Postoperative Pain After Pediatric Umbilical Hernia Repair
Condition: Pediatric Postoperative Pain
MeSH terms: Hernia, Umbilical; Pain, Postoperative; Hernia
Study type: Interventional

Summary: 
      The purpose of this study is to compare the use of ultrasound-guided bilateral rectus sheath
      blocks to local infiltration of anesthetic agent in the surgical wound in a pediatric
      population of patients undergoing umbilical hernia repair.
    

Detailed description: 
      Recent studies on adult patients' perceptions of their hospital care have shown that
      improvements are needed in pain management (Jha, Orav, Zheng, and Epstein). The use of
      regional anesthetic techniques to block specific peripheral nerves in adult patients has
      increased in recent decades as an alternative to general anesthesia or to decrease opioid use
      during and after surgery. Decreased postoperative complications have been observed, with
      fewer ambulatory patients requiring prolonged recovery room stays and/or costly unplanned
      hospital admissions (Chan, Peng, Kaszas, Middleton, Muni, Anastakis, and Graham).

      Regional anesthetic techniques have not been widely performed in pediatric patients because
      of the challenge in requiring children to report paresthesias during needle placements.
      However, pediatric anesthesiologists have recently begun to use ultrasound to identify
      anatomy, and to guide needle insertion and local anesthetic infiltration, thereby enabling
      peripheral nerve blocks to be performed safely in children under general anesthesia. Several
      studies have illustrated that umbilical nerve blocks (Jose Maria, Götzens, and Mabrok) and
      rectus sheath blocks (Willschke, Bosenberg, Marhofer, Johnston, Kettner, Wanzel, and Kapral)
      can be used safely and effectively with ultrasound guidance in pediatric outpatient surgery.
      To date, few studies have explored whether ultrasound-guided regional blocks of the abdomen
      in children have the desired outcome of reducing postoperative pain and/or decreasing opioid
      use.

      The use of ultrasound to guide the deposition of local anesthetic in the posterior sheath of
      the rectus muscle containing the peripheral nerves that innervate the abdomen may decrease
      postoperative pain, opioid and non-opioid analgesic consumption, as well as minimize
      opioid-related complications. Currently, at Children's Hospital Boston, the most common
      regimen for pain control after umbilical hernia repair performed under general anesthesia
      (i.e. standard of care) has been surgeon-administered nonspecific local anesthetic
      infiltration in the wound at the conclusion of surgery, followed by opioids in the
      Post-Anesthesia Care Unit and an oral opioid/acetaminophen combination post-discharge. In
      sporadic cases over the past year, several pediatric surgeons have collaborated with
      anesthesiologists from the pain service to allow ultrasound-guided bilateral rectus sheath
      blocks to be performed in patients undergoing umbilical hernia repair, usually prior to the
      surgical repair, and often concomitantly with surgeon-administered local anesthetic
      infiltration in the wound. Because of the anecdotal nature of these practices, specific
      conclusions regarding improvements in post-operative pain or decreased need for
      post-operative opioid use cannot be drawn. However, anecdotal reports from parents at the
      time of outpatient post-operative follow-up visits have been encouraging regarding perceived
      success in achieving adequate post-operative pain control in patients receiving the regional
      block.

      We propose an interdisciplinary, prospective, randomized, single-blinded clinical trial of
      the use of ultrasound-guided bilateral rectus sheath blocks versus local anesthetic
      infiltration in a pediatric population of patients undergoing ambulatory umbilical hernia
      repair at Children's Hospital Boston and Children's Hospital Boston at Waltham.
    

Intervention name(s): bilateral ultrasound-guided rectus sheath block; Wound infiltration
Intervention type(s): Procedure; Procedure
Intervention description(s): Ultrasound is used to guide the deposition of Ropivacaine 0.2% 1cc/kg in the posterior sheath of the rectus muscle containing the peripheral nerves that innervate the abdomen.; Ropivacaine 0.2% 1cc/kg is injected subcutaneously at the site of incision by the surgeon.
Other intervention name(s): ropivacaine; ropivacaine
Intervention MeSH terms: Ropivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Prevention
Keywords: postoperative pain; pediatric; umbilical hernia; ropivacaine; rectus sheath block; regional block; ultrasound-guided regional block; local infiltration; ambulatory surgery