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Hui M, Mohr-Sasson A, Hernandez N, Bhalwal A, Montealegre A, Dziadek O, Leon M, Ghorayeb T, Pedroza C, Santos RB, Jalloul R. Effect of Preoperative Bilateral Ultrasound-guided Quadratus Lumborum Nerve Block on Quality of Recovery after Minimally Invasive Hysterectomy in an Enhanced Recovery after Surgery (ERAS) Setting. J Minim Invasive Gynecol 2024:S1553-4650(24)00231-0. [PMID: 38797277 DOI: 10.1016/j.jmig.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/16/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
STUDY OBJECTIVE To assess the effect of preoperative bilateral ultrasound-guided quadratus lumborum nerve block (QLB) on quality of recovery after minimally invasive hysterectomy, in an enhanced recovery after surgery setting. DESIGN Randomized, controlled, double-blinded trial (Canadian Task Force level I). SETTING University-affiliated tertiary medical center. PATIENTS All women undergoing an elective robotic or laparoscopic hysterectomy. Women with chronic pain, chronic anticoagulation, and body mass index >50 kg/m2 were excluded. INTERVENTION Patients were randomized with a 1:1 allocation, to one of the following 2 arms, and stratified based on robotic versus laparoscopic approach. 1. QLB: QLB (bupivacaine) + sham local trocar sites infiltration (normal saline) 2. Local infiltration: sham QLB (normal saline) + local infiltration (bupivacaine) MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as the quality of recovery score based on the validated questionnaire Quality of Recovery, completed 24 hours postoperatively. Secondary outcomes included dynamic pain scores, accumulated opioid consumption up to 24 hours, postoperative nausea and vomiting, surgical complications, length of hospital stay, time to first pain medication administration in the postanesthesia care unit, and adverse events. A total of 76 women were included in the study. Demographic characteristics were similar in both groups. Median age was 44 years (interquartile range 39-50), 47% of the participants were African American, and mean body mass index was 32.8 kg/m2 (standard deviation [SD] 8.1). The mean Quality of Recovery score was 179.1 (SD ± 10.3) in the QLB and 175.6 (SD ± 9.7) for the local anesthesia group (p = .072). All secondary outcomes were comparable between groups. CONCLUSIONS QLBs do not significantly improve quality of recovery after elective robotic or laparoscopic hysterectomy compared with local anesthetic port site infiltration.
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Affiliation(s)
- Mason Hui
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Aya Mohr-Sasson
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Nadia Hernandez
- Department of Anesthesiology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Dr. Hernandez)
| | - Asha Bhalwal
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Alvaro Montealegre
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Olivia Dziadek
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Mateo Leon
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Tala Ghorayeb
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Claudia Pedroza
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Rafael Bravo Santos
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos)
| | - Randa Jalloul
- Department of Obstetrics, Gynecology, and Reproductive Sciences - Division of Minimally Invasive Gynecologic Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Drs. Hui, Mohr-Sasson, Bhalwal, Montealegre, Dziadek, Leon, Ghorayeb, Pedroza, Santos).
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Hymes-Green Z, LaGrone EL, Peabody Lever JE, Feinstein J, Piennette PD, Lawson P, Gerlak JB, Godlewski CA, Brooks B, Kukreja P. Efficacy of Erector Spinae Plane (ESP) Block for Non-cardiac Thoracic and Upper Abdominal Surgery: A Single Institute Comparative Retrospective Case Series. Cureus 2024; 16:e58926. [PMID: 38800304 PMCID: PMC11122672 DOI: 10.7759/cureus.58926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022. All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD) 1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and required significantly more antiemetic pharmacotherapy (mean 1.4 antiemetics administered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24 hours (95% CI -9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral block techniques in thoracic and upper abdominal surgeries for perioperative pain management.
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Affiliation(s)
- Zasmine Hymes-Green
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Erin L LaGrone
- School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Jacelyn E Peabody Lever
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Joel Feinstein
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Paul D Piennette
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Prentiss Lawson
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Jason B Gerlak
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Christopher A Godlewski
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Brandon Brooks
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Promil Kukreja
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
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Althans AR, Kumpati B, Lavage DR, Esper SA, Subramaniam K, Boisen ML, Holder-Murray J. Use of Perioperative Intravenous Lidocaine as Part of an Abdominal Surgery Enhanced Recovery Pathway Does Not Significantly Impact Postoperative Pain. Am Surg 2024; 90:624-630. [PMID: 37786239 DOI: 10.1177/00031348231204916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND The utility of perioperative intravenous lidocaine in improving postoperative pain control remains unclear. We aimed to compare postoperative pain outcomes in ERP abdominal surgery patients who did vs did not receive intravenous lidocaine. We hypothesized that patients receiving lidocaine would have lower postoperative pain scores and consume fewer opioids. METHODS We performed a retrospective cohort study of patients undergoing elective abdominal surgery at a single institution via an ERP from 2017 to 2018. Patients who received lidocaine in the 6 months prior to a lidocaine shortage were compared to those who did not receive lidocaine for 6 months following the shortage. The primary outcome measures were pain scores as measured on the visual analogue scale and opioid consumption as measured by oral morphine equivalents (OME). RESULTS We identified 1227 consecutive ERP abdominal surgery patients for inclusion (519 patients receiving lidocaine and 708 patients not receiving lidocaine). Demographics between the two cohorts were similar, with the following exceptions: more females, and more patients with a history of psychiatric diagnoses in the group that did not receive lidocaine. Adjusted, mixed linear models for both OME (P = .23) and pain scores (P = .51) found no difference between the lidocaine and no lidocaine groups. DISCUSSION In our study of ERP abdominal surgery patients, perioperative intravenous lidocaine did not offer improvement in postoperative pain scores or OME consumed. We therefore do not recommend the use of intravenous lidocaine as part of an ERP multimodal pain management strategy in abdominal surgery patients.
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Affiliation(s)
- Alison R Althans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Danielle R Lavage
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Schott N, Chamu J, Ahmed N, Ahmed BH. Perioperative truncal peripheral nerve blocks for bariatric surgery: an opioid reduction strategy. Surg Obes Relat Dis 2023; 19:851-857. [PMID: 36854643 DOI: 10.1016/j.soard.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 01/14/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Bariatric surgical patients are vulnerable to cardiopulmonary depressant effects of opioids. The enhanced recovery after surgery (ERAS) protocol to improve postoperative morbidity recommends regional anesthesia for postoperative pain management. However, there is limited evidence that peripheral nerve blocks (PNB) have added benefit. OBJECTIVE Study the effect of PNB on postoperative pain and opioid use following bariatric surgery. SETTING Academic medical center, United States. METHODS We conducted a cohort study of patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. A total of 44 patients received the control ERAS protocol with preoperative oral extended-release morphine sulfate (MS), while 45 patients underwent a PNB with either intrathecal morphine (IM) or oral MS per local ERAS protocol. The PNB group either underwent preoperative bilateral T7 paravertebral (PVT) PNBs (27 patients) with IM or postoperative transversus abdominis plane (TAP) PNBs (18 patients) with oral MS. The primary outcome compared total opioid consumption between the ERAS control group and the PNB group up to 48 hours postoperatively. Secondary outcomes included comparison by block type and postoperative pain scores. RESULTS PVT or TAP PNB patients had a reduction in mean postoperative oral morphine equivalent (OME) requirements compared with the ERAS protocol cohort at 24 hours (93.9 versus 42.8 mg), P < .0001; at 48 hours (72.6 versus 40.5 mg); and in pain scores at 24 hours (5.64/10 versus 4.46/10), P = .02. OME and pain scores were higher in the SG cohort. CONCLUSION Addition of truncal PNB to standard ERAS protocol for bariatric surgical patients reduces postoperative total opioid consumption.
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Affiliation(s)
- Nicholas Schott
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jauhleene Chamu
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Noor Ahmed
- North Allegheny Senior High School, Pittsburgh, Pennsylvania
| | - Bestoun H Ahmed
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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