Bilateral Paravertebral Blockade vs. Incisional Local Anesthetic Administration for Laparoscopic Cholecystectomy

Pain after laparoscopic cholecystectomy is a result of many mechanisms such as tissue
injury, local trauma to gallbladder removal, chemical irritation of the peritoneum,
pneumoperitoneum. Effective analgesia in the immediate post-operative period following
laparoscopic cholecystectomy is necessary for optimal recovery. Many methods for pain
control after laparoscopic cholecystectomy have been evaluated, but none of them provided
optimal postoperative analgesia. When used as a complement to general anesthesia, bilateral
paravertebral blockade T5-T6 for adult laparoscopic cholecystectomy has been found to
improve postoperative pain control. Whether this is also the case with pediatric patients
is not certain. Analgesia from administration of local anesthetic by surgeon at
insufflations ports is of short duration and may not provide sufficient pain relief.

Research design, specific aims and methods:

The primary end-point of this research is to determine which technique is better for
postoperative pain control after laparoscopic cholecystectomy.

Screening: 100 pediatric patients (8-17 yrs old) coming for elective laparoscopic
cholecystectomy.

84 pediatric patients (8-17 yrs old) will be randomly assigned to two groups: Group 1(
treatment group ): 42 patients will have six paravertebral nerve blocks with ropivacaine
0.5 %, and incisional administration of placebo / normal saline at all four laparoscopic
ports.

Group 2(control group): 42 patients will have placebo/normal saline in paravertebral space,
same amount, and injection at incision sites for all for insufflation ports with ropivacaine
0.5%.

Both the anesthesiologist and the surgeon will be blinded to patient randomization.

Additional postoperative pain control will be provided via patient administered dilaudid
PCA, for 12 hours after paravertebral block. After PCA is discontinued, the patient will
receive oxycodone po and dilaudid iv for breakthrough pain.

Pain assessment will continue until 24 hours after paravertebral block or patient discharge
if earlier than 24 hours.

The 2 groups will be compared for total amount of fentanyl, dilaudid, oxycodone and morphine
(after conversion of above opioids to morphine based on opioids potency) used
intraoperatively and 24 hours postoperatively (or until the patient is discharged, if
sooner).

Postoperative pain scores will be assessed and compared at 4, 8, 12, 18 and 24 hr after
paravertebral block.

The secondary end-points will include possible side effects from opioids administration
(nausea, emesis, itching, and episodes of respiratory depression) and possible complications
associated with nerve blocks: pleural and vascular punctures, pneumothorax, back pain,
bruises, and intravascular administration of local anesthetic.

In addition, the type of postoperative pain (parietal, visceral, shoulder pain) after
laparoscopic cholecystectomy and patient's satisfaction will be assessed and compared in
these two groups.

Inclusion Criteria:

- pediatric patients scheduled for elective laparoscopic cholecystectomy under general
anesthesia

- 8-17 yrs, female and male

- ASA 1, 2, 3

- more than 30 Kg

- BMI less than 35

- the patient must be able to self administer opioids via patient control analgesia
(PCA)

- the patient must be able to complete postoperative questionnaires for pain score,
pain type, location, patient satisfaction

- the patient will to be admitted for 24 hrs after surgery

Exclusion Criteria:

- patient refusal

- parental/guardian refusal

- history of coagulopathy, INR more than 1.5, platelets less than 100 000, PT , PTT
more than normal value, patient on Coumadin, heparin or low molecular weight heparin
( LMWH)

- local infection at the planned block site

- vertebral anomalies, (e.g. scoliosis)

- BMI more than 35

- patient unable to self administer medications via PCA

- allergy to dilaudid, oxycodone, acetaminophen, ropivacaine

- chronic opioid use

- current weight less than 30 kg

- acute pain (pain on day of surgery that requires pain medication)

- pregnancy test positive