Iliohypogastric and Ilioinguinal Nerve Block for Acute and Chronic Pain Relief After Cesarean Section.
Condition: Iliohypogastric and Ilioinguinal Nerve Block for Acute and Chronic Pain in Cesarean Section
MeSH terms: Chronic Pain
Study type: Interventional

Summary: 
      The increase in CS in recent years makes even a small prevalence of persistent pain after CS
      a significant burden, both financially and in terms of quality of life, for a large number of
      otherwise healthy young women. Persistent pain after CS has been shown to be associated with
      postpartum depression, interferes with daily activities, and causes sleep disturbances, all
      of which negatively and directly impact the mother. As a result, the care of the baby by the
      mother is affected negatively.

      To adequately control postoperative pain, healthcare providers use a one-size-fits-all
      multimodal analgesic approach and sensible opioid prescription with monitoring to prevent
      addiction. The challenge is in tailoring this approach to the outliers who may be opioid
      tolerant or opioid-sensitive. However, the severity and duration of postoperative pain and
      its management may be predictive of developing persistent pain at two to 12 months or later.

      Previous studies revealed different outcomes regarding the analgesic efficacy of II-IH nerve
      block for post caesarean pain, inguinal repair and surgery involving the female genital
      tract. Moreover, exploring the efficacy of II-IH nerve block could help to tackle sever
      postoperative pain after cesarean delivery particularly in settings where there is shortage
      of epidural kit supply and availability of strong opioids for pain management. We aimed to
      assess the analgesic efficacy of bilateral ilioinguinal and iliohypogastric nerve block for
      planned caesareans delivery under spinal anaesthesia and evaluate the incidence of persistent
      pain with transition from acute to chronic pain.
    

Detailed description: 
      All patients will be assessed preoperatively by history taking, physical examination, and
      laboratory evaluation. On arrival of the patients to the operative room, electrocardiography,
      non-invasive blood pressure and pulse oximetry will be applied.

      The patients will be positioned in sitting position to give the spinal anesthesia at
      L3-L4/L2-L3 intervertebral level in the midline approach. After local infiltration of skin
      and subcutaneous tissue with 2% lignocaine, 25 G B-braun spinal needle will be used to
      administer subarachnoid block (SAB) with 2.5 ml of hyperbaric bupivacaine (5%) and 20 µg of
      fentanyl after confirmation of free flow of cerebrospinal fluid (CSF) at the hub of the
      needle. Patients will be coloaded with 10-12 ml/kg (over the period of 15 min) of Ringer's
      Lactate (RL) solution at the time of SAB. Thereafter, patients will be placed in supine
      position with wedge under the right hip.

      64 Patients were randomly allocated into two equal groups (each 32 patients):

        -  Group B (IL/IH group): Each patient will receive spinal anesthesia plus bilateral
           ultrasound-guided IL/IH nerve block. The abdomen will be scanned through anterior
           superior iliac spine (ASIS)-umbilicus line. Ilioinguinal nerve can be visualized between
           the internal oblique and transverse or external oblique muscles and within 1 to 3 cm
           from the ASIS. The iliohypogastric nerve lies immediately adjacent. After negative
           aspiration (to exclude intravascular injection), 10 mL of 0.25% bupivacaine will be
           injected. The same technique will be performed on the other side

        -  Group C (Controlled group): Each patient will receive spinal anesthesia alone with no
           block.

      Postoperative Analgesia Protocol

      All patients will be given a standardized patient controlled intravenous analgesia (PCIA)
      regimen. The disposable PCIA device (Coopdech Syrinjector PCA set; Daiken Medical) contained
      30 mg morphine in 45 ml saline. Patients will be instructed on how to use the PCIA device,
      which was set with a bolus of 2 mg morphine and a minimum interval of 30 min. If the
      analgesic effect was not satisfactory, complementary use of intravenous morphine will be
      applied.

      Assessment of Acute Postoperative Pain

      At 24 hours after surgery, pain intensity will be recorded on a 10-point verbal pain rating
      scale ranging from 0 to 10 (VPRS; 0 = no pain to 10 = worst pain imaginable), at rest
      (VPRS-R) and while moving into the sitting position (VPRS-S). Pain will be considered none,
      mild, moderate, or severe if scored 0, 1 to 3, 4 to 6, or 7 to 10, respectively.

      Assessment of Persistent Postoperative Pain (3 and 6 Months) The Short-Form McGill Pain
      Questionnaire-Revised (SFMPQ- 2) was designed specifically and validated to assess both
      neuropathic and non-neuropathic aspects of chronic pain.

      Women will report their average and worst pain the week prior to and at the time of the
      telephone interview using a previously developed scripted telephone interview. Persistent
      pain will be defined as new onset of pain related to the CS, located around the scar or in
      the abdomen, and still present at 8 weeks. Chronic pain will be defined if same symptoms were
      still present at 3 and 6 months.

      Measurements The following parameters will be recorded by an anesthesia resident not included
      in the study and blinded to its groups: -

        -  Demographic data (Age in month, body mass index, and ASA class)

        -  Total consumption of analgesia (mg/kg) in first day postoperatively. (Primary outcome)

        -  The time to the first rescue analgesic request. (Secondary outcome) The postoperative
           pain score (NRS pain score). Assessment of the presence and intensity of pain was done
           immediately after transfer to the ward (0 h) and at 4 h, 6 h , 12 h and 24 h after
           surgery both at rest and with movement (turning from side to side) by using verbally
           administered Numerical rating scale pain assessment tools.

        -  The incidence of perioperative complications including bradycardia, hypotension, nausea
           and vomiting, localized hematoma, infection, or pruritis.

        -  Incidence of chronic pain at 3 & 6 months.
    

Intervention name(s): Iliohypogastric and ilioinguinal nerve block; Controlled Group
Intervention type(s): Procedure; Procedure
Intervention description(s): Each patient will receive spinal anesthesia plus bilateral ultrasound-guided IL/IH nerve block. The abdomen will be scanned through anterior superior iliac spine (ASIS)-umbilicus line. Ilioinguinal nerve can be visualized between the internal oblique and transverse or external oblique muscles and within 1 to 3 cm from the ASIS. The iliohypogastric nerve lies immediately adjacent. After negative aspiration (to exclude intravascular injection), 10 mL of 0.25% bupivacaine will be injected. The same technique will be performed on the other side; Each patient will receive spinal anesthesia alone with no block.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Treatment