Quadratus Lumborum Blocks in Nephrectomy: A Narrative Review

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.

Fascial Plane Blocks With Glucocorticoids or Liposomal Bupivacaine Versus Local Infiltration for Laparoscopic Non-donor Nephrectomy: A Propensity Score-Weighted Study

Study objective The purpose of this study is to investigate the analgesic efficacy of ultrasound-guided fascial plane blocks (FPBs) versus local infiltration in patients undergoing laparoscopic non-donor nephrectomy. This study specifically compares the efficacy of FPBs with liposomal bupivacaine (LB) versus FPBs with dexamethasone sodium phosphate (DXP) and methylprednisolone acetate (MPA) versus surgical site local anesthetic infiltration without FPBs.  Design This is a retrospective cohort study conducted over a five-year period (January 2018-December 2022). Setting The study was conducted in a tertiary care, academic, multi-hospital healthcare system.  Participants Patients who underwent elective radical or partial laparoscopic non-donor nephrectomy were included in the study. Intervention Patients either received preoperative FPBs without intraoperative surgical site local anesthetic infiltration or received surgical site local anesthetic infiltration without FPBs (n = 141) at participating hospitals. Measurements The primary endpoint of this study was postoperative opioid use, measured as oral milligram morphine equivalents (MME). Secondary endpoints included postoperative pain scores, length of hospital stays, and significant adverse events within 30 days. The impact of medications utilized in FPBs was determined by univariate and multivariable analyses with covariates balancing propensity score weighting. Main results Patients undergoing non-donor laparoscopic radical or partial nephrectomy who received FPBs with bupivacaine or ropivacaine plus glucocorticoids DXP and MPA were more likely to be opioid-free 24-48 hours postoperatively compared to those who received FPBs with LB or surgical site local anesthetic infiltration without FPBs (40.5% vs. 30% vs. 13.9%, respectively; p = 0.017). Patients who received FPBs with glucocorticoids also reported the lowest pain scores at rest and with activity 0-12 hours postoperatively as compared to patients who received LB or local infiltration (p = 0.006 and p = 0.014, respectively). Additionally, patients who received FPBs with glucocorticoids received over 30% fewer opioids during the first 48 hours postoperatively compared to patients who received surgical site local anesthetic infiltration alone (30 MME vs. 44 MME, respectively). However, there was no significant difference in total opioid use during the first 48 hours postoperatively between patients who received FPBs with bupivacaine plus glucocorticoids and those who received FPBs with bupivacaine plus LB (mean ratio: 0.91, (95% CI: 0.05 ~ 15.97); p = 0.948). There was also no difference in the length of hospital stays or rate of adverse events between the groups. Conclusion Perioperative FPBs for non-donor laparoscopic nephrectomy using glucocorticoids as an adjuvant to long-acting local anesthetics may decrease postoperative opioid use and reduce pain scores as compared to FPBs with LB or surgical site local anesthetic infiltration. Bupivacaine or ropivacaine combined with DXP and MPA is a safe and effective alternative to LB for FPBs in laparoscopic nephrectomy.

Continuous Erector Spinae Plane Block for Pain Management in a Pediatric Kidney Transplant Recipient: A Case Report and Review of the Current Literature

Pain management in patients undergoing kidney transplantation requires careful consideration due to their altered physiology, and potential risks associated with certain analgesic options. In recent years, personalized and multimodal approaches have proven to be pivotal in perioperative pain management, as well as in children. Implementing regional analgesia methods offers a valuable solution in many pediatric surgical settings and the erector spinae plane block (ESPB) could represent a possible analgesic strategy in pediatric patients undergoing renal transplantation. Here, we report the case of a 13-year-old child who underwent living-donor kidney transplantation (LDKx) and received continuous erector spinae plane block (ESPB) for perioperative pain management. This multimodal approach with continuous ESPB resulted in optimal pain control without the need for opioids, allowing for early mobilization and for an optimal postoperative course.

Comparison of the effects of subcostal anterior quadratus lumborum block and thoracic paravertebral block in laparoscopic nephrectomy: a randomized study

BACKGROUND

Thoracic paravertebral block (TPVB) may provide sufficient postoperative analgesia in laparoscopic nephrectomy (LSN) by ensuring ipsilateral somatic and visceral analgesia. However, there are serious reservations due to the complexity of the technique, and various complications thereof. Subcostal anterior quadratus lumborum block (S-QLB3) may be a safe alternative in LSN procedures. Therefore, this study aimed to compare the postoperative analgesic effects of TPVB and S-QLB3.

METHODS

This prospective, randomized, double-blind study included 60 patients aged 18-70 years who were planned to undergo LSN. The patients were randomly assigned to receive either unilateral ultrasound-guided S-QLB3 or TPVB. The primary outcome was postoperative cumulative 24-h morphine consumption. In addition, numeric rating scale (NRS) scores at rest/activity and the American Pain Society Patient Outcome Questionnaire (APS-POQ-R-TR) scores were also evaluated.

RESULTS

While postoperative cumulative 24-h morphine consumption was lower in the TPVB group compared to the other group (mean±SD, 12±3.4 mg vs. 15.4±7.8 mg, P=0.03), NRS pain scores at rest/activity were similar in both groups at all measurement points. Considering the postoperative APS-POQ-R-TR data, only the score related to the pain-daily activity relationship was high in the S-QLB3 group (median [Q1-Q3], 0 [0-1] vs. 2 [0-5], P=0.004), whereas there was no difference between the other scores.

CONCLUSIONS

In this study, NRS and APS-POQ-R-TR scores were similar in the S-QLB3 and TPVB groups, whereas cumulative morphine consumption was modestly lower in the TPVB group. This suggested that S-QLB3 could be an alternative to TPVB in patients undergoing LSN.

Modified subcostal approach to anterior quadratus lumborum block for managing postoperative pain in patients undergoing open nephrectomy

BACKGROUND

Quadratus lumborum block is a relatively new truncal block and different approaches to this block have been described. With a recent modification to the subcostal approach to the anterior quadratus lumborum block (QLB3), the injection point was moved further cranially and medially, thereby aiming to enhance the spread of the local anesthetic into the thoracic paravertebral space. Although the level of blockade achieved with this modification seems sufficient for open nephrectomy, the modification is still for clinical evaluation. In this retrospective study, we aimed to evaluate the effects of the modified subcostal QLB3 approach on postoperative analgesia.

METHODS

All adult patients who received a modified subcostal QLB3 for postoperative analgesia following open nephrectomy between January 2021- 2022 were retrospectively evaluated. Accordingly, total opioid consumption and pain scores during rest/activity within the first 24 h after surgery were evaluated.

RESULTS

A total of 14 patients underwent open nephrectomy were analyzed. Pain scores within the first 6 h postoperatively, particularly the dynamic numeric rating scale (NRS) scores (4-6.5/10), were high. The median (interquartile range) resting and dynamic NRS scores for the first 24 h were 2.75 (1.79) and 3.91 (1.67), respectively. The mean ± standard deviation IV-morphine equivalent dose for the first 24 h was 30.9 ± 10.9 mg.

CONCLUSIONS

It was found that the modified subcostal QLB3 did not provide satisfactory analgesia in the early postoperative period. Further randomized studies that extensively investigate the postoperative analgesic efficacy are required to draw a stronger conclusion.

Comparison of the Postoperative Analgesic Effects between Ultrasound-Guided Transmuscular Quadratus Lumborum Block and Thoracic Paravertebral Block in Laparoscopic Partial Nephrectomy Patients: A Randomized, Controlled, and Noninferiority Study

Background

This prospective, randomized, double-blinded, noninferiority study aimed to compare the effects of analgesia and recovery between transmuscular quadratus lumborum block (TMQLB) and paravertebral block (PVB).

Methods

Sixty-eight, American Society of Anesthesiologists level I-III patients, who underwent laparoscopic partial nephrectomy in Peking Union Medical College Hospital were randomly allocated to either TMQLB or PVB group (independent variable) in a 1 : 1 ratio. The TMQLB and PVB groups received corresponding regional anesthesia preoperatively with 0.4 ml/kg of 0.5% ropivacaine and follow-up at postoperative 4, 12, 24, and 48 hours. The participants and outcome assessors were blinded to group allocation. We hypothesized that the primary outcome, postoperative 48-hour cumulative morphine consumption, in the TMQLB group was not more than 50% of that in the PVB group. Secondary outcomes including pain numerical rating scales (NRS) and postoperative recovery data were dependent variables.

Results

Thirty patients in each group completed the study. The postoperative 48-hour cumulative morphine consumption was 10.60 ± 5.28 mg in the TMQLB group and 6.40 ± 3.40 mg in the PVB group. The ratio (TMQLB versus PVB) of postoperative 48-hour morphine consumption was 1.29 (95% CI: 1.13-1.48), indicating a noninferior analgesic effect of TMQLB to PVB. The sensory block range was wider in the TMQLB group than in the PVB group (difference 2 dermatomes, 95% CI 1 to 4 dermatomes, P=0.004). The intraoperative analgesic dose was higher in the TMQLB group than in the PVB group (difference 32 µg, 95% CI: 3-62 µg, P=0.03). The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups (all P  >  0.05).

Conclusions

The postoperative 48-hour analgesic effect of TMQLB was noninferior to that of PVB in laparoscopic partial nephrectomy. This trial is registered with NCT03975296.

Effect of transversus abdominis plane block on the quality of recovery in laparoscopic nephrectomy: A prospective double-blinded randomized controlled clinical trial

BACKGROUND

Poorly controlled acute postoperative pain after laparoscopic nephrectomy may adversely affect surgical outcomes and increase morbidity rates. In addition, excessive use of opioids during surgery may slow postoperative endocrine and metabolic responses and cause opioid-related side effects and opioid-induced hyperalgesia. The purpose of this study was to evaluate the effect of ultrasound-guided transversus abdominis plane (TAP) block on the postoperative quality of recovery and intraoperative remifentanil requirement in laparoscopic nephrectomy.

METHODS

Sixty patients who underwent laparoscopic nephrectomy were randomly divided into 2 groups: TAP and Control groups. After induction of anesthesia and before awakening from anesthesia, the TAP group was administered 40 mL of 0.375% ropivacaine and the Control group was administered 40 mL of normal saline to deliver ultrasound-guided TAP block using 20 mL of each of the above drugs. The main objectives of this study were to evaluate the effect of the TAP block on quality of recovery using the Quality of Recovery 40 (QoR-40) questionnaire and assessments of intraoperative remifentanil requirement. In addition, to evaluate the postoperative analgesic effect of the TAP block, the total usage time for patient-controlled analgesia (PCA) and the number of PCA bolus buttons used in both groups were analyzed.

RESULTS

The QoR-40 score, measured when visiting the ward on the third day after surgery, was significantly higher in the TAP group (171.9 ± 23.1) than in the Control group (151.9 ± 28.1) (P = .006). The intraoperative remifentanil requirement was not significantly different between the groups (P = .439). In the TAP group, the frequency of bolus dose accumulation at 1, 2, 3, 6, 12, 24, 48, and 72 hours after surgery was low enough to show a significant difference, and the total usage time for PCA was long enough to show a significant difference.

CONCLUSION

In conclusion, we determined that ultrasound-guided TAP block during laparoscopic nephrectomy improves the quality of postoperative recovery and is effective for postoperative pain control but does not affect the amount of remifentanil required for adequate anesthesia during surgery.

Clinical Assessment of Introducing Locoregional Anaesthesia Techniques as Part as the Intraoperative Analgesia Management for Canine Ovariohysterectomy in a Veterinary Teaching Hospital

This study compared four methods to provide intraoperative analgesia during canine ovariohysterectomy in a veterinary teaching hospital. A retrospective study was designed to assess the nociceptive response, cardiorespiratory stability, quality of recovery and complications of four analgesic protocols: epidural analgesia (EPIDURAL group), Quadratus Lumborum block (QLB group), Transversus Abdominis Plane block (TAP group), and just systemic analgesia (GENERAL group). Undergraduate students carried out all the loco-regional techniques under the direct supervision of a qualified anaesthetist. A total of 120 cases met the inclusion criteria and were included in the study and were distributed as follows: 22, 27, 32 and 39 cases with EPIDURAL, GENERAL, QLB and TAP groups, respectively. Data were analysed with statistical software R using different statistical methods. Significant differences among groups were defined as p < 0.05. Based on our results, all the groups needed the same number of rescue analgesia during the intra-operative period. The use of loco-regional techniques anticipated a better quality of recovery compared with the general group. The EPIDURAL group showed a statistically lower expired fraction of sevoflurane. No differences were found regarding complications. In conclusion, these four analgesic methods are suitable and safe to be performed for canine ovariohysterectomy, although loco-regional techniques might have some advantages.

Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus transmuscular quadratus lumborum block for postoperative analgesia in patients undergoing laparoscopic nephrectomy: A randomized controlled trial

STUDY OBJECTIVE

The analgesic efficacy of transmuscular quadratus lumborum block (TQLB) to decrease the need for opioid consumption after laparoscopic nephrectomy has been demonstrated in several studies. However, the effect of an anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL) in this surgical context is unclear. Here, we aimed to compare postoperative analgesic effects of the two block approaches in laparoscopic nephrectomy.

DESIGN

A single-center, randomized controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

A total of 106 patients with American Society of Anesthesiologists (ASA) physical status of I-III scheduled to undergo elective laparoscopic nephrectomy under general anesthesia.

INTERVENTIONS

Patients were randomly allocated to receive preoperative TQLB or QLB-LSAL with 0.5% ropivacaine (25 mL). Postoperatively, patient-controlled analgesia with intravenous sufentanil was administered.

MEASUREMENTS

The primary outcome was postoperative intravenous morphine equivalent consumption within the first 24 h postoperatively. Secondary outcomes included pain scores, satisfaction scores, levels of sedation, and incidence of nausea or vomiting.

MAIN RESULTS

Patients who underwent preoperative QLB-LSAL used a significantly lower intravenous morphine equivalent dose than those who underwent preoperative TQLB within the initial 24 h after surgery (34.3 ± 6.3 mg vs 23.5 ± 3.2 mg, P < 0.001). No significant differences were observed in pain scores, satisfaction scores, sedation scores, or incidence of nausea or vomiting between the groups.

CONCLUSIONS

The results indicate that, compared to TQLB, QLB-LSAL is a beneficial nerve block that can reduce postoperative opioid consumption, making it a potentially superior approach to achieve multimodal analgesia after laparoscopic nephrectomy.