Ultrasound guided continuous transmuscular quadratus lumborum analgesia for open renal surgery: A case series

Interventional pathway in the management of refractory post cholecystectomy pain (PCP) syndrome: a 6-year prospective audit in 60 patients

OBJECTIVES

Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome.

METHODS

The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits.

RESULTS

Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced.

CONCLUSIONS

Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.

Evaluation of Sensory Loss and Postoperative Analgesia Obtained by Diaphragmatic Apposition Zone Block Under Direct Laparoscopic Visualization in Patients Undergoing Nephrectomy: A Descriptive Study

Purpose

Local anesthetics can spread into the subendothoracic fascia compartment via the arcuate ligament and apposition zone of the diaphragm after the anterior quadratus lumborum blocks. Therefore, a new block may be achieved if local anesthetic is administered into the diaphragmatic apposition zone (DAZ) under direct laparoscopic visualization by surgeons. Therefore, we evaluated the sensory loss and postoperative analgesic efficacy of this new block in patients receiving laparoscopic nephrectomy.

Methods

A total of 28 patients scheduled to receive elective laparoscopic nephrectomy under general anesthesia were enrolled in this study. The DAZ blocks were performed in patients under direct laparoscopic visualization with 20 mL of 0.5% ropivacaine before the dissected kidneys or renal tumors were taken out from the incision. All patients received the intravenous patient-controlled analgesia after surgery. The dermatomes of sensory loss and the muscle weakness of quadriceps femoris were assessed at 2 h post-surgery in the wards. The postoperative pain was scored. The opioid consumption in the first 24 h after surgery was recorded.

Results

The average number of dermatomes of sensory block was 8.6 ± 1.2. The highest level of sensory loss was T6 (T5-T6) [median (interquartile range, IQR)], and the lowest level of sensory block was L1 (L1–L2). The postoperative pain scores at rest or on movement at 2 h, 6 h, 12 h, 24 h and 48 h were kept at the low levels (less than 4). The muscle strength of the quadriceps femoris evaluated was 5 (5–5) points [median (IQR)]. Total dose of intravenous morphine equivalent consumption in the first 24 h after surgery was 21.2 ± 4.1 mg.

Conclusion

The DAZ block manifests a wide dermatomal coverage of sensory loss and is associated with the low levels of postoperative pain intensity and opioid use. It provides a new postoperative analgesia option for patients undergoing laparoscopic nephrectomy.

Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus transmuscular quadratus lumborum block for postoperative analgesia in patients undergoing laparoscopic nephrectomy: A randomized controlled trial

STUDY OBJECTIVE

The analgesic efficacy of transmuscular quadratus lumborum block (TQLB) to decrease the need for opioid consumption after laparoscopic nephrectomy has been demonstrated in several studies. However, the effect of an anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL) in this surgical context is unclear. Here, we aimed to compare postoperative analgesic effects of the two block approaches in laparoscopic nephrectomy.

DESIGN

A single-center, randomized controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

A total of 106 patients with American Society of Anesthesiologists (ASA) physical status of I-III scheduled to undergo elective laparoscopic nephrectomy under general anesthesia.

INTERVENTIONS

Patients were randomly allocated to receive preoperative TQLB or QLB-LSAL with 0.5% ropivacaine (25 mL). Postoperatively, patient-controlled analgesia with intravenous sufentanil was administered.

MEASUREMENTS

The primary outcome was postoperative intravenous morphine equivalent consumption within the first 24 h postoperatively. Secondary outcomes included pain scores, satisfaction scores, levels of sedation, and incidence of nausea or vomiting.

MAIN RESULTS

Patients who underwent preoperative QLB-LSAL used a significantly lower intravenous morphine equivalent dose than those who underwent preoperative TQLB within the initial 24 h after surgery (34.3 ± 6.3 mg vs 23.5 ± 3.2 mg, P < 0.001). No significant differences were observed in pain scores, satisfaction scores, sedation scores, or incidence of nausea or vomiting between the groups.

CONCLUSIONS

The results indicate that, compared to TQLB, QLB-LSAL is a beneficial nerve block that can reduce postoperative opioid consumption, making it a potentially superior approach to achieve multimodal analgesia after laparoscopic nephrectomy.

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.

Quadratus lumborum block (transmuscular approach) versus transversus abdominis plane block (unilateral subcostal approach) for perioperative analgesia in patients undergoing open nephrectomy: a randomized, double-blinded, controlled trial

Study objective

Patients undergoing open nephrectomy surgery experience severe perioperative pain, which is primarily due to incision of several muscles. Abdominal wall blocks are known to reduce pain without causing epidural-associated hypotension. We conducted this study to compare unilateral ultrasound-guided transmuscular quadratus lumborum block and posterior transversus abdominis block in combination with general anesthesia alone in terms of intraoperative and postoperative analgesics and hemodynamics and postoperative complications.

Methods

This was a randomized, double-blinded, controlled trial conducted in the operating room. This study included 48 patients aged 20–60 years, with ASA I and II, and a body mass index ≤ 30 kg.m^-2 who were scheduled for open nephrectomy procedure.The 48 patients scheduled for nephrectomy were randomly allocated into one of the following three groups after induction of general anesthesia: Group A (n = 16) received USG transmuscular QLB; Group B (n = 16) received unilateral USG posterior transversus abdominis plane (TAP) block; and Group C (n = 16; control group) did not receive any blocks. Introperative fentanyl consumption, and hemodynamics (heart rate and mean arterial pressure (MAP)) were recorded after anesthesia induction, at surgical incision, and every 15 min till the end of surgery. Visual Analogue Scale (VAS) was evaluated immediately at 30 min and 1,2,4,6, and 12 hours postoperatively. The time of first analgesic request was also recorded.

Results

Intraoperative fentanyl consumption (μg) was significantly lower in Groups A and B (164.69 ± 27.35 and 190.31 ± 44.48, respectively) than in Group C (347.50 ± 63.64) (p < 0.001). Postoperatively, total pethidine consumption was significantly lower in Groups A and B than in Group C (85.31 ± 6.68, 84.06 ± 4.17 mg, and 152.19 ± 43.43 mg, respectively) (p < 0.001. Time to rescue analgesia was longer in Groups A and B than in Group C (138.75 ± 52.39 min, 202.50 ± 72.25 min, and 37.50 ± 13.42 min, respectively) (p < 0.001). VAS score was significantly lower in Groups A and B than in Group C at 30 min and 1, 2, 4, and 6 hours postoperatively.

Conclusion

Transmuscular quadratus lumborum block and posterior transversus abdominis blocks were effective in providing perioperative analgesia in patients undergoing open nephrectomy. However, quadratus lumborum block provided superior analgesia.

Serratus intercostal interfascial plane block in supraumbilical surgery: a prospective randomized comparison

BACKGROUND

Upper abdominal wall surgical incisions may lead to a severe postoperative pain. Therefore, adequate analgesia is important. Here we investigate whether the low serratus-intercostal interfascial plane block (SIPB) achieves an effective analgesia, considering opioids consumption, pain control and recovery quality in upper abdominal surgeries.

METHODS

This blinded, randomized controlled study was conducted on 102 patients undergoing open upper abdominal wall surgery under general anesthesia. All patients who received serratus-intercostal plane block at the eighth rib as analgesic technique were included in SIPB group and in control group those who received continuous intravenous morphine analgesia. Pain scores in numeric verbal scale (NVS) and opioids consumption at 0, 6, 12, 24 and 48 hours postoperatively were assessed. The quality of the postoperative recovery was evaluated using the QoR-15 questionnaire at 24 hours.

RESULTS

This study showed lower postoperative opioid consumption at 24 hours (P<0.0001; 4.17 mg vs. 41.52 mg of morphine) and better pain control (P<0.005) with mean pain scores (NVS 1.8±1.5 vs. 4.8±1.6) in group 0 (SIPB). The global QoR-15 scores 24 hours postoperatively were higher (better quality) in the SIPB group (122 vs. 100).

CONCLUSIONS

The low serratus-intercostal interfascial plane block (SIPB) provides efficient analgesia leading to a saving of opioids and improvement of the recovery quality in patients undergoing upper abdominal wall surgeries.

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.

Comparison of ultrasound-guided transmuscular quadratus lumborum block catheter technique with surgical pre-peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85 years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20 ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5 ml.h^-1 , continued up to 48 h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48 h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p = 0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p = 0.036) and satisfaction scores on days 1 and 30 (p = 0.004, p = 0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

Transmuscular quadratus lumborum block for percutaneous nephrolithotomy reduces opioid consumption and speeds ambulation and discharge from hospital: a single centre randomised controlled trial

BACKGROUND

Percutaneous nephrolithotomy (PNL) is associated with severe postoperative pain. The current study aimed to investigate the analgesic efficacy of transmuscular quadratus lumborum (TQL) block for patients undergoing PNL surgery.

METHODS

Sixty patients were enrolled in this single centre study. The multimodal analgesic regime consisted of oral paracetamol 1 g and i.v. dexamethasone 4 mg before surgery and i.v. sufentanil 0.25 μg kg-1 30 min before emergence. After operation, patients received paracetamol 1 g regularly at 6 h intervals. Subjects were allocated to receive a preoperative TQL block with either ropivacaine 0.75%, 30 ml (intervention) or saline 30 ml (control). Primary outcome was oral morphine equivalent (OME) consumption 0-6 h after surgery. Secondary outcomes were OME consumption up to 24 h, pain scores, time to first opioid, time to first ambulation, and hospital length of stay. Results were reported as mean (standard deviation) or median (inter-quartile range).

RESULTS

Morphine consumption was lower in the intervention group at 6 h after surgery (7.2 [8.7] vs 90.6 [69.9] mg OME, P<0.001) and at 24 h (54.0 [36.7] vs 126.2 [85.5] mg OME, P<0.001). Time to first opioid use was prolonged in the intervention group (678 [285-1020] vs 36 [19-55] min, P<0.0001). Both the time to ambulation (302 [238-475] vs 595 [345-925] min, P<0.004) and length of stay (2.0 [0.8] vs 3.0 [1.2] days, P≤0.001) were shorter in the intervention group.

CONCLUSIONS

This is the first blinded, RCT that confirms that unilateral TQL block reduces postoperative opioid consumption and hospital length of stay. Further study is required for confirmation and dose optimisation.

CLINICAL TRIAL REGISTRATION

NCT02818140.

Esmolol does not improve quality of postsurgical recovery after ambulatory hysteroscopy: A prospective, randomized, double-blinded, placebo-controlled, clinical trial

INTRODUCTION

Intraoperative systemic esmolol has been shown to reduce postsurgical pain. Nonetheless, it is unknown whether the use of intraoperative systemic esmolol can improve patient-reported postsurgical quality of recovery. The main objective of the current investigation was to evaluate the effect of intraoperative esmolol on postsurgical quality of recovery. We hypothesized that patients receiving intraoperative esmolol would report better quality of postsurgical recovery than the ones receiving saline.

METHODS

The study was a prospective randomized double-blinded, placebo-controlled, clinical trial. Healthy female subjects undergoing outpatient hysteroscopic surgery under general anesthesia were randomized to receive intravenous esmolol administered at a rate of 0.5 mg/kg bolus followed by an infusion of 5 to 15 μg/kg/min or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included postoperative opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test.

RESULTS

Seventy subjects were randomized and 58 completed the study. There was not a clinically significant difference in the global QoR-40 scores between the esmolol and saline groups at 24 hours, median (interquartile range) of 179 (171-190) and 182 (173-189), respectively, P = .82. In addition, immediate post-surgical data in the post-anesthesia care unit did not show a benefit of using esmolol compared to saline in regard to pain scores, morphine consumption, and postoperative nausea and vomiting.

CONCLUSIONS

Despite current evidence in the literature that intraoperative esmolol improves postsurgical pain, we did not detect a beneficial effect of intraoperative esmolol on patient-reported quality of recovery after ambulatory surgery. Our results confirm the concept that the use of patient-centered outcomes rather than commonly used outcomes (e.g., pain scores and opioid consumption) can change the practice of perioperative medicine.