A Comparison of Postoperative Outcomes Provided by a Continuous Preperitoneal Infusion Versus Ultrasound Guided Transversus Abdominis Plane Block for Abdominoplasty
Phase: NA
Conditions: Abdominal Pain
Sponsor: Dr Manar Mamdouh Fahmy Elsharkawi

A comparison of postoperative outcomes provided by a 
continuous preperitoneal infusion versus ultrasound 
guided rectus sheath block for midline emergency 
laparotomy. 
 
Poor pain control in the post-operative period can lead to chronic pain 
syndromes (1) , increased post-operative morbidities (2) and poor quality of 
life (3). Therefore , good post-operative pain management is imperative for 
the patient and is one of the new pain management standards recommended 
(4). 
 
Pain control after laparotomy can be difficult to achieve and often requires a 
multimodality approach . Opiate use can have serious side effects, including 
significant nausea, respiratory depression , slowing of gastrointestinal 
function and urinary retention (5). 
 
Epidural analgesia , when used as an adjunct to parenteral opioids in elective 
intra-abdominal surgery , results in superior postoperative pain control 
compared with systemic opioids alone (6). Unfortunately , there are many 
unique morbidities associated with epidural infusion catheters , including, 
hypotension , fluid retention , urinary tract infections (UTIs) ,  urinary 
retention , epidural site infection , epidural hematoma and inadequate 
analgesic distribution which may affect a patient’s postoperative outcomes 
and hospital costs (7).In addition , epidural analgesia is not an option for 
every patient undergoing laparotomy . Coagulopathy is a contraindication to 
epidural placement , and epidurals are often not used in emergency 
surgery(5). 
 
Continuous preperitoneal infusion (CPI) of loco-regional anesthetic through 
an elastomeric pain pump is an alternative to epidural analgesia . Multiple 
studies have shown that CPI is a safe adjunct for postoperative analgesia in 
many subspecialties (8-10).A  CPI system can be placed in emergent cases, 
can be used in patients with coagulopathy , can be removed without 
interruption of deep vein thrombosis prophylaxis , does not require a 
consulting physician service to monitor and has not been shown to increase 
rates of wound infection in clean-contaminated cases (5). 
 

In recent years , rectus sheath block  provided safer and more reliable 
analgesia by the development of ultrasound tools. Ultrasound guided rectus 
sheath block can reduced the risk of peritoneal puncture and bleeding. 
Rectus sheath block is very effective to reduce postoperative pain in upper 
abdominal surgery as an alternative method to epidural anesthesia in 
anticoagulated patients (11). 
 
The aim of this study is to compare the  postoperative analgesia provided 
bya continuous preperitoneal infusion versus ultrasound guided rectus sheath 
block for midline emergency laparotomy. 
 
Patients and Methods: 
 
This  randomized prospective study will be carried out after the approval of 
Rashid Hospital’s Research  Ethical Committee and patient’s written 
informed consent. 
 
Sixty  adult patients , of both gender , 18-70 years old, ASA I-III who will 
be scheduled for emergency laparotomy with upper  abdominal midline 
incision will be included in the study. Exclusion criteria will be patients with 
known allergic response or contraindications to paracetamol, parecoxib, 
morphine or ropivacaine  and pregnant women  
 
The enrolled patients will be randomly assigned to one of three groups: 
 
Group I ( 20 patients) will  receive an ultrasound guided rectus sheath block 
by the end of the surgery using 15 ml ropivacaine 0.5% on either side. 
 
Group II ( 20 patients) for whom a 7.5 , 15 , 30 cm 19-gauge multiholed 
catheter will be inserted at the end of surgery and after the closure of the 
peritoneal layer at 3 to 5 cm away from the lower end of the surgical incision 
through an introducer peel-away needle. The length of the catheter will be 
established to guarantee homogenous distribution of the holes all along the 
length of the incision of the fascia. The catheter will be allocated above the 
peritoneum within the musculofascial layer and secured to the skin with an 
occlusive transparent dressing. A 10 ml bolus of ropivacaine 0.2% will be 
administered through the catheter and then connected to an elastomeric 
pump delivering a continuous fixed -rate of ropivacaine 10 ml/h. 

Group III( 20 patients)  a multiholed catheter will be inserted as in Group II 
and will receive also an ultrasound guided rectus sheath block as described 
for Group I. 
 
No premedication will be administered. General anesthesia will be induced 
using target controlled intravenous infusion (TCI)  using remifentanil  (1-10 
ng/ml effect concentration ) and propofol ( 1-10 mcg/ml effect 
concentration) titrated to Bi-spectral index (BIS) value between 40-60.Once 
anesthesia level will be reached , succinyl choline 1mg/kg intravenously will 
be given. After  the airway will be secured , TCI will be adjusted to maintain 
BIS value between 40 to 60.An initial dose of 0.1 mg/kg intravenous 
cisatracurium will be administered and further doses will be given according 
to neuromuscular monitoring maintaining a train of four (TOF) value of 
zero. 
Pre-incision , all patients will receive 15 mg/kg intravenous bolus and 40 mg 
intravenous parecoxib. 0.5 mg intravenous ketamine will be administered to 
avoid remifentanil's  induced hyperalgesia. 
All patients will be mechanically ventilated to maintain normocapnia 
throughout  the procedure. Standard  intraoperative monitoring will include 
electrocardiography, pulse oximetry , automatic non-invasive blood pressure 
, end tidal capnography , Bi-spectral index and train of four monitoring. 
 
At the end of surgery and before extubation ,  patients who will be randomly 
assigned to Group I will receive an ultrasound-guided bilateral rectus sheath 
block using 15 ml of ropivacaine 0.5% on each side. 
For patients who will be assigned to either Group II or Group III ,  a 7.5 , 15 
or  30 cm 19-gauge multiholed catheter will be inserted by the operating 
surgeon at the end of surgery and after the closure of the peritoneal layer at 3 
to 5 cm away from the lower end of the surgical incision through an 
introducer peel-away needle. The length of the catheter will be established to 
guarantee homogenous distribution of the holes all along the length of the 
incision of the fascia. The catheter will be allocated above the peritoneum 
within the musculofascial layer and secured to the skin with an occlusive 
transparent dressing. A 10 ml bolus of ropivacaine 0.2% will be 
administered through the catheter and then connected to an elastomeric 
pump delivering a continuous fixed -rate of ropivacaine 10 ml/h. 
For patients who will be assigned to Group III  will receive also an 
ultrasound-guided bilateral rectus sheath block using 15 ml of ropivacaine 
0.5% on each side. 
 

Then the patients will be extubated and shifted to Post-Anesthesia Care Unit 
(PACU) where they will be monitored for heart rate , blood pressure , 
oxygen saturation by pulse oximetry and pain score using visual analogue 
scale (VAS) both at rest and deep breathing . These data will be recorded 
every 15 minutes for the first hour. 
After one hour , the patients will be discharged from PACU according to 
Modified Aldrete Scoring if they will reach a score of 9 or more. All patients 
will receive parecoxib 40 mg intravenously twice a day and  paracetamol in 
a dose of 40 mg/kg intravenously in three divided doses regularly for 48 
hours postoperatively. 
In the postoperative period, all the patients will be evaluated for their 
hemodynamic variables ( heart rate , respiratory rate , arterial blood pressure 
and arterial oxygen saturation ) and postoperative analgesia using VAS at 
rest and with deep breathing at 2,4,8,12,18,24,36 and 48 hours 
postoperatively. 
If the patient's VAS will reach 4 at any time in the 48 hours postoperatively, 
0.1 mg/kg titrated  intravenous morphine rescue analgesia will be 
administered and repeated if required to maintain VAS less than 4.  
All patients will respond to a quality of life questionnaire (QR 40) at 24 and 
48 hours postoperatively. 
 
Statistical methods: 
 
Data will be presented as mean (+/- standard deviation) . Data from the three 
groups will be compared using the unpaired t test. Statistical analysis will be 
performed using Statistical Package for the Social Science program (SPSS) . 
A p value of < 0.05 will be considered statistically significant.  
 
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11- 
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