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

Efficacy of quadratus lumborum block type 3 on postoperative cell-mediated immunity and analgesia for laparoscopic radical gastrectomy: a prospective randomized controlled trial

PURPOSE

Various methods have been formulated to reduce pain and relieve immunosuppression in order to improve prognosis. The current study aimed to evaluate the effect of ultrasound-guided quadratus lumborum block (QLB) on the postoperative analgesia and perioperative cell-mediated immunity in patients underwent laparoscopic radical gastrectomy.

PATIENTS AND METHODS

A total of 54 patients scheduled for laparoscopic radical gastrectomy were randomly evenly assigned into both groups. The participants in Group Q received US-guided QLB 3 bilaterally with ropivacaine (0.25%, 30 mL on each side) before surgery along with GA, and those in Group C received GA without any special treatment. Both groups were given patient-controlled intravenous analgesia postoperatively. The primary outcomes were the T-cell subsets and Natural killer (NK) cell level at 30 min before surgery (T0) and at 0, 12, 24, and 48 h postoperatively (T1, T2, T3, and T4) were measured. The secondary outcomes were as fellows: the visual analog scale (VAS) pain score (rest and movement) at T1, T2, T3, and T4. In addition, the opioid consumption, and the incidence of postoperative adverse reactions.

RESULTS

The level of CD3 + , CD4 + T, and natural killer (NK) cells, besides the CD4 + /CD8 + ratio showed less reduction at T1, T2, T3, and T4 in Group Q (P < 0.05). The VAS pain scores (at rest and on movement) were significantly lower in Group Q at T1-T4 (P < 0.05). Opioid consumption and the incidence of adverse reactions were lower in Group Q (P < 0.05).

CONCLUSION

For patients undergoing LRG, the ultrasound-guided QLB 3 could alleviate perioperative cell-mediated immunity suppression, improve postoperative analgesia, decrease opioid consumption, and reduce the incidence of adverse reactions.

CLINICAL TRIAL REGISTRATION NUMBER

The Chinese Clinical Trial Registry (ChiCTR2000034592).

Quadratus lumborum block is feasible alternative to epidural block for postoperative analgesia after open radical cystectomy: surgical and oncological outcomes of a randomised clinical trial

OBJECTIVE

The current lack of standardised perioperative pain management protocols for open radical cystectomy (ORC) underscores the need for alternative approaches to the longstanding tradition of epidural block. The aim of this study was to assess the impact of bilateral single injection quadratum lumborum block (QLB) on patients' recovery and complication rates compared with epidural analgesia after ORC in a single-centre, randomised, parallel-group trial including adult patients with bladder cancer.

MATERIAL AND METHODS

Consecutive ORC patients were randomly allocated into QLB and the epidural group. The primary endpoint of this study was related to opioid consumption, and the results have been published earlier. This report focuses on secondary outcomes.

RESULTS

This study included a total of 41 patients, with 20 patients in the QLB group and 21 patients in the epidural group. Finally, 39 patients were included in the analysis.  There was a trend for more frequent need for postoperative norepinephrine and fluid support in the epidural group but without statistical significance. Postoperative complication rate was similar. Two patients in the epidural group compared to none in the QLB group were rehospitalised within 30 and 90 days. Mortality rate within 90 days was higher in the epidural group (4 vs. 0 patients, P = 0.064).

CONCLUSIONS

In this trial, there were no significant differences in surgical and oncological outcomes after ORC when QLB is compared with epidural block for postoperative analgesia.  Trial registration: ClinicalTrials.gov Identifier: NCT03328988.

Anterior quadratus lumborum blocks for postoperative pain treatment following intra-abdominal surgery: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery.

METHODS

We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias.

CONCLUSIONS

The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.

Comparative study between lateral versus latero-ventral quadratus lumborum block for perioperative analgesia in canine laparoscopic ovariectomy

OBJECTIVE

To compare the perioperative analgesic effect of lateral versus latero-ventral quadratus lumborum block (QLB) in dogs undergoing laparoscopic ovariectomy.

STUDY DESIGN

Randomized, blinded clinical study.

ANIMALS

A total of 15 client-owned female dogs undergoing laparoscopic ovariectomy.

METHODS

Animals were randomly assigned to receive a bilateral QLB, performed with 0.3 mL kg-1 ropivacaine 0.5%, either with lateral (group LQLB, n = 7) or latero-ventral approach (group LVQLB, n = 7). Dogs were premedicated intramuscularly with methadone 0.2 mg kg-1 and dexmedetomidine 3 μg kg-1. General anaesthesia was induced intravenously (IV) with propofol and maintained with isoflurane. Cardiovascular and respiratory variables were continuously monitored and recorded every 5 minutes during surgery. Fentanyl 3 μg kg-1 was administered IV if there was a 20% increase in heart rate and/or mean arterial pressure from previous values recorded 5 minutes before. Meloxicam 0.2 mg kg-1 was administered IV to all dogs during recovery. The short-form of the Glasgow Composite Pain Scale was used hourly for 8 hours post-QLB. Methadone 0.2 mg kg-1 was administered IV when pain score was ≥ 6/24. A chi-square test compared the number of dogs requiring intraoperative rescue fentanyl. A Friedman test with a Dunn's post hoc was used to evaluate the trend in postoperative pain scores within each group, and a Mann-Whitney U test compared scores between the groups at each time point; p < 0.05.

RESULTS

Significantly fewer dogs required intraoperative rescue fentanyl in group LQLB than in group LVQLB. No dog required postoperative rescue methadone, and there were no significant differences in pain scores.

CONCLUSIONS AND CLINICAL RELEVANCE

Bilateral QLB performed with lateral approach reduced the number of dogs requiring intraoperative rescue analgesia in comparison with the latero-ventral approach. No differences were detected postoperatively, possibly owing to the confounding effects of methadone, dexmedetomidine and meloxicam.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Rescue analgesia with a transversus abdominis plane block alleviates moderate-to-severe pain and improves oxygenation after abdominal surgery: a randomized controlled trial

Background

Abdominal surgery is a common surgical procedure that is frequently associated with substantial postoperative pain. However, rescue analgesia using opioids is associated with several adverse effects. The transversus abdominis plane block (TAPB) has been demonstrated to be effective as part of multimodal analgesia. This study aims to evaluate the effects of rescue analgesia using the TAPB following abdominal surgery.

Methods

Ninety patients undergoing abdominal surgery and reporting a numeric rating scale (NRS) score of cough pain ≥4 on the first postoperative day were randomized to receive either sufentanil or TAPB for rescue analgesia. Pain scores and arterial oxygen pressure (PaO2) were evaluated before and after the administration of rescue analgesia. Sleep quality and gastrointestinal function were assessed postoperatively. The primary outcome was the degree of pain relief on coughing 30 min after the administration of rescue analgesia.

Results

Patients of both groups reported a significantly reduced NRS score on coughing 30 min after receiving rescue analgesia (P paired < 0.001 for both groups). Notably, the degree of pain relief was significantly higher in the TAPB group than in the sufentanil group [median (interquartile range), -3 (-4 to -2) vs. -2 (-2 to -1), median difference = -1; 95% confidence interval, -2 to -1; P < 0.001]. Moreover, patients in the TAPB group experienced less pain than those in the sufentanil group during the following 24 h. When evaluated, PaO2 increased significantly after rescue analgesia was administered in the TAPB group (P paired < 0.001); however, there were no significant intragroup differences in the sufentanil group (P paired = 0.129). Patients receiving the TAPB experienced better quality of sleep than those receiving sufentanil (P = 0.008), while no statistical differences in gastrointestinal function were observed between the two groups.

Conclusion

Rescue analgesia with the TAPB on the first postoperative day alleviated pain, enhanced oxygenation, and improved sleep quality in patients undergoing abdominal surgery; however, its effect on gastrointestinal function requires further research.

Clinical Trial Registration

This study was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=170983, ChiCTR2200060285) on 26 May 2022: Patients were recruited during the period between 30 May 2022 and 14 February 2023, and a follow-up of the last enrolled patient was completed on 16 March 2023.

Anterior quadratus lumborum block for analgesia after living-donor renal transplantation: a double-blinded randomized controlled trial

INTRODUCTION

Limited non-opioid analgesic options are available for managing postoperative pain after renal transplantation. We aimed to investigate whether the unilateral anterior quadratus lumborum (QL) block would reduce postoperative opioid consumption after living-donor renal transplantation in the context of multimodal analgesia.

METHODS

Eighty-eight adult patients undergoing living-donor renal transplantation were randomly allocated to receive the unilateral anterior QL block (30 mL of ropivacaine 0.375%) or sham block (normal saline) on the operated side before emergence from anesthesia. All patients received standard multimodal analgesia, including the scheduled administration of acetaminophen and fentanyl via intravenous patient-controlled analgesia. The primary outcome was the total opioid consumption during the first 24 hours after transplantation. The secondary outcomes included pain scores, time to first opioid administration, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulation, and length of hospital stay.

RESULTS

The total opioid consumption in the first 24 hours after transplantation did not differ significantly between the intervention and control groups (median (IQR), 160.5 (78-249.8) vs 187.5 (93-309) oral morphine milligram equivalent; median difference (95% CI), -27 (-78 to 24), p=0.29). No differences were observed in the secondary outcomes.

CONCLUSIONS

The anterior QL block did not reduce opioid consumption in patients receiving multimodal analgesia after living-donor renal transplantation. Our findings do not support the routine administration of the anterior QL block in this surgical population.

TRIAL REGISTRATION NUMBER

NCT04908761.

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

Erector Spinae Plane Block versus Quadratus Lumborum Block for Postoperative Analgesia after Laparoscopic Resection of Colorectal Cancer: A Prospective Randomized Study

Background

In recent years, the attention paid to colorectal cancer (CRC) surgery and postoperative analgesia has increased.

Objective

The objective of the current study was to compare the impact of ultrasound-guided erector spinae plane block (ESPB) and transmuscular quadratus lumborum block (TQLB) upon providing relief to patients with postoperative pain who underwent laparoscopic resection for CRC.

Methods

In this prospective, comparative, and randomized study, the authors considered a total of 60 patients who chose to undergo laparoscopic resection for colorectal cancer. The total number of patients was randomly divided into two groups (such as ESPB and TQLB) so that each group had a total of 30 patients. For the former group, i.e., the ESPB group, 20 ml of 0.25% bupivacaine was administered at each side for bilateral ultrasound-guided erector spinae plane block, while the latter group received the same dose of medicine for bilateral ultrasound-guided transmuscular quadratus lumborum block (TQLB). The researchers recorded the first time to rescue an analgesic, the whole amount of rescue analgesia under consumption in the first 24 hours after the surgical procedure, and associated adverse events.

Results

Among the groups considered, the ESPB group took a significantly lengthy time to raise a first request for rescue analgesic (280 ± 15.5 min) in comparison with the TQLB group (260 ± 13.8 min). Likewise, the consumption of overall nalbuphine was remarkably lesser in the ESPB group during the first 24 hours (24 ± 2.5 mg) compared to the TQLB group (30.5 ± 1.55 mg).

Conclusion

The analgesic efficacy of ESPB was better when compared to TQLB in terms of time to rescue analgesia and overall opioid consumption during the first 24 hours. This study was registered at ClinicalTrials.gov on 10/10/2022 (registration number: NCT05574283).

[Old and New Regional Anesthesia Procedures Under Review - Abdomen to Toe]

Ultrasound (US) technology has significantly expanded the spectrum of regional anesthesiological procedures in recent years. Abdominal wall blocks are becoming an increasingly integral part of a multimodal postoperative pain concept after abdominal surgery, gynecological or urological interventions. Thoracic epidural analgesia remains the gold standard for extensive surgery. The requirement for rapid postoperative mobilization and discharge after lower extremity surgery has led to the abandonment of neuroaxial or plexus blocks in favor of selective, peripheral blocks such as the PENG block or adductor canal block. The following article is intended to show the reader the change in the use of regional anesthesiological procedures for abdominal wall and lower extremity blocks using selected blockages.

Quadratus lumborum block for postoperative pain management in patients undergoing total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

The use of quadratus lumborum nerve blocks (QLB) for pain control following elective total hip arthroplasty (THA) has increased substantially in recent years. The objective of this systematic review and meta-analysis was to compare outcomes from randomised controlled trials (RCTs) utilising QLBs following elective THA.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched for RCTs perioperative QLBs for THA. Quantitative synthesis was conducted for pain scores, opioid consumption and adverse events.

RESULTS

A total of 7 RCTs with 429 patients undergoing THA were included. No differences in pain scores were demonstrated between QLBs and control interventions. Subgroup analysis demonstrated no differences between QLBs and sham procedures or active comparators. No differences in postoperative opioid consumption between QLB and control interventions was found. In trials reporting adverse events, they were rare and similar between groups. Overall, the certainty of the evidence was graded as low or very low.

CONCLUSIONS

The current literature suggests that a QLB for THA does not reduce pain or opioid consumption compared to sham or active comparators.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BACKGROUND

Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.

METHODS

One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.

DISCUSSION

This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.

TRIAL REGISTRATION

Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Analgesic Efficacy of Quadratus Lumborum Block in Patients Undergoing Nephrectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the analgesic efficacy of quadratus lumborum block (QLB) in adults undergoing nephrectomy.

DESIGN

Systematic review and meta-analysis.

PATIENTS

Adult patients (≥18 years of age) received nephrectomy under general anesthesia.

METHODS

We searched PubMed, Embase, the Cochrane Library, and Web of Science on January 10, 2022, including randomized controlled trials that evaluated the analgesic efficacy of QLB for patients undergoing nephrectomy.

RESULTS

A total of 12 randomized controlled trials (N = 821 patients) were included in the study. Compared with the non-block, single-shot QLB reduced postoperative opioid consumption (mean difference [MD], -8.37 mg intravenous morphine equivalent; 95% confidence interval [CI], -12.19 to -4.54 mg) and pain scores at 2 hours, 6 hours, 12 hours, and 24 hours at rest and during movement after nephrectomy. Single-shot QLB also prolonged the time to first analgesic request (MD, 6.44 hours; 95% CI, 2.23 to 10.65 hours), shortened the length of hospital stay (MD, -0.32 day; 95% CI, -0.55 to -0.09 day), and decreased the incidence of postoperative nausea and vomiting (risk ratio, 0.48; 95% CI, 0.36 to 0.65). Compared with continuous epidural anesthesia, repeated QLB could provide comparable postoperative analgesic benefits.

CONCLUSIONS

Single-shot QLB provided a statistically significant but clinically small improvement in postoperative analgesia and recovery for patients undergoing nephrectomy. The QLB would be beneficial as part of multimodal analgesia. Future research might need to determine which approach of QLB is superior for postoperative analgesia after nephrectomy.

Posterior quadratus lumborum block versus epidural analgesia for postoperative pain management after open radical cystectomy: A randomized clinical trial

BACKGROUND

In open abdominal surgery, continuous epidural analgesia is commonly used method for postoperative analgesia. However, ultrasound (US)-guided fascial plane blocks may be a reasonable alternative.

METHODS

In this randomized controlled trial, we compared posterior quadratus lumborum block (QLB) with epidural analgesia for postoperative pain after open radical cystectomy (ORC). Adult patients aged 18-85 with bladder cancer (BC) scheduled for open RC were randomized in two groups. Exclusion criteria were complicated diabetes mellitus type I, lack of cooperation, and persistent pain for reasons other than BC. In one group, a bilateral US-guided single injection posterior QLB was performed with 3.75 mg/ml ropivacaine 20 ml/side. In the other group, continuous epidural analgesia with ropivacaine was used. Basic analgesia was oral paracetamol 1000 mg three times daily, and long-acting opioid twice daily in both groups. All patients had patient-controlled rescue analgesia with oxycodone. Postoperative cumulative rescue opioid consumption was recorded for the day of surgery, and the following 2 postoperative days (POD 0-2). Secondary outcomes were postoperative pain and nausea and vomiting.

RESULTS

In total, 20 patients (QLB), and 19 patients (epidural analgesia) groups, were included in the analyses. Cumulative rescue opioid consumption on POD 0, being of duration 9-12 h, was 14 mg (7.6-33.3) in the QLB group versus 6.1 mg (2.0-16.1) in the epidural analgesia group, p = 0.089, and as doses, 8 doses (3.6-15.7) versus 4 doses (1.3-8.5), p = .057. On POD 1 consumption was 25.3 mg (11.0-52.9) versus 18.0 mg (14.4-43.7), p = .749, and as doses 12 (5.5-23.0) versus 10 (8-20), p > .9, respectively. On POD 2 consumption was 19.1 mg (7.9-31.0) versus 18.0 mg (5.4-27.6) p = .749, and as doses 8.5 (5.2-14.7) versus 11 (3.0-18.0) p > .9, respectively.

CONCLUSION

Opioid consumption did not differ significantly between posterior QLB and an epidural infusion with ropivacaine for the first 2 postoperative days following RC.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03328988.

Efficacy of Ultrasound-Guided Quadratus Lumborum Block for Postoperative Analgesia After Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Ultrasound-guided quadratus lumborum (QL) block as a novel regional anesthetic technique was proposed in 2007 that can be applied in patients following hip arthroplasty. This study aimed to evaluate the efficacy of the QL block for pain control in patients undergoing hip arthroplasty.

METHODS

We performed a comprehensive search of PubMed, Web of Science, Scopus, Cochrane Library, Embase databases, Google Scholar, and CNKI for randomized controlled trials up to December 2021. According to the inclusion and exclusion criteria established in advance, "QL block" and "hip arthroplasty" related MeSH terms and free-text words were used.

RESULTS

Our meta-analysis included 11 randomized controlled trials involving a total of 830 patients between 2018 and 2021. The results indicated that compared to the non-QL block group, Visual Analog Scale (VAS) score at mobilization in the QL block group demonstrated statistical and clinical significance at all time points (12, 24, and 48 hours), but VAS score at rest failed to reach the MCID (minimal clinically important difference). Meanwhile, opioid consumption in the QL block group only demonstrated statistical and clinical significance at 48 hours postoperatively, but did not reach the MCID at 12 or 24 hours postoperatively. The QL block increased satisfaction scores. There was a statistically significant reduction in the incidence of postoperative nausea and vomiting, but no difference in the incidence of pruritus and urinary retention.

CONCLUSION

The QL block significantly reduced postoperative VAS score at mobilization, and opioid consumption at 48 hours in patients after hip arthroplasty compared to no block, which reached the MCID. The QL block also decreased postoperative nausea and vomiting and increased satisfaction scores. Although these are promising results, the clinical relevance of the efficacy of the QL block remains to be further understood as larger studies are needed.

Ultrasound-Guided Quadratus Lumborum Block Combined with General Anaesthesia or General Anaesthesia Alone for Laparoscopic Radical Gastrectomy for Gastric Adenocarcinoma: A Monocentric Retrospective Study

PURPOSE

To investigate, in patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, the effects of ultrasound-guided quadratus lumborum block (UG-QLB) combined with general anaesthesia (GA) on the postoperative recovery compared with GA alone.

PATIENTS AND METHODS

The retrospective study enrolled 231 patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, including 119 patients who received UG-QLB combined with GA (Group QG), and 112 patients undergoing GA alone (Group GA). The primary endpoint was the postoperative 3-year recurrence-free survival (RFS). The secondary endpoints were the average visual analogue scale (VAS) scores within 48 h after surgery, the first time of postoperative ambulation, the first time of flatus, postoperative hospitalization, perioperative opioid requirement and adverse effects after surgery.

RESULTS

UG-QLB combined with GA did not affect the 3-year RFS in patients undergoing laparoscopic radical gastrectomy (HR 0.659, 95% CI 0.342-1.269, P=0.212). However, the VAS ranking analysis implicated that it could significantly alleviate the postoperative pain in laparoscopic radical gastrectomy patients (P<0.01). In addition, it dramatically facilitated the early recovery of postoperative ambulation and flatus, while shortening the duration of postoperative hospitalization (P<0.01). The most important was it could remarkably reduce the opioid consumption (P<0.01), which in the meanwhile, reduced the incidence of postoperative nausea and vomiting (PONV) (P=0.01).

CONCLUSION

Although UG-QLB combined with GA did not improve the 3-year RFS for patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, it could provide satisfactory postoperative pain relief, reduce opioid consumption and adverse effects, which subsequently facilitates postoperative early rehabilitation.

Analgesic benefits of the quadratus lumborum block in total hip arthroplasty: a systematic review and meta-analysis

The quadratus lumborum block (QLB) is reported to reduce pain and improve function following total hip arthroplasty; however, randomised controlled trials evaluating the benefits of adding this block to general or spinal anaesthesia in this population are conflicting. We performed a systematic review seeking randomised controlled trials investigating QLB benefits for total hip arthroplasty, stratifying comparisons regarding the addition of QLB to either general or spinal anaesthesia. The primary outcome was 24-h area under the curve (AUC) pain score. Pain scores were interpreted in the context of a population-specific minimal clinically important difference of 1.86 cm on a 10-cm visual analogue scale, or an AUC pain score of 5.58 cm.h. Secondary outcomes included analgesic consumption, functional recovery and opioid-related side-effects. In all, 18 trials (1318 patients) were included. Adding QLB to general or spinal anaesthesia improved 24-h AUC rest pain scores by a mean difference (95%CI) of -3.56 cm.h (-6.70 to -0.42; p = 0.034) and - 4.19 cm.h (-7.20 to -1.18; p = 0.014), respectively. These improvements failed to reach the pre-determined minimal clinically important difference, as did the reduction in analgesic consumption. Quadratus lumborum block improved functional recovery for general, but not spinal, anaesthesia. Opioid-related side-effects were reduced with QLB regardless of anaesthetic modality. Low-to-moderate quality evidence suggests that the extent to which adding QLB to either general or spinal anaesthesia reduces postoperative pain and opioid consumption after total hip arthroplasty is statistically significant but may be clinically unimportant for most patients. However, adding QLB to general anaesthesia might enhance functional recovery. Taken together, our findings do not support the routine use of QLB as part of multimodal analgesic regimens for total hip arthroplasty.

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.

Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

Effect of Intravenous Paracetamol on Opioid Consumption in Multimodal Analgesia After Lumbar Disc Surgery: A Meta-Analysis of Randomized Controlled Trials

Background: Intravenous paracetamol, as an adjunct to multimodal analgesia, has been shown to successfully reduce opioid consumption after joint arthroplasty, abdominal surgery, and caesarean delivery. However, there are limited data on the opioid-sparing effect of intravenous paracetamol on lumbar disc surgery. Objectives: The aim of this study was to investigate the effectiveness and safety of intravenous paracetamol for reducing opioid consumption in lumbar disc surgery. The primary outcome was cumulative opioid consumption within 24 h postoperatively. Method: We followed the PRISMA-P guidelines and used GRADE to assess the quality of evidence. The review was registered in PROSPERO under the registration number CRD42021288168. Two reviewers conducted electronic searches in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Clarivate Analytics). Randomized controlled trials (RCTs) that compared the postoperative opioid consumption of intravenous paracetamol with placebo in lumbar discectomy were included. Results: Five trials comprising a total of 271 patients were included. The overall opioid consumption within 24 h postoperatively was reduced [mean difference (MD), -10.61 (95% CI, -16.00 to -5.22) mg, p = 0.0001, I2 = 90%] in patients with intravenous paracetamol. Intravenous paracetamol significantly reduced the postoperative pain scores at 1 h [MD, -2.37 (95%CI, -3.81 to -0.94), p = 0.001, I2 = 82%], 2 h [MD, -3.17 (95%CI, -3.85 to -2.48), p < 0.00001, I2 = 38%], 6 h [MD, -1.75 (95%CI, -3.10 to -0.40), p = 0.01], 12 h [MD, -0.96 (95%CI, -1.77 to -0.15), p = 0.02], and 24 h [MD, -0.97 (95%CI, -1.67 to -0.27), p = 0.006] compared with the placebo. There were no differences in postoperative adverse effects. Conclusion: Intravenous paracetamol reduced postoperative opioid consumption and decreased postoperative pain scores without increasing adverse effects. The overall GRADE quality of the evidence was rated as low to moderate. Intravenous paracetamol appears to be an applicable option as an important part of multimodal analgesia for postoperative analgesia after lumbar disc surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, CRD42021288168.

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 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.

Efficacy of Quadratus Lumborum Block for Pain Control in Patients Undergoing Hip Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have reported the use of anterior, posterior and lateral quadratus lumborum block (QLB) for pain control in hip surgeries. However, high-quality evidence is lacking. The current review aimed to summarize data on the efficacy of QLB for pain control in patients undergoing hip surgeries.

METHODS

PubMed, Embase, and Google Scholar databases were searched up to August 5, 2021 for randomized controlled trials (RCTs) or non-RCTs assessing the efficacy of QLB for any type of hip surgery.

RESULTS

Thirteen studies were included (nine RCTs and four non-RCTs). On pooled analysis, there was a statistically significant reduction of 24-h total opioid consumption in patients receiving QLB as compared to the control group (MD: -9.92, 95% CI: -16.35, -3.48 I 2 = 99% p = 0.003). We noted a statistically significant reduction of pain scores in the QLB group as compared to control group at 2-4 h (MD: -0.57, 95% CI: -0.98, -0.17 I 2 = 61% p = 0.005), 6-8 h (MD: -1.45, 95% CI: -2.09, -0.81 I 2 = 86% p < 0.00001), 12 h (MD: -1.12, 95% CI: -1.89, -0.34 I 2 = 93% p = 0.005), 24 h (MD: -0.71, 95% CI: -1.27, -0.15 I 2 = 89% p = 0.01) and 48 h (MD: -0.76, 95% CI: -1.37, -0.16 I 2 = 85% p = 0.01) after the procedure. There was a statistically significant reduction in the risk of nausea/vomiting (RR: 0.40, 95% CI: 0.18, 0.88 I 2 = 62% p = 0.02) in patients receiving QLB but no difference in the risk of pruritis (RR: 0.46, 95% CI: 0.17, 1.24 I 2 = 16% p = 0.13) and urinary retention (RR: 0.44, 95% CI: 0.19, 1.02 I 2 = 0% p = 0.06).

CONCLUSION

QLB as a part of a multimodal analgesic regimen reduces opioid consumption and pain scores in patients undergoing hip surgeries. The certainty of evidence based on GRADE was moderate. Despite the statistically significant results, the clinical relevance of the analgesic efficacy of QLB is debatable due to the small effect size.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021267861.

A systematic review and meta-analysis of efficacy of ultrasound-guided single-shot quadratus lumborum block for postoperative analgesia in adults following total hip arthroplasty

STUDY OBJECTIVE

To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA).

DESIGN

Systematic review and meta-analysis.

SETTING

Perioperative period.

PATIENTS

Adult patients undergoing THA.

METHODS

Studies were identified by performing electronic searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis.

MAIN RESULTS

The 24 hr opioid consumption was similar in both the groups [WMD -4.09; 95%CI (-9.00, 0.83); P = 0.10; I2 = 95%]. The pain scores at rest at 24 hr was significantly less in QLB group [WMD -0.62; 95% CI (-1.15, -0.10); P = 0.02; I2 = 75%].The difference in pain scores was not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request and time to discharge from hospital were similar in both the groups.

CONCLUSIONS

QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

PROSPERO REGISTRATION NO

CRD42021253425.

Effect of Ultrasound-Guided Quadratus Lumborum Block Preemptive Analgesia on Postoperative Recovery of Patients with Open Radical Colon Cancer Surgery: A Retrospective Study

Purpose

To evaluate the effect of ultrasound-guided quadratus lumborum block (QLB) preemptive analgesia on recovery in colon cancer patients undergoing open radical surgery and provide reference for its clinical application.

Methods

From July 2019 to June 2020, according to the anesthesia method, 56 patients who received open radical colon surgery were divided into two groups: Group Q (n=27), which received QLB combined general anesthesia, and Group C (n=29), which received general anesthesia only. Both groups were given self-controlled intravenous analgesia pump after surgery. The primary outcome is a series of parameters representing postoperative recovery. The secondary outcome was VAS scores and opioid consumption.

Results

The first time of getting up, flatus, taking semi-liquid diet and the postoperative hospital stay in Group Q were significantly reduced (P<0.01). The rest and active VAS scores were significantly lower in Group Q (P<0.01). The opioids consumption was significantly decreased in Group Q (P<0.05).

Conclusion

The application of ultrasound-guided QLB preemptive analgesia in open radical colon cancer surgery can significantly enhance the postoperative analgesia effect, reduce opioid consumption, and accelerate the postoperative recovery of the patients.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-2000034824).