The Treatment of Acute Postoperative Pain in Patients Undergoing Open Abdominal Aortic Repair: Epidural Analgesia and Rectus Sheath Block

The open abdominal aorta repair is a highly traumatic intervention and analgesia is an important aspect of enhanced recovery after surgery. Epidural analgesia (EA) is the «gold method» of perioperative pain management after this surgery. Despite the fact that the best of analgesic effect in the group EA the first 24 hours after surgery, later other regional techniques become comparable of analgesic effect in this patients. The other regional technique can be to use how an alternative method of multimodal analgesia after laparotomy.

Purpose: to summarise the available compare the effectiveness of rectus sheath block (RSB) and epidural analgesia (EA) in postoperative pain management after open surgical repair of abdominal aortic.

Materials and metods: the prospective single-center randomized trial included 36 patients who underwent open surgical repair of abdominal aortic with median laparotomy during the period 2017-2023. Before surgery, the patients were randomized using a random number generator. Group 1 - epidural analgesia with injection of 0.2% -10 ml/hour of ropivacaine into the epidural space, followed by dose adjustment according to hemodynamic parameters; Group 2 - rectus sheath block performed under ultrasound control with the injection of 20 ml of 0.2% ropivacaine on each side after induction, followed by the insertion of catheters and bolus injection of 10 ml of 0.2% ropivacaine into the catheter on each side, every 4 hours. In all patients in the group, the pain level according to VAS was 0 points at the time of the start of anesthesia, then the assessment was carried out on the 1st day. All patients underwent surgery under standardized combined general anesthesia and the selected additional method of analgesia.

Results: in the study, the groups were similar in terms of basic anthropometric and hemodynamic parameters (p >0.05). The time of anesthesia, aortic clamping, and blood loss were also similar in the groups (p >0.05). We found that the pain level in our study corresponded to other studies. We did not observe a significant difference between the two groups when comparing and was 2.5 [2-4] cm in 1st group vs 3 [2-3] cm in the 2nd group, and 3 [0-5] in 1st group vs 2,5 [0-3] cm both on awakening and at the morning of the next day (p>0.05). Additionally, there were no signs of arterial hypotension when comparing EA to RSB upon awakening (Mean arterial pressure was 87±14 mmHg in the 1st group vs 92±15 mmHg in the 2nd group, p=0.33). The doses have used norepinephrine of intraoperatively in the groups did not differently (0.12±0.06 mcg/kg/min in the 1st group vs 0.1±0.05 mcg/kg/min in the 2nd group, p>0.05). We did not observe a difference in the amount of fentanyl administered during anesthesia in the EA and RSB groups, 2.31 [1.88-3.07] vs 2.84 [2.46-3.16] mcg /kg/hour (p=0.2). In the postoperative period, we observed higher doses of tramadol in the in 2nd group, 20 [18-23] mg/hour versus 14.5 [12-16] mg/hour in the 1st group (p=0.001). This is associated with the presence of drainage. The length of hospital stay was statistically comparable between the groups: 7.5 [7-8] days for the 1st group and 8 [7-10] days for 2nd group (p=0.1).

Conclusion: the study has shown that rectus sheath block is a viable alternative to epidural analgesia in a multimodal analgesia approach to pain management.

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