Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic review and meta-analysis of randomized controlled trials

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.

Utility of Quadratus Lumborum Blocks in Patients Who Undergo Liver Transplant: A Single-Center Retrospective Study

BACKGROUND

Regional anesthesia is an alternative to opioids for pain in patients undergoing liver transplantation. Quadratus lumborum blocks may provide appropriate dermatomal coverage with an excellent safety profile.

METHODS

Data were collected retrospectively on adult patients who underwent liver transplant at an academic medical center from 2019 to 2022 (n = 207). The primary outcome was opioid administration during the 48 h after transplant.

RESULTS

Patient demographics did not differ between groups. No association was found between patients who received a block and postoperative opioid administration (p = 0.848). However, among patients extubated in the operating room, patients who received a block reported, on average, a 0.9-unit lower pain score than patients who received no block (p = 0.041). Patients who received a block were also more likely to be extubated in the operating room (87.8% block vs. 44.4% no block; p < 0.001).

CONCLUSION

Patients who underwent liver transplantation had similar postoperative opioid use whether or not they received a quadratus lumborum block. Yet, when evaluating additional factors, such as extubation, pain scores were lower in patients who received a quadratus lumborum block. This important finding supports the idea that quadratus lumborum blocks may be a safe and valuable technique for controlling postoperative pain in adult patients who undergo liver transplantation.

Quadratus Lumborum Block and Transversus Abdominis Plane Block in Non-emergency Cesarean Delivery: A Systematic Review and Meta-analysis

PURPOSE

Investigate the analgesic efficacy of quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block in postoperative pain management in nonemergent cesarean section.

DESIGN

Systematic review with meta-analysis.

METHODS

PubMed, Cochrane, CINAHL, Google Scholar, and gray literature were searched for evidence. Only randomized controlled trials examining the effects of QL and TAP block for nonemergent cesarean delivery were included. Mean difference (MD) was used to estimate continuous outcomes with appropriate effect models. The quality of evidence was rated using the Risk of Bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system.

FINDINGS

Six studies involving 543 parturients were included. Compared to the TAP block, the cumulative 24-hour pain score at rest (MD, -0.60; 95% CI, -1.03 to -0.17; P = .007) and during activity (MD, -1.05; 95% CI, -1.54 to -0.56; P < .0001) were significantly lower in QL block. Time to the first analgesic rescue (MD, 21.67; 95% CI, -18.58 to 61.91; P = .29) and opioid consumption (MD, -1.96; 95% CI, -4.59 to 0.66; P = .14) were similar in both groups. No difference was found in the incidence of postoperative nausea and vomiting and sedation. However, patients treated with QL block reported higher patient satisfaction scores.

CONCLUSIONS

There is limited evidence to suggest that QL block is superior to TAP block for postoperative pain management in nonemergent cesarean delivery. The study limitations must be considered when extrapolating the review's findings to clinical practice.

[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.

Successful Use of Ultrasound Guided Quadratus Lumborum Block Without General Anesthesia for Open Appendectomy in a Patient with Heart Failure with Reduced Ejection Fraction- A Case Report and Literature Review

Background

Patients diagnosed with Heart Failure with Reduced Ejection Fraction (HFrEF) are at high risk of perioperative cardiovascular complications. While it is important to focus on optimizing their cardiac function, it is also crucial to address and optimize any other modifiable risk factors that could potentially impact postoperative outcome. This also includes careful consideration of anesthetic techniques to suit the patient and facilitate the surgery. However, there is a scarcity of evidence regarding the safety of specific anesthetic approaches for heart failure patients.

Case Presentation

We describe the case of an adult patient in mid-50s, with a history of ischemic dilated cardiomyopathy with reduced Ejection Fraction (about 25%) who presented with acute gangrenous appendicitis and was scheduled for an open appendectomy. It was deemed to be a high-risk patient for general and spinal anesthesia. With the guidance of a multidisciplinary team, surgery was successfully performed using a quadratus lumborum block with standard monitoring. The patient was comfortable and hemodynamically stable throughout the procedure. The postoperative course was uneventful.

Conclusion

Quadratus Lumborum Block for open appendectomy can be a beneficial alternative anesthesia technique in high-risk patients that significantly lowers perioperative cardiovascular risk, maintains hemodynamics, enhances satisfaction, and shortens hospital stay.

Analgesic Effect of Quadratus Lumborum Block Type III and Type II Versus Lateral Transversus Abdominis Plane Block in Cesarean Section: A Randomized Controlled Multicenter Trial

Background

Appropriate pain management promotes immediate mobilization and allows the parturient to adequately care for her neonate after cesarean section (CS).

Objectives

This trial objective was to compare the type III and type II quadratus lumborum block (QLB) to transversus abdominis plane block (TAPB) regarding postoperative analgesic effect in CS.

Methods

This randomized, controlled, single-blind trial involved 60 women presenting for CS under spinal anesthesia. The patients were assigned randomly to either the QLB type III, QLB type II, or lateral TAPB group. All blocks were performed using 20 mL of bupivacaine 0.25% bilaterally at the end of the operation with ultrasound guidance. Pain was assessed using the numerical rating scale (NRS) score at the post-anesthesia care unit (PACU) at 2, 4, 6, 8, 12, 18, and 24 hours. The level of patient satisfaction was graded on a 5-point Likert scale.

Results

Numerical rating scale measurements at 6, 8, and 12 hours and total consumed meperidine in the 1st 24 hours after the operation were reduced significantly in QLB III than in QLB II and TAPB groups (P < 0.05) with an insignificant difference between the QLB II and TAPB groups (P > 0.05). The onset of the first request for analgesia was delayed significantly in QLB III, compared to QLB II and TAPB groups (P < 0.05), without a significant difference between the QLB II and TAPB groups (P > 0.05). Patient satisfaction and adverse events (e.g., postoperative nausea and vomiting, bradycardia, and hypotension) exhibited insignificant differences among the three groups (P > 0.05).

Conclusions

The QLB type III ensured better analgesia as evidenced by significantly lower pain measurements and amount of meperidine in the first 24 hours after the operation with delayed time of the first rescue analgesia in comparison to QLB II and TAPB; however, QLB II and TAPB were similar.

Postoperative analgesic effects of the quadratus lumborum block in pediatric patients: a systematic review and meta-analysis

Background

This study assessed the postoperative analgesic efficacy and safety of the quadratus lumborum block (QLB) in pediatric patients.

Methods

Electronic databases were searched for studies comparing the QLB to conventional analgesic techniques in pediatric patients. The primary outcome was the need for rescue analgesia 12 and 24 hours after surgery. Secondary outcomes covered the Face-Legs-Activity-Cry-Consolability Scale (FLACC) scores at various time points; parental satisfaction; time to the first rescue analgesia; hospitalization time; block execution time; block failure rates, and adverse events.

Results

Sixteen randomized controlled trials were analyzed involving 1,061 patients. The QLB significantly reduced the need for rescue analgesia both at 12 and 24 hours after surgery (12 hours, relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.01, 0.88; 24 hours, RR: 0.51; 95% CI: 0.31, 0.70). In case of 24 hours after surgery, type 1 QLB significantly reduced the need for rescue analgesia (RR: 0.56; 95% CI: 0.36, 0.76). The QLB also exhibited lower FLACC scores at 1 hour (standardized mean difference [SMD]: -0.87; 95% CI: -1.56, -0.18) and 6 hours (SMD: -1.27; 95% CI: -2.33, -0.21) following surgery when compared to non-QLB. Among QLBs, type 2 QLB significantly extended the time until the first rescue analgesia (SMD: 1.25; 95% CI: 0.84, 1.67). No significant differences were observed in terms of parental satisfaction, hospitalization time, block execution time, block failure, or adverse events between QLB and non-QLB groups.

Conclusions

The QLB provides non-inferior analgesic efficacy and safety to conventional methods in pediatric patients.

Regional anesthesia for transplantation surgery - A White Paper Part 2: Abdominal transplantation surgery

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of Enhanced Recovery after Surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focused on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations. Specifically, regional anesthesia in liver, kidney, pancreas, intestinal, and uterus transplants or applicable surgeries are discussed.

REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system

INTRODUCTION

Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future.

METHODS AND ANALYSIS

In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping.

ETHICS AND DISSEMINATION

The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol.

TRIAL REGISTRATION NUMBER

NCT04606264.

Comparative efficacy and safety of non-neuraxial analgesic techniques for midline laparotomy: a systematic review and frequentist network meta-analysis of randomised controlled trials

BACKGROUND

Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic review and network meta-analysis of randomised controlled trials to synthesise the evidence with respect to pain, opioid consumption, and adverse events.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Central, and Scopus databases for studies comparing commonly used non-neuraxial analgesic techniques for midline laparotomy in adult patients. The co-primary outcomes of the study were 24-h cumulative opioid consumption and 24-h resting pain score, reported as i.v. morphine equivalents and 11-point numerical rating scale, respectively. We performed a frequentist meta-analysis using a random-effects model and a cluster-rank analysis of the co-primary outcomes.

RESULTS

Of 6115 studies screened, 67 eligible studies were included (n=4410). Interventions with the greatest reduction in 24-h cumulative opioid consumption compared with placebo/no intervention were single-injection quadratus lumborum block (sQLB; mean difference [MD] -16.1 mg, 95% confidence interval [CI] -29.9 to -2.3, very low certainty), continuous transversus abdominis plane block (cTAP; MD -14.0 mg, 95% CI -21.6 to -6.4, low certainty), single-injection transversus abdominis plane block (sTAP; MD -13.7 mg, 95% CI -17.4 to -10.0, low certainty), and continuous rectus sheath block (cRSB; MD -13.2 mg, 95% CI -20.3 to -6.1, low certainty). Interventions with the greatest reduction in 24-h resting pain score were cRSB (MD -1.2, 95% CI -1.8 to -0.6, low certainty), cTAP (MD -1.0, 95% CI -1.7 to -0.2, low certainty), and continuous wound infusion (cWI; MD -0.7, 95% CI -1.1 to -0.4, low certainty). Clustered-rank analysis including the co-primary outcomes showed cRSB and cTAP blocks to be the most efficacious interventions.

CONCLUSIONS

Based on current evidence, continuous rectus sheath block and continuous transversus abdominis plane block were the most efficacious non-neuraxial techniques at reducing 24-h cumulative opioid consumption and 24-h resting pain scores after midline laparotomy (low certainty). Future studies should compare techniques for upper vs lower midline laparotomy and other non-midline abdominal incisions.

CLINICAL TRIAL REGISTRATION

PROSPERO Registration Number: CRD42021269044.

Navigating Pain Relief: A Comprehensive Review of Transversus Abdominis Plane Block

This comprehensive review explores the multifaceted role of the transversus abdominis plane (TAP) block in contemporary pain management. Beginning with a definition and historical evolution, the article elucidates the mechanism of action, emphasizing local anesthesia, interference with pain signal transmission, and its impact on visceral and somatic pain. The review systematically investigates the diverse indications for TAP block, ranging from its applications in various surgical procedures to postoperative pain management and chronic pain conditions. Noteworthy abdominal wall block variations, including rectus sheath block and quadratus lumborum block, underscore the adaptability of TAP block in diverse clinical scenarios. The implications for clinical practice highlight its pivotal role in enhancing recovery after surgery, reducing opioid reliance, and providing patient-centered care. Furthermore, the article outlines recommendations for further research, addressing ongoing trials, technological innovations, and potential expansions into non-surgical settings. In conclusion, TAP block emerges as a dynamic and indispensable tool in pain management, potentially redefining paradigms and optimizing patient outcomes across a spectrum of medical contexts.

Quadratus Lumborum block as primary anesthetic technique for colostomy procedure: a case report

An elderly patient was admitted to the hospital due to an enterovesical fistula and a terminal colostomy was proposed. The patient had a high anesthetic risk and thus a quadratus lumborum block was chosen as the sole anesthetic technique. This block has been described to provide both somatic and visceral analgesia to the abdomen. In fact, it yielded good anesthetic conditions to perform the procedure and allowed the patient to be hemodynamically stable and comfortable throughout the case. The postoperative period was uneventful.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain.

RECENT FINDINGS

Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

Ultrasound-guided quadratus lumborum block: a powerful way for reducing postoperative pain

Ultrasound-guided quadratus lumborum block (QLB) has been gradually carried out in clinical practice. However, some clinical evidence is contradictory, and no studies have summarized and described these results. The authors reviewed the anatomical characteristics of QLB and summarized the advantages and disadvantages of four puncture methods, so as to facilitate the clinical application of QLB.

Quadratus lumborum block and transversus abdominis plane block in laparoscopic nephrectomy: a meta-analysis

Aim: To study the efficacy of quadratus lumborum block (QLB) and transversus abdominis plane (TAP) in laparoscopic nephrectomy patients. Materials & methods: We conducted a meta-analysis of randomized controlled trials for QLB and/or TAP technique compared with each other or a control. Results: Direct analysis of 24 h post-op pain score at rest for each compared with control showed significant reduction, QLB (mean differences [MD] [95% CI]: -1.12 [-1.87,-0.36]; p = 0.004) and TAP (MD [95% CI]: -0.36 [-0.59, -0.12]; p = 0.003). With movement both were respectively lower than control QLB (MD [95% CI]: -1.12 [-1.51, -0.72]; p = <0.0001) and TAP (MD [95% CI]: -0.50 [-0.95, -0.05]; p = 0.03). Moreover, QLB demonstrated less risk 24 h of post-op nausea vomiting (PONV) versus control (PONV; risk ratios [RR] [95% CI]: 0.64 [0.45,0.90]; p = 0.01). Conclusion: TAP and QLB reduce pain scores compared with control, whereas only QLB reduces PONV compared with control.

A Comparative Study of Ultrasound-Guided Quadratus Lumborum Block and Transversus Abdominis Plane Block for Postoperative Analgesia Following Total Abdominal Hysterectomy

BACKGROUND

 Total abdominal hysterectomy (TAH) results in remarkable postoperative pain. Truncal nerve blocks like the quadratus lumborum (QL) block and transversus abdominis plane (TAP) block are described to combat this pain. The aim of the present study was to compare the effectiveness of the QL block with the TAP block in terms of numeric rating scale (NRS) scores as the primary outcome for postoperative pain in TAH. The secondary outcome was time of the first analgesic demand, total analgesic demands required in 24 hr, and patient satisfaction level.

METHODS

 Seventy patients of American Society of Anesthesiologists (ASA) physical status class I and II, aged 35-65 years with a body mass index (BMI) 18-30 kg/m² planned for elective TAH under spinal anaesthesia were randomly allocated into two groups. Group Q received QL block and Group T received TAP block under ultrasound guidance with 40 ml of 0.25% bupivacaine of which 20 ml was injected on either side.

RESULTS

 Demographic data of both groups was comparable. The NRS pain score was significantly lower in Group Q compared to Group T at the fourth and sixth hour. The mean first analgesic demand was significantly early in Group T compared to Group Q (5.69 ± 0.87 hr vs. 11.23 ± 2.22 hr) and total analgesic demands were significantly greater in Group T than Group Q. The mean patient satisfaction score was significantly high in Group Q compared to Group T (5.8 ± 0.41 vs. 4.74 ± 0.44).

CONCLUSION

The combined posterior and anterior approach of the QL block may represent a more efficacious alternative to the TAP block in patients after TAH. Further studies are recommended to evaluate the ideal dose, volume and approach for the QL block.

Ultrasound-Guided Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Laparoscopic Inguinal Hernia Repair and Appendicectomy Using Ropivacaine With Dexmedetomidine

Background The present study aims to investigate the efficacy of ultrasound-guided quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block for laparoscopic inguinal hernia repair and appendicectomy using ropivacaine with dexmedetomidine for quality and duration of postoperative analgesia. Settings and design This was a prospective, randomized, single-blind study conducted for one year (September 2020-August 2021) in the Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, after obtaining ethical clearance from the institutional ethics committee. Methods A total of 64 patients of American Society of Anesthesiologists (ASA) grades I-II and ages between 20 and 50 years undergoing laparoscopic inguinal hernia repair and appendicectomy were randomly allocated into two groups of 32 each; group A received ultrasonography (USG)-guided quadratus lumborum block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight, and group B was given USG-guided transversus abdominis plane block using 0.5% ropivacaine 20 ml with dexmedetomidine 0.5 mcg/kg of body weight after the induction of general anesthesia and before surgical incision. Data were analyzed using Student's t-test, Mann-Whitney U test, and chi-square test as applicable. Results The duration of analgesia was statistically higher (P<0.001) in group A (21.00±3.73 hours) as compared to group B (14.44±2.99 hours). Group A had significantly less analgesic (P<0.001) at 12, 18, and 24 hours postoperatively. The visual analog scale (VAS) was significantly decreased in group A at rest and movement. The range of percentage changes in heart rate (HR) was significantly higher in group B as compared to group A at 12, 18, and 24 hours (group A: 7.23%-14.70%; group B: 6.41%-28.01%). The mean blood pressure (MBP) was significantly increased in group B at 12, 18, and 24 hours as compared to group A. The range of changes in baseline MBP in group A was less than in group B (group A: 0.73%-8.34%; group B: 0.73%-18.20%). Conclusion Quadratus lumborum block is effective and better than transversus abdominis plane block for providing postoperative analgesia during laparoscopic inguinal hernia repair and appendicectomy.

Efficacy of quadratus lumborum block on postoperative pain and side effects in patients who underwent urological surgery: A meta-analysis

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB) is considered a novel nerve block for postoperative pain control. However, its efficacy after urological surgery remains unclear.

OBJECTIVES

The purpose of the current meta-analysis was to evaluate the effects of the QLB block versus control (placebo or no injection) on postoperative pain and other adverse outcomes after urological surgery, providing extensive evidence of whether quadratus lumborum block is suitable for pain management after urological surgery.

STUDY DESIGN

Systematic review with meta-analysis of randomized clinical trials.

METHODS

We searched PubMed, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov to collect studies investigating the effects of QLB on analgesia after urological surgery. The primary outcomes included visual analog scale (VAS) at rest and during movement, 24-h postoperative morphine consumption, and the incidence of postoperative nausea and vomiting (PONV).

RESULTS

Overall, 13 randomized controlled trials (RCTs) were reviewed, including 751 patients who underwent urological surgery. The QLB group exhibited a lower VAS score postoperatively at rest or on movement at 0, 6, 12, and 24 h, with less 24-h postoperative morphine consumption and lower incidence of PONV.

LIMITATIONS

Although the result is stable, heterogeneity exists in the current research.

CONCLUSIONS

QLB exhibited a favorable effect of postoperative analgesia with reduced postoperative complications at rest or during movement after urological surgery. However, it is still a novel technology at a primary stage, which needs further research to develop.

Transversus Abdominis Plane Block as a Strategy for Effective Pain Management in Patients with Pain during Laparoscopic Cholecystectomy: A Systematic Review

Laparoscopic cholecystectomy (LC), unlike laparotomy, is an invasive surgical procedure, and some patients report mild to moderate pain after surgery. Transversus abdominis plane (TAP) block has been shown to be an appropriate method for postoperative analgesia in patients undergoing abdominal surgery. However, there have been few studies on the efficacy of TAP block after LC surgery, with unclear information on the optimal dose, long-term effects, and clinical significance, and the analgesic efficacy of various procedures, hence the need for this review. Five electronic databases (PubMed, Academic Search Premier, Web of Science, CINAHL, and Cochrane Library) were searched for eligible studies published from inception to the present. Post-mean and standard deviation values for pain assessed were extracted, and mean changes per group were calculated. Clinical significance was determined using the distribution-based approach. Four different local anesthetics (Bupivacaine, Ropivacaine, Lidocaine, and Levobupivacaine) were used at varying concentrations from 0.2% to 0.375%. Ten different drug solutions (i.e., esmolol, Dexamethasone, Magnesium Sulfate, Ketorolac, Oxycodone, Epinephrine, Sufentanil, Tropisetron, normal saline, and Dexmedetomidine) were used as adjuvants. The optimal dose of local anesthetics for LC could be 20 mL with 0.4 mL/kg for port infiltration. Various TAP procedures such as ultrasound-guided transversus abdominis plane (US-TAP) block and other strategies have been shown to be used for pain management in LC; however, TAP blockade procedures were reported to be the most effective method for analgesia compared with general anesthesia and port infiltration. Instead of 0.25% Bupivacaine, 1% Pethidine could be used for the TAP block procedures. Multimodal analgesia could be another strategy for pain management. Analgesia with TAP blockade decreases opioid consumption significantly and provides effective analgesia. Further studies should identify the long-term effects of different TAP block procedures.

Perioperative Analgesic Efficiency of Ultrasound-Guided Quadratus Lumborum Block versus Epidural Analgesia in Bladder Cancer Patients Undergoing Radical Cystectomy

Background and Aim: Multimodal analgesia is currently used for perioperative pain management after Radical cystectomy (RC). This study aimed to compare quadratus lumborum block (QLB) and thoracic epidural block (TEA) in patients subjected to RC. Methods: This prospective randomized controlled study included 34 patients with bladder cancer subjected to RC under general anesthesia, divided into two groups. The Quadratus Group (n=17) underwent bilateral ultrasound-guided continuous QLB, and the Epidural Group (n=17) underwent continuous TEA. The primary outcome was pain intensity measured by VAS score, and the secondary outcomes were total morphine consumption during the first 48 hours after surgery, postoperative nausea score, and patient satisfaction. Results: There were no differences between the two groups in postoperative VAS scores starting immediately after surgery up to 48 hours. Reduction of VAS score after QLB was delayed compared to that after TEA. The two groups had a comparable number of patients requesting rescue analgesia (p = 0.271) and total postoperative morphine consumption (p = 0.976) in the remaining patients. The nausea score was significantly lower in the Quadratus Group than in the Epidural Group (p = 0.020). There was no significant difference between the two groups in the satisfaction score (p=0.612). Few mild complications were detected in the two studied groups. Conclusion: QLB and TEA are safe and effective in managing postoperative pain after radical cystectomy with similar analgesic profiles. QLB was more effective in reducing postoperative nausea and vomiting.

Comparison of the postoperative analgesic effect of transversus abdominis plan block and quadratus lumborum block: A prospective randomized study

Background and Aims

In this study, we aimed to compare the transversus abdominis plan block (TAP) and quadratus lumborum block (QL) efficacy for postoperative analgesia in patients undergoing varicocelectomy under spinal anesthesia.

Methods

American Society of Anesthesiologists (ASA) 1 and 2 patients, aged 18-45 years, who underwent varicocelectomy operation under elective conditions, were included. Eighty patients were divided into three groups as TAP group, QL group, and control group by prospective randomization. The patients were operated under spinal anesthesia. At the end of the operation, TAP was applied to the TAP group with a posterior approach using ultrasound (USG) in the supine position. To the QL group, the patient was placed in the lateral decubitus position and the lateral QL was applied via USG. No block type was applied to the control group. Patient-controlled analgesia (PCA) device containing tramadol was administered intravenously at the end of the surgery in all groups. Visual analogue scale (VAS) score was questioned at 0, 2, 4, 6, 8, 10, 12, 18, 24 h in the follow-up of the patients. Intravenous 1 g paracetamol was given over VAS 4. PCA usage time and usage amounts were recorded.

Results

As a result of comparing the groups according to the VAS scores at all hours were significantly different between the three groups (p < 0.001). There was a significant difference between the groups when comparing the number of PCA bolus administrations (p < 0.001). TAP and QL blocks significantly reduced the number of PCA bolus when compared with the control group (p < 0.001) but the number of PCA bolus was found to be similar between TAP and QL blocks (p > 0.05).

Conclusion

TAP and QL, which are administered to evaluate the effectiveness of postoperative analgesia in patients undergoing varicocelectomy under spinal anesthesia, are both effective in reducing pain scores and the amount of analgesia consumption.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Perioperative analgesia with ultrasound-guided quadratus lumborum block for transurethral resection of prostate

BACKGROUND

Prostatic hyperplasia is a physiological aging process in men. After transurethral resection of prostate (TURP), visceral pain is the main cause. The effective postoperative analgesia can reduce the occurrence of postoperative complications. This study mainly studied the analgesic effect of quadratus lumborum block (QLB) on TURP.

METHODS

We divided 62 patients undergoing TURP into 2 groups using a random number table method (QLB 2 group and non-QLB [control] group). Patients in the QLB group underwent ultrasound-guided posterior QLB with 20 mL of 0.25% ropivacaine on each side, and those in the control group received only general anesthesia. The primary outcome for this study was the consumption analgesic pump during 0 to 24 hours. The secondary outcomes included the first pressing time of analgesic pump during 0 to 24 hours, the pain at rest and when coughing at 1, 4, 8, 12, and 24 hours post-operation as measured with a visual analogue scale for pain, length of the hospital stay, and complications (nausea and vomiting, dizziness, and abdominal distension).

RESULTS

Patients in the QLB group presented less consumption, later first pressing time of analgesic pump during 0 to 24 hours after surgery lower visual analogue scale scores at 1, 4, 8, 12, and 24 hours postsurgery than those in the control group. Moreover, their mean length of hospital stay was shorter (P = .023), and they experienced less postoperative complications than the patients in the control group.

CONCLUSIONS

Ultrasound-guided QLB in TURP provided a significant analgesic effect in our patients the first day after surgery. This analgesic model may improve the postoperative recovery after TURP.

Ultrasound-Guided Continuous Transmuscular Quadratus Lumborum Block for Postoperative Analgesia in Patients Undergoing Radical Nephrectomy: A Randomized Controlled Trial

Introduction

Ultrasound (US) guided transmuscular quadratus lumborum block (TMQLB) has been widely used as regional anaesthesia (RA) technique for managing postoperative pain after intraperitoneal and retroperitoneal procedures like nephrectomy, percutaneous nephrostomy, cholecystectomy, and also for hip surgeries. Although continuous epidural analgesia is considered the gold standard for most of these procedures, alternative techniques such as transversus abdominis plane (TAP) block and continuous rectus sheath block have also been used successfully. US-guided TMQLB seems to have more advantages than TAP block as it blocks the visceral afferents. With more cephalad spread of the local anaesthetic into the thoracic paravertebral space, it might block somatic pain from T6 to L2 as well.

Methods

After institutional ethics committee approval, we recruited 64 consecutive patients in the study and randomized them into two groups. Patients in the study group received bupivacaine (0.125%) and the control group received normal saline as a continuous infusion for 48 hours. Both groups were compared for 48 hours morphine consumption, time to first analgesic, hemodynamics, postoperative nausea/vomiting (PONV), sedation, and other adverse events.

Results

Data from 60 patients were analyzed. Forty-eight hours of morphine consumption in group A (study) was less than group B (7.4 ± 4.57 mg versus 11.86 ± 5.58 mg) and the time to first morphine requirement was 240 min (105-500) in group A compared to 90 min (90-225) in group B which was statistically significant. Demographic data, American Society of Anesthesiologists physical status, hemodynamics, Ramsay sedation score (RSS), and PONV were comparable in both groups.

Conclusion

Continuous US-guided TMQLB appears to be a safe and effective RA technique for managing postoperative pain after nephrectomy for up to 48 hours. Trial registration: German Clinical Trials Register-DRKS-ID: DRKS00014611.

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.

Randomized controlled trial of a quadratus lumborum block with liposomal bupivacaine for postoperative analgesia in laparoscopic donor nephrectomy

Perioperative pain management is an important consideration in early recovery and patient satisfaction following laparoscopic donor nephrectomy. Transmuscular quadratus lumborum block has been described to reduce pain and opioid usage following several abdominal surgeries. In this prospective single‐blind randomized controlled trial, we compared 52 patients who adhered to our institutional donor nephrectomy Early Recovery After Surgery pathway, which includes a laparoscopic‐guided transversus abdominus plane block, to 40 patients who additionally received a transmuscular quadratus lumborum block with liposomal bupivacaine. Compared to control patients, those who received the block spent longer in the operating room prior to the surgical start (65.4 vs. 51.6 min, P < .001). Both groups had similar total hospital length of stay (33.3 h vs. 34.4 h, P = .61). Pain scores from postoperative days 0–30, number of patients requiring opioids, postoperative nausea, and pain management satisfaction were similar between both groups. Patients who received the block consumed less opioid on postoperative day 1 compared to controls (P = .006). No complications were attributable to the block. The quadratus lumborum block provides a safe pain management adjunct for some patients, and may reduce opioid use in the early postoperative period when combined with our standard institutional protocol for kidney donors.

A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future

Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

Background and objectives

Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy and selection criteria

Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results

Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions

Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

A novel ultrasound-guided lateral quadratus lumborum block in dogs: a comparative cadaveric study of two approaches

OBJECTIVE

To describe an ultrasound-guided lateral quadratus lumborum (LQL) block technique and the spread characteristics of lidocaine-dye injected in the LQL plane using a transversal (LQL-T) or a longitudinal (LQL-L) approach.

STUDY DESIGN

Experimental anatomic study.

ANIMALS

A total of eight canine cadavers.

METHODS

Bilateral ultrasound-guided injections in the fascial plane lateral to the quadratus lumborum muscle and medial to the thoracolumbar fascia (LQL plane) with the needle directed at the first lumbar (L1) transverse process were performed using lidocaine-dye (0.3 mL kg^-1). Anatomical dissection determined the dye distribution, sympathetic trunk staining and number of spinal nerves stained circumferentially >1 cm.

RESULTS

The LQL fascial plane was ultrasonographically recognized in all cadavers and filled with lidocaine-dye in all eight cadavers with the LQL-T approach and in six with LQL-L. The injectate spread ventral to the lumbar transverse processes, around the quadratus lumborum muscle and dorsal to the transversalis fascia, affecting the ventral branches of the spinal nerves and the sympathetic trunk. A median (range) of 4 (3-5) and 3 (0-4) ventral branches of the thoracolumbar nerves were dyed with LQL-T and LQL-L approaches, respectively (p = 0.04). The most cranial nerve stained was the twelfth thoracic (T12) with the LQL-T approach and T13 with LQL-L, and the most caudal was L3 with both approaches. The incidence of sympathetic trunk staining was significantly higher using LQL-T (six injections) compared with LQL-L (one injection; p = 0.04). Dye was not observed in the lumbar plexus, epidural space or abdominal cavity.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided LQL-T approach resulted in a more consistent spread toward the spinal nerves and sympathetic trunk compared with LQL-L approach. Further studies are necessary to assess the LQL block effectiveness and success rate in live dogs.