Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis.

BACKGROUND: Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. METHODS: We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system. RESULTS: Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. CONCLUSIONS: Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. TRIAL REGISTRATION: PROSPERO (CRD42021238916); registered 25 February 2021.

RéSUMé: CONTEXTE: La laparotomie médiane est associée à une douleur sévère. L'analgésie péridurale est la norme de soins établie, mais plusieurs modalités alternatives d'anesthésie régionale sont aujourd'hui disponibles. Dans cette revue systématique et méta-analyse en réseau, nous avons cherché à comparer les techniques d'anesthésie régionale continue et par injection unique. MéTHODE: Nous avons inclus les études randomisées contrôlées portant sur des adultes devant bénéficier d'une laparotomie avec une simple incision médiane sous anesthésie générale et qui ont reçu une anesthésie neuraxiale ou régionale pour la douleur. Une méta-analyse en réseau a été réalisée avec une méthode fréquentiste, et les résultats continus et dichotomiques ont été présentés sous forme de différences moyennes et de rapports de cotes, respectivement, avec des intervalles de confiance à 95 %. La qualité des données probantes a été évaluée avec le système GRADE (Grading of Recommendations Assessment, Development and Evaluation). RéSULTATS: Au total, 36 études portant sur 2056 patients ont été incluses. Aucune des études n'a évalué le bloc du plan des muscles érecteurs du rachis ou du carré des lombes. Les blocs de la gaine des grands droits et du plan des muscles transverses de l'abdomen ont été combinés en blocs de la paroi abdominale (BPA). Concernant le critère d'évaluation principal de score de douleur au repos à 24 heures, avec une différence minimale cliniquement pertinente (DMCP) de 1, l'analgésie péridurale était cliniquement supérieure au BPA de contrôle et par injection unique; l'analgésie péridurale était statistiquement mais non cliniquement supérieure à l'infiltration continue de la plaie; et aucune différence statistique ou clinique n'a été constatée entre le BPA de contrôle et par injection unique. Pour le deuxième critère d'évaluation principal portant sur la consommation cumulative de morphine à 24 heures, avec une DMCP de 10 mg, la péridurale et le BPA continu étaient cliniquement supérieurs au groupe contrôle; la péridurale était cliniquement supérieure à l'infusion continue de la plaie, au BPA par injection unique, à l'infiltration par injection unique de la plaie et à la rachianesthésie; et le BPA continu était cliniquement supérieur au BPA par injection unique. La qualité des données probantes était faible compte tenu d'importantes limites et d'imprécisions. De plus, le BPA par injection unique n'a fourni aucun avantage analgésique cliniquement pertinent au-delà de deux heures; l'infiltration continue de la plaie était cliniquement supérieure de 8 à 12 heures à l'infiltration de la plaie en injection unique; et une équivalence clinique a été observée entre la péridurale, le BPA continu et l'infiltration continue de la plaie en ce qui avait trait au score de douleur au repos, et entre la péridurale et l'infiltration continue de la plaie en ce qui touchait à la consommation cumulative de morphine à 48 heures. CONCLUSION: Les BPA par injection unique n'étaient cliniquement efficaces pour procurer une analgésie qu'au début de la période postopératoire. Les modalités d'anesthésie régionale continue ont augmenté la durée de l'analgésie par rapport aux modalités équivalentes par injection unique. L'analgésie péridurale est demeurée cliniquement supérieure aux techniques alternatives d'anesthésie régionale continue pendant les 24 premières heures, mais a atteint l'équivalence, au moins en ce qui concerne la douleur statique, avec les BPA et les infiltrations de lésions continus à 48 heures. Enregistrement de l'étude : PROSPERO (CRD42021238916); enregistrée le 25 février 2021.

Bi-level erector spinae plane catheters for multiple rib fractures in a high-risk patient.

Rib fractures are associated with significant morbidity and mortality. Most of the morbidity stems from poorly controlled pain and therefore immobility and weak respiratory effort. Moreover, the number of injured ribs correlates with increasing risk of associated morbidity and mortality. We describe the analgesic management of an elderly co-morbid patient on oral anticoagulant therapy presenting with extensive multilevel rib fractures. According to the Western Trauma Association 2017 risk stratification, her mortality was as high as 20%. When a large number of ribs are involved, single level regional blocks may not provide sufficient local anesthetic spread to cover the extensive injury. Therefore, we employed erector spinae plane catheters at two levels. We believe that our therapeutic approach provided comprehensive, reliable and continuous analgesia, leading to a successful outcome in the case of our patient.

Postoperative pain management.

This article provides an overview of current methods used in acute pain management and explains why effective analgesia is crucial in the early postoperative period. It describes the pharmacology of both common and specialist analgesics, as well as explaining the role and uses of regional and neuraxial analgesia, for the non-anaesthetist.

Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study.

BACKGROUND: The cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyroidotomy to provide emergency oxygenation. Despite the apparent simplicity of the technique, this rescue maneuver frequently fails to achieve its goals and complications are numerous. The reasons for this failure are unclear. We sought to determine the ability of physicians to correctly identify the CTM in female patients. METHODS: Using fluorescent "invisible" ink, the physician was asked to mark the CTM with the patient in the supine neutral position and then with the head extended. The actual level was identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. A correct estimation was defined as a mark made between the upper and lower limits of the membrane and within 5 mm of midline. Participants were also asked to assess the ease of CTM palpation using a 10-cm visual analog scoring (VAS) scale. RESULTS: Fifty-six patients participated of whom 15 were obese. In the supine neutral neck position, the CTM was identified in 10/41 vs 0/15 (P = 0.048) in nonobese versus obese, respectively. Of the 46 incorrectly identified CTMs in this position, 24 were above (maximum 3 cm) and 22 below (maximum 3 cm) the actual level. Similar results were observed when the patients were placed with the neck in the extended position; the CTM was identified correctly in 12/41 vs 1/15 nonobese and obese patients, respectively. The range of values was also extensive; the estimation of the position of the membrane was as high as 2.5 cm above and 4 cm below the actual level, and up to 1.6 cm laterally. Participating doctors found palpation of the CTM subjectively more difficult in the obese than nonobese groups; VAS score for palpation difficulty was 5.25 ± 2.5 vs 3.3 ± 2.5, respectively, P = 0.005. Using multiple linear regression, VAS scores for palpation correlated negatively with increased patient height (P < 0.001) and greater thyromental distance (P = 0.006), and correlated positively with increased sternomental distance (P = 0.011) and neck circumference (P = 0.001). CONCLUSIONS: Misidentification of the CTM in female patients is common and its localization is less precise in those who are obese. This has implications for the likely success of invasive airway access via the CTM.