Ultrasound‐guided rectus sheath catheter placement

We read with interest the excellent article by Niraj et al. 1, which documented the effectiveness of continuous transversus abdominis plane (TAP) block as an alternative to epidural anesthesia. We concur with their observations and have also found that TAP blocks can provide reasonable analgesia for selective major abdominal procedures when epidural anesthesia is contraindicated, or if there are other concerns about administering an epidural. Although rare, serious complications of epidurals can be potentially devastating and may result in permanent neurologic damage 2. Indeed, a recent editorial 3 suggested that the benefits of epidural analgesia are probably limited to high-risk patients undergoing major surgery. As alternatives to epidurals, we use infusion catheters in the paravertebral space (open nephrectomy and open cholecystectomy), TAP (hepatobiliary and general surgery), and rectus sheath (midline laparotomy) 4. There is limited published information regarding ultrasound-guided rectus sheath blocks, particularly in the adult population. Recently, we have adapted rectus sheath block as an alternative to epidural block for midline incisions. Using a technique described previously for single-shot rectus sheath blocks 4, a linear transducer is placed in transverse orientation at the midpoint between the umbilicus and xiphisternum and moved laterally to the lateral border of the rectus sheath (Fig. 1). A lateral approach avoids the epigastric artery. Using a previously described catheter-over-needle technique (E-Catheter, Pajunk, Germany) 5, the catheter needle is then advanced in-plane from the lateral side of the probe towards the midline to enter the lateral border of the rectus sheath. Hydrodissection will separate the rectus muscle from the posterior rectus sheath, and the catheter is advanced to lie between these two layers (Fig. 1). A second catheter is inserted on the other side. An initial bolus of 20 ml ropivacaine 0.2% is delivered through each catheter before commencing 1 ml.h−1 infusion regimens with programmed 20-ml boluses every 4 h. It is important to note that, while the rectus sheath catheter is effective at relieving somatic pain, it usually needs to be run in conjunction with a multimodal analgesia regimen (e.g. patient-controlled opioid analgesia) to control visceral pain. Alternative techniques for placement and management of rectus sheath catheters have been described 6, and familiarity with this technique provides another alternative to epidural analgesia during a time when emphatic indications for epidural catheters appear to be decreasing.

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