A review of peripheral nerve blocks for cesarean delivery analgesia

Comparison of erector spinae plane and transversus abdominis plane block for postoperative analgesia after caesarean delivery under spinal anaesthesia: A randomised controlled trial

BACKGROUND

Truncal blocks contribute to multimodal analgesia that enhances early recovery after caesarean delivery. The transversus abdominis plane (TAP) block is an established technique that offers somatic abdominal wall analgesia. The erector spinae plane (ESP) block is a fascial plane technique that may offer additional visceral analgesic effects. This study hypothesized that ESP block would offer superior analgesic efficacy to TAP block in women undergoing caesarean delivery under spinal anaesthesia.

METHODS

Sixty-six ASA physical status grade 1-3 (≥18 years) patients undergoing elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided TAP (N = 33) or ESP blocks at the T9 vertebral level (N = 35). The primary outcome measure was 24-hour cumulative morphine consumption. The secondary outcomes included time to first analgesic request, duration of block placement, numeric rating scale (NRS) pain scores at rest and movement, effect of pain on activities of daily living (ADLs) and care for the infant, patient analgesic satisfaction, frequency and severity of opioid-related side effects.

RESULTS

There was no statistically significant difference in mean (95% CI) 24-hour cumulative morphine consumption between groups: 32.0 (27.0 to 37.0) mg with TAP versus 27.0 (19.9 to 34.0) mg with ESP (p = 0.16). The mean (SD) duration of block placement was longer for ESP than for TAP blocks (10.7 (2.2) minutes versus 9.0 (2.5) minutes; p = 0.004). There were no significant differences in the other secondary outcomes.

CONCLUSION

This study found similar postoperative opioid use and analgesic efficacy between ESP and TAP block after caesarean delivery performed under spinal anaesthesia.

TRIAL REGISTRATION

South African National Clinical Trial Registry (DOH-27-102022-5278): https://sanctr.samrc.ac.za/TrialDisplay.aspx?TrialID=8100, Pan African Clinical Trials Registry (PACTR202301645957324): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24267.

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.

Posterior quadratus lumborum block versus intrathecal morphine analgesia after scheduled cesarean section: a prospective, randomized, controlled study

BACKGROUND

During the postoperative period of elective cesarean section, intrathecal morphine is effective in the multimodal analgesic regimen, but can cause significant adverse effects. Bilateral posterior quadratus lumborum block could be alternatively used. The aim of this study was to compare efficacy and safety of both strategies as part of a multimodal analgesic regimen.

METHODS

This was a prospective, randomized, blinded, controlled study. 104 parturients were randomly selected to receive intrathecal morphine or posterior quadratus lumborum block during cesarean section under spinal anesthesia. The primary endpoint was patient-controlled 24-hour cumulative intravenous morphine use. Secondary endpoints were 48-hour cumulative morphine use, static/dynamic pain scores, functional recovery (ObsQoR-11 questionnaire) and adverse effects.

RESULTS

There was no statistical difference in the mean cumulative morphine dose at 24-hour between groups (posterior quadratus lumborum block group, 13.7 (97.5% CI 10.4 to 16.9) mg; intrathecal morphine group, 11.1 (97.5% CI 8.4 to 13.8) mg, p=0.111). Pain scores did not show any difference between groups, excepted at 6 hours for the pain at cough/movement in favor of the posterior quadratus lumborum block group (p=0.013). A better recovery quality was observed at 24 hours in the posterior quadratus lumborum block group (p=0.009). Pruritus was more frequent in intrathecal morphine group parturients (35% vs 2%) CONCLUSIONS: No difference in cumulative morphine dose at 24 hours was observed in posterior quadratus lumborum block group compared with intrathecal morphine group. Posterior quadratus lumborum block can be considered an alternative to intrathecal morphine in cesarean postoperative analgesia, especially in cases of intolerance to morphine.

TRIAL REGISTRATION NUMBER

NCT04755712.

Comparison of ultrasound-guided erector spinae plane block versus transmuscular quadratus lumborum block for postoperative analgesia after caesarean delivery: A prospective randomized non-inferiority clinical trial

Background and Aims

Regional techniques are a part of multimodal analgesia following cesarean delivery. Cesarean delivery warrants a regional technique, which can provide somatic and visceral analgesia-like quadratus lumborum block (QLB) and erector spinae plane block (ESPB). In this study, we investigated the non-inferiority of ESPB at T12 and transmuscular-QLB (TQLB) at L2-L3 for postoperative analgesia in cesarean delivery.

Material and Methods

In this prospective, randomized, non-inferiority trial, 124 patients undergoing cesarean delivery were enrolled to receive bilateral TQLB or ESPB with 20 mL of 0.25% ropivacaine on each side. All patients received prophylactic acetaminophen and ketorolac for 2 days. Our primary objective was to compare the total tramadol consumption in the first 48 h between the two groups. Secondary objectives were to compare cumulative tramadol consumption, postoperative Numeric Rating Scale (NRS) score at rest, and with movement at various time points, the time for first rescue analgesic requirement, development of complications related to the block, and patient satisfaction with analgesia between the two groups.

Results

The total tramadol consumption in 48 h (47.3 ± 34.9 mg in ESPB and 50.9 ± 38.7 mg in TQLB), duration of first rescue analgesic (22.8 ± 15.8 h in ESPB and 22.7 ± 15.6 h in TQLB), and patient satisfaction were similar between the two groups. Both groups had similar pain scores except at rest at 6 h and on movement at 4 h, 6 h, and 36 h, whereas the ESPB group had lower NRS scores (P < 0.05).

Conclusion

The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB post-caesarean delivery.

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients

Introduction

With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section.

Methods

A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate.

Results

In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population.

Conclusion

Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.

The analgesic effect of transmuscular quadratus lumborum block versus erector spinae plane block for women undergoing elective Caesarean section: A randomized controlled trial

Background

We aimed to compare the analgesic effect and quality of recovery of transmuscular quadratus lumborum block (QLB) and erector spinae plane block (ESPB) in the presence of multimodal analgesia following Caesarean section.

Methods

This randomised controlled trial included full-term pregnant women who underwent elective Caesarean section under spinal anaesthesia without intrathecal morphine. The included women were randomised to receive either bilateral QLB (n = 51) or bilateral thoracic ESPB (n = 51), in addition to the control group (n = 51) who did not receive any block. All participants received regular paracetamol (1 g/6h) and diclofenac (50 mg/8 h). Intravenous morphine was used as a rescue analgesic. The primary outcome was time to first morphine requirement. Secondary outcomes included total postoperative morphine consumption and total Obstetric Quality of Recovery-11 (ObsQoR-11) score.

Results

We analysed 51, 50 and 48 patients in the QLB, ESPB and control groups, respectively. The time to first morphine requirement in both QLB and ESPB groups was longer than that in the control group (median [quartiles] time: 6 [6,12] h, 6 [6,6] h and 4 [3,4] h, respectively; p-value <0.001), without significant differences between the two former groups. The total morphine consumption in both QLB and ESPB groups was lower than that in the control group (median [quartiles]:0 [0,5] mg, 0 [0,5] mg and 25 [25,30] mg, respectively; p-value <0.001), without significant differences between the two former groups. The QLB and ESPB groups had comparable ObsQoR-11 score, and both groups' scores were higher than the control group.

Conclusion

In patients undergoing elective Caesarean section under spinal anaesthesia without intrathecal morphine, both QLB and ESPB provided superior analgesia and quality of recovery compared to the standard care, without significant difference between the two blocks.

Design and development of microformulations for rapid release of small molecules and oligonucleotides

A systemic delivery of therapeutics frequently results in sub-optimal exposure of the targeted locus and undesired side effects. To address these challenges, a platform for local delivery of diverse therapeutics by remotely controlled magnetic micro-robots was introduced. The approach involves micro-formulation of active molecules using hydrogels that exhibit wide range of loading capabilities and predictable release kinetics. This work introduces two specific hydrogels based on thiol-maleimide and PEG-PLA-diacrylate chemistries that afford high, reliable and reproducible loading and release of several model molecules including doxorubicin, 25-mer poly-dT oligonucleotide and a 5.4 kBp GFP DNA plasmid. The described formulations are suitable for micro-dosing using both conventional or remote delivery devices.

Analgesia after cesarean section - what is new?

PURPOSE OF REVIEW

Cesarean section is the most frequent surgical intervention, and pain following cesarean delivery unfortunately remains a common issue. The purpose of this article is to highlight the most effective and efficient options for postcesarean analgesia and to summarize current guidelines.

RECENT FINDINGS

The most effective form of postoperative analgesia is through neuraxial morphine. With adequate dosing, clinically relevant respiratory depression is extremely rare. It is important to identify women with increased risk of respiratory depression, as they might require more intensive postoperative monitoring. If neuraxial morphine cannot be used, abdominal wall block or surgical wound infiltration are very valuable alternatives. A multimodal regimen with intraoperative intravenous dexamethasone, fixed doses of paracetamol/acetaminophen, and nonsteroidal anti-inflammatory drugs reduce postcesarean opioid use. As the use of postoperative lumbar epidural analgesia impairs mobilization, double epidural catheters with lower thoracic epidural analgesia are a possible alternative.

SUMMARY

Adequate analgesia following cesarean delivery is still underused. Simple measures, such as multimodal analgesia regimens should be standardized according to institutional circumstances and defined as part of a treatment plan. Neuraxial morphine should be used whenever possible. If it cannot be used, abdominal wall blocks or surgical wound infiltration are good alternatives.

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Ultrasound-Guided Quadratus Lumborum Block Versus Caudal Block for Pain Relief in Children Undergoing Lower Abdominal Surgeries: A Randomized, Double-Blind Comparative Study

Background

The quadratus lumborum (QL) block, also known as the abdominal truncal block, was developed to provide visceral and somatic analgesia during abdominal procedures.

Objectives

This study aimed to assess pain alleviation, the incidence of complications in lower abdominal procedures, and hemodynamic stability between the caudal block and ultrasound-guided QL block.

Methods

Fifty-two patients aged 1 to 7 years old from both genders scheduled for unilateral lower abdominal surgery were randomly assigned to 2 study groups: group QL, unilateral QL block (n = 26), and group C, caudal block (n = 26). In group C, children received caudal block. In group QL, an ultrasound-guided QL block was performed. The time to first rescue analgesia was evaluated as a primary outcome. The quality of analgesia was determined using the face, legs, activity, cry, consolability scale (FLACC scale), hemodynamic parameters, and incidence of complications because hemodynamic instability was recorded under ultrasound guidance. Signs of local anesthetics toxicity and the parents' satisfaction were secondary outcomes.

Results

The time until the first demand for analgesia postoperatively was statistically longer in group QL compared to group C. A non-significant difference was observed between the 2 groups (P > 0.05) regarding age, weight, gender, duration of surgery, type of surgery, FLACC scale, and hemodynamics (SBP, systolic blood pressure), except at 30 minutes, which was significant in QL block. Also, a non-significant difference was observed in the severity of postoperative pain up to 1 day postoperatively. Group QL showed more satisfaction than group C. No intraoperative complications were detected.

Conclusions

Compared to caudal block, QL block produced sustained and adequate analgesia time postoperatively, with higher satisfaction.

Erector spinae plane block for analgesia after cesarean delivery: a systematic review with meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a regional block that may be used for several surgeries. However, the evidence regarding obstetrical procedures is not pooled in the literature.

OBJECTIVES

To assess whether ESPB improves the postoperative pain after cesarean section by a systematic review and meta-analysis.

METHODS

The protocol of this review was registered on PROSPERO (CRD42020192760). We included randomized controlled trials from databases until August 2020. The primary outcome was pain measured on a visual analogic scale; secondary outcomes were analgesic duration, postoperative opioid dose within the 24 hours, nausea/vomiting. The risk of bias and the GRADE criteria to assess quality of evidence were analyzed.

RESULTS

From 436 retrieved studies, three were selected. There was no difference in the pain scores between ESPB and controls at rest after surgery at 4 h (mean difference [MD] = 0.00; 95% CI: -0.72 to 0.72; I² = 0%; very low certainty), 12 h (MD = -1.00; 95% CI: -2.00 to -0.00; I² = 0%, low certainty) and 24 h (MD = -0.68; 95% CI: -1.56 to 0.20; I² = 50%; very low certainty). There was a smaller consumption of tramadol with ESPB compared with controls (MD = -47.66; 95% CI: -77.24 to -18.08; I² = 59%; very low certainty). The analgesic duration of ESPB was longer than the controls (MD = 6.97; 95% CI: 6.30 to 7.65; I² = 58%; very low certainty).

CONCLUSION

ESPB did not decrease the postoperative pain scores when compared to other comparators. However, ESPB showed a lower consumption of tramadol and a longer blockade duration, although the quality of evidence of these outcomes were very low.

Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Choice of local anesthetic in obstetric anesthesiology: literature review and demonstration of our own experience

Regional anesthesia is widely used in obstetric practice, and in many cases is the method of choice. It in­cludes neuroaxial anesthesia (spinal, epidural, combined spinal­epidural, epidural with dura mater puncture), region­al blocks (eg, TAP block, QL block, ESP block, pudendal block, etc.), as well as local infiltration anesthesia, which is used for both anesthesia and postoperative analgesia. The correct choice of local anesthetic, its dose and concentration is of fundamental importance in obstetric anesthesiology, as it is necessary to ensure the highest quality blockade with mini­mal side effects on mother and fetus.

Spinal Versus General Anesthesia for Cesarean Delivery in Pregnant Women With Moyamoya Disease: A Retrospective Observational Study

BACKGROUND

Moyamoya disease, a rare chronic cerebrovascular disease with a fragile vascular network at the base of the brain, can cause ischemic or hemorrhagic strokes or seizures. Precise blood pressure control and adequate analgesia are important for patients with moyamoya disease to prevent neurological events such as ischemia and hemorrhage. This study aimed to compare the intraoperative mean arterial pressure of pregnant women with moyamoya disease according to the mode of anesthesia (general anesthesia versus spinal anesthesia) used during cesarean delivery.

METHODS

We retrospectively reviewed the medical records of 87 cesarean deliveries in 74 patients who had been diagnosed with moyamoya disease before cesarean delivery. The primary outcome, intraoperative maximum mean arterial pressure during anesthesia, was compared according to the type of anesthesia administered (general versus spinal anesthesia). Other perioperative hemodynamic data (lowest mean arterial pressure, incidence of hypotension, vasopressor use, and antihypertensive agent use), maternal neurologic symptoms, neonatal outcomes (Apgar scores <7, ventilatory support, and intensive care unit admission), maternal and neonatal length of stay, postoperative pain scores, and rescue analgesic use were assessed as secondary outcomes.

RESULTS

While the lowest blood pressure during anesthesia and incidence of hypotension did not differ between the 2 groups, the maximum mean arterial pressure during anesthesia was lower in the spinal anesthesia group than that in the general anesthesia group (104.8 ± 2.5 vs 122.0 ± 4.6; P = .002). Study data did not support the claim that maternal neurologic symptoms differ according to the type of anesthesia used (5.6% vs 9.3%; P = .628); all patients recovered without any sequelae. The postoperative pain scores were lower, and fewer rescue analgesics were used in the spinal anesthesia group than in the general anesthesia group. Other maternal and neonatal outcomes were not different between the 2 groups.

CONCLUSIONS

Compared with general anesthesia, spinal anesthesia mitigated the maximum arterial blood pressure during cesarean delivery and improved postoperative pain in patients with moyamoya disease.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

Effect of Bilateral Quadratus Lumborum Block Type I on Patient Satisfaction and Incidence of Chronic Postsurgical Pain Following Cesarean Section-A Randomized Controlled Trial

BACKGROUND

Quadratus lumborum block (QLB) provides a reduction in pain scores and opioid consumption after cesarean section (CS). Intrathecal morphine (ITM) is still considered as the gold standard of acute postoperative pain therapy, but it does have some significant side effects. The aim of this clinical study was to evaluate whether performing the quadratus lumborum block type I in patients undergoing CS would be associated with an increased satisfaction of pain therapy and a decreased incidence of chronic postsurgical pain (CPSP).

METHODS

Sixty patients scheduled for elective CS were enrolled. All patients received spinal anesthesia and were randomly allocated to either the QLB group (received bilateral quadratus lumborum block type I with the use of 24 m mL 0.375% ropivacaine) or the control group (received no block). The level of satisfaction was evaluated using a three-step scale and the answers provided in a questionnaire regarding the patients' satisfaction with the method of postoperative pain treatment in the first 48 h. After a 6-month period, all patients were interviewed to evaluate the incidence and possible severity of CPSP.

RESULTS

Satisfaction scores were significantly lower in the QLB group than in the control group (p = 0.0000). There were no significant differences between the QLB and control groups regarding the occurrence of chronic postsurgical pain after 6 months following CS (p = 0.102). No statistical differences between the groups were recorded when we compared the results of the questionnaire after a period of 48 h from CS (the number of participants were limited in number).

CONCLUSIONS

QLB type I is an analgetic option that increased the satisfaction of parturients with pain therapy after CS compared to patients who did not receive the block, and there is a tendency for a lower incidence of CPSP.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Objective

Cesarean section (CS) is one of the most frequently performed major surgical interventions. Local anesthetic techniques, a universal component of perioperative multimodal analgesia, are reportedly effective in reducing pain scores and opioid requirements. However, the optimal local anesthetic technique for postoperative CS pain remains unclear.

Methods

Six databases were searched, and a Bayesian network meta-analysis was performed. The outcomes included cumulative morphine consumption and pain scores at four time points, time to first analgesic request, postoperative nausea and vomiting, pruritus, and sedation.

Results

Sixty-eight studies with 5039 pregnant women were included. Six local anesthetic techniques were involved, including transversus abdominis plane block (TAPB), ilioinguinal and iliohypogastric nerve block, quadratus lumborum blocks, transversalis fascia plane block, erector spinae block, and wound infiltration. Compared to inactive controls, TAPB reduced cumulative morphine consumption at 6, 12, 24, and 48 h, pain scores at 6, 12, and 24 h (with the exception of 24 h at rest), the risk of postoperative nausea and vomiting, and sedation. Compared with inactive controls, ilioinguinal and iliohypogastric nerve block reduced cumulative morphine consumption at 6 and 24 h and pain scores at 6, 12, and 24 h during movement. Compared with inactive controls, quadratus lumborum blocks reduced cumulative morphine consumption at 24 and 48 h and pain scores at 6 and 12 h and lengthened the time to first analgesic request. Compared with inactive controls, wound infiltration reduced cumulative morphine consumption at 12 and 24 h, pain scores at 12 and 24 h during movement, and risk of sedation. Compared with inactive controls, erector spinae block reduced pain scores at 6 and 12 h. Transversalis fascia plane block was found to have similar outcomes to inactive controls.

Conclusion

TAPB is the most comprehensive local anesthetic technique for postoperative CS analgesia in the absence of intrathecal morphine.

Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report

Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.

Quadratus Lumborum and Transversus Abdominis Plane Blocks and Their Impact on Acute and Chronic Pain in Patients after Cesarean Section: A Randomized Controlled Study

BACKGROUND

Severe postoperative pain is a significant problem after cesarean sections.

METHODS

This study was a randomized, controlled trial of 105 patients conducted in two hospitals. All patients were anesthetized spinally for elective cesarean section. Each participant was randomly allocated to one of three study groups: the quadratus lumborum block (QLB) group, the transversus abdominis plane block (TAPB) group, or the control (CON) group. The primary outcome of this study determined acute pain intensity on the visual analog scale (VAS). The secondary outcomes determined morphine consumption and chronic pain evaluation according to the Neuropathic Pain Symptom Inventory (NPSI) after hospital discharge.

RESULTS

At rest, the pain intensity was significantly higher in the CON group than in the QLB and TAPB groups at hours two and eight. Upon activity, the pain in the control subjects was more severe than in the QLB and TAPB groups in three and two of five measurements, respectively. Moreover, morphine consumption was significantly lower in the QLB (9 (5-10)) and TAPB (10 (6-14)) groups than in the CON (16 (11-19)) group. Persistent postoperative pain was significantly lower in the QLB group than in the CON group at months one and six following hospital discharge.

CONCLUSIONS

Both the QLB and TAPB can improve pain management after cesarean delivery. Moreover, the QLB might reduce the severity of persistent postoperative pain months after cesarean section.

Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial

BACKGROUND

Achieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine, with IT morphine and bilateral QLB, or only bilateral QLB.

METHODS

Parturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared.

RESULTS

Eighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period was significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04-3.96) in Group IT vs. 7.75 (5.67-9.83) in IT+QLB vs. 1.75 (0.75-2.75) in QLB (p < 0.001)]. The median (min, max) amount of morphine required during 24 h was 5.5 (0-25) in Group IT vs. 5.0 (0-36) in IT+QLB vs. 17.5 (1-40) mg in Group QLB (p < 0.001). In the final analysis the median pain-free period was 2.50 (1.23-3.77) hours (95%CI) in Group IT (n = 27) vs. 8.02 (5.96-10.07) in IT+QLB (n = 28). (p = 0.027).

CONCLUSION

US-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB could provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period.

TRIAL REGISTRATION

ClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia

BACKGROUND

Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine.

METHODS

Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects.

RESULTS

Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (-2 to 1) and -0.1 cm (-0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (-2 to 15) and 0.6 cm (-0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of -18 mg (-28 to -7) and -1.5 cm (-2.4 to -0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by -4.4 cm · h (-5.0 to -3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons.

CONCLUSIONS

Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spinal morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used.

EDITOR’S PERSPECTIVE

Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.

Placenta accreta spectrum disorders - Peri-operative management: The role of the anaesthetist

The incidence of placenta accreta spectrum (PAS) is increasing and will become more commonly encountered by obstetric anaesthetists in the elective and emergency settings. Significant maternal and neonatal morbidity is associated with these disorders, and hence it is important for anaesthetists to have early involvement in perioperative planning. Major haemorrhage should be anticipated and requires robust perioperative preparation including Patient Blood Management (PBM) and use of intraoperative strategies for haemorrhage management wherever possible. Several institutions have demonstrated good outcomes with regional anaesthesia alone, but the choice of anaesthetic technique requires individualised planning considering patient, anaesthetic and surgical factors. Optimisation of postoperative analgesia needs additional consideration; it is key to good recovery, minimising the impact on quality of life and reducing the risk of persistent post-surgical pain. Further research is required to ascertain the optimal multi-modal analgesic regime including the role of peripheral nerve blockade.

[Peripheral truncal blocks-Overview and assessment]

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia 2020;76:393-403. [PMID: 32621529 DOI: 10.1111/anae.15160]

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.