P-P26 Post-laparotomy pain: the Rectus Sheath Pocket technique compared to other analgesic modalities

Background Wound pain is a major cause of morbidity after laparotomy, leading to reduced mobility, poor respiratory effort, and delayed discharge. In our centre, we have developed a safe and effective post-operative analgesia technique that reliably delivers a continuous, stable infusion of local anaesthetic solution into a pocket superficial to the posterior rectus sheath. Methods Sixty-eight adult patients were enrolled in the study. Group A, n = 38 received rectus sheath catheter (RSC) analgesia and Group B, n = 30 received standard post-operative analgesia. The pain score on day 1 and total opioid dosage over the first 72 hours post-operatively were recorded. All patients were recruited from Mater Dei Hospital which is the main acute hospital in Malta. The patients who were recruited consecutively for the study group underwent elective or emergency laparotomies within a pancreatic-biliary firm. For the control group, patients underwent elective or emergency laparotomies under the care of other teams within the same surgical department. Results Group A displayed significantly diminished mean pain scores (2.81±2.26 vs 4.66±2.86 p = 0.003) but no statistically significant reduction in cumulative opiate usage. On further subgroup analysis, patients over 65 years of age with RSC, displayed significantly less overall cumulative opiate usage (10.09±15.71 vs 25.79±32.97, p = 0.005). Few mild complications were recorded; catheter dislodgement (5), entrapment of catheter in wound sutures (1) and a wound hematoma (1) caused upon insertion. Conclusions Although inter-cohort demographics are consistent, case heterogeneity is acknowledged as a weakness of this endeavour. In adult patients, RSC has been demonstrated to be feasible, safe, and effective at diminishing pain scores in the postoperative period, especially so in the elderly population.

Difficult subarachnoid anaesthesia Prediction and Performance

Spinal anaesthesia (SA) has enjoyed a long history of success, celebrating soon its 125th anniversary. Puncturing the dura mater is considered a simple procedure, followed by a subarachnoid injection of a local anaesthetic (LA) agent into the cerebrospinal fluid (CSF). Even when the technique is performed perfectly, there is no guarantee that the block sits perfectly. Failure is not uncommon and encompasses a range from total absence of any neuraxial blockade, a partial block (insufficient height, quality or duration) or a patchy block. Table 1 lists a large number of potential causative factors that may result in a failed spinal anaesthetic, providing suggestions of solutions. Analysing each distinct phase of the procedure, i.e., spinal puncture, injection of local anaesthetic solution, spread of the local anaesthetic solution through the cerebrospinal fluid, action of the drug on subarachnoid neural tissue and patient management, are the keys to success at each stage. Mechanisms of failure of spinal anaesthesia include insufficient preparation and check of equipment and drugs, suboptimal positioning of the patient, unsuccessful puncture due to inadequate training or experience and inadequate use of needles and local anaesthetic solution.1-5 Besides operator, preparation, technique-dependent and patient-related factors (anatomical variations), there are also organisational factors (lack of block room, lack of adequate monitoring and trained personnel, insufficient time between block and onset of surgery, subsequent management following block). The use of the correct local anaesthetic (dose, volume, concentration) injected at the correct lumbar interspace is of paramount importance to produce an adequate spinal block for the right surgical intervention. Nevertheless, failures may still occur. Therefore, the anaesthetist should always have a contingency plan for a failed spinal block. Indeed, patients expect reliable surgical anaesthesia when undergoing an operation

Safety and efficacy of dexamethasone as an adjuvant to bupivacaine in bilateral transversus abdominis plane block in children undergoing major abdominal surgery

Background This prospective randomized controlled double-blind clinical study was conducted on 52 patients of both genders divided into two groups (26 patients each). Local anaesthetic solution of isobaric bupivacaine 0.25% (0.3 ml/kg) was prepared. Group A received bilateral transversus abdominis plane (TAP) block with bupivacaine and dexamethasone (0.3 mg/kg) while group B received bilateral TAP block with bupivacaine and volume of saline equal to the amount of dexamethasone given in group A. Patients were observed for FLACC pain scale at the time of discharge from the post-anaesthesia care unit and then every 2 h for 36 h after the operation. This study was conducted to assess the safety and efficacy of adding dexamethasone to bupivacaine on the quality of bilateral US-guided transversus abdominis plane (TAP) block in children undergoing major abdominal surgery Results Dexamethasone added to local anaesthetic in ultrasound-guided TAP block significantly decreased FLACC score at 8, 10, and 12 up to 24 h postoperatively, The time to the first requested analgesia was prolonged in the dexamethasone group (P = 0.000). The total dose of acetaminophen consumption over 36 h after surgery was also reduced (P = 0.000), but no difference was found regarding the total dose of rectal diclofenac (P = 0.068). Conclusion Adding dexamethasone to isobaric bupivacaine TAP block reduces postoperative pain and analgesic requirements compared to isobaric bupivacaine TAP block alone in children undergoing major abdominal surgery.

Hyaluronidase to Reduce Pain from Local Anaesthetic Infiltration for Carpal Tunnel Decompression.

Aims: The aim of this prospective cohort study is to investigate the effect of hyaluronidase on pain experienced during local anaesthetic infiltration for carpal tunnel decompression. Methods: Two cohorts of twenty consecutive patients each underwent carpal tunnel release by a single surgeon over a five-month period. The first twenty patients received a local anaesthetic solution of lignocaine and adrenaline whilst the second group received a mixture of lignocaine, adrenaline and hyaluronidase (Hyalase®). All consecutive patients booked for simple open carpal tunnel decompression under local anaesthesia were included. Patients with other compressive neuropathies, generalised neuropathies or other concomitant hand pathologies were excluded from the study. The primary outcome measurement was pain experienced during local anaesthetic infiltration. Patients were asked to indicate the level of pain felt using a visual analogue scale (VAS) between 0 (no pain) to 10 (maximum pain they can imagine). Secondary outcome measures were operating time, measured as tourniquet time and early complication rates. Results: Patients administered local anaesthesia with hyaluronidase experienced significantly less pain on infiltration of the proximal palm (p < 0.05) and distal palm (p < 0.05) compared to those that did not receive hyaluronidase. Infiltration of the palm was the most painful part of the procedure for both groups. There was no statistically significant difference in pain reported on initial needle insertion (p = 0.95) or on infiltration of the distal forearm (p = 0.10). No patients in either group required additional local anaesthetic. The mean tourniquet time for the group receiving local anaesthesia without hyaluronidase was 3.79 minutes (range 3 to 5 minutes, SD 0.71) versus to 3.65 minutes (range 3 to 5 minutes, SD 0.67) for the hyaluronidase group. There was therefore no significant difference in operating time between the two cohorts (p = 0.53). No early complications were observed in either groups. Conclusion: This study finds that hyaluronidase is effective at reducing pain during local anaesthetic infiltration for carpal tunnel release. We therefore recommend its routine use.

An In-vitro Assessment of Effect of Interaction Between Local Anaesthetic Solution with Sodium Hypochlorite on the Sealing Ability of Root Canal Obturation

Introduction: Endodontic treatment failures are caused by persistent or secondary infection due to inefficient cleaning or re-infection of the obturated root canal system because of coronal or apical leakage. Intrapulpal Injection (IPI) technique is the most commonly employed supplemental anaesthetic procedure and NaOCl is considered as gold standard irrigating solution. Therefore, this study was designed to explore the action of precipitate form by interaction between LA and Sodium Hypochlorite (NaOCL) on sealing of root canal obturating material. Aim: To evaluate the effect of precipitate formed by interaction of local anaesthetic solution and NaOCl on the sealing ability of root canal obturation, using a push-out bond strength test. Materials and Methods: This was an in-vitro study from October 2019 to January 2020. In this study, forty single rooted premolars were selected and were randomly distributed equally into 4 groups with 10 specimens in each group, based on the test solutions employed. All the teeth were decoronated and the root length was standardised. Group I - irrigated with saline only, Group II- treated with 2% lidocaine hydrochloride with adrenaline 1:100,000 (2% LA) followed by 3% NaOCl, Group III - 2% LA followed by saline and 3% NaOCl, Group IV- 3% NaOCl followed by saline. All root canals were than instrumented using ProTaper Universal rotary system upto F3 and obturation was done using AH plus sealer and GuttaPercha. Sealing ability was evaluated using a micro push-out bond strength, with the help of a universal testing machine and data were analysed statistically. Results: One-way analysis of variance (ANOVA) showed that there is highly significant difference among the various groups (p <0.0001). Within the experimental groups, Group II showed minimum mean push out bond strength (16.39±2.40) as compared to Group III (21.83±1.25) and Group IV (22.50±2.12). Conclusion: Interaction of LA with NaOCl forms precipitate which blocks the dentinal tubules and reduces the mean push out bond strength. It is recommended to irrigate thoroughly with saline after intrapulpal injection (2%LA) before irrigating with NaOCl.