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Keywords:

  • rectus sheath catheters;
  • open pelvic surgery;
  • analgesia

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

Objective

  • To report on the safety and efficacy of rectus sheath blocks, ‘topped-up’ using bilateral rectus sheath catheters (RSCs), in patients undergoing major open urological surgery.

Methods

  • The RSCs were inserted under ultrasound guidance into 200 patients between April 2008 and August 2011, of whom 106 patients underwent radical retropubic prostatectomy (RRP) and 94 underwent open radical cystectomy (ORC).
  • A retrospective case-note review was undertaken.
  • Outcomes included technical success and complication rates of the insertion and use of RSC, visual analogue pain scores, additional analgesia requirements and length of hospital stay (LOS).

Results

  • All RSCs were successfully placed without complication and used for a mean of 3.6 days for ORC and 2.1 days for RRP.
  • Early removal occurred in 6.49% of patients.
  • Low overall pain scores were reported in both groups.
  • Patients were more likely to require a patient-controlled analgesia system in the ORC group but the overall need for additional analgesia was low in both groups, reducing significantly after the initial 24 h.
  • In combination with an enhanced recovery programme, LOS reduced from 17.0 to 10.8 days in the ORC group and from 6.2 to 2.8 days in the RRP group.

Conclusion

  • The use of RSCs appears to offer an effective and safe method of peri-operative analgesia in patients undergoing major open urological pelvic surgery.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

Bladder and prostate cancer are the most common urological malignancies that require radical surgical intervention. Enhanced recovery programmes have demonstrated the benefit of early mobilization, of which a key element is the need for adequate postoperative analgesia [1, 2]. When performed using an open surgical approach, pelvic cancer resections usually involve a lower midline abdominal incision, and thoracic epidural analgesia (TEA) remains popular with evidence of superior postoperative pain control compared with systemic analgesia [3]. Epidural catheters, however, are not without problems, both in terms of their initial placement and their postoperative care [4-6]. Technical failure of insertion is reported in 6–7% of cases [7, 8] and, in 25–30% of patients, TEA does not offer adequate analgesia [9-11]. There is conflicting evidence regarding the effects of TEA on bowel recovery after colonic surgery. Concern exists regarding the effect of TEA on blood flow and anastomotic healing, and there remains concern that excess fluid and electrolyte disturbance as a result of the management of TEA-induced hypotension may prolong ileus and affect anastomotic healing [4, 12-17]. Furthermore, controversy remains regarding their impact on cancer recurrence and patient survival [18-20]. TEA is known to be resource heavy and a recent cost-effectiveness analysis demonstrated a higher use of medical and nursing time in the placement and ongoing supervision of TEA when compared with patient-controlled analgesia (PCA) or a continuous wound infiltration device [21].

Rectus sheath catheters (RSCs) have emerged as an alternative to TEA for the management of postoperative pain in selected patient groups undergoing major abdominal surgery [22, 23]. The aim of the technique is to block the ventral rami of the 7th to 12th intercostal nerves that supply the rectus abdomini muscles and overlying skin [24]. A rectus sheath block, whereby a compartmental block of T7–T12 is achieved by injecting local anaesthetic into the potential space that exists between the rectus muscles and the posterior rectus sheath, has been previously described in paediatric anaesthesia [25, 26]. The addition of an indwelling catheter within the space allows the block to be ‘topped up’ at regular intervals and has been variously described in point-of-technique reports and small case series [23, 27]. The routine use of RSCs in major urological surgery was previously reported in a retrospective series of 20 patients undergoing open radical cystectomy (ORC), 10 of whom had RSCs and 10 of whom had epidural analgesia. In the RSC group, this demonstrated a high success rate of insertion, with good levels of pain control and low rates of failure or complications [24].

In the current series, we have analysed data on a large cohort of 200 patients undergoing open radical pelvic urological surgery.

Patients and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

Patient Identification

All patients undergoing ORC or radical retropubic prostatectomy (RPP) during the period 18 April 2008 to 31 August 2011 were identified using the institution's electronic theatre schedule (Microsoft® Outlook). After approval by the institutional audit committee, a detailed retrospective case-note review was performed on all patients in whom RSCs were placed. In total, 200 consecutive patients were analysed and their demographics are shown in Table 1.

Table 1. Patient demographics
 ORC, N = 94RRP, N = 106Combined, N = 200
Mean (range) age, years66 (37–83)64 (54–75)65 (37–83)
Sex (M:F)68:26n/a174:26
ASA grade, n   
ASA 1182543
ASA 25555110
ASA 39211
Not recorded122436
Urinary diversion, n   
Ileal conduit71n/a
Neobladder23  

Technique for Insertion of the RSC

The consultant anaesthetist obtained consent from the patient for placement of a RSC as part of the routine anaesthetic preoperative review. As with all patients undergoing general anaesthesia, the various methods of pain control were discussed. Specific risks of RSC placement that were highlighted included failure of catheter placement, catheter-related infection, iatrogenic haematoma and the need for additional analgesia.

Rectus sheath blocks were achieved after induction of anaesthesia by inserting bilateral RSCs in the upper abdomen under real-time ultrasound guidance using a SonoSiteS-NerveTM portable ultrasound machine with a sheathed L38e transducer probe (Fujifilm Sonosite, Seattle, Washington, USA). This was performed by one of two consultant anaesthetists experienced in ultrasonography-guided regional anaesthesia in the anaesthetic room under strict aseptic conditions. On-site mentoring was provided by a consultant colleague, who had previously sited >200 RSCs, until competency was achieved.

The detailed method of insertion of RSCs is as follows. Under ultrasound vision, the linea alba is identified in the epigastrium (Fig. 1A) and the probe is moved laterally to visualize the body of the rectus abdominus muscle. The posterior rectus sheath and transversalis fascia are then visible posterior to the rectus muscle as a set of ‘tramlines’ (Fig. 1B). Within this potential space between the posterior aspect of the rectus muscle and the tramlines are the ventral rami of the intercostal nerves supplying the anterior abdominal wall. By then rotating the ultrasound probe into a coronal plane, an in-plane approach is used to insert a 16-G tuohy needle (Fig. 1C; epidural minipack: SIMS PortexTM, Hythe, UK). The needle is then advanced until the tip lies on top, or just anterior to the tramlines, but posterior to the rectus muscle. The correct position is confirmed by injecting a bolus of normal saline to separate the planes and achieve hydrodissection (Fig. 1D). A further 20mL of 0.25% levobupivicaine is injected down the tuohy needle, and this further opens up the potential space between the rectus muscle and the posterior rectus sheath, facilitating the insertion of the catheters. The position of the catheters is confirmed within the hydrodissected space by ultrasonography. The tuohy needle is removed and the catheters are tunnelled s.c. in a lateral cephalad direction to emerge above the costal margins at the level of the xiphisternum to keep outside of the surgical field (Fig. 1E–H). The procedure is repeated on the opposite side and the catheters are secured with an Epifix® (Unomedical, Clayton, Australia) and transparent dressing, and the catheters capped with luer-lock filters and caps (Fig. 1I, J). Each RSC then requires a 20mL bolus of 0.25% levobupivicaine every 6 h, which is administered by ward nurses who have completed a competency-based training package. To date, there have been no critical incidents reported within our hospital related to nurse-led administration of levobupivacaine.

figure

Figure 1. Insertion of RSCs. (A) The linea alba is identified in the upper abdomen using ultrasonography. (B) The ‘tramlines’ indicate the posterior rectus sheath and the transversalis fascia. (C) In the coronal plane, a 16-G tuohy needle inserted into the potential space between the ‘tramlines’ and posterior to the rectus muscle. (D) A bolus of normal saline (to confirm position) and then 20 mL of 0.25% levobupivicaine is injected. The catheters can then be fed down into the space. (E–H) After removing the tuohy needle, the catheters are tunnelled s.c. (I and J) The catheters are secured with an Epifix, capped with luer-lock filters and caps and further secured with adhesive dressing.

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The operation commenced after insertion of the RSCs. Anaesthesia was maintained with a volatile anaesthetic agent and a target-controlled infusion of remifentanil was administered to cover visceral nociception. At the end of surgery, anti-emetics and opiate analgesia were given to all patients before extubation in theatre. Patients were then transferred to recovery where full monitoring and ongoing assessments of the patients were made.

A multimodal analgesia technique was used consisting of paracetamol 1g four times a day (i.v. initially then orally), tramadol 50–100mg four times a day (i.v. or orally) and ibuprofen 400mg three times a day orally as required.

The first top-up of the RSCs was 4 h from insertion and in the ORC group this continued 4-hourly whilst in a high dependency area. Back on the ward, top-ups were prescribed every 6 h.

Rescue analgesia consisted of i.v. morphine or fentanyl in recovery as required. Individual opiate requirements varied greatly in recovery and it was possible then to assess which patients would need PCA. All patients had oral morphine prescribed.

Operation Details

Open radical cystectomy involved a lower midline abdominal incision, with the ORC completed using an extraperitoneal approach. Urinary diversion was performed intra-abdominally with formation of an ileal conduit or ileal neobladder, according to patient choice. Postoperatively, patients were transferred to a high dependency setting overnight, and thereafter received standard ward-based care. Recovery was protocol-driven according to enhanced recovery principles; bowel preparation and nasogastric drainage were avoided, oral fluids were commenced in the immediate postoperative period, mobilization commenced on postoperative day 1 and full diet recommenced on postoperative day 2.

Open RRP involved a lower midline abdominal incision and an extraperitoneal approach. After a stable period in recovery, patients were transferred to the ward for postoperative care that was protocol-driven in line with enhanced recovery principles. Patients were allowed a full diet on the day of surgery and were mobilized to a chair on the day of surgery with a view to discharge on postoperative day 2.

Outcome Measures and Data Handling

Outcome measures included: RSCs (insertion difficulties and complications), pain scores (visual analogue score of 0–10), analgesia usage (peri-operative, regular postoperative and the need for rescue opiate analgesia), postoperative complications (hypotensive episodes, gastrointestinal morbidity), time to mobilization and length of hospital stay (LOS). Ileus was defined as cessation of normal diet owing to abdominal distension and vomiting, with or without the insertion of a nasogastric tube. Patients were required to meet the following criteria for discharge from hospital; adequate pain control with oral analgesia, mobilizing independently, tolerating oral fluids and diet, resumption of normal bowel activity, and satisfactory self care of stoma device.

Data were collated onto a Microscoft® Excel spreadsheet and analysed retrospectively. Analysis of the data was descriptive.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

Insertion and Use of RSCs

All RSCs were judged to be successfully inserted with no procedures abandoned and no immediate complications observed. The mean (range) duration of postoperative use was 3.56 (2–7) days for ORC and 2.14 (1–5) days for RRP, with a low requirement for early removal (Table 2).

Table 2. Duration of RSC use, early removal and postoperative problems
 ORC, N = 94RRP, N = 106
Mean duration of use, days3.562.14
Early removal of RSC, %6.386.60
Reasons for discontinuation, n  
Blocked catheter22
Leaking catheter(s)23
Fell out/dislodged14
Other40

Postoperative Pain and Analgesia

Postoperative pain scores, recorded using a visual analogue score at 12-hourly intervals, are summarized in Fig. 2.

figure

Figure 2. Visual analogue pain scores (with se) per 12-h period postoperatively for patients with RSCs who have undergone ORC or RRP.

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A multimodal analgesic regimen was used in all patients: 99.5% received regular paracetamol as per protocol, 69% received either regular (19%) or as required (50%) tramadol and 36.5% received either regular (25%) or as required (11.5%) NSAIDS. RSC top-ups were given as prescribed, and opiates were used for rescue.

Table 3 shows the proportion of patients receiving opiate analgesia in the form of PCA, i.v or orally. I.v. morphine given within the first 24 h to patients in the RRP group was given in recovery before return to the ward. Patients undergoing ORC who received postoperative morphine predominantly received this in the high-dependency area as a bolus, before starting PCA if deemed necessary.

Table 3. Percentage of patients within the study who received postoperative opioid analgesia in the form of PCA, i.v. or oral morphine
 Time after surgery
0–24 h24–48 h48–72 h
ORCRRPORCRRPORCRRP
PCA, %43.646.236.210.3831.96.6
Morphine i.v., %23.448.12.13000
Oral morphine, %6.383.7717.023.7711.583.73

Overall, it can be seen that 43.6% and 46.2% of patients received PCA in the ORC and RRP groups respectively. PCA systems were removed earlier for patients undergoing RRP than for those undergoing ORC (Fig. 3); however, their use in combination with i.v. morphine was noted to change over time in both the RRP and ORC groups. As experience was gained with RSCs, practice changed so that PCA is now rarely used after RRP. The use of opiates in general was noted to change over time in both groups as the opiate-sparing effect of RSCs became more evident (Fig. 4).

figure

Figure 3. Proportion of patients undergoing ORC or RRP with a PCA per 12-h period postoperatively.

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figure

Figure 4. Yearly breakdown of the proportion of patients requiring opiate analgesia on postoperative days 1–3 (PCA and i.v.) after A, ORC (4.1) and B, RRP with RSCs.

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Figure 5 summarises the opiate requirements in patients managed without PCA.

figure

Figure 5. Mean quantity (mg morphine equivalent) of opiates received by patients who did not receive PCA in the initial 72 h after ORC and RRP.

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Complications

Hypotension instigated non-routine medical review in four patients undergoing RRP (three isolated hypotension, one vasovagal episode) and three patients undergoing ORC (two isolated hypotension, one collapse). Wound problems were rare with six (3%) documented cases. Five superficial wound infections were recorded and one superficial wound dehiscence. There were no cases of ileus in patients undergoing RRP, whilst 22.3% who underwent ORC developed an ileus. In a subset analysis of the 20 most contemporary patients who had undergone ORC, seven (35%) complained of nausea in the initial 24 h, of whom one patient vomited (5%).

Length of Hospital Stay

The mean LOS in patients who underwent ORC fell from 17 days at the beginning of the series to a mean of 10.8 days by the end of the series. Similarly, mean LOS in patients undergoing RRP fell from 6.2 days at the start of the series to 2.8 days by the end of the series.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

The present paper reports our experience using an alternative analgesic technique to TEA for patients undergoing major open pelvic urological surgery. From a patient safety perspective, RSCs can avoid the rare but potentially catastrophic complications associated with infection in the epidural space [28]. The benefit may have increasing relevance when taking into consideration the increasing use of antiplatelet medications, such as clopidogrel or the more recent direct thrombin inhibitors such as dabigatran. A haematoma of the rectus sheath is of much less significance than that of the epidural space and, as a consequence, allows the use of RSCs when epidural catheters are otherwise contra-indicated owing to concomitant anticoagulation. In our experience, RSCs appear to meet the requirements of enhanced recovery principles in providing effective pain control whilst allowing early mobilization. Following the introduction of an enhanced recovery programme which incorporated RSCs, we noted a marked reduction in the LOS for patients undergoing both ORC and RRP in the present series. We accept the reduced LOS cannot be solely attributed to RSC usage, but, compared with TEA, RSC facilitates early mobilization of patients and would seem more beneficial to an enhanced recovery programme.

The rate of successful placement of RSCs was high, as judged by ultrasound visualization of catheter placement. Their reliability in the postoperative period was also found to be high with low numbers requiring early removal (Table 2). This compares favourably with published failure rates of TEA [6]. Surgical placement of RSCs, either blindly or with dissection, is an alternative technique [29]; however, in a recent audit of practice within our hospital, the surgically placed RSCs were more likely to have problems such as blockage or early removal. It was also noted that patients required a greater amount of rescue analgesia.

Our experience during the ‘spread and adoption’ phase of this technique suggests that the learning curve for the insertion of RSCs is steep, particularly in those individuals previously experienced in ultrasonography-guided regional anaesthesia. The identification of the relevant radiological landmarks is straightforward and there are clear endpoints associated with successful insertion.

In combination with a multimodal analgesia regimen, the use of RSCs was associated with low patient-reported pain scores in both groups. In the initial postoperative 24 h (Fig. 2), ORC was associated with a higher level of discomfort when compared with RRP and this is most probably attributable to the more significant visceral pain component associated with intra-abdominal dissection.

As anticipated, all patients had additional analgesia requirements over and above RSC usage suggesting that a multimodality regimen is required. Regular paracetamol was used as per protocol and patients had varying needs for tramadol and NSAID administration. The requirement for additional opiate analgesia was more complex, and varied according to the nature of the procedure, the individual patient, clinician choice and evolving experience with RSC. Postoperative opiates were delivered by three main routes; namely, as an i.v. bolus, in the form of PCA, or as oral morphine.

Within the noted limitations of the paper, some pragmatic observations on opiate administration can be made. Approximately 40–50% of patients undergoing ORC appear to need regular, additional opiate administration, usually in the form of PCA. Conversely, > 50% of patients undergoing ORC did not require PCA. This figure hasn't altered greatly during the 3-year implementation and adoption phase of RSC use within our institution. It is likely to represent the varying degrees of visceral pain in a proportion of patients having ORC. Interestingly, the visceral pain component appears to be relatively short-lived, and opiate requirements fell sharply after 24 h, suggesting that RSCs are an effective way to maintain adequate analgesia.

By contrast to ORC, the use of PCA in patients undergoing RRP has diminished over the 3 years of the series and routine use of PCA in this patient group has almost ceased. In the early adoption period, PCA was administered routinely on the assumption that visceral pain would be problematic. The extraperitoneal approach used in RRP suggests that the majority of postoperative pain in this group is in fact wound-related and hence ideally suited to the RSC technique. For patients in whom no PCA was used (Fig. 5), there was a low opiate requirement and this was given mainly as oral morphine.

Very few additional reviews of the patient were required for hypotension. When this is considered in conjunction with Table 2, patients who underwent ORC or RRP with RSCs required a low number of out of hours review by the medical staff. This supports the noted perception by ward staff that the RSC led to fewer problems compared with other methods of analgesia and it is possible they will represent less of a burden than TEA, but this would need to be assessed in a prospective randomized setting.

The low rate of wound infections in this series (3%) is likely to be multifactorial and compares favourably with recent series of open cystectomy procedures [30-32]. It has been postulated that, as RSCs deliver local anaesthetic to the anterior abdominal wall, this may play a role in reducing wound infection rates. It has been demonstrated in the laboratory that local anaesthetics, including bupivacaine, at concentrations typically found in the clinical setting possess inherent antimicrobial properties against a wide spectrum of human pathogens [33]. More recently, the use of local anaesthesia was associated with a lower incidence of surgical site infections in day-case general and vascular surgery [34].

The ileus rate for patients undergoing ORC in this series was ∼20%. The criteria used to define ileus in the current series deliberately erred on the side of overdiagnosis and hence the rate compares favourably with historical series of ORC where ileus rates of 18–22% were reported, suggesting equivalence with epidural analgesia at the very least [30-32]. In the subset of patients studied, approximately one third were documented to have nausea within the initial 24 h.

In terms of costs, the current methodology was not designed to capture the full economic costing associated with the new technique when compared with TEA so only limited comments can be made. For the majority of units performing major surgery, portable ultrasound machines are likely to be in routine use and therefore not a directly incurred cost of RSC adoption. The cost of disposable items used in the block is marginally greater than TEA as two catheters are required in addition to two fixation Epifix dressings. Procedural time appears equivalent once the procedure is routinely embedded in clinical practice. Local anaesthetic costs are low as the local anaesthetic is drawn up on the ward rather than relying on the more expensive pre-filled syringes used for TEA. In terms of the nursing and clinical manpower required to maintain the block, the results of our series suggest that non-scheduled review of RSCs is infrequent and it would clearly be of interest to compare this aspect with an equivalent TEA-based cohort. Only a randomized controlled trial would be able to answer whether RSC offers an advantage in terms of reducing LOS and the incumbent costs compared with TEA.

Our findings support the continued investigation of RSCs as an effective alternative to TEA for patients undergoing major open urological pelvic surgery, but the study has some limitations. This was a retrospective review of a technique, therefore, only data that were available within the 200 cases could be analysed. In addition, the present series, by its nature, does not allow any direct comparison with other analgesia techniques. Naturally, comparison is drawn with TEA, but only anecdotal evidence for such a comparison is available at present. There is a need for adequately powered randomized controlled trials to further investigate the role of RSCs in major pelvic surgery. A pilot of such a trial is currently underway (ISRCTN77620476). Such a trial would also aid in the determination of cost of using RSCs in practice. As discussed above, whilst a ‘procedural’ cost can be attributed to the disposables used, determining the true cost of an alternative technique such as this is complex and beyond the capability of the current case series. The methodology would necessitate a prospectively designed trial intended to capture total costs, including not only the procedural time and hardware costs but also those of nursing and medical time as well as the projected cost of unintended consequences with regard to complication rates. The data available in this current series do not allow this aspect to be explored fully.

In conclusion, although it is recognized that an increasing number of pelvic urological procedures are being performed with minimally invasive surgery, RSCs offer a reliable, safe and effective method by which analgesia can be delivered to patients recovering from major open pelvic surgery. They can be a key component of a multimodal analgesia regime and have been associated with a low number of complications. They are a low-maintenance device for patients and ward staff and early mobilization is possible. Further work is needed to determine their exact role in patient recovery as well as the optimum adjunctive forms of analgesia within different patient groups. Future planned work will allow direct comparison with TEA in terms of pain control, complication rates and compatibility with enhanced recovery principles.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

We thank Malcolm Crundwell, Richard Pocock, Robert Mason, and Keith Allman for their assistance with this study.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References
Abbreviations
RSC

rectus sheath catheter

RRP

radical retropubic prostatectomy

ORC

open radical cystectomy

LOS

length of hospital stay

TEA

thoracic epidural analgesia

PCA

patient-controlled analgesia