Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery

Proof of concept study of the posterior quadratus lumborum block for laparoscopic myomectomy: A randomized controlled trial

In the United States, 65,000 myomectomies are performed annually to treat uterine fibroids. The quadratus lumborum block (QLB) is an effective block for laparoscopic pelvic surgery, urologic surgery, hip surgery and cesarean sections, with limited data for laparoscopic myomectomies. We evaluated the posterior QLB in reducing MME consumption and numeric rating scale (NRS) pain scores in patients undergoing laparoscopic myomectomies. Twenty-two subjects were enrolled in this single-center, randomized, controlled study between March 28, 2019 and June 16, 2020 and were randomized to either the QLB or control group. Seven subjects were excluded from the final analysis, 5 after being lost to follow-op and 2 for not meeting the inclusion criteria. Recipients in the QLB group received bilateral posterior QLBs, with 30 mL of 0.25% ropivacaine per injection. The primary outcome of MME use at 24 hours was not significant between the QLB group and the control group (23.3 ± 8.5 mg vs. 25.7 ± 14.4 mg, p = 0.859). The secondary outcome of NRS pain scores was also not significant between groups (p > 0.05). While this study did not provide evidence that QLB may be useful in reducing opioid consumption or pain scores in patients undergoing laparoscopic myomectomies, further studies with a larger sample size will be valuable to determine the effectiveness of this block for laparoscopic myomectomy.

Efficacy of Quadratus Lumborum Block for Postoperative Pain Management in Single-Port Total Laparoscopic Hysterectomy: A Randomized Observer-Blinded Controlled Trial

Background and Objectives: Quadratus lumborum block (QLB) is a regional anesthesia technique widely utilized in multimodal analgesia strategies for abdominal surgeries. While a few studies have investigated its efficacy in multiport total laparoscopic hysterectomy (TLH), its effectiveness in single-port TLH remains uncertain. This study aimed to evaluate whether QLB reduces opioid consumption and postoperative pain in patients undergoing single-port TLH. Materials and Methods: This randomized, controlled, observer-blinded trial included 64 patients undergoing elective single-port TLH. Participants were randomly allocated to either the QLB group (n = 27) or the control group (n = 29). QLB was performed bilaterally under ultrasound guidance after surgery. The primary outcome was cumulative fentanyl consumption within 24 h postoperatively. Secondary outcomes included pain scores at predefined intervals, time to first opioid demand, the incidence of postoperative nausea and vomiting (PONV), and other complications. Results: The 24 h cumulative fentanyl consumption, which was the primary outcome, did not differ significantly between the QLB group, 342.8 [220, 651] mcg, and the control group, 470 [191.6, 648.1] mcg (p = 0.714). Similarly, cumulative fentanyl consumption at other time points, including 2 h, 4 h, 8 h, 12 h, 32 h, and 48 h, as well as in the PACU, also showed no significant differences between the two groups. Pain scores measured at these time points, along with the time to first bolus on demand, were comparable between groups. However, PONV occurred more frequently in the QLB group than in the control group (25.9% vs. 3.4%, p = 0.023). Conclusions: QLB did not significantly reduce opioid consumption, time to first opioid demand, or postoperative pain scores in single-port TLH. However, PONV occurred more frequently in the QLB group. These findings suggest that QLB may have limited analgesic benefits in single-port TLH.

Preoperative posterior quadratus lumborum block: determining the minimum effective ropivacaine concentration in 90% of patients (MEC90) for postoperative analgesia after laparoscopic myomectomy

BACKGROUND

Quadratus lumborum block (QLB) has gained traction as a regional anesthesia technique to manage postoperative pain following laparoscopic surgery. However, the 90% minimum effective concentration (MEC90) of local anesthetics for posterior QLB remains undetermined.

METHODS

We conducted a double-blind, comparative dose-finding study involving 54 women scheduled for elective laparoscopic myomectomy under general anesthesia. Each patient received a bilateral posterior QLB with 20 mL of ropivacaine on each side. The concentration administered varied for each patient and was determined based on the response of the previous participant. The initial concentration was set at 0.20%. Upon successful block, the subsequent patient was assigned to receive either the same (probability of 0.89) or a 0.05% lower concentration (probability of 0.11). In cases of block failure, the concentration was increased by 0.05% for the next patient. The trial concluded when 45 successful blocks were achieved, with block success defined as a pain score of three or fewer 30 minutes after arrival in the post-anesthesia care unit.

RESULTS

The 90% minimum effective concentration (MEC90) of ropivacaine was 0.340% (95% CI 0.329 to 0.344%).

CONCLUSIONS

The optimal concentration of ropivacaine for posterior QLB to achieve satisfactory analgesia following laparoscopic myomectomy is a 20 mL volume of 0.340% ropivacaine per side.

REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200055743.

Use of quadratus lumborum block in gynecologic procedures

OBJECTIVE

Adequately managing post-operative pain is essential for improving patient outcomes and reducing post-operative complications. The quadratus lumborum (QL) block is a truncal nerve block technique that was recently developed to provide analgesia during abdominal and hip surgical procedures. While many studies have shown the outstanding analgesic effect of QL blocks, this technique is not well-known or commonly used in gynecologic procedures.

FINDINGS

This narrative review describes evidence in current literature on the safety and effectiveness of QL blocks when used for gynecologic procedures. The studies show that including QL blocks as part of the approach to managing post-operative pain in gynecologic patients can reduce post-operative pain, reduce analgesic consumption, and lengthen time to first analgesic. They also suggest that QL blocks are more effective at managing post-operative pain and have a lower risk for systemic toxicity compared with transversus abdominis plane blocks.

SUMMARY

According to current randomized controlled trials, QL blocks have been shown to be effective in managing post-operative pain after gynecologic surgical procedures. Further studies on effectiveness in different procedures, adjuvants, and optimum dosing of local anesthetic are needed to determine the best application of QL blocks in gynecologic procedures.

Comparison of two approaches to quadratus lumborum block for postoperative analgesia in radical cystectomy: a randomized clinical trial

BACKGROUND

The aim of this study was to evaluate the analgesic effects following radical cystectomy using two ultrasound guided quadratus lumborum block (QLB) techniques: anterior and intramuscular.

METHODS

Sixty patients aged 40-60 years old with ASA I, II were considered for this study. They were divided into two equal groups. Bilateral ultrasound guided QLB was performed via either the anterior (QLBa) or intramuscular (QLBi) approach with 2.5 mg/kg of 0.25% bupivacaine diluted to 20 mL of normal saline after surgery. The primary outcome was the time to the first request for analgesia, while the secondary outcomes were the dose of postoperative morphine consumption, numerical rating scale (NRS) at rest and on movement, Bromage Scale, adverse events, and patient satisfaction.

RESULTS

The mean time to first request for analgesia was significantly prolonged in group QLBa (14.7±1.33 hours) compared to group QLBi (9.8±0.72 hours) (P<0.001). NRS either at rest or on movement were not statistically significant until six hours postoperatively. At 10, 12, and 14 h, Group QLBi had a significantly higher NRS Score at rest and on movement (P<0.001). Group QLBa had a significantly lower total morphine consumption (5.37±0.49 mg) compared to Group QLBi (6.4±0.77 mg) (P<0.001). The QLBa had higher patient satisfaction than the QLBi.

CONCLUSIONS

Compared with QLBi, bilateral ultrasound guided QLBa provided a longer time to the first analgesic request, less postoperative opioid consumption, lower NRS at rest and on movement, and higher patients' satisfaction after radical cystectomy under general anesthesia.

Analgesic effects of ultrasound-guided preoperative posterior Quadratus Lumborum block in laparoscopic hepatectomy: A prospective double-blinded randomized controlled trial

STUDY OBJECTIVE

To determine if single-injection bilateral posterior quadratus lumborum block (QLB) with ropivacaine would improve postoperative analgesia in the first 24 h after laparoscopic hepatectomy, compared with 0.9% saline.

DESIGN

Prospective, double blinded, randomized controlled trial.

SETTING

A single tertiary care center from November 2021 and January 2023.

PATIENTS

A total of 94 patients scheduled to undergo laparoscopic hepatectomy due to hepatocellular carcinoma.

INTERVENTIONS

Ninety-four patients were randomized into a QLB group (receiving 20 mL of 0.375% ropivacaine on each side, 150 mg in total) or a control group (receiving 20 mL of 0.9% saline on each side).

MEASUREMENTS

The primary outcome was the cumulative opioid consumption during the initial 24-h post-surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters.

MAIN RESULTS

The mean cumulative opioid consumption during the initial 24-h post-surgery was 30.8 ± 22.4 mg in the QLB group (n = 46) and 34.0 ± 19.4 mg in the control group (n = 46, mean differences: -3.3 mg, 95% confidence interval, -11.9 to 5.4, p = 0.457). The mean resting pain score at 1 h post-surgery was significantly lower in the QLB group than in the control group (5 [4-6.25] vs. 7 [4.75-8], p = 0.035). No significant intergroup differences were observed in the resting or coughing pain scores at other time points or in other secondary outcomes.

CONCLUSIONS

Preoperative bilateral posterior QLB did not reduce cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy.

Ultrasound-guided erector spinae nerve block for relief of endometriosis pain in the emergency department

Endometriosis is a debilitating chronic condition often accompanied by severe pelvic pain and infertility issues. When outpatient medical management is not adequate, controlling pain can be challenging for providers in the acute setting. We report the case of a 23-year-old female with a past medical history of endometriosis who presented to a freestanding emergency department with a chief complaint of 10/10 pelvic pain on a numeric rating scale. She had tried non-steroidal inflammatory medications and heat with no success. The patient had medication intolerances to opioid analgesics and was given ketorolac intramuscularly with no relief of her pain. The emergency physician discussed and offered to perform an erector spinae plane nerve block (ESPB) for pain relief. Ultrasonography was utilized for visualization of landmarks with a curvilinear transducer; a 20-gauge Pajunk® Sonoplex needle was used to inject a total of 100 mg bupivacaine 0.25% without epinephrine along with dexamethasone 10 mg under the bilateral erector spinae fascial planes at the T9 level. Post-procedure, the patient had significant improvement in pain and rated it a 2/10. Utilizing nerve blocks for endometriosis and other chronic pelvic pain in the acute care setting can serve as an effective alternative to opioids. In patients with multiple medication intolerances and for providers navigating pain control in the setting of a nationwide opioid crisis, ESPB blocks can help alleviate acute pain or exacerbations of chronic pain. This case demonstrates the first known use of an ESPB to relieve endometriosis pain in the emergency department.

Quadratus Lumborum Block for Ovarian Cystectomy Surgery in a Patient With Severe Kyphoscoliosis

Quadratus lumborum block (QLB) has been described as a regional analgesic technique in various abdominal surgeries. We present a case report of a high-risk patient who underwent ovarian cystectomy with QLB and deep sedation after failed neuraxial anesthesia. A 29-year-old female patient with comorbidities osteogenesis imperfecta, severe kyphoscoliosis with restrictive lung disease, and cervical syringomyelia with cranio-cervical junction stenosis (C2/C3). The patient had large ovarian cysts with associated dyspnea. She accepted surgery-an open bilateral ovarian cystectomy-despite being advised that general anesthesia would be high-risk. Regional anesthetic options were limited and challenging, given her anatomy and difficulty in positioning. Neuraxial anesthesia was attempted but was unsuccessful. The patient safely underwent surgery (lower midline laparotomy) using QLB. This clinically challenging case demonstrates the feasibility of QLB as the mainstay multimodal anesthetic approach (without general and neuraxial anesthesia) for abdominal surgery under exceptional circumstances.

Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery.

DESIGN AND SETTING

This retrospective cohort study was performed in a tertiary care hospital.

PATIENTS

A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study.

INTERVENTIONS

The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge.

MEASUREMENTS AND MAIN RESULTS

The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block.

CONCLUSIONS

The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

Comparative analysis of lumbar quadratus lumborum block and epidural block for analgesia in uterine surgery at Dr. Soetomo Hospital, Surabaya

Over 80% of surgical patients experience postoperative pain, which, if inadequately managed, can lead to complications, prolonged rehabilitation, chronic pain, and decreased quality of life. Epidural block and quadratus lumborum block are techniques commonly used for postoperative pain management. This comparative analytic study aimed to analyze the differences in the analgesic effects of quadratus lumborum block and epidural block in uterine surgery at Dr. Soetomo General Hospital. The outcomes assessed were the numerical rating score (NRS) as a pain score and the administration of opioids as an adjuvant analgesic. Statistical analysis employed the Mann-Whitney test and Chi-square test. The study included 32 patients who underwent uterine surgery at Dr. Soetomo General Hospital and met the inclusion and exclusion criteria. Among the patients, 90.6% experienced mild pain, and 9.4% experienced moderate pain. Epidural blocks were performed in 50% of the patients, while quadratus lumborum blocks were performed in the other 50%. Additionally, 9.4% of the patients received opioids as adjuvant analgesics. The Mann-Whitney test revealed no significant difference in NRS between the epidural block and quadratus lumborum block groups (p-value>0.05). However, the Chi-square test indicated a significant difference in NRS between patients who received additional opioids as adjuvant analgesics and those who did not (p-value<0.00). There was no significant difference in NRS between patients who underwent epidural block and quadratus lumborum block as analgesic techniques.

Implementation of a quadratus lumborum regional block protocol with assessment of effectiveness for patients with appendicitis: a quality improvement project

PURPOSE

This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia.

METHODS

Children undergoing laparoscopic appendectomy within a multi-hospital children's healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type.

RESULTS

2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively.

CONCLUSION

QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries to minimize rescue opioid analgesic use.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Effects of intraoperative esketamine addition on gastrointestinal function after benign gynaecological laparoscopic surgery: a double-blind, randomized controlled study

BACKGROUND

Gastrointestinal hypokinesis can occur transiently after benign gynecologic surgery. Opioids cause the side effect of postoperative gastrointestinal hypokinesis, but an opioid-sparing anaesthetic protocol based on esketamine reduces intraoperative opioid consumption. Therefore, this study hypothesised that an opioid-sparing anaesthetic protocol based on esketamine would shorten the gastrointestinal function recovery time after benign gynaecological laparoscopic surgery.

METHODS

This was a prospective randomized controlled double-blind study conducted in a single centre. All patients scheduled for elective benign laparoscopic gynaecological surgery at Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, from November 2021 to April 2022 were consecutively enrolled and randomly divided into the opioid-sparing anaesthesia group (Group OS) and the conventional anaesthesia group (Group C). Postoperative first exhaust time, feeding time and postoperative nausea and/or vomiting (PONV) were analyzed in both groups.

RESULTS

A total of 71 patients were enrolled in this study, including 35 in Group OS and 36 in Group C. The general condition, operative time, type of surgery, intraoperative bleeding, intraoperative fluid volume and intraoperative urine volume were not statistically different between the two groups. Compared with Group C, significantly shorter first postoperative flatus time (11 [8, 14] h vs. 14 [11, 18], p = 0.003) and anaesthesia resuscitation time (7 [6, 9] h vs. 9 [7, 11] h, p = 0.013)were observed in the OS group. The incidence of PONV in Group OS was significantly lower compared with Group C (11.4% vs. 41.7%, p = 0.007).

CONCLUSION

The esketamine-based opioid-sparing anaesthetic protocol can shorten the postoperative first flatus time after benign laparoscopic surgery in gynaecology, and reduce the incidence of PONV. In addition, the application of esketamine may reduce the postoperative opioid dose requirement of patients.

TRIAL REGISTRATION

This study was registered with the China Clinical Trials Registry (registration number: ChiCTR2100052528, 30/10/2021).

Quadratus Lumborum Block Against Coupled Transversus Abdominis Block and Ilioinguinal/Iliohypogastric Nerve Blocks for Postoperative Analgesia After Total Abdominal Hysterectomy: A Randomized Controlled Trial

Background

Nerve blocks have been one of the most common anesthetic methods for abdominal surgeries since the last four decades.

Objectives

This study aimed to compare the postoperative analgesic efficacy of bilateral ultrasound-guided quadratus lumborum block (QLB) against bilateral ultrasound-guided transversus abdominis block (TAB) and Ilioinguinal/Iliohypogastric nerve blocks (IINB) in abdominal total hysterectomy.

Methods

Sixty female patients scheduled for the surgery of total abdominal hysterectomy under spinal anesthesia participated in this randomized prospective trial. They were randomly assigned to two dual TAB / IINB (n = 30) and QLB (n = 30) groups. Moreover, the visual analog scores (VAS), the total amount of morphine consumed after surgery during the first 24 hours, the number of individuals requiring rescue analgesia, postoperative analgesia duration, and postoperative complications were recorded.

Results

Morphine consumption was equal in both groups (P = 0.908). Furthermore, the analgesia duration in the two groups was statistically insignificant (P = 0.879), with mean values of 15.4 and 15.6 hours, respectively. During 24 hours, there was no statistically significant difference in terms of VAS between the two groups (P > 0.05).

Conclusions

The QLB might be a viable replacement for TAB/IINB for postoperative analgesia after total abdominal hysterectomy.

Effect of Quadratus Lumborum Block on Pain and Stress Response after Video Laparoscopic Surgeries: A Randomized Clinical Trial

BACKGROUND

There are many surgical and anesthetic factors that affect pain and the endocrine-metabolic response to trauma. The ability of anesthetic agents and neuronal blockade to modify the response to surgical trauma has been widely studied in the last few years.

OBJECTIVE

To evaluate if the anterior quadratus lumborum block contributes to improved surgical recovery, using as parameters analgesia, pulmonary function and neuroendocrine response to trauma.

METHODS

We carried out a prospective, randomized, controlled, and blinded study, in which 51 patients scheduled for laparoscopic cholecystectomy. Patients were randomly selected and assigned to 2 groups. The control group received balanced general anesthesia and venous analgesia, and the intervention group was treated under general, venous analgesia and anterior quadratus lumborum block. The parameters evaluated were: demographic data, postoperative pain, respiratory muscle pressure and inflammatory response to surgical stress with the plasma dosage of IL-6 (Interleukin 6), CRP (C-Reactive protein) and cortisol.

RESULTS

Anterior quadratus lumborum block induced the slowing of IL-6 cytokine production and a decrease in cortisol release. This effect was accompanied by the significant reduction of postoperative pain scores.

CONCLUSION

Anterior quadratus lumborum block is an important strategy for analgesia in abdominal laparoscopic surgery and contributes to reducing the inflammatory response to surgical trauma with an early return of preoperative baseline physiological functions.

Comparison of ultrasound-guided quadratus lumborum block-2 and quadratus lumborum block-3 for postoperative pain in cesarean section: A randomized clinical trial

INTRODUCTION

The aim of this study was to compare the postoperative analgesic effects of ultrasound-guided quadratus lumborum block-2 (QLB-2) and quadratus lumborum block-3 (QLB-3) after cesarean section (C/S) under general anesthesia.

METHOD

This was a prospective, randomized, double-blind study. A total of 143 term pregnant women with American Society of Anesthesiologists II status, who were scheduled for elective C/S under general anesthesia were randomly separated into QLB-2 and QLB-3 groups. After surgery under standardized general anesthesia, QLBs were performed with 0.3 mL.Kg-1 0.25% bupivacaine in both groups. Patient-controlled analgesia (PCA) devices were used for additional analgesia. The primary outcomes were pain scores evaluated at 0, 2, 6, 12, and 24 hours. In addition, PCA demands, actual delivered tramadol doses, rescue analgesic requirements, anesthesia time, and patient satisfaction were recorded.

RESULTS

A total of 104 patients were analyzed statistically. Pain scores were statistically lower in the QLB-3 group at 2, 6, 12, and 24 hours postoperatively (P = .001). Anesthesia time was longer in the QLB-3 group. Patients who received QLB-3 block demonstrated significantly fewer PCA demands and lower consumption of tramadol (P = .003). Moreover, the first analgesic requirement time was longer along with higher patient satisfaction. In addition, all procedures were performed without any complications and side effects due to PCA were negligible.

CONCLUSIONS

This study demonstrated that, although both QLBs were safe and reliable, QLB-3 provides more effective analgesia and patient satisfaction than QLB-2 in C/S.

Ultrasound-guided quadratus lumborum block provided more effective analgesia for children undergoing lower abdominal laparoscopic surgery: a randomized clinical trial

BACKGROUND

Postoperative pain treatment for pediatrics is often inadequate and the evidence of pediatric postoperative analgesia is scarce. To our knowledge, no report regarding the comparison among caudal block, transversus abdominis plane (TAP) block and quadratus lumborum (QL) block for children undergoing lower abdominal laparoscopic surgery was found at present. Thus this trial aimed to compare the efficacies of them for children undergoing lower abdominal laparoscopic surgery.

METHODS

One hundred and eighty children aged from 1 to 12 years undergoing lower abdominal laparoscopic surgery were included and randomized to receive caudal block, TAP block or QL block. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) score at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h and tramadol consumption during first 24 h postoperatively. Secondary outcomes included the number of children received tramadol, time to first tramadol request, parents' satisfaction and postoperative adverse reactions.

RESULTS

The QLB group had lower postoperative FLACC scores at 8 h (median difference - 0.43, P = 0.03) than the Caudal group and at 4 h (median difference - 0.6, P = 0.001) and 8 h (median difference - 0.43, P = 0.03) than the TAPB group. The tramadol consumption was lower in the QLB group (28.43 ± 6.55) than the TAPB group (37.17 ± 6.12, P = 0.023). Although the number of children received tramadol did not differ among the three groups, the time to first tramadol request was longer in the QLB group (7.20 ± 0.79) than the caudal group (8.42 ± 0.61, P = 0.008). No statistical difference was observed concerning other secondary outcomes.

CONCLUSIONS

QLB produced more effective postoperative analgesia for children undergoing laparoscopic abdominal surgery compared with the TAPB and caudal block.

Perioperative Analgesic Efficiency of Ultrasound-Guided Quadratus Lumborum Block versus Epidural Analgesia in Bladder Cancer Patients Undergoing Radical Cystectomy

Background and Aim: Multimodal analgesia is currently used for perioperative pain management after Radical cystectomy (RC). This study aimed to compare quadratus lumborum block (QLB) and thoracic epidural block (TEA) in patients subjected to RC. Methods: This prospective randomized controlled study included 34 patients with bladder cancer subjected to RC under general anesthesia, divided into two groups. The Quadratus Group (n=17) underwent bilateral ultrasound-guided continuous QLB, and the Epidural Group (n=17) underwent continuous TEA. The primary outcome was pain intensity measured by VAS score, and the secondary outcomes were total morphine consumption during the first 48 hours after surgery, postoperative nausea score, and patient satisfaction. Results: There were no differences between the two groups in postoperative VAS scores starting immediately after surgery up to 48 hours. Reduction of VAS score after QLB was delayed compared to that after TEA. The two groups had a comparable number of patients requesting rescue analgesia (p = 0.271) and total postoperative morphine consumption (p = 0.976) in the remaining patients. The nausea score was significantly lower in the Quadratus Group than in the Epidural Group (p = 0.020). There was no significant difference between the two groups in the satisfaction score (p=0.612). Few mild complications were detected in the two studied groups. Conclusion: QLB and TEA are safe and effective in managing postoperative pain after radical cystectomy with similar analgesic profiles. QLB was more effective in reducing postoperative nausea and vomiting.

Elevated serum TLR4 level as a potential marker for postsurgical chronic pain in pediatric patients with different approaches to analgesia

Introduction

The perioperative period of any surgery is accompanied by immune suppression. The level of Toll-like receptor 4 (TLR4) is known to increase in inflammation and after nerve injury and contributes to the development of neuropathic pain. The interaction of TLRs in response to the effect of opioids results in paradoxical hyperalgesia. Regional anesthesia techniques are the standard of care for perioperative pain management in children.

Aim

The aim of the study was to determine and evaluate the indicators of TLR4 for different methods of pain relief in anesthetic management of hernia repair in children and their effect on pain chronification.

Materials and methods

There were examined 60 children with inguinal hernia during 2020-2022. Children were divided into 3 groups: Group I included 20 children who underwent surgery under general anesthesia using the block of the anterior abdominal wall-transversalis fascia plane block (TFPB), combined with the quadratus lumborum block (QLB-4) via a single intramuscular injection; Group II included 20 children who underwent surgery under general anesthesia using the TFPB; Group III comprised 20 children who underwent surgery under general anesthesia using opioid analgesics. The levels of TLR4 were evaluated at a discharge from the hospital, 3 and 6 months after surgery.

Results

There was no difference in age and body weight among all groups. In Group II, boys prevailed. In Group III, the length of hospital stay was the longest (3.28 ± 0.24 days, p < 0.05, t = 4.09) as compared to children of Group II and Group I (3.0 ± 0.30 (p < 0.05, t = 2.647) and 2.1 ± 0.16 days, respectively). While staying in the surgical department, children of Group III demonstrated significantly higher FLACC and VAS scores. The prevalence of chronic pain was the highest among children of Group III (35%) as compared to those in Group II and Group I (20 and 15%, respectively). The highest increase in the level of TLR4 was found in the group of opioid analgesia on the third and sixth months after surgery (68.86 + 10.31 pg/ml and 143.15 + 18.77 pg/ml (p < 0.05, t = 6.33), respectively) as compared to patients who received regional anesthesia.

Conclusions

There were confirmed the following advantages of the transversalis fascia plane block combined with the quadratus lumborum block (QLB + TFPB) via a single intramuscular injection: ease of use; adequate perioperative pain control as evidenced by the FLACC and VAS pain assessment scales; reduced perioperative use of opioid analgesics; shortening the length of hospital stay.

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE

 To review our experience with quadratus lumborum block (QLB) in pediatric urology.

MATERIALS AND METHODS

 This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry.

RESULTS

 There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction.

CONCLUSION

 Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Ultrasound-Guided Quadratus Lumborum Block Enhances the Quality of Recovery after Gastrointestinal Surgery: A Randomized Controlled Trial

Background

Quadratus lumborum block (QLB) has been used to reduce postoperative acute pain and opioid consumption. However, the efficacy of QLB on the quality of recovery (QoR) after gastrointestinal surgery has not been established. The aim of this study was to evaluate the ability of QLB to enhance the postoperative QoR in patients undergoing open gastrointestinal surgery.

Methods

Eighty-four patients undergoing open gastrointestinal surgery were randomized to receive ultrasound-guided QLB with either 20 ml of 0.375% ropivacaine or saline. The primary outcome was the QoR-15 score at 24 h after surgery. The secondary outcomes were the postoperative pain intensity, opioid consumption, the incidence of nausea, vomiting, and chronic pain.

Results

The global QoR-15 score at 24 h postoperatively was significantly higher in the QLB group than in the control group (mean difference: 16.9; 95% CI: 11.9–21.9). Additionally, the QoR-15 scores for five dimensions were significantly higher in the QLB group than in the control group. The cumulative oxycodone consumption was significantly lower in the QLB group during 0–6, 6–24, 0–24, 24–48, and 0–48 h postoperatively than in the control group. At rest or during coughing, the pain verbal rating scale scores were significantly lower at 1, 3, 6, 12, and 24 h after surgery in the QLB group than in the control group. The incidence of postoperative nausea was significantly different between the groups, but postoperative vomiting was not.

Conclusion

Single-injection posteromedial QLB with ropivacaine enhanced the QoR at 48 h after surgery and improved analgesia during the early postoperative period in patients undergoing gastrointestinal surgery.

Ultrasound-guided posterior quadratus lumborum block for postoperative pain control after minimally invasive radical prostatectomy: a randomized, double-blind, placebo-controlled trial

A minimally invasive approach to radical prostatectomy offers improved ambulation and discharge times. Postoperative pain control is one of the key factors that facilitates rapid recovery. With the aim to assure adequate analgesia and minimize the use of opioids, application of truncal nerve blocks has been proposed in a number of endoscopic procedures. The aim of this double-blind, placebo-controlled study was to evaluate the efficacy of bilateral posterior quadratus lumborum block (pQLB) in alleviating pain and reducing postoperative opioid demand in patients following endoscopic extraperitoneal and laparoscopic prostatectomy. We enrolled 50 patients who were diagnosed with prostate cancer and scheduled for prostatectomy. They were randomized to receive preoperative, ultrasound-guided pQLB with the use of either 30 ml of 0.375 % ropivacaine (ropivacaine group) or 30 ml of 0.9 % NaCl (placebo group). Our primary endpoint was opioid consumption in the first 24 hours after surgery. Secondary endpoints were pain intensity at predefined timepoints and the incidence of nausea and vomiting and pruritus. No differences were detected between the ropivacaine and placebo groups in intravenous oxycodone consumption during the first 24 hours after surgery. Similarly, there were no differences in pain intensity at any of the timepoints assessed. The rate of nausea and vomiting was equal in both groups and pruritus was not observed. Application of bilateral pQLB does not reduce opioid consumption after minimally invasive prostatectomy.

Ultrasound-Guided Posterior Quadratus Lumborum Block for Acute Postoperative Analgesia in Adult Patients: A Meta-Analysis of Randomized Controlled Trials

Objective

The quadratus lumborum block provides postoperative analgesia for patients undergoing abdominal surgery, although there are three common approaches to perform this block. The present meta-analysis investigated the effectiveness of posterior quadratus lumborum block (QLB2) after surgery.

Methods

PubMed, Embase, and the Cochrane Central Register were searched from inception to 26 August 2021 for randomized controlled trials that evaluated the analgesic efficacy of QLB2 vs control (placebo or no block). The primary outcomes were pain scores at 6 h, 12 h, and 24 h after surgery. The secondary outcomes were morphine consumption at 24 h after surgery and the postoperative complications.

Results

The present meta-analysis included 14 studies conducted with a total of 1001 patients. In comparison to control group, the QLB2 group presented significantly lower rest pain scores at 6 h (SMD -0.59; 95% CI: -1.05, -0.12; p = 0.01, I2 = 84%; GRADE = moderate), 12 h (SMD: -0.83; 95% CI: -1.47, -0.19; p = 0.01; I2 = 88%; GRADE = low), and 24 h (SMD: -0.37; 95% CI: -0.71, -0.03; p = 0.03; I2 = 80%; GRADE = moderate) after surgery. The dynamic pain scores were significantly reduced, compared to control, in the QLB2 group at 12 h (SMD: -0.93; 95% CI: -1.52, -0.33; p = 0.002; I2 = 83%; GRADE = low) and 24 h (SMD: -0.52; 95% CI: -0.93, -0.11; p = 0.01; I2 = 83%; GRADE = moderate) after surgery. In addition, the QLB2 group presented reduced postoperative opioid consumption at 24 h (SMD: -0.45; 95% CI: -0.86, -0.03; p = 0.03; I2 = 78%; GRADE = moderate). The subgroup analyses revealed that the analgesic benefit of QLB2 did not persist beyond 24 h when the patients were under spinal anesthesia.

Conclusion

Ultrasound-guided QLB2 could provide effective analgesia for patients under general anesthesia by decreasing the intensity of pain and opioid requirement when used within 24 h after abdominal surgery.

Perioperative analgesia with ultrasound-guided quadratus lumborum block for transurethral resection of prostate

BACKGROUND

Prostatic hyperplasia is a physiological aging process in men. After transurethral resection of prostate (TURP), visceral pain is the main cause. The effective postoperative analgesia can reduce the occurrence of postoperative complications. This study mainly studied the analgesic effect of quadratus lumborum block (QLB) on TURP.

METHODS

We divided 62 patients undergoing TURP into 2 groups using a random number table method (QLB 2 group and non-QLB [control] group). Patients in the QLB group underwent ultrasound-guided posterior QLB with 20 mL of 0.25% ropivacaine on each side, and those in the control group received only general anesthesia. The primary outcome for this study was the consumption analgesic pump during 0 to 24 hours. The secondary outcomes included the first pressing time of analgesic pump during 0 to 24 hours, the pain at rest and when coughing at 1, 4, 8, 12, and 24 hours post-operation as measured with a visual analogue scale for pain, length of the hospital stay, and complications (nausea and vomiting, dizziness, and abdominal distension).

RESULTS

Patients in the QLB group presented less consumption, later first pressing time of analgesic pump during 0 to 24 hours after surgery lower visual analogue scale scores at 1, 4, 8, 12, and 24 hours postsurgery than those in the control group. Moreover, their mean length of hospital stay was shorter (P = .023), and they experienced less postoperative complications than the patients in the control group.

CONCLUSIONS

Ultrasound-guided QLB in TURP provided a significant analgesic effect in our patients the first day after surgery. This analgesic model may improve the postoperative recovery after TURP.

Emerging drugs for the treatment of postsurgical pain

INTRODUCTION

Postoperative pain is a distressful experience and remains to be a significant concern after surgery. Current agents either fail to prevent or minimize postoperative pain or cause a series of adverse effects, addiction, or abuse. Opioids have been the gold standard in the treatment of postoperative pain despite their well-described adverse effects. Many new agents with different mechanisms of action have been recently introduced to address this issue.

AREAS COVERED

This current review summarizes the list of new and emerging drugs investigated for their efficacy in controlling the postoperative pain and decreasing the need for rescue opioid use, adverse effect profile, abuse, and addiction potential.

EXPERT OPINION

Opioids have unrivaled analgesic efficacy. However adverse effects of opioids led to the search for better options. In mild pain most of the emerging drugs have been shown to control postoperative pain and decrease the use of rescue opioid, however fail to control pain after major surgeries causing severe pain. Specific agents such as Oliceridine, new local anesthetics, etc., are effective in controlling severe pain and hold a promise to replace opioids in the near future.

Description and Comparison of Acute Pain Characteristics After Laparoscope-Assisted Vaginal Hysterectomy, Laparoscopic Myomectomy and Laparoscopic Adnexectomy

Purpose

To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other.

Patients and Methods

Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them.

Results

There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups.

Conclusion

There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries.

Evaluation of analgesic effects and safety of quadratus lumborum block in patients undergoing laparoscopic surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

Recent years have witnessed the rapid expansion of quadratus lumborum block (QLB) technique in laparoscopic surgeries. However, inconsistent conclusions from latest studies prompted us to conduct present study to evaluate comprehensively the effects of QLB in patients undergoing laparoscopic surgery.

EVIDENCE ACQUISITION

Databases including PubMed, Embase, and Cochrane Library were searched from inception to March 2021 by us. Randomized controlled trials comparing QLB versus placebo or different block techniques were involved. Coprimary outcomes included number of patients requiring additional analgesia, opioids consumption and incidence of postoperative nausea/vomiting (PONV).

EVIDENCE SYNTHESIS

Data from 20 studies involving a total of 1,332 patients were acquired. Based on the current evidences, the results indicated that application of QLB was associated with less number of patients requiring additional analgesia (RR = 0.67, with 95% CI [0.49, 0.91]), reduced intraoperative opioid consumption (SMD - 0.97 with 95% CI [-1.48, -0.45]) and postoperative opioid consumption (SMD -19.12 with 95% CI [-34.83, -3.41]), and less incidence of postoperative nausea and vomiting (RR = 0.71, with 95% CI [0.58, 0.87]) compared to placebo. In addition, no significant intergroup (QLB vs different regional block techniques) differences were observed for most outcomes.

CONCLUSIONS

Current evidences exhibited several superiorities of QLB for patients in laparoscopic surgeries. Differences between QLB and some other block techniques in analgesic effects and PONV controlling effects were not significant. However, it calls for more high-quality evidences with large samples and trials with consistent evaluation scales for pain evaluation to draw more reliable conclusions.

Liposomal bupivacaine addition versus standard bupivacaine alone for colorectal surgery: a randomized controlled trial

Aim: This study evaluated use of liposomal bupivacaine (LB) versus standard bupivacaine (SB) alone in quadratus lumborum (QL) blocks for laparoscopic colorectal surgery. Materials & methods: In this prospective, randomized controlled trial, patients received QL1 blocks with either LB (40 ml 0.125% SB plus 20 ml of LB) or SB (60 ml of 0.25% SB) with 30 ml per side. Opioid usage, pain scores, side effects and other medications were recorded. Results: For 78 patients (38 LB; 40 SB), all parameters were similar between groups, except that the LB group had a higher 48 h need for metoclopramide. Conclusion: LB provided no analgesic benefit over SB alone for QL blocks. Clinical Trials registration number: NCT03702621.

Posterior quadratus lumborum versus transversus abdominis plane block for inguinal hernia repair: a prospective randomized controlled study

Background and objectives

We aimed to compare the analgesic effects of both posterior (type 2) Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) compared to spinal anesthesia alone for postoperative pain management in inguinal hernia repair.

Methods

This study enrolled 63 patients scheduled for open inguinal hernia repair. The eligibility criteria were undergoing elective unilateral inguinal hernia repair surgery, having an American Society of Anesthesiologists (ASA) physical status I, II, or III, and not suffering from any chronic pain condition. Group S patients received spinal anesthetics and no additional analgesic treatments. Group T patients received TAPB, and Group Q patients received QLB as analgesic technique in addition to spinal anesthetics.

Results

The pain scores at 6 hours (VAS 6) and 24 hours (VAS 24) were significantly different between groups (p < 0.01). Additionally, the sensory and motor block levels were significantly different between groups (p < 0.05). Multiple comparison tests showed that patients in Group Q had significantly higher sensory and motor block levels (p < 0.01 compared with Group S; p < 0.05 compared with Group T). Opioid consumption was significantly different between Groups Q and S (p < 0.01) after surgery.

Conclusions

Our findings show that both blocks are similarly effective for the management of postoperative pain compared to spinal anesthesia alone for inguinal hernia repair. We found that QLB resulted in a significant cranial spread compared to TAPB. Opioid consumption in QLB was significantly lower than that in controls but similar to that in TAPB.

Transmuscular quadratus lumborum block versus oblique subcostal transversus abdominis plane block for analgesia in laparoscopic hysterectomy: a randomised single-blind trial

OBJECTIVE

The transmuscular quadratus lumborum (TQL) block and the oblique subcostal transversus abdominis plane (OSTAP) block both contribute to multimodal analgesia after laparoscopic surgery. The objective of this study was to compare the analgesic effects of the TQL block versus OSTAP block after laparoscopic hysterectomy.

DESIGN

Prospective single-centre randomised single-blind trial.

SETTING

University-affiliated hospital.

PARTICIPANTS

Patients aged between 18 and 65 years scheduled for laparoscopic hysterectomy.

INTERVENTIONS

Patients were randomised into two groups (1:1 ratio) and received bilateral TQL block or bilateral OSTAP block with 0.375% ropivacaine 20 mL on each side before surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the cumulative morphine dose in the first 24 hours. The secondary outcome measures were the morphine consumption at each time interval after surgery, the time from the end of surgery to the first need for morphine, the Numerical Rating Scale (NRS) scores for visceral and incisional pain intensity, and the incidence of adverse events.

RESULTS

The cumulative morphine dose was significantly lower in the TQL group than in the OSTAP group (17.2 (12.5) vs 26.1 (13.3) mg, p=0.010). Compared with the OSTAP group, the morphine doses from 6 to 12, 12 to 18, and 18 to 24 hours were significantly lower, the time of first need for morphine was significantly longer and the NRS scores for visceral pain intensity were significantly lower in the TQL group.

CONCLUSION

Compared with the OSTAP block, the TQL block reduced morphine consumption and provided better visceral pain relief with a longer duration of effect after laparoscopic hysterectomy.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1800017995); pre-results.

Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: A prospective randomised double-blinded study

BACKGROUND AND AIMS

Transmuscular Quadratus Lumborum Block (TQLB) is a novel regional anaesthesia technique, however, its analgesic efficacy as a component of multimodal analgesia (MMA) in Total Laparoscopic Hysterectomy (TLH) is not well studied. The aim of the study was to evaluate the analgesic efficacy of TQLB as a component of MMA for postoperative pain in TLH.

METHODS

A prospective double-blind randomised controlled study was done after approval from the ethical committee and informed patient consent. After randomisation, 37 patients in Group-Q received 20 ml 0.375% ropivacaine and in Group-C, 37 patients received saline in TQLB bilaterally after TLH surgery. All patients received intravenous patient controlled analgesia (IV-PCA) with fentanyl along with diclofenac 75 mg every 12 h. All the patients were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcome measures were total fentanyl consumption in 24 hrs, pain scores during rest and movement, postoperative nausea-vomiting, sedation and complications related to local anaesthetic and TQLB procedure.

RESULTS

The mean [standard deviation (SD)] time to first analgesic request was 7.8 (1.5) hours in Group-Q and 3.2 (1.0) hours in Group-C (P < 0.0001). The mean (SD) dose of fentanyl used in 24 hours was 167.3 (44) μg in Group-Q and 226.5 (41.9) μg in Group-C (P < 0.0001).

CONCLUSION

The ultrasound-guided TQLB provides effective postoperative analgesia after TLH surgery in a multimodal analgesia approach. It reduces the fentanyl consumption and improves the visual analogue scale (VAS) score.

Anterior quadratus lumborum block for ambulatory laparoscopic cholecystectomy: a randomized controlled trial

AIM

To explore the effects of an anterior quadratus lumborum block (QLB) on opioid consumption, pain, nausea, and vomiting (PONV) after ambulatory laparoscopic cholecystectomy.

METHODS

This randomized controlled study recruited 70 patients scheduled for ambulatory laparoscopic cholecystectomy from January 2018 to March 2019. The participants were randomly allocated to one of the following groups: 1) anterior QLB (n=25) with preoperative ropivacaine 3.75 mg/mL, 20 mL bilaterally; 2) placebo QLB (n=22) with preoperative isotonic saline, 20 mL bilaterally; and 3) controls (n=23) given only standard intravenous and oral analgesia. The primary endpoint was opioid analgesic consumption. The secondary endpoints were pain (numeric rating scale 0-10) and PONV (scale 0-3, where 0=no PONV and 3=severe PONV). Assessments were made up to 48 hours postoperatively.

RESULTS

The groups did not significantly differ in opioids consumption and reported pain at 1, 2, 24, and 48 hours postoperatively. PONV in the QLB group was lower than in the placebo and control groups.

CONCLUSION

Preoperative anterior QLB for laparoscopic cholecystectomy did not affect postoperative opioid requirements and pain. However, anterior QLB may decrease PONV.

Quadratus Lumborum Blocks in Nephrectomy: A Narrative Review

The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections, hip arthroplasty, gynecologic surgery, colectomy, and recently nephrectomy. To date, there are no reviews that outline the efficacy and performance of the quadratus lumborum blocks in patients receiving laparoscopic nephrectomy. The objective of this project was to outline the current available data from both clinical trials along with case series and reports regarding the methods and utility of quadratus lumborum blocks for analgesia in patients receiving nephrectomy. For this literature review, we searched Pubmed, Embase, and Web of Science from their inception until 5/31/2020. Our search terms were as follows: “(nephrectomy OR laparoscopic nephrectomy) AND (QL block OR Quadratus Lumborum block OR QL OR TQL OR Thoracolumbar fascia block).” We analyzed all relevant clinical trials for quality using the Jadad scale. Our search yielded a total of 30 articles, 23 of which we ultimately reviewed for this manuscript. The qualitative sum of these data show that patients receiving quadratus lumborum block for nephrectomies have reduced opioid requirements, reduced pain scores, and improved side-effects relative to other analgesic modalities like epidurals. Based on these findings, we conclude that the quadratus lumborum block is a useful analgesic for patients undergoing nephrectomy.

Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study

BACKGROUND

Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty.

METHODS

Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups.

RESULTS

Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg; p = 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p < 0.0001).

CONCLUSIONS

Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Ultrasound guided lateral quadratus lumborum block enhanced recovery in patients undergoing laparoscopic colorectal surgery

PURPOSE

This study aimed to evaluate the effects of lateral quadratus lumborum block (QLB) on postoperative pain and recovery in patients undergoing laparoscopic colorectal surgery.

MATERIALS AND METHODS

Patients between 18 and 70 years old, diagnosed with colon or rectal cancer, with American Society of Anesthesiologists (ASA) physical status I or II, and scheduled for laparoscopic colorectal surgery were recruited. Patients were excluded if they were allergic to local anesthetics and unable to complete the procedure of puncture or follow-up evaluation. All included patients were randomly allocated to either QLB or Sham group. The primary outcome was perioperative cumulative sufentanil consumption.

RESULTS

There were no significant differences between the groups in anesthetic time, operation time, dosage of propofol, and remifentanil (P ​> ​0.05). Patients in the QLB group had significantly less sufentanil consumption both intraoperatively and postoperatively, compared with the Sham group (P ​< ​0.05). Postoperative VAS pain scores on coughing in the QLB group at 2 ​h, 6 ​h, 12 ​h, 24 ​h time points and VAS pain score at rest 2 ​h, 6 ​h after surgery were significantly lower than in the Sham group (P ​< ​0.05). Compared with the Sham group, time to first ambulation and anal flatus after surgery in the QLB group were significantly shorter (P ​< ​0.05). Significant differences of postoperative rescue analgesic usage and QoR-15 score at 48 ​h were found between the two groups (P ​< ​0.05).

CONCLUSIONS

Ultrasound-guided lateral QLB significantly reduced perioperative opioid consumption, alleviated postoperative pain, shortened the time to first ambulation and anal flatus, and enhanced postoperative recovery of the patients undergoing laparoscopic colorectal surgery.

Comparison of the analgesic effect of quadratus lumborum block and epidural block in open uterine surgery: a randomized controlled trial

BACKGROUND

Effective regional analgesia during open surgery could reduce opioid consumption and enhance early recovery. We compared the effects of the newly developed quadratus lumborum block (QLB) and the traditional epidural block (EB) in open uterine surgery.

METHODS

In this randomized controlled trial, we included patients scheduled for elective open uterine surgery during May - September 30, 2019. Patients received QLB or EB for perioperative pain relief before general anesthesia. Perioperative opioid consumption, and numeric rating scale (NRS: 0-10) pain scores after surgery, heart rate (HR), mean arterial pressure (MAP), ephedrine and urapidil use during surgery, lower limb muscle strength, timing of first flatus and defecation, nausea, vomiting, and other complications within 24 h post-surgery, were the primary and secondary outcomes, respectively.

RESULTS

Data of 72 (86%; 36/group) of 83 eligible patients were analyzed. Remifentanil consumption during surgery was higher in the QLB than in the EB group, while cumulative sufentanil consumption within 24 h post-surgery was similar between both groups. NRS pain scores at rest and during activity were higher at 1 h post-surgery, and MAP was higher at 5-, 15-, and 30-min postincision in the QLB than in the EB group; HR was similar between groups. Lower ephedrine requirements, higher lower limb muscle strength at 1 h post-surgery, and lower nausea incidence were observed in the QLB group.

CONCLUSIONS

QLB produces a less intense but longer block and fewer side effects in the first 24 h after open uterine surgery than those produced by EB.

Ultrasound-guided quadratus lumborum block for postoperative analgesia: A systematic review and meta-analysis

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB) is a truncal block with several technique variations. It has been reported as providing effective analgesia for postoperative pain.

OBJECTIVES

The aim of this review was to evaluate the efficacy and safety of QLB for postoperative analgesia. The primary outcome was cumulative opioid consumption at 24 h postoperatively. The main secondary outcomes were the time to the first rescue opioid analgesic, pain scores at 24 h postoperatively and the incidence of postoperative nausea and vomiting (PONV).

DESIGN

This was a systematic review and meta-analyses of observational studies and randomised controlled trials (RCTs). PRISMA-P guidelines were followed, and the review was registered in PROSPERO. GRADE was used to assess the quality of evidence.

DATA SOURCES

The search was performed from several databases (Ovid MEDLINE, PubMed, Scopus, Web of Science, CINAHL and the Cochrane CENTRAL) from inception up to June 2019.

ELIGIBILITY CRITERIA

RCTs and prospective observational studies that investigated the postoperative analgesic properties of US-guided single shot QLB in adult patients undergoing abdominal or hip surgery were included. QLB was compared with other analgesics.

RESULTS

Twenty-seven studies constituting 1557 patients were reviewed. Twelve studies with 803 patients were included in the meta-analysis on the primary outcome. Overall opioid consumption at 24 h postoperatively was reduced [mean difference, -11.15 (95% CI, -15.33 to -6.97) mg, I2 = 99%, moderate certainty in GRADE] and the time to the first opioid analgesic was longer in patients with QLB: 7 studies with 499 patients, mean difference, 189.32 (95% CI, 114.4 to 264.23) min, I2 = 98%. There were no differences in pain grades. The incidence of PONV was lower in patients with QLB [11 studies with 744 patients, OR 0.40 (95% CI, 0.27 to 0.58), I2 = 7%]. Reported complications and adverse effects of QLB were minimal.

CONCLUSION

QLB reduced postoperative opioid consumption, prolonged the time to the first rescue opioid analgesic and diminished the incidence of PONV. QLB appears to be an applicable option for postoperative analgesia after abdominal and hip surgery.

REGISTRATION NUMBER

PROSPERO, https://www.crd.york.ac.uk/prospero/, CRD42016039921.

Postoperative analgesic effectiveness of ultrasound-guided transmuscular quadratus lumborum block in congenital hip dislocation surgery : A randomized controlled study

BACKGROUND/OBJECTIVE

Congenital hip dysplasia (CHD) defines a spectrum of pathologies in which the acetabulum and proximal femur of babies and children abnormally develop. Open surgery in congenital hip dysplasia leads to severe postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided quadratus lumborum block (QLB) in pediatric patients undergoing surgery for congenital hip dysplasia.

MATERIAL AND METHODS

Following ethical board approval, 40 children aged between 1-5 years undergoing surgery for congenital hip dysplasia were randomized into two groups. Patients (n = 20) received ultrasound guided quadratus lumborum block (group QLB) using 0.5 mL/kg body weight 0.25% bupivacaine preoperatively. The same standard postoperative analgesia protocol was used in both groups. Pain scores, parental satisfaction, requirement for ibuprofen and opioids were recorded. Pain was measured using the face, legs, activity, crying, consolability (FLACC) scale.

RESULTS

The FLACC scores were lower at 30min and 1h, 2h, 4h, 6h, 12h and 24h in the QLB group when compared to the control group (p < 0.05). The requirement for rescue opioid analgesia was statistically significantly higher in the control group when compared to the QLB group (15/20 vs. 3/20, p < 0.001). Rate of ibuprofen usage in the ward was higher in the control group when compared to the QLB group (14/20 vs. 4/20, p = 0.004). Parental satisfaction was higher in the QLB group (p < 0.001).

CONCLUSION

Ultrasound-guided quadratus lumborum block reduces pain scores and analgesic requirements following congenital hip dysplasia surgery.

Evaluation of ultrasound-guided quadratus lumborum block for post-operative analgesia in unilateral laparoscopic renal surgeries - A randomised controlled trial

Background and Aims:

Quadratus lumborum block (QLB) is a novel anaesthetic technique for abdominal wall block providing excellent post-operative analgesia. The primary objective of this study was to evaluate the duration of post-operative analgesia with QLB in unilateral laparoscopic renal surgeries. The secondary objectives were to assess total morphine consumption during the first 24 h postoperatively and observe for complications.

Methods:

Sixty patients undergoing unilateral laparoscopic renal surgeries were randomly divided into two groups, with patients receiving QLB (Group A) or no block (Group B) at the end of surgery. General anaesthesia was standardised in both the groups. The pain was assessed by a Visual Analogue Scale (VAS) of 1–10. The duration of analgesia was taken as time from extubation to VAS of ≥3. Morphine was administered in patient-controlled analgesia pump with a bolus of 1 mg and a lockout interval of 10 min (min). The total morphine consumption was recorded. The statistical analysis was performed with the Student's t-test and Chi-square test.

Results:

The duration of post-operative analgesia was significantly prolonged in Group A (1288 ± 288.92 min) than Group B (138 ± 54.92 min). Morphine consumption was also less in Group A (3.1 ± 0.87 mg) than Group B (10.46 ± 1.8 mg). There was a significant difference in the VAS score from 16 to 20 h. No complications were recorded.

Conclusions:

Ultrasound-guided QLB after laparoscopic renal surgery is safer to perform, effective with an increased post-operative duration of analgesia, reduces the consumption of opioids and is associated with fewer side effects.

Interaction of Analgesic Effects of Dezocine and Sufentanil for Relief of Postoperative Pain: A Pilot Study

Purpose

The combination of dezocine and sufentanil is often used for postoperative analgesia in China and other areas, but the interaction of both two drugs is still unclear. The purpose of this study was to evaluate the interaction of the analgesic effects of dezocine and sufentanil in the patients after gynecological laparoscopic surgery.

Patients and Methods

We conducted a prospective, randomized, double-blinded clinical trial. A total of 150 patients were divided into 5 groups (30 in each group) in the post-anesthesia care unit, namely, dezocine group (Group D), sufentanil group (Group S) and dezocine mixed sufentanil groups (Group DS1-3). In group D and S, the initial dose of dezocine or sufentanil was 5mg and 5μg intravenously, respectively. In Group DS1, the initial dose was dezocine 5mg × 3/4 and sufentanil 5μg × 1/4. In Group DS2, the initial dose was dezocine 5mg × 1/2 and sufentanil 5μg × 1/2. In Group DS3, the initial dose was dezocine 5mg × 1/4 and sufentanil 5μg × 3/4.

Results

The median effective dose (ED50) of dezocine and sufentanil alone was 3.92 (95% confidence interval (CI) 3.01~4.64) mg and 3.71 (95% CI 2.78~4.39) μg, respectively. The isobolographic analysis showed that the combination of dezocine and sufentanil at 1:3, 1:1 or 3:1 appeared in the additive line.

Conclusion

In conclusion, when simultaneously administered intravenously, combined dezocine and sufentanil produce an additive effect for relieving the acute nociception after gynecological laparoscopic surgery.

Interfascial Plane Blocks and Laparoscopic Abdominal Surgery: A Narrative Review

Laparoscopic abdominal surgery has become a mainstay of modern surgical practice. Postoperative analgesia is an integral component of recovery following laparoscopic abdominal surgery and may be improved by regional anesthesia or intravenous lidocaine infusion. There is inconsistent evidence supporting the use of interfascial plane blocks, such as transversus abdominis plane (TAP) blocks, for patients undergoing laparoscopic abdominal surgery as evidenced by variable patterns of local anesthetic spread and conflicting results from studies comparing TAP blocks to local anesthetic infiltration of laparoscopic port sites and multimodal analgesia. Quadratus lumborum (QL) and erector spinae plane (ESP) blocks may provide greater areas of somatic analgesia as well as visceral analgesia, which may translate to more significant clinical benefits. Aside from the locations of the surgical incisions, it is unclear what other factors should be considered when choosing one regional technique over another or deciding to infuse lidocaine intravenously. We reviewed the current literature in attempt to clarify the roles of various regional anesthesia techniques for patients undergoing laparoscopic abdominal surgery and present one possible approach to evaluating postoperative pain.

Ilioinguinal/Iliohypogastric versus quadratus lumborum nerve blockade for elective open inguinal herniorrhaphy: a prospective, randomized, double-blinded, equivalency trial

BACKGROUND

Open inguinal herniorrhaphy (OIH) is a commonly performed surgical procedure with expected postoperative pain. Historically, an option for regional analgesia has been an ilioinguinal and iliohypogastric nerve block (IINB). More recently, the transmuscular quadratus lumborum block (QLB) has been used as an analgesic technique for a variety of abdominal and truncal surgical procedures. Given our own institutional experiences with the performance of QLB combined with the body of literature supporting the proximal blockade of the ilioinguinal and iliohypogastric nerves via this approach, we compared the analgesia provided by an IINB to a QLB. We hypothesized that the two blocks would provide equivalent analgesia, as defined by a difference of less than±2 points on the pain scale (0-10 numeric rating scale (NRS)), for patients undergoing OIH.

METHODS

Sixty patients scheduled for elective outpatient OIH under general anesthesia were randomized to preoperatively receive either an IINB or a transmuscular QLB with 0.25% bupivacaine/epinephrine/clonidine for postoperative analgesia. The primary endpoint was movement NRS pain scores at 8 hours. Secondary outcomes included resting NRS pain scores at 8 and 24 hours, movement NRS pain scores at 24 hours, incidence of opioid related side effects (nausea, vomiting, pruritus), time-to-first oral opioid analgesic, and total opioid consumption at 24 hours.

RESULTS

Fifty-nine patients were analyzed per an intention-to-treat approach (one patient was excluded because the surgical procedure was canceled). Movement pain scores at 8 hours were equivalent (IINB 5.10±3.02 vs QLB 5.03±3.01 (mean NRS±SD); two one-sided test mean difference (90% CI), 0.07 (-1.24 to 1.38), p ≤0.01). There were no differences between groups for any of the secondary endpoints.

CONCLUSION

An IINB and a transmuscular QLB are equivalent with regards to their ability to provide postoperative analgesia after OIH.

Analgesic Effect of Ultrasound-Guided Preoperative Unilateral Lateral Quadratus Lumborum Block for Laparoscopic Nephrectomy: A Randomized, Double-Blinded, Controlled Trial

Purpose

The quadratus lumborum block (QLB) is a relatively new regional analgesic technique that could provide analgesia to the abdominal wall and reduce postoperative opioid consumption. We investigated the opioid-sparing effect of a unilateral lateral QLB in laparoscopic nephrectomy.

Patients and Methods

A total of 60 patients undergoing laparoscopic nephrectomy were included in the study. Patients were randomized into two groups as QLB and control group. QLB group received QLB with 25mL 0.25% ropivacaine, and the control group received 25mL 0.9% saline at anterolateral border of quadratus lumborum muscle preoperatively. Opioid consumption and the pain intensity at rest and on movement were measured at 2nd, 6th, 24th, and 48th hour postoperatively. We also assessed the time to first flatus to measure the extent of paralytic ileus and the quality of recovery-15 (QoR-15) questionnaire.

Results

Postoperative opioid consumption was significantly lower in the QLB group than in the control group at 6, 24, and 48h after surgery (P < 0.05). The pain intensity at rest and on movement was significantly lower in the QLB group than in the control group during the first 24 hours after surgery (P < 0.05). The incidence of postoperative nausea and vomiting, time to first flatus, and QoR-15 score did not show significant differences.

Conclusion

Preoperative unilateral QLB successfully decreased postoperative pain and opioid consumption after laparoscopic nephrectomy and could be an option for analgesia after laparoscopic nephrectomy.

The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after cesarean section with vertical incision: a randomized, double-blinded placebo-controlled study

PURPOSE

Quadratus lumborum block (QLB) has recently been used for postoperative analgesia after abdominal surgery. Although there are several approaches to QLB, the effectiveness of intramuscular QLB (QLBi) remains controversial. The aim of the present study was to examine the effectiveness of QLBi for postoperative analgesia after cesarean section with a vertical midline incision.

METHODS

In this single-center, randomized, double-blinded placebo-controlled study, 36 women who were scheduled for elective cesarean section were randomly divided into a QLBi group (n = 18) and a placebo group (n = 18). In both groups, spinal anesthesia was performed with 10-11 mg hyperbaric bupivacaine and 15 µg fentanyl. After the surgery, in the QLBi group, 0.4 mL/kg of 0.25% ropivacaine was injected into the bilateral quadratus lumborum muscle under ultrasound guidance (the total volume was 0.8 mL/kg). In the placebo group, instead of ropivacaine, the subjects were injected with the same amount of normal saline. The primary outcome measure was elapsed time to first analgesic use from the QLBi block after cesarean section.

RESULTS

The data from all 36 patients were analyzed. There were no significant differences between the QLBi and placebo groups regarding elapsed time to first postoperative analgesic use [mean 230 (standard deviation 103) vs 194 (89) min; 95% confidence interval - 101 to 30; p = 0.27].

CONCLUSIONS

QLBi with the concentration and amount of local anesthetic used in the present study was clinically slightly effective, and the effect was limited for postoperative analgesia after cesarean section.