Bilateral Continuous Quadratus Lumborum Block for Acute Postoperative Abdominal Pain as a Rescue After Opioid-Induced Respiratory Depression

Quadratus Lumborum Block versus Fascia Iliaca Compartment Block for Acetabular Fracture Surgery by Stoppa Method: A Double-Blind, Randomized, Noninferiority Trial

Background

Acetabular fracture surgeries are frequently accompanied by protracted and severe perioperative pain, and there is no consensus on optimal pain relief management.

Aim

This study aimed at comparing the analgesic efficacy of fascia iliaca compartment block (FICB) and quadratus lumborum block (QLB) in patients with acetabular fractures undergoing surgery using the Stoppa method.

Methods

In this double-blind, randomized, noninferiority clinical trial, adult patients undergoing spinal anesthesia for acetabular fracture surgery, in Imam Hossein Hospital, Tehran, Iran (IRCT20191114045435N1), were randomly divided into two groups: FICB (n = 22) and QLB (n = 24). The visual analog scale (VAS) was used to assess the pain intensity at different times for all participants. In addition, the dose of fentanyl required to induce the patient to sit for spinal anesthesia and the pain intensity were evaluated. Moreover, the duration of analgesia and the total amount of morphine consumed in the first 24 h following surgery were evaluated, analyzed, and compared between the two study groups.

Results

FICB and QLB demonstrated effective comparative postoperative analgesic profiles following acetabular fracture surgery; however, no significant differences in VAS values were observed between the two groups during the study. FICB experienced reduced cumulative fentanyl consumption during spinal anesthetic placement, whereas QLB had a significantly lower total morphine demand in the initial postoperative 24 h period.

Conclusion

The lateral QLB and FICB can be introduced as effective routes for analgesia in acetabular fracture surgery using the Stoppa method. Clinical Trial Registration. The study was prospectively registered in the clinical trials registry system, on 2021-02-17, with registration number: IRCT20191114045435N1.

Preliminary Experience With Quadratus Lumborum Catheters for Postoperative Pain Management in Pediatric-Aged Patients With Contraindications to Epidural Anesthesia

BACKGROUND

Although neuraxial techniques such as caudal and epidural anesthesia were initially the predominant regional anesthetic technique used to provide postoperative analgesia in children, there has been a transition to the use of peripheral nerve blockade such as the quadratus lumborum block (QLB). We present preliminary experience with QL catheters for continuous postoperative analgesia in a cohort of pediatric patients following colorectal surgery.

METHODS

After institutional review board (IRB) approval, we retrospectively reviewed the records of patients who underwent major colorectal surgery and received QL catheters for postoperative analgesia. The postoperative pain control data consisted of QL catheter characteristics, anesthetic agents, adjuncts, pain scores, and opioid consumption during the postoperative period.

RESULTS

The study cohort included eight pediatric patients, ranging in age from 1 to 19 years (median age 11.8 years). The QL catheters were placed in the operating room after the induction of anesthesia. Comorbid conditions in the cohort that were contraindications to neuraxial anesthesia included spinal/vertebral malformations, presence of a ventriculoperitoneal (VP) shunt, anal atresia, tracheo-esophageal fistula (VACTERL) association, and coagulation disturbances. All patients underwent complex colorectal or genito-urologic procedures. Bilateral QL catheters were placed in six patients, and unilateral catheters were placed in two patients. Four patients received 0.5% ropivacaine and four patients received 0.2% ropivacaine of an initial bolus. The local anesthetic used for continuous infusion was 0.2% ropivacaine in five patients, 0.1% ropivacaine in two patients, and 1.5% chloroprocaine in one patient, with a median infusion rate of 0.11 mL/kg/h. QL catheter infusions were supplemented with intravenous opioids delivered by patient-controlled or nurse-controlled analgesia. The median opioid requirements in oral morphine milligram equivalents (MME) were 1.2, 1.0, 1.1, 0.5, and 0.6 MME/kg on postoperative days 1 - 5. Daily median pain scores were ≤ 2 during the 5-day postoperative course. All catheters functioned successfully and were in place for a median of 79.3 h. Other than early inadvertent removal of two catheters, no adverse effects were noted.

CONCLUSIONS

Although our preliminary data suggest the efficacy of QL catheters in providing prolonged postoperative analgesia for up to 3 - 5 days following colorectal procedures, attention needs to be directed at measures to ensure that the catheter is secured to avoid inadvertent removal.

Effects of quadratus lumborum block on perioperative multimodal analgesia and postoperative outcomes in patients undergoing radical prostatectomy

BACKGROUND

This study aimed to investigate the effects of ultrasound-guided quadratus lumborum block (QLB) on perioperative multimodal analgesia and postoperative outcomes in patients undergoing radical prostatectomy.

METHODS

A total of 80 patients undergoing radical prostatectomy were randomly divided into two groups: general anaesthesia with QLB (QLB group; n = 40) and general anaesthesia with sham QLB (normal saline [NS] group; n = 40). QLB or sham QLB was performed before the induction of anaesthesia. Sufentanil was intravenously administered for postoperative analgesia. The primary outcome was the pain score (measured using a numerical rating scale [NRS]) at different time points within 48 h postoperatively. Secondary outcomes included the cumulative dose of sufentanil within 48 h postoperatively, subjective comfort, grip strength, first time of exhaustion, first fluid intake time, time to get out of bed, length of postoperative hospital stay and overall satisfaction. The SPSS software, version 17.0, was used for all statistical analyses.

RESULTS

Postoperative NRS at rest was significantly lower at 2 h (1.7 ± 1.1 versus 3.0 ± 2.1), 4 h (1.8 ± 1.2 versus 4.1 ± 2.3), 6 h (1.9 ± 2 versus 4.4 ± 2) and 12 h (3.5 ± 2.3 versus 5 ± 3.3) and was also lower when coughing at 2 h (2.3 ± 1.1 versus 4 ± 2.1), 4 h (2.3 ± 1. 1 versus 4.3 ± 2) and 6 h (2.4 ± 1.1 versus 5.9 ± 2.3) in the QLB than that in the NS group. The cumulative dose of sufentanil was significantly lower in the QLB than that in the NS group at 4 h, 6 h, 12 h, 24 h and 48 h. The nausea score was significantly lower in the QLB group at 24 h postoperatively, and the first time of exhaustion and time to get out of bed were significantly shorter (P < 0.05). The overall satisfaction score was significantly higher in the QLB than in the NS group (4 ± 0.7 versus 2.6 ± 0.9).

CONCLUSION

Ultrasound-guided bilateral QLB can provide effective postoperative analgesia for patients undergoing radical prostatectomy, reduce the need for sufentanil, facilitate comfort and improve postoperative outcomes. QLB can be a good component of multimodal analgesia.

TRIAL REGISTRATION

The clinical trial is registered in the Chinese Clinical Trial Registry (ChiCTR). Current Controlled Trials: ChiCTR1900022009 . the date of registration:2019/03/20.

Anterior quadratus lumborum block for ambulatory laparoscopic cholecystectomy: a randomized controlled trial

AIM

To explore the effects of an anterior quadratus lumborum block (QLB) on opioid consumption, pain, nausea, and vomiting (PONV) after ambulatory laparoscopic cholecystectomy.

METHODS

This randomized controlled study recruited 70 patients scheduled for ambulatory laparoscopic cholecystectomy from January 2018 to March 2019. The participants were randomly allocated to one of the following groups: 1) anterior QLB (n=25) with preoperative ropivacaine 3.75 mg/mL, 20 mL bilaterally; 2) placebo QLB (n=22) with preoperative isotonic saline, 20 mL bilaterally; and 3) controls (n=23) given only standard intravenous and oral analgesia. The primary endpoint was opioid analgesic consumption. The secondary endpoints were pain (numeric rating scale 0-10) and PONV (scale 0-3, where 0=no PONV and 3=severe PONV). Assessments were made up to 48 hours postoperatively.

RESULTS

The groups did not significantly differ in opioids consumption and reported pain at 1, 2, 24, and 48 hours postoperatively. PONV in the QLB group was lower than in the placebo and control groups.

CONCLUSION

Preoperative anterior QLB for laparoscopic cholecystectomy did not affect postoperative opioid requirements and pain. However, anterior QLB may decrease PONV.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique

Background and Aims

Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours.

Material and Methods

Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System.

Results

Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus.

Conclusion

LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.

Effects of quadratus lumborum block regional anesthesia on postoperative pain after colorectal resection: a randomized controlled trial

INTRODUCTION

Postoperative pain following colorectal surgery is associated with a significant use of opioids. Recently, regional anesthesia, such as the posterior quadratus lumborum block (QL2), has been proposed to improve pain relief and reduce opioid use. However, the benefit of the QL2 on postoperative pain control remains controversial.

METHODS

We conducted a randomized controlled trial of patients undergoing colorectal surgery at the CHU de Québec-Université Laval. Patients were randomized to regional QL2 anesthesia with 150 mg of ropivacaine combined with standard analgesia or to QL2 with a sham intervention and standard analgesia. Our primary outcome was postoperative opioid administration at 24 h. Secondary outcomes included opioid administration in the post-anesthesia care unit (PACU), at 48 h and at hospital discharge, postoperative pain scores, delay in resumption of intestinal transit, nausea and vomiting, and hospital length of stay.

RESULTS

A total of 62 patients were enrolled from November 2017 to February 2018. QL2 regional anesthesia compared with a sham intervention was not associated with a reduction in postoperative morphine dose equivalent (100.2 mg, 95% CI 68.9-131.5 versus 88.7 mg, 95% CI 59.3-118.0, p = 0.81, respectively). Compared to QL2 regional anesthesia, postoperative pain scores in the control group were lower although statistical significance was not consistent for all postoperative time points. Other secondary outcomes were comparable between both groups.

CONCLUSION

We did not observe a reduction in postoperative opioid administration at 24 h with a posterior quadratus lumborum block regional anesthesia in patients undergoing elective colorectal surgery.

Quadratus Lumborum Block

A review of anatomy, potential mechanisms of action, and techniques and summary of clinical evidence for quadratus lumborum block.

Novel use of combination of electromyography and ultrasound to guide quadratus lumborum block after open appendicectomy

The quadratus lumborum (QL) block facilitates the administration of anaesthesia to the anterior abdominal wall. The use of ultrasound (US) improves the accuracy of the QL block and reduces the risk of adverse events. Electromyography (EMG) in combination with US for muscle plane blocks has not been described previously. We postulated that the addition of EMG-guided needle positioning might assist the execution of this block. This case report describes the first use of combined needle EMG and US to carry out a QL block performed for postoperative analgesia following an open appendicectomy.

Quadratus Lumborum Block as an Alternative to Lumbar Plexus Block for Hip Surgery: A Report of 2 Cases

Quadratus lumborum (QL) block was first described several years ago, but few articles have been published regarding this technique, for the most part case series involving abdominal surgery. We report 2 cases of prolonged, extensive block of thoracic and lumbar dermatomes after QL block in patients undergoing different hip surgery procedures for whom QL block was used in place of lumbar plexus block. Further prospective studies comparing these 2 techniques are necessary to better characterize the role of QL block in hip surgery.

Quadratus lumborum block for femoral-femoral bypass graft placement: A case report

INTRODUCTION

Atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs. Patients with atherosclerosis can have severe complications of this condition, with widespread systemic manifestations, and the operations undertaken are often challenging for anesthesiologists.

CASE REPORT

A 79-year-old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis. Femoral-femoral bypass graft and bilateral foot amputations were planned. Spinal anesthesia failed due to severe scoliosis and deformed vertebrae. General anesthesia was induced after performing multiple nerve blocks including quadratus lumborum, sciatic nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve blocks. However, general anesthesia was abandoned because of deterioration in systemic perfusion. The surgery was completed; the patient remained comfortable and awake without the need for further analgesics.

CONCLUSION

Quadratus lumborum block may be a useful anesthetic technique to perform femoral-femoral bypass.

Quadratus lumborum catheters for breast reconstruction requiring transverse rectus abdominis myocutaneous flaps

Patients diagnosed with breast cancer may opt to undergo surgical reconstructive flaps at the time of or after mastectomies. These surgeries leave patients with significant postoperative pain and sometimes involve large surgical beds including graft sites from the abdomen to reconstruct the breast. Consequently, multimodal methods of pain management have become highly favored. Quadratus lumborum catheters offer an opioid-sparing technique that can be performed easily and safely. We present a case of a patient who underwent a breast flap reconstruction and had bilateral quadratus lumborum catheters placed for perioperative pain control.