Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy.

INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) is increasingly applied for cholecystectomy and has been reported as safe and feasible, with short-term operative outcomes equivalent to four-port cholecystectomy. Although many investigators in randomized studies have noted the cosmetic advantages of SILC, the benefit of decreased pain in SILC remains controversial. Therefore, this study aimed to assess the efficacy of the rectus sheath block in SILC with respect to subjective pain. METHODS: From April 2010 to March 2012, 75 patients with symptomatic gallstone or gallbladder polyps were assigned to one of three groups: (i) four-port laparoscopic cholecystectomy (n = 29); (ii) SILC (n = 15); and (iii) rectus sheath block in SILC (n = 30). We evaluated the operative details, length of hospital stay, and the need and usage of analgesia. Postoperative pain was recorded at 2, 6, 12, and 24 h after surgery based on a visual analog scale. RESULTS: There was no difference with regard to age, ASA score, BMI, duration of operation, or length of hospital stay among the three groups. A significantly lower pain score was observed in the rectus sheath block in SILC group than in the SILC group at 2 and 6 h after operation. The pain score and need for analgesia were similar between the SILC group and the four-port cholecystectomy group. CONCLUSION: SILC using an ultrasound-guided rectus sheath block significantly reduces postoperative pain.

Anesthetic management of a patient with deteriorated cardiac function following cardiopulmonary resuscitation.

A 73-year-old woman suffering from an abdominal aortic aneurysm (AAA), unstable angina, and low cardiac function (32% of ejection fraction) was scheduled for abdominal aortic replacement and coronary artery bypass grafting. However, before the scheduled operation the patient fell into cardiopulmonary arrest with ventricular fibrillation due to rupture of the AAA. Immediate cardiopulmonary resuscitation (CPR) using epinephrine and electrical defibrillation restored the spontaneous circulation. Following CPR, a continuous high-dose dopamine infusion (15 µg/kg/min) was initiated and emergent abdominal aortic replacement was performed. On arrival at the operating room, the patient showed serious hypotension, atrial fibrillation with multifocal ventricular premature contractions, and metabolic acidosis. Transesophageal echocardiography (TEE) suggested that the circulatory collapse might have resulted from diastolic dysfunction and deteriorated compliance of the left ventricular (LV) wall, possibly due to myocardial stunning induced by myocardial ischemia, and tachycardia induced by hypovolemia, both of which are influenced by high doses of catecholamine. We accordingly transfused adequate amounts of blood products and gradually decreased the infusion rate of dopamine to 4 µg/kg/min, while carefully monitoring blood pressure, central venous pressure, and TEE. By the end of surgery hemodynamic parameters had recovered to near normal levels. In post-resuscitated and hypovolemic patients, caution should be taken when administering high levels of exogenous catecholamines, which can induce myocardial stunning and circulatory collapse.