Ultrasound-Guided Quadratus Lumborum Block at the Lateral Supra-Arcuate Ligament versus Subcostal Transversus Abdominis Plane Block for Postoperative Analgesia Following Open Hepatectomy: A Randomized Controlled Trial

Quadratus lumborum block for total abdominal hysterectomy: a double-blind, randomized, controlled trial

Background/aim

The Quadratus lumborum block (QLB) is an interfascial block recommended for multimodal pain therapy after cesarean section in patients who cannot receive intrathecal morphine. We wanted to investigate whether QLB contributes to better analgesia after total abdominal hysterectomy (TAH). The study was registered on the website ClinicalTrials.gov (registration number NCT05765318).

Materials and methods

Patients scheduled for TAH were randomized into two groups of 30 members each. The treatment group received QLB, while the control group did not undergo any block. The primary outcome was the amount of morphine during the first 12 postoperative h. Secondary outcomes included the total amount of morphine for 24 h, time to the first request for additional analgesia, pain intensity at rest and during activity, frequency of nausea and vomiting, and the degree of sedation at 2, 6, 12, and 24 h postoperatively.

Results

Patients in the QLB group received significantly less morphine (4.13 mg) compared to the control group (9.73 mg) during the first 12 postoperative h (p < 0.001) and also during the first 24 h. The patients in the QLB group had longer time interval to the first breakthrough pain (7.87 h) compared to the control group (2.63 h) (p < 0.001), lower NRS scores at rest and during activity after 2, 12, and 24 h, and better satisfaction with provided pain relief during the first 24 h postoperatively.

Conclusion

QLB reduces postoperative morphine use and postoperative pain intensity on the NRS scale, both at rest and during activity, as part of multimodal pain therapy for TAH.

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.

Erector spinae plane block for laparoscopic surgeries: a systematic review and meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a novel analgesic technique that can reduce post-operative pain and postoperative opioid consumption in laparoscopic surgeries.

METHODS

We searched PubMed, Scopus, and Web of Science on November 17th, 2023 for clinical trials comparing ESPB with other analgesic techniques or placebo for laparoscopic surgeries. We meta-analyzed post-operative pain at rest, postoperative opioid consumption, time to first rescue analgesic request, and postoperative nausea and vomiting using a random effects model.

RESULTS

ESPB significantly reduced opioid consumption compared to placebo (SMD, (95CI), p-value; -1.837, (-2.331, -1.343), < 0.001) and also compared to transversus abdominis plane block (TAPB) (SMD, (95CI), p-value; -1.351, (-1.815, -0.887), < 0.001) but not quadratus lumborum plane block (QLB) (SMD, (95CI), p-value; 0.022, (-0.241, 0.286), 0.869). ESPB also significantly reduced participant-reported pain scores at rest at 24h post-operation compared to placebo (SMD, (95CI), p-value; -0.612, (-0.797, -0.428), < 0.001) and TAPB (SMD, (95CI), p-value; -0.465, (-0.767, -0.162), < 0.001), however, there was a significant increase in pain score compared to QLB (SMD, (95CI), p-value; 1.025, 0.156, 1.894), 0.021). A statistically significant increase in time to first rescue analgesic in ESPB groups compared to placebo and TAPB groups was observed in our meta-analysis. There was a lower post-operative nausea and vomiting rate in the ESPB groups compared to placebo groups, yet a comparable rate with QLB and TAPB groups was observed in the meta-analysis.

CONCLUSION

ESPB is an effective and safe analgesic technique for managing post-operative pain and opioid consumption in laparoscopic surgeries compared to placebo, reducing postoperative nausea or vomiting as well. Compared to other techniques, ESPB has a similar efficacy to QLB, except for the pain score at 24 h post-operation, but appears to be superior to TAPB as an analgesic technique in laparoscopic surgeries, with a similar safety profile.

TRIAL REGISTRATION

Prospero registration ID: CRD42024508363. Link: https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Application of ultrasound-guided anterior quadratus lumborum block approach at the lateral supra-arcuate ligament in elderly patients undergoing colorectal cancer surgery

OBJECTIVE

To investigate the anesthetic and analgesic effects of combining general anesthesia with an anterior quadratus lumborum block at the lateral supra-arcuate ligament (SA-AQLB) in elderly patients undergoing laparoscopic radical resection for colorectal cancer (CRC).

METHODS

In this prospective study, 92 elderly patients scheduled for radical CRC resection were randomly divided into three groups: ultrasound-guided SA-AQLB group (SA group, n=31), ultrasound-guided subcostal AQLB (SC-AQLB) group (SC group, n=31), and a general anesthesia-only group (GA group, n=30). Measurements included mean arterial pressure (MAP) and heart rate (HR) at predefined time points, ranging from pre-operation to the end of surgery. Visual analog scale (VAS) pain scores were recorded at multiple postoperative time points up to 48 hours. Additional data collected included intraoperative drug dosages, anesthetic recovery times, patient-controlled intravenous analgesia (PCIA) usage, Lovett muscle strength scores, and early postoperative recovery indicators.

RESULTS

The SA group consistently showed lower MAP and HR compared to the SC group, which in turn was lower than the GA group during the monitored time points (all P<0.05). Sensory block levels were significantly higher in the SA group than that in the SC group (P<0.05). Postoperative VAS scores were also significantly lower in the SA group compared to the other groups at all recorded times (all P<0.05). The SA group required lower doses of propofol, remifentanil, and sufentanil, but higher doses of ephedrine compared to the SC and GA groups (all P<0.05). Anesthesia recovery time was shorter in the SA group, and the total number of PCIA pump presses was least in the SA group (P<0.05). Early ambulation was achieved sooner in the SA and SC groups (P<0.05), and the incidence of nausea and vomiting was reduced in these groups compared to the GA group (P<0.05).

CONCLUSION

General anesthesia combined with ultrasound-guided SA-AQLB provides superior outcomes to general anesthesia alone in elderly patients undergoing laparoscopic CRC surgery. This approach significantly reduces general anesthesia drug dosage, decreases postoperative pain, minimizes perioperative adverse events, and accelerates patient recovery.

Quadratus lumborum block vs. transversus abdominis plane block for postoperative pain control in patients with nephrectomy: A systematic review and network meta-analysis

STUDY OBJECTIVE

This systematic review and network meta-analysis aimed to compare the analgesic efficacy of transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) on nephrectomy.

DESIGN

Systematic review and network meta-analysis.

PATIENTS

Patients undergoing nephrectomy.

INTERVENTIONS

TAPB and QLB for postoperative analgesia.

MEASUREMENTS

The primary outcome was 24 h morphine-equivalent consumptions after surgery. Secondary outcomes included postoperative pain scores, postoperative opioid consumption, postoperative rescue analgesia, postoperative nausea and vomiting (PONV), length of hospital stay after surgery, and patient satisfaction.

MAIN RESULTS

Fourteen studies involving 883 patients were included. Seven studies compared TAPB to control, six studies compared QLB to control, and one study compared TAPB to QLB. For direct meta-analysis of the post-surgical 24 h morphine-equivalent consumption, QLB was lower than control (mean difference [95%CI]: -18.16 [-28.96, -7.37]; I2 = 88%; p = 0.001), while there was no difference between TAPB and control (mean difference [95%CI]: -8.34 [-17.84, 1.17]; I2 = 88%; p = 0.09). Network meta-analysis showed similar findings that QLB was ranked as the best anesthetic technique for reducing postoperative 24 h opioid consumption (p-score = 0.854). Moreover, in direct meta-analysis, as compared to control, the time of first postoperative rescue analgesia was prolonged after QLB (mean difference [95%CI]: 165.00 [128.99, 201.01]; p < 0.00001), but not TAPB (mean difference [95%CI]: 296.82 [-91.92, 685.55]; p = 0.13). Meanwhile, QLB can effectively reduce opioid usages at intraoperative period, as well as at postoperative 6 h and 48 h, while TAPB can only reduce opioid consumption at 6 h after surgery. As compared to control, both TAPB and QLB exhibited the reduction in PONV and pain scores at post-surgical some timepoints. Also, QLB (mean difference [95%CI]: -0.29 [-0.49, -0.08]; p = 0.006) but not TAPB (mean difference [95%CI]: 0.60 [-0.25, 1.45]; p = 0.17) exhibited the shorter postoperative length of hospital stay than control.

CONCLUSIONS

QLB is more likely to be effective in reducing postoperative opioid use than TAPB, whereas both of them are superior to control with regard to the reduction in postoperative pain intensity and PONV.

TRIAL REGISTRATION

PROSPERO identifier: CRD42022358464.