Peri-operative Rectus Sheath Block Versus TEA Abdominal Surgeries
Condition: Abdominal Cancer
MeSH terms: Abdominal Neoplasms
Study type: Interventional
Phase: Phase 3

Summary: 
      Thoracic epidural analgesia (TEA) can be considered the gold standard for postoperative
      analgesia in major abdominal surgeries, as proved by a lot of number of systematic reviews
      and meta-analyses have demonstrated that TEA was associated with superior postoperative
      analgesia, better patients' outcomes, reducing (systemic opiate requirements, ileus and
      pulmonary complications).

      The rectus sheath block (RSB) is effective for the surgeries that necessitated midline
      abdominal incisions as local anesthetics instillation will be within the posterior rectus
      sheath bilaterally providing intense analgesia for the middle anterior wall from the xiphoid
      process to the symphysis pubis in adults.
    

Detailed description: 
      The aim of the study was to assess the efficacy and safety of intra and post operative
      ultrasound-guided RSB versus intra and post operative TEA and to investigate role of Fentanyl
      as an adjuvant in both RSB and TEA, in patients undergoing elective major abdominal surgery
      with midline abdominal incisions.

      Pre operative medications in the form of oral ranitidine tablet, 50 mg and lorazepam tablet,
      3 mg on the night of surgery were given to all patients.

      All patients were taught- The day before surgery- how to evaluate their own pain intensity
      using the visual analog scale (VAS), scored from 0 to 10 (where 0=no pain and 10= worst pain
      imaginable) and how to use the patient controlled analgesia (PCA) device (Abbott
      Laboratories, North Chicago, IL, USA).

      Patients were randomly assigned into two groups, 50 patients each, by using opaque sealed
      envelopes containing a computer generated randomization schedule; the opaque envelopes were
      sequentially numbered and were opened before application of anesthetic plan.

      TEA group (No. =50); where patients received TEA in conjunction with GA, intraoperative
      analgesia was started before skin incision by epidural bolus dose of 0.1 ml ∕ kg of 0.125%
      levo-bupivacaine ∕ fentanyl 2 µg ∕ ml. Postoperative analgesia was provided through Patient
      controlled epidural analgesia (PCEA) for 48 hours postoperative, by continuous infusion of a
      mixture of (0.0625% levo-bupivacaine ∕ fentanyl 2 µg ∕ ml) in a dose of of 0.1 ml ∕ kg, and
      bolus dose of 3 ml, lockout interval of 20 minutes).

      RSB group (No. =50); combined general plus US guided rectus sheath block (group-RSB): where
      20 mL of (0.25% levo-bupivacaine + fentanyl 30 µg) in saline were injected into the rectus
      sheath plane on either side under direct US visualization 15 minutes before skin incision.

      And before closure of abdominal wall, bilateral surgically placed catheters in rectus sheath
      plane for post operative analgesia for 48 hours.

      Postoperative analgesia was as following; injection of 20 mL of (0.125% levo-bupivicaine
      +Fentanyl 30 μg) every 12 hours in to each catheter, A postoperative rescue analgesia with
      intravenous Fentanyl per a titration protocol (Fentanyl 30 μg IV as a bolus dose that could
      be repeated every 10 minute) was employed if visual analog pain scale (VAS) ≥4.
    

Intervention name(s): Thoracic epidural block (TEA); Rectus sheath block (RSB)
Intervention type(s): Procedure; Procedure
Intervention description(s): Under complete aseptic precautions and before induction of GA, thoracic epidural catheter was inserted using a 17 gauge, Tuohy epidural needle by a midline approach. T9-T10 interspace was chosen for the injection after skin infiltration by 5 mL of lidocaine 1%. The epidural space was identified by the loss of resistance technique then the catheter was introduced 2 cm into the epidural space, and epidural test dose of 3 mL of lidocaine 2% with 1:200,000 adrenaline was injected to exclude vascular or subarachnoid position.; Under aseptic technique, the rectus muscle was imaged with the ultrasound probe, A broadband (5-12 MHz) linear array probe of Sonosite ™ 3000 ultrasound (FUJIFILM, Sonosite EDGE II -UAS) in a transverse orientation at or immediately above the level of the umbilicus, with an imaging depth of 4-6 cm.
Inserting the needle: An 18G Tuohy needle was introduced few millimeters from the probe using an in plane technique in an angle of 45 degrees to the skin. (posterior rectus sheath and fascia transversalis). Under direct vision, the needle tip was advanced to the desired position where 20 mL of (levo-bupivacaine 0.25% Fentanyl 30 μg) were injected causing hydro dissection of the rectus muscle away from the posterior rectus sheath. The technique is repeated on the opposite side.
Other intervention name(s): Thoracic epidural analgesia
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention
Keywords: TEA; Rectus sheath block; Major abdominal cancer surgery