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Lirk P, Badaoui J, Stuempflen M, Hedayat M, Freys SM, Joshi GP. PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management. Eur J Anaesthesiol 2024; 41:161-173. [PMID: 38298101 DOI: 10.1097/eja.0000000000001945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.
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Affiliation(s)
- Philipp Lirk
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital (PL, JB, MS), Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA (MH), Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF) and Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, USA (GPJ)
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Zhu Y, Li Z, Qin S, Xu H, He J, Sheng F, Zhao Q, Kang Y, Gao X, Li S, Chai J, Chen L, Wang W. Ultrasound-guided posterior quadratus lumborum block can reduce postoperative opioid consumption and promote rapid recovery in patients undergoing sutureless laparoscopic partial nephrectomy: A triple-blind, randomized, controlled study. Front Oncol 2022; 12:969452. [PMID: 36276114 PMCID: PMC9582236 DOI: 10.3389/fonc.2022.969452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose We hypothesized that posterior quadratus lumborum block would reduce postoperative opioid consumption and improve the quality of recovery in patients undergoing sutureless laparoscopic partial nephrectomy. Materials and methods The study included 60 patients, ages 18−65 with American Society of Anesthesiologists scores of I-II scheduled for elective sutureless laparoscopic partial nephrectomy. Before general anesthesia, 60 participating patients were randomly allocated to receive a 30-ml injection posterior to the quadratus lumborum muscle with either 0.375% ropivacaine (n = 30) or normal saline (n = 30). The primary outcomes included cumulative opioid consumption within 12 h postoperatively and quality of postoperative recovery at 48 h. Secondary outcomes included the Numerical Rating Scale (NRS), opioid consumption by period, first time to press the analgesic pump, number of patients needing rescue analgesia, blood glucose and cortisol concentrations, early postoperative recovery indicators, and adverse events. Results There were 48 patients included in the final analysis. The intervention group had lower cumulative consumption of sufentanil within 12 h postoperatively and higher quality of postoperative recovery scores at 48 h postoperatively compared with the control group (p < 0.001). The NRS at resting and movement of the intervention group was lower at 0 h, 6 h, and 12 h after surgery than in the control group (p < 0.05). At prespecified intervals (0 to 2 h, 2 to 6 h, 6 to 12 h, 12 to 24 h, and 24 to 48 h) after surgery, the intervention group had lower consumption of sufentanil compared with the control group (p < 0.05). The intervention group took longer to press the analgesic pump for the first time within 48 h after surgery compared with the control group (p < 0.001). The postoperative blood glucose and cortisol concentrations in the intervention group were lower than in the control group (p < 0.05). The times to first excretion, ambulation, and discharge were shorter in the intervention group compared with the control group (p < 0.05). There was no significant difference in adverse events between the two groups. Conclusions Our trial demonstrated that patients who received posterior quadratus lumborum block had significantly lower opioid consumption within 12 h postoperatively and had a better quality of recovery at 48 h postoperatively. Therefore, we recommend posterior quadratus lumborum block as an option for postoperative analgesia in patients undergoing sutureless laparoscopic partial nephrectomy. Trial Registration http://www.chictr.org.cn, identifier ChiCTR2100053439.
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Affiliation(s)
- Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhichao Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shangyuan Qin
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hao Xu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianshuai He
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fang Sheng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qin Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yihan Kang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin Gao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Si Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun Chai
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Jun Chai,
| | - Lina Chen
- Department of Anesthesiology, Shandong provincial Qianfoshan Hospital, Jinan, China
| | - Weiwei Wang
- Department of Anesthesiology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China
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Chin KJ, Lirk P, Hollmann MW, Schwarz SKW. Mechanisms of action of fascial plane blocks: a narrative review. Reg Anesth Pain Med 2021; 46:618-628. [PMID: 34145073 DOI: 10.1136/rapm-2020-102305] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks. OBJECTIVES This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research. FINDINGS There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain. CONCLUSION Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.
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Affiliation(s)
- Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philipp Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam Medical Centre, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Stephan K W Schwarz
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
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