position, place the linear (6-13 MHz) transducer in the 
transverse plane just above the umbilicus and center 1-2 cm off the midline.  
 
3. Identify the rectus abdominus muscle (RAM) which appears as a thick, lenticular-
shaped muscle, and the posterior rectus sheath, a hyperechoic fascial covering deep 
to the muscle. 
4. Adjust the probe laterally as required to identify the medial edge of the transverse 
abdominus muscle (TAM) deep to the rectus sheath.  
 
5. Using an echogenic (50 mm/22-gauge often sufficient), advance needle in-plane with 
a lateral to medial approach aiming trajectory toward the lateral edge of the TAM 
 
6. Once the needle tip is advanced posterior to the RAM and anterior to the posterior 
sheath hydro dissect with saline to confirm needle tip placement then can inject LA. 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 17 of 19 
 
 
7. Repeat steps for the contralateral side.  
 
 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 18 of 19 
 
8. REFERENCES 
1. Tomecka, M. J., Bortsov, A. V, Miller, N. R., Solano, N., Narron, J., Mcnaull, P. P., … 
Mclean, S. A. (n.d.). Substantial postoperative pain is common among children 
undergoing laparoscopic appendectomy. https://doi.org/10.1111/j.1460-
9592.2011.03711.x 
2. Shim, H., & Gan, T. J. (2019). Side effect profiles of different opioids in the 
perioperative setting: are they different and can we reduce them? British Journal of 
Anaesthesia, 123(3), 266–268. https://doi.org/10.1016/J.BJA.2019.06.009 
3. Yu, T. C., Hamill, J. K., Liley, A., & Hill, A. G. (2013). Warm, humidified carbon dioxide 
gas insufflation for laparoscopic appendicectomy in children: A double-blinded 
randomized controlled trial. Annals of Surgery, 257(1), 44–53. 
https://doi.org/10.1097/SLA.0B013E31825F0721 
4. Bosenberg, A. (n.d.). Benefits of regional anesthesia in children. 
https://doi.org/10.1111/j.1460-9592.2011.03691.x 
5. Russell, P., Von Ungern-Sternberg, B. S., & Schug, S. A. (2013). Perioperative 
analgesia in pediatric surgery. Current Opinion in Anaesthesiology, 26(4), 420–427. 
https://doi.org/10.1097/ACO.0B013E3283625CC8 
6. Hamill JK, Rahiri JL, Liley A, et al. Rectus sheath and transversus abdominis plane 
blocks in children: a systematic review and meta-analysis of randomized trials. 
Paediatr Anaesth 2016;26(4):363–71.  
7. Hamill JK, Liley A, Hill AG. Rectus sheath block for laparoscopic appendicectomy: a 
randomized clinical trial. ANZ J Surg 2015;85:951–6.  
8. Maloney C, Kallis M, El-Shafy IA, Lipskar AM, Hagen J, Kars M. Ultrasound-guided 
bilateral rectus sheath block vs. conventional local analgesia in single port 
laparoscopic appendectomy for children with nonperforated appendicitis. J Pediatr 
Surg. 2018 Mar;53(3):431-436. doi: 10.1016/j.jpedsurg.2017.05.027. Epub 2017 Jun 
2. PMID: 28610706. 
9. Desai, N., & Albrecht, E. (2023). Local anesthetic adjuncts for peripheral nerve 
blockade. Current Opinion in Anaesthesiology, 36(5), 533–540. 
https://doi.org/10.1097/ACO.0000000000001272 
10.  Edinoff, A. N., Houk, G. M., Patil, S., Siddaiah, H. B., Kaye, A. J., Iyengar, P. S., … Kaye, 
A. D. (2021). Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 
Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs. 
Anesthesiology and Pain Medicine, 11(3). https://doi.org/10.5812/AAPM.117197 
11. Pehora, C., Pearson, A. M. E., Kaushal, A., Crawford, M. W., & Johnston, B. (2017). 
Dexamethasone as an adjuvant to peripheral nerve block. The Cochrane Database of 
Systematic Reviews, 11(11), CD011770–CD011770. 
https://doi.org/10.1002/14651858.CD011770.PUB2 
12. Cheng O, Cheng L, Burjonrappa S. Facilitating factors in same-day discharge after 
pediatric laparoscopic appendectomy. J. Surg Res. 2018 Sept; 229: 145-149. 
doi:10.1016/j.jss.2018.03.072 Epub 2018 Apr 15. 

 
 
RSB Appendectomy [H23-03547] –  Protocol 
Version 2 – 12 November 2024 
Page 19 of 19 
 
13. Alkhoury F, Burnweit C, Malvezzi L, Knight C, Diana J, Pasaron R, Mora J, Nazarey P, 
Aserlind A, Stylianos S. A prospective study of safety and satisfaction with same-day 
discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg. 
2012 Feb;47(2):313-6. doi: 10.1016/j.jpedsurg.2011.11.024. PubMed PMID: 
22325382. 
14. Cairo SB, Raval MV, Browne M, Meyers H, Rothstein DH. Association of Same-Day 
Discharge With Hospital Readmission After Appendectomy in Pediatric Patients. 
JAMA Surg. 2017 Dec 1;152(12):1106-1112. doi: 10.1001/jamasurg.2017.2221. 
PubMed PMID: 28678998; PubMed Central PMCID: PMC5710416. 
15. Gee K, Ngo S, Burkhalter L, Beres AL. Safety and feasibility of same-day discharge for 
uncomplicated appendicitis: A prospective cohort study. J Pediatr Surg. 2018 Feb 9. 
pii: S0022-3468(18)30085-X. doi: 10.1016/j.jpedsurg.2018.02.031. [Epub ahead of 
print] PubMed PMID: 29510871. 
16. Shafy, S. Z., Miller, R., Uffman, J. C., Tobias, J. D., Fetzer, M., Nordin, A. B., … 
Veneziano, G. (2019). An Enhanced Recovery Protocol that Facilitates Same-day 
Discharge for Simple Laparoscopic Appendectomies. Pediatric Quality & Safety, 4(6), 
E243. https://doi.org/10.1097/PQ9.0000000000000243 
17. Pearson, A. M. E., Roberts, S., & Turbitt, L. R. (2022). New blocks on the kids: core 
basic nerve blocks in paediatric anaesthesia. https://doi.org/10.1111/anae.15876 
18. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG: Research electronic 
data capture (REDCap) – A metadata-driven methodology and workflow process for 
providing translational research informatics support. J Biomed Inform. 2009; 
42(2):377-81. 
19. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, McLeod L, Delacqua 
G, Delacqua F, Kirby J, Duda SN: The REDCap consortium: Building an international 
community of software platform partners. J Biomed Inform. 2019; 95:103208