Comparison of Analgesic Efficacy of Erector Spinae Plane Block and Posterior Quadratus Lumborum Block in Laparoscopic Liver Resection: A Randomized Controlled Trial

Erector spinae plane block versus quadratus lumborum block for postoperative analgesia after laparoscopic nephrectomy: A randomized controlled trial

STUDY OBJECTIVE

We compared the analgesic effects of erector spinae plane block versus quadratus lumborum block following laparoscopic nephrectomy.

DESIGN

A randomized controlled trial.

SETTING

A tertiary hospital in Beijing, China.

PATIENTS

Patients scheduled for elective laparoscopic nephrectomy.

INTERVENTIONS

A total of 110 patients were enrolled and randomized to receive either erector spinae plane block (n = 55) or quadratus lumborum block (n = 55) under ultrasound guidance. Patient-controlled sufentanil analgesia was provided after surgery.

MEASUREMENTS

Our primary outcome was cumulative opioid consumption within 24 h after surgery. Secondary outcomes included postoperative pain intensity, subjective sleep quality, and quality of recovery.

MAIN RESULTS

All 110 patients (mean 53 years, 57.3% female) were included in the intention-to-treat analysis. Cumulative sufentanil equivalent within 24 h was lower in patients given erector spinae plane block (median 13 μg, interquartile range 4 to 33) than in those given quadratus lumborum block (median 25 μg, interquartile range 13 to 39; median difference - 8 μg, 95% CI -15 to 0, P = 0.041). Pain intensity (0-10 range where 0 = no pain and 10 = the worst pain) at 2, 6, 12, and 24 h after surgery was lower with erector spinae plane block (at rest: median differences -1 point, all P ≤ 0.009; with movement: median differences -2 to -1 points, all P < 0.001). Subjective sleep quality on the night of surgery (the Richards-Campbell Sleep Questionnaire: 0-100 range, higher score better; median difference 12, 95% CI 2 to 23, P = 0.018) and quality of recovery at 24 h (the Quality of Recovery-15: 0-150 range, higher score better; median difference 8, 95% CI 2 to 15, P = 0.012) were better with erector spinae plane block. No procedure-related adverse events occurred.

CONCLUSIONS

Compared with quadratus lumborum block, erector spinae plane block provided better analgesia as manifested by lower opioid consumption and pain intensity for up to 24 h after laparoscopic nephrectomy.

Analgesic effects of ultrasound-guided preoperative posterior Quadratus Lumborum block in laparoscopic hepatectomy: A prospective double-blinded randomized controlled trial

STUDY OBJECTIVE

To determine if single-injection bilateral posterior quadratus lumborum block (QLB) with ropivacaine would improve postoperative analgesia in the first 24 h after laparoscopic hepatectomy, compared with 0.9% saline.

DESIGN

Prospective, double blinded, randomized controlled trial.

SETTING

A single tertiary care center from November 2021 and January 2023.

PATIENTS

A total of 94 patients scheduled to undergo laparoscopic hepatectomy due to hepatocellular carcinoma.

INTERVENTIONS

Ninety-four patients were randomized into a QLB group (receiving 20 mL of 0.375% ropivacaine on each side, 150 mg in total) or a control group (receiving 20 mL of 0.9% saline on each side).

MEASUREMENTS

The primary outcome was the cumulative opioid consumption during the initial 24-h post-surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters.

MAIN RESULTS

The mean cumulative opioid consumption during the initial 24-h post-surgery was 30.8 ± 22.4 mg in the QLB group (n = 46) and 34.0 ± 19.4 mg in the control group (n = 46, mean differences: -3.3 mg, 95% confidence interval, -11.9 to 5.4, p = 0.457). The mean resting pain score at 1 h post-surgery was significantly lower in the QLB group than in the control group (5 [4-6.25] vs. 7 [4.75-8], p = 0.035). No significant intergroup differences were observed in the resting or coughing pain scores at other time points or in other secondary outcomes.

CONCLUSIONS

Preoperative bilateral posterior QLB did not reduce cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy.

A progress of research on the application of fascial plane blocks in surgeries and their future direction: a review article

Fascial plane blocks (FPBs) are gaining popularity in clinical settings owing to their improved analgesia when combined with either traditional regional anesthesia or general anesthesia during the perioperative phase. The scope of study on FPBs has substantially increased over the past 20 years, yet the exact mechanism, issues linked to the approaches, and direction of future research on FPBs are still up for debate. Given that it can be performed at all levels of the spine and provides analgesia to most areas of the body, the erector spinae plane block, one of the FPBs, has been extensively studied for chronic rational pain, visceral pain, abdominal surgical analgesia, imaging, and anatomical mechanisms. This has led to the contention that the erector spinae plane block is the ultimate Plan A block. Yet even though the future of FPBs is promising, the unstable effect, the probability of local anesthetic poisoning, and the lack of consensus on the definition and assessment of the FPB's success are still the major concerns. In order to precisely administer FPBs to patients who require analgesia in this condition, an algorithm that uses artificial intelligence is required. This algorithm will assist healthcare professionals in practicing precision medicine.

Erector Spinae Plane Block versus Quadratus Lumborum Block for Postoperative Analgesia after Laparoscopic Resection of Colorectal Cancer: A Prospective Randomized Study

Background

In recent years, the attention paid to colorectal cancer (CRC) surgery and postoperative analgesia has increased.

Objective

The objective of the current study was to compare the impact of ultrasound-guided erector spinae plane block (ESPB) and transmuscular quadratus lumborum block (TQLB) upon providing relief to patients with postoperative pain who underwent laparoscopic resection for CRC.

Methods

In this prospective, comparative, and randomized study, the authors considered a total of 60 patients who chose to undergo laparoscopic resection for colorectal cancer. The total number of patients was randomly divided into two groups (such as ESPB and TQLB) so that each group had a total of 30 patients. For the former group, i.e., the ESPB group, 20 ml of 0.25% bupivacaine was administered at each side for bilateral ultrasound-guided erector spinae plane block, while the latter group received the same dose of medicine for bilateral ultrasound-guided transmuscular quadratus lumborum block (TQLB). The researchers recorded the first time to rescue an analgesic, the whole amount of rescue analgesia under consumption in the first 24 hours after the surgical procedure, and associated adverse events.

Results

Among the groups considered, the ESPB group took a significantly lengthy time to raise a first request for rescue analgesic (280 ± 15.5 min) in comparison with the TQLB group (260 ± 13.8 min). Likewise, the consumption of overall nalbuphine was remarkably lesser in the ESPB group during the first 24 hours (24 ± 2.5 mg) compared to the TQLB group (30.5 ± 1.55 mg).

Conclusion

The analgesic efficacy of ESPB was better when compared to TQLB in terms of time to rescue analgesia and overall opioid consumption during the first 24 hours. This study was registered at ClinicalTrials.gov on 10/10/2022 (registration number: NCT05574283).

Living liver donor pain management

PURPOSE OF REVIEW

Optimal pain control in living liver donors undergoing hepatectomy is strongly recommended considering their unique status as healthy individuals willingly undergoing surgery for the benefit of the recipient. This review aims to examine and evaluate different strategies aimed at ensuring effective postoperative pain management in living liver donors.

RECENT FINDINGS

Enhanced recovery after surgery (ERAS) protocols have proven effective in optimizing patient outcomes, including in living liver donor hepatectomy. By implementing these protocols, healthcare professionals can enhance postoperative pain control and accelerate recovery. Multimodal analgesia, which combines different techniques and agents, is crucial in pain management for living liver donors. Regional analgesia techniques, such as spinal anesthesia and various peripheral nerve blocks, have shown efficacy in reducing pain and facilitating early recovery. Systemic nonopioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, ketamine, lidocaine, and dexmedetomidine act synergistically to alleviate pain and reduce inflammation. Minimizing the use of opioids is important to avoid adverse effects, and they should be reserved for rescue medication or breakthrough pain.

SUMMARY

Applying the principles of ERAS and multimodal analgesia to living liver donors can effectively control pain while promoting early recovery.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following open major hepatectomy: an open-label, randomised, controlled, non-inferiority trial

Background

Convincing clinical evidence regarding completely opioid-free postoperative pain management using erector spinae plane block (ESPB) in patients undergoing open major hepatectomy (OMH) is lacking. Herein, we aimed to compare the postoperative analgesic efficacy of the visualised continuous opioid-free ESPB (VC-ESPB) and conventional intravenous opioid-based postoperative pain management in hepatocellular carcinoma (HCC) patients undergoing OMH.

Methods

This open-label, randomised, controlled, non-inferiority trial enrolled patients with HCC undergone open major hepatectomy in Fujian Provincial Hospital and compared the postoperative analgesic efficacy of VC-ESPB (VC-ESPB group) and conventional intravenous opioid-based pain management regimen (conventional group). Patients were randomly assigned (1:1) to VC-ESPB group and conventional group. Patients were not masked to treatment allocation. The VC-ESPB group was treated with intermittent injections of 0.25% ropivacaine (bilateral, 30 mL each side) given every 12 h through catheters placed in the space of erector spinae and an opioid-free intravenous pump (10-mg tropisetron diluted to 100 mL with 0.9% normal saline [NS]) for postoperative pain management. The conventional group did not receive ESPB and was treated with a conventional intravenous opioid-based pump (2.5-μg/kg sufentanil and 10-mg tropisetron diluted to 100 mL with 0.9% NS). Patients in the VC-ESPB group underwent magnetic resonance imaging (MRI) to identify local anaesthetic diffusion after ESPB was performed under ultrasound guidance. The primary outcome was postoperative analgesic efficacy, which was indicated by the cumulative area under the curve (AUC) of the pain visual analogue scale scores (range, 0-10; a higher score indicates more pain) obtained at rest and at movement until 48 h postoperatively after leaving the post-anaesthesia care unit (PACU). Herein, an AUC of 26.5 was set as the noninferiority margin, which needed to be satisfied for both cumulative AUCPACU-48 h at rest and cumulative AUCPACU-48 h at movement. Per protocol participants were included in primary and safety analyses. This trial was registered with ChiCTR.org.cn (ChiCTR1900026583).

Findings

Between October 30, 2019, and May 1, 2023, 106 patients were enrolled and randomly assigned to the VC-ESPB group (n = 53) and the conventional group (n = 53). After the dropout (n = 5), a total of 101 patients (VC-ESPB group, n = 50; conventional group, n = 51) were analysed. Both the level of cumulative AUCPACU-48 h (at rest: 160.08 ± 38.00 vs. 164.94 ± 31.00; difference [90% CI], -4.861 [-16.308, 6.585]) and cumulative AUCPACU-48 h (at movement: 209.64 ± 28.98 vs. 212.59 ± 33.11; difference [90% CI], -2.948 [-13.236, 7.339]) were similar between the VC-ESPB and control groups within the first postoperative 48 h. The upper limit of the 90% CIs for the difference in cumulative ACUPACU-48 h at rest and at movement did not reach the upper inferiority margin (26.5). During the first postoperative 48 h, the rate of nonsteroidal anti-inflammatory drug rescue analgesia was similar between the VC-ESPB group and conventional group (n = 16, 32.0% vs. n = 11, 21.6%; P = 0.236). Treatment-related death was not observed in the VC-ESPB group (n = 0, 0%) and conventional group (n = 0, 0%). In VC-ESPB group, local site paralysis (n = 1, 2.0%) was observed in one patient and rash (n = 1, 2.0%) was observed in another patient. One patient in the conventional group was observed with rash preoperatively (n = 1, 2.0%). The VC-ESPB group had significantly lower rates of postoperative nausea (n = 2, 4.0%, vs. n = 9, 17.6%, P = 0.028), vomiting (n = 1, 2.0% vs. n = 8, 15.7%, P = 0.031) and lower incidence of major complications (n = 4, 8.0% vs. n = 6, 11.8%; P = 0.033).

Interpretation

This study demonstrates the noninferiority of VC-ESPB when compared with the conventional opioid-based approach for postoperative pain management after OMH, suggesting that it is feasible to achieve opioid-free postoperative pain management for OMH.

Funding

The Joint Funds for the Innovation of Science and Technology, Fujian Province, China; the Youth Scientific Research Project of Fujian Provincial Health Commission; the Fujian Research and Training Grants for Young and Middle-aged Leaders in Healthcare; and the Key Clinical Specialty Discipline Construction Program of Fujian, China.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BACKGROUND

Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.

METHODS

One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.

DISCUSSION

This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.

TRIAL REGISTRATION

Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Quadratus Lumborum Blockade for Postoperative Analgesia in Infants and Children Following Colorectal Surgery

Background

Adult studies have indicated that the quadratus lumborum block (QLB) may provide superior analgesia compared to single-shot neuraxial and other truncal peripheral nerve blocks. The technique is being increasingly used for postoperative analgesia in children undergoing lower abdominal surgery. To date, these pediatric reports have been limited by small sample sizes, which may hinder the interpretation of results and assessment of safety. In this study, we retrospectively examined QLBs performed at a large tertiary care hospital for evidence of effectiveness and safety in the pediatric colorectal surgery population.

Methods

Patients less than 21 years of age who underwent abdominal surgery and received a unilateral or bilateral QLB over a 4-year period were identified in the electronic medical record. Patient demographics, surgery type, and QLB characteristics were retrospectively examined. Pain scores and opioid consumption were tabulated over the first 72-h postoperative period. QLB procedural complications or adverse events attributable to the regional anesthetic were obtained.

Results

The study cohort included 204 QLBs in 163 pediatric-aged patients (2 days to 19 years of age, median age of 2.4 years). The most common indication was unilateral blockade for ostomy creation or reversal. The majority of QLBs were performed using ropivacaine 0.2% with a median volume of 0.6 mL/kg. The median opioid requirement in oral morphine milligram equivalents (MMEs) was 0.7, 0.5, and 0.3 MME/kg on the first, second, and third postoperative days, respectively. Median pain scores were less than 2 over each time period. Aside from block failure (incidence 1.2%), there were no complications or postoperative adverse events related to the QLBs.

Conclusion

This retrospective review in a large cohort of pediatric patients demonstrates that the QLB can be performed safely and efficiently in children undergoing colorectal surgery. The QLB provides adequate postoperative analgesia, has a high success rate, may limit postoperative opioid consumption, and is associated with a limited adverse effect profile.

Comparison of ultrasound-guided quadratus lumborum block and erector spinae plane block in terms of their effects on postoperative pain in open nephrectomy

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB 2) and erector spinae plane block (ESPB) were suggested to prevent somatic and visceral pain in a small number of abdominal surgeries. In this study, we aimed to compare these fascial plane blocks in terms of efficacy and safety in patients undergoing open nephrectomy.

METHODS

This double-blind randomized controlled trial included a total of 40 patients (aged 18-70 years, with an ASA Score of I-III) and underwent partial or radical nephrectomy with subcostal incision. Unilateral ESPB and QLB 2 were performed at the end of the operation. The patients were then assessed for total morphine consumption, pain scores, and side effects at the postoperative 24^th hour.

RESULTS

The ESPB and QLB 2 groups showed similar total morphine consumption (20.95+12.40 mg and 25.05+13.60 mg, P=0.870) and morphine demands (37.85+29.43 and 41.15+31.75, P=1.000), respectively. Despite the lower VAS scores at rest and movement in the ESPB group, there were no statistically significant differences between groups.

CONCLUSIONS

Ultrasound-guided QLB 2 and ESP block were found to achieve similar results on at rest and at movement pain scores and morphine consumption of the patients undergoing open nephrectomy. Both blocks may be preferred, depending on the clinician's experience.

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Background

Posterior quadratus lumborum block (QLB) and intrathecal morphine are accepted analgesic strategies in laparoscopic liver resection, but their effects have not been compared after laparoscopic donor hepatectomy. This study was planned to perform this comparison.

Methods

Fifty-six donors were randomized to receive bilateral posterior (QLB2, 20 mL of 0.375% ropivacaine on each side, 150 mg total) or preoperative injection of 0.4 mg morphine sulfate intrathecally. Primary outcome was resting pain score at 24 hour postsurgery. Secondary outcomes included cumulative opioid consumption and recovery parameters. Serial plasma ropivacaine concentrations were measured in QLB group. Only the outcome assessor was properly blinded.

Results

Mean resting pain score at 24-hour postsurgery was 4.19±1.66 in QLB group (n=27) and 3.07±1.41 in intrathecal morphine group (n=27, p=0.04). Mean difference (QLB group-intrathecal morphine group) was 1.11 (95% CI 0.27 to 1.95), and the upper limit of CI was higher than prespecified non-inferiority margin (δ=1), indicating an inferior effect of QLB. Cumulative opioid consumption was significantly higher in QLB group at 24 hours and 48 hours postsurgery. QLB group exhibited lower incidence of postoperative pruritus at all time points, and there were no differences in other recovery outcomes. All measured ropivacaine concentrations were below the threshold for systemic toxicity (4.3 µg/mL).

Conclusions

Bilateral posterior QLB elicited higher resting pain scores at 24-hour after laparoscopic donor hepatectomy than intrathecal morphine and did not meet the definition of non-inferiority.

Trial registration number

KCT0005360.

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies

OBJECTIVE

To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.

METHOD

A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.

RESULTS

Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I² = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I² = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I² = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I² = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I² = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I² = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I² = 0%]. There have been no reports of complications from ESPB or other blocks.

CONCLUSION

Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.