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      Ultrasound-Guided Rectus Sheath Block Combined with Butorphanol for Single-Incision Laparoscopic Cholecystectomy: What is the Optimal Dose of Ropivacaine?

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          In recent years, ultrasound-guided rectus sheath block (RSB) has been widely used in postoperative analgesia of abdominal operation. However, there is no uniform standard for the optimal dose of local anesthetics (LA) under ultrasound-guided rectus sheath block. This study aimed to determine the dose of ropivacaine combined with butorphanol that is effective in 50% (ED50) and 95% (ED95) of subjects for successful pain-free ultrasound-guided RSB in single-incision laparoscopic cholecystectomy (SILC).

          Patients and Methods

          Twenty-four patients scheduled to undergo single-incision laparoscopic cholecystectomy received an ultrasound-guided RSB. The initial dose of ropivacaine injected was 1.7 mg/kg, which was subsequently increased or decreased by 0.2 mg/kg, depending on whether the previous patient was free from pain (numeric rating scale (NRS) score of incisional pain at rest within 12 h after operation ≤ 3). All patients were treated with butorphanol 0.02 mg/kg as preemptive analgesia. The ED50 and ED95 were calculated using a probit regression model.


          The ED50 and ED95 of ropivacaine combined with butorphanol in ultrasound-guided rectus sheath block for analgesia in SILC, which were calculated by the probit regression model, were 0.719 mg/kg (95% confidence interval (CI), 0.553 mg/kg−0.873 mg/kg) and 0.967 mg/kg (95% CI, 0.835 mg/kg−1.91 mg/kg), respectively.


          As part of a multimodal analgesia strategy, a dose of 0.719 mg/kg ropivacaine provided successful RSB under ultrasound guidance in 50% of the patients who underwent SILC. A dose of 0.967 mg/kg would be successful in 95% of patients.

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          Most cited references 27

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          Advances in and limitations of up-and-down methodology: a précis of clinical use, study design, and dose estimation in anesthesia research.

          Sequential design methods for binary response variables exist for determination of the concentration or dose associated with the 50% point along the dose-response curve; the up-and-down method of Dixon and Mood is now commonly used in anesthesia research. There have been important developments in statistical methods that (1) allow the design of experiments for the measurement of the response at any point (quantile) along the dose-response curve, (2) demonstrate the risk of certain statistical methods commonly used in literature reports, (3) allow the estimation of the concentration or dose-the target dose-associated with the chosen quantile without the assumption of the symmetry of the tolerance distribution, and (4) set bounds on the probability of response at this target dose. This article details these developments, briefly surveys current use of the up-and-down method in anesthesia research, reanalyzes published reports using the up-and-down method for the study of the epidural relief of pain during labor, and discusses appropriate inferences from up-and-down method studies.
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            Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block.

            The transversus abdominis plane block is a novel technique involving injection of local anaesthetic between the internal oblique and the transversus abdominis muscles of the abdominal wall. It is possible that injection of a large dose of local anaesthetic into a relatively vascular plane may result in toxic concentrations. One previously published study examined plasma lidocaine concentrations after transversus abdominus plane block and showed potentially toxic plasma concentrations. Although ropivacaine is most commonly used for this technique, plasma concentrations of ropivacaine after this block have not been reported previously. Adult female patients undergoing elective open gynaecological surgery received bilateral ultrasound-guided transverse abdominal plane blocks before surgical incision (3 mg kg(-1) of ropivacaine diluted to 40 ml). Venous blood was collected each 15 min for the first hour, each 30 min for the second hour, and then at 3, 4, 12, and 24 h post-block. Twenty-eight patients were recruited. The mean (sd) peak total ropivacaine concentration occurred 30 min post-injection and was 2.54 (sd 0.75) µg ml(-1). The highest measured concentration was 4.00 µg ml(-1), also 30 min post-injection. Mean total concentrations remained above 2.20 µg ml(-1) for up to 90 min post-injection. The mean unbound peak venous concentration was 0.14 (0.05) µg ml(-1), and the peak was 0.25 µg ml(-1). Transversus abdominus plane block using 3 mg kg(-1) of ropivacaine produces venous plasma concentrations that are potentially neurotoxic, although broadly consistent with plasma levels found after injection at other comparable sites.
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              Chronic pain after surgery: pathophysiology, risk factors and prevention.

              Interest in chronic pain after surgery has grown since the finding that more than a fifth of patients attending chronic pain clinics cite surgery as the cause for their chronic pain. The problem is not limited to major surgery; even common minor procedures such as hernia repair have a significant risk of chronic pain. Surgical technique can influence the development of chronic postsurgical pain (CPSP) and techniques to minimise nerve injury should be used where possible. Central nervous system changes contribute to the development of persistent pain following surgical trauma and nerve injury. Pharmacological agents that interrupt the mechanisms contributing to central sensitisation may be helpful in reducing the incidence of CPSP. Psychosocial factors are also important in the development of chronic pain and should be addressed as part of a holistic approach to perioperative care.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                15 October 2020
                : 13
                : 2609-2615
                [1 ]Department of Anesthesiology, Affiliated Hospital of Nantong University , Nantong, Jiangsu, People’s Republic of China
                Author notes
                Correspondence: Xingguo Xu; Yongtao GaoDepartment of Anesthesiology, Affiliated Hospital of Nantong University , No. 20 Xisi Road, Nantong, Jiangsu226001, People’s Republic of ChinaTel +86 15162771638; +86 13962988003Fax +86 051381160318 Email TDFYXXG@126.com; gyt19700114@sina.com
                © 2020 Fu et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 5, Tables: 3, References: 27, Pages: 7
                Funded by: the Social Development Foundation of Nantong City;
                This study was supported by grants from the Social Development Foundation of Nantong City (MS12019023).
                Original Research


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