High-flow nasal cannula versus standard oxygen therapy assisting sedation during endoscopic retrograde cholangiopancreatography in high risk cases (OTHER): study protocol of a randomised multicentric trial.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly common intervention in the treatment of pancreaticobiliary disorders. Patients are often elderly with complex co-morbidities. While monitored anaesthesia care with sedation is commonly used for most cases, few would require general anaesthesia with an endotracheal tube. Both low-flow and high-flow nasal cannulas (HFNC) are established ways of delivering supplemental oxygen, but it is unclear whether one technique is better than the other. HFNC seems a promising tool for advanced procedures but evidence to support its application in high-risk ERCP cases is limited. The rate of oxygen desaturation during endoscopy has been reported to be as high as 11%-50% and the method of oxygen delivery for ERCP merits further study. METHODS/DESIGN: This is a prospective, randomised, multicentre trial comparing the efficacy of oxygen supplementation through HFNC versus low-flow nasal cannula during ERCP, in a cohort of patients at risk of adverse respiratory events. A total of 132 patients will be recruited across three sites and randomly assigned to either the low-flow or the HFNC group. The primary outcome is the proportion of patients experiencing hypoxia, defined by any event of SpO2 < 90%. The secondary outcomes include parameters centred on oxygenation, requirement of airway manoeuvres, successful completion of procedure, perioperative complications, patient satisfaction and cost analysis of the consumables. An intention-to-treat principle will be applied while analysing. DISCUSSION: The demand for ERCPs is likely to increase in the future with the aging population. Our study results may lead to improved outcomes and reduce airway-related complications in patients undergoing ERCPs. The results will be presented at national and international meetings and published in peer-reviewed journals. TRIAL REGISTRATION: www.ANZCTR.org.au, CTRN12619000397112. Registered on 12 March 2019.

Anatomical and ultrasound description of two transmuscular quadratus lumborum block approaches at L2 level and their application in abdominal surgery.

The transmuscular quadratus lumborum (TQL) block is one of the recently evolved myofascial blocks utilised in abdominal surgery. It involves injecting local anaesthetic into the fascial plane anterior to the thoracolumbar fascia. This block has previously been described with a transverse oblique paramedian approach at the L2 level in the sitting position. We describe a TQL block at the same level in the lateral position using a transverse posterolateral approach to provide analgesia for patients undergoing abdominal surgery. We elaborate on these two approaches of TQL block at the L2 level, in relation to the anatomy, sonoanatomy and technical aspects.

Evaluation of postoperative pain scores following ultrasound guided transversus abdominis plane block versus local infiltration following day surgery laparoscopic cholecystectomy-retrospective study.

BACKGROUND AND AIMS: Postoperative pain for day surgery laparoscopic cholecystectomy has traditionally been managed with the surgeon infiltrating the wound with local anesthetic (LA). However, transversus abdominis plane (TAP) block has recently been used, although its superiority over LA remains uncertain. The primary aim was to compare LA and TAP block pain scores and analgesia used. The secondary aim was to assess satisfaction score and cost. MATERIAL AND METHODS: This retrospective study was commenced after ethics committee approval and ANZ clinical trial registry (ACTRN: 12612000737831). The data were collected from the theatre database and medical records of patients presenting for day case laparoscopic cholecystectomy. The sample included patients who received either bilateral port site LA infiltration with 20 ml of 0.25% Bupivacaine or bilateral TAP block with 20 ml of 0.5% ropivacaine and fentanyl postoperative pain protocol. The patients with incomplete medical records were excluded as were those admitted to an inpatient ward. Demographics and clinical characteristics were obtained from the hospital record along with pain score and postsurgery analgesia use. Postoperative pain satisfaction scores were collected by telephonic interview 30-180 days postsurgery. RESULTS: Of 51 patients analyzed, 19 were in TAP group 29 in LA group. There were no significant differences between the LA and TAP groups with respect to postoperative pain scores (P = 0.31) or patient satisfaction scores (1 and 2+) (P = 0.36). However, fentanyl consumption in the recovery room was significantly lower in TAP group (P = 0.0079.). The consumables cost were >3 times higher in the TAP when compared to LA group. CONCLUSION: The performance of the TAP block with respect to pain management was comparable to LA. However, LA remains more cost effective.

Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy.

The quadratus lumborum (QL) block as a postoperative analgesic method following abdominal surgery has been described by Blanco for superficial surgeries but not used for major laparotomy. This ipsilateral QL block had low pain scores and opioid use on day one with sensory block upto T8-L1. The options of various volume used and pros and cons are discussed.