P9

RECTUS SHEATH CATHETERS MAY NOT PROVIDE EFFECTIVE ANALGESIA AFTER PAEDIATRIC MIDLINE LAPAROTOMY

E. Potter, H. Gill, C. Wilson

Bristol Royal Hospital for Children, UK

Introduction and Aims

Rectus sheath catheters (RSCs) may be used as an alternative to epidural catheters for post-operative analgesia in midline laparotomy. Although effective, epidural infusions are not without a significant side effect profile [1]. Recent studies in adults have shown RSCs provide superior analgesia and fewer adverse effects compared to thoracic epidurals [2]. Despite RSCs becoming increasingly popular in the adult population, evidence for their use in children is scarce. We introduced RSCs for paediatric laparotomy in 2020. Audit in April 2022 suggested they may not be effective, with 32% of RSC patients requiring an opioid background infusion adding to their NCA/PCA (nurse or patient-controlled analgesia) [3]. Consequently, the RSC local anaesthetic infusion rate was increased from 0.15 to 0.2ml/kg/hr 0.2% ropivacaine. We aimed to assess whether RSCs provide ‘effective’ analgesia following this protocol change.

 Methods

Data was collected prospectively from May 2022 to July 2023. All patients <18 years-old with RSCs inserted following midline laparotomy were included. Patients were reviewed daily by senior pain nurses and opioid background infusions were added to NCA/PCA where warranted. Effectiveness of RSC analgesia was determined on retrospective data review. ‘Ineffective’ analgesia was defined by one or more of: i) pain score at rest >7 (24, 48 or 72 hours post-operatively), ii) total opioid consumption >2.0mg/kg, or iii) background infusion added to NCA/PCA.

 Results

Twenty children had RSCs inserted. One patient was excluded due to equipment failure. Median age was 11 (1-15) years and 47.3% were male. All patients received regular paracetamol (oral or IV), bolus-only morphine NCA/PCA, and RSC infusion of 0.2% ropivacaine (0.2ml/kg/hr). RSCs were deemed ‘effective’ in 14/19 (73.7%). Median (IQR) total opioid consumption was 1.08 (0.96) mg/kg. Figure 1 demonstrates opioid consumption by group. Two patients (10.5%) had background infusions added. No opioid side-effects were reported by 78.9% of patients on day one post-operatively, this increased to 94.1% by day three.

 Discussion and Conclusion

Following the ropivacaine dose increase in 2022, fewer RSC patients (10.5% vs 32% [3]) required an additional background infusion, suggesting our protocol change has been of analgesic benefit. However, given that RSCs were deemed ‘ineffective’ for 26.3%, their clinical efficacy still remains undetermined. Our recent systematic literature search identified no clinical trials evaluating RSCs in paediatric laparotomy. Given the significant gap in the literature, further primary research in this field is necessary. Therefore, similar to the CAMELOT trial underway in the adult population [4], we aim to design a pragmatic randomised-controlled trial to objectively assess the efficacy of RSCs in paediatric patients.

References:

1. Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. British Journal of Anaesthesia. 2001; 87(1): 47–61. https://doi.org/10.1093/bja/87.1.47
2. Krige A, Brearley SG, Mateus C, Carlson GL, Lane S. A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: Randomized clinical trial. BJS Open. 2022; 6(3): zrac055. doi:10.1093/bjsopen/zrac055
3. Barnes J, Abeysekera C, Parry S, Woodward T, Burns K, Wilson C. Rectus sheath catheters for post-laparotomy analgesia at a tertiary paediatric centre. Abstract 111. Anaesthesia. 2022; 77(S3): 7–78. http://doi.org/10.1111/anae.15766 [abstract]
4. CAMELOT - Continuous rectus sheath Analgesia in eMErgency LaparOTomy. ISRCTN15475290. Accessed Feb 2024. Available from: https://www.isrctn.com/ISRCTN15475290