Ultrasound-guided anterior and posterior quadratus lumborum block for analgesia after laparoscopic hysterectomy

Ultrasound-guided quadratus lumborum block: Posterior versus anterior approach in paediatrics undergoing laparoscopic inguinal hernia repair

Background and Aims

Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the peri-operative pain management techniques used during abdominal surgeries. However, no consensus about the best approach has been reached.

Material and Methods

Sixty paediatric patients with ages ranging from 1 to 6 as well as classification I and II of the American Society of Anesthesiologists, scheduled for laparoscopic inguinal hernia, were allocated to receive either a posterior approach (Group I) or an anterior approach (Group II) QLB. Twenty four-hour morphine consumption, the face, legs, activity, cry, and consolability (FLACC) score, duration of analgesia, performance time, and block-related complications were recorded.

Results

Group II showed significantly lower morphine consumption as well as a longer duration of analgesia (P = 0.039*, 0.020*, respectively), with an equivalent period for block performance being reported in the two groups (P = 0.080). At 2, 4, 6, and 12 hours post-operatively, the FLACC scores were substantially diminished in Group II compared to Group I (P = 0.001*, 0.012*, 0.002*, 0.028*, respectively). However, at twenty-four hours, comparable pain scores were observed between both groups (P = 0.626). In addition, there were no block-related complications.

Conclusions

In paediatric patients scheduled for laparoscopic inguinal hernia repair, the ultra-sound-guided anterior approach of the QLB was associated with significantly reduced post-operative morphine consumption, a lower FLACC score, and a longer analgesia duration when compared to the posterior approach.

Effects of Erector Spinae Plane Block and Transmuscular Quadratus Lumborum Block on Postoperative Opioid Consumption in Total Laparoscopic Hysterectomy: A Randomized Controlled Clinical Trial

INTRODUCTION

Total laparoscopic hysterectomy (TLH) is a common surgical procedure that is frequently associated with substantial postoperative pain. As part of multimodal analgesia, the erector spinae plane block (ESPB) and transmuscular quadratus lumborum block (TQLB) have been demonstrated to be effective. This study aimed to evaluate whether ESPB and TQLB reduce postoperative pain and opioid consumption after TLH.

METHODS

A total of 90 female patients undergoing TLH were randomized to receive either ESPB, TQLB, or no intervention before general anesthesia. All patients received a patient-controlled sufentanil analgesia postoperatively. Postoperative pain and sufentanil consumption were evaluated. The primary outcome was cumulative sufentanil consumption at 12 h postoperatively.

RESULTS

The cumulative sufentanil consumption at 12 h postoperatively was significantly lower in Group ESPB than in Group CON after Bonferroni correction (median [interquartile range], 0 [0, 4] μg vs. 6 [0, 10] μg; median difference = - 3; 95% confidence interval, - 6-0; P = 0.010). There were no significant differences between Group TQLB and CON (0 [0, 4] μg vs. 6 [0, 10] μg; P = 0.098) or between the two block groups (P = 1.000). When compared with Group CON, ESPB and TQLB persistently reduced pain scores until 6 and 4 h after surgery, respectively (P < 0.05). However, no significant differences were found in pain scores between the two block groups.

CONCLUSIONS

ESPB and TQLB improved the quality of multimodal analgesia for TLH. ESPB may be more favorable due to the prolonged period of analgesia and decreased opioid consumption after TLH.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2100048165, Registry URL: http://www.chictr.org.cn/showproj.aspx?proj=129578 . Date of registration: July 4, 2021. The patient enrollment began on July 12, 2021.

Ultrasound-guided transversalis fascia plane block versus lateral quadratus lumborum plane block for analgesia after inguinal herniotomy in children: a randomized controlled non-inferiority study

BACKGROUND

Surgical repair of inguinal hernia is one of the most common day case surgeries in the pediatric population. This study compared the postoperative analgesic effects of transversalis fascia plane block (TFB) versus quadratus lumborum block (QLB) in children scheduled for open unilateral inguinal herniotomy.

METHODS

In this prospective, randomized, double-blind, controlled non-inferiority study, 76 eligible patients were recruited. Patients were randomly allocated to either the TFB or QLB group. The primary outcome measure was the proportion of patients who needed rescue analgesia during the first postoperative 12 h. The secondary outcomes were, the time needed to perform the block, the postoperative FLACC score, intraoperative heart rate (HR) and mean arterial pressure (MAP).

RESULTS

The proportion of patients who required a rescue analgesic was comparable (p = 1.000) between the TFB group (7/34, 20.5%) and the QLB group (6/34, 17.6%). The median [Q1-Q3] time needed to perform the block (min) was significantly longer (p < 0.001) in the QLB group (5[5]) compared with the TFB group. The postoperative FLACC pain scale was comparable between the two groups at all-time points of assessment. There is no difference regarding the heart rate and mean arterial blood pressure values at the time points that the values were recorded. (P > 0.005).

CONCLUSIONS

Both TFB and QLB similarly provide good postoperative analgesia by reducing the proportion of patients who required rescue analgesia, pain scores and analgesic consumption. Moreover, TFB is technically easier than QLB.

Predictors of new persistent opioid use after benign hysterectomy in the United States

BACKGROUND

Despite substantial reductions in the past decade, prescription opioids continue to cause widespread morbidity and mortality in the United States. Little is known regarding patterns and predictors of opioid use among women undergoing benign hysterectomy.

OBJECTIVE

This study aimed to identify the incidence and predictors of new persistent opioid use after benign hysterectomy among opioid-naïve women from a set of demographic, operative, and opioid prescription characteristics of patients.

STUDY DESIGN

In this retrospective cohort study, we identified women undergoing benign hysterectomy from 2011 to 2016 using a validated national insurance claims database (IBM MarketScan Commercial Database). After excluding women with prevalent opioid use (from 365 to 31 days preoperatively), we identified patients who received a perioperative opioid prescription (30 days before to 14 days after hysterectomy) and evaluated them for new persistent opioid use, defined as at least 1 prescription from 15 to 90 days and at least 1 prescription from 91 to 365 days postoperatively. Multivariate logistic regression was used to examine demographic, clinical, operative, and opioid prescription-related factors associated with new persistent use. International Classification of Diseases, Ninth and Tenth Revisions, and Clinical Classification Software codes were used to identify hysterectomies, preoperative pain and psychiatric diagnoses, surgical indications, and surgical complications included as covariates.

RESULTS

We identified 114,260 women who underwent benign hysterectomy and were not prevalent opioid users, of which 93,906 (82.2%) received at least 1 perioperative opioid prescription. Of 93,906 women, 4334 (4.6%) developed new persistent opioid use. Logistic regression demonstrated that new persistent use odds is significantly increased by younger age (18-34 years; adjusted odds ratio, 1.97; 95% confidence interval, 1.69-2.30), southern geographic location (adjusted odds ratio, 2.03; 95% confidence interval, 1.79-2.27), preoperative psychiatric and pain disorders (anxiety: adjusted odds ratio, 1.20 [95% confidence interval, 1.09-1.33]; arthritis: adjusted odds ratio, 1.30 [95% confidence interval, 1.21-1.40]), >1 perioperative prescription (adjusted odds ratio, 1.53; 95% confidence interval, 1.24-1.88), mood disorder medication use (adjusted odds ratio, 1.51; 95% confidence interval, 1.40-1.64), tobacco smoking (adjusted odds ratio, 1.65; 95% confidence interval, 1.45-1.89), and surgical complications (adjusted odds ratio, 1.84; 95% confidence interval, 1.69-2.00). Although statistically nonsignificant, total morphine milligram equivalent of ≥300 in the first perioperative prescription increased persistent use likelihood by 9% (95% confidence interval, 1.01-1.17). Dispensing of a first perioperative prescription before the surgery, as opposed to after, increased new persistent use odds by 61% (95% confidence interval, 1.50-1.72). Each additional perioperative day covered by a prescription increased the likelihood of persistent use by 2% (95% confidence interval, 1.02-1.03). In contrast, minimally invasive hysterectomy (laparoscopic: adjusted odds ratio, 0.89 [95% confidence interval, 0.71-0.88]; vaginal: adjusted odds ratio, 0.82 [95% confidence interval, 0.72-0.93]) and a more recent surgery year (2016 vs reference 2011: adjusted odds ratio 0.58; 95% confidence interval, 0.51-0.65) significantly decreased its likelihood.

CONCLUSION

New persistent opioid use after hysterectomy was associated with several patient, operative, and opioid prescription-related factors. Considering these factors may be beneficial in counseling patients and shared decision-making about perioperative prescription to decrease the risk of persistent opioid use.

Evaluation of Quadratus Lumborum Block as Part of an Opioid-Free Anaesthesia for Canine Ovariohysterectomy

Simple Summary

The aim of this study was to assess an anaesthetic protocol involving the quadratus lumborum block (QLB) for canine ovariohysterectomy. Ten healthy dogs were included. Anaesthetic protocol consisted of medetomidine and meloxicam, induction of anaesthesia with propofol and maintenance with sevoflurane in oxygen/medical air. The QLB was performed at the level of L₁–L₂ injecting 0.4 mL kg⁻¹ of 0.25% bupivacaine/iohexol per side. Computed Tomography (CT) was performed before and after surgery. Fentanyl was administered as rescue analgesia during surgery. The Short Form of The Glasgow Composite Pain Scale and thermal threshold (TT) at the level of the humerus, T₁₀, T₁₃ and L₃ were assessed before premedication and every hour postoperatively. Methadone was given as rescue analgesia when it was needed. CT images showed spreading of a median (range) of 3 (2–5) vertebrae, without differences between preoperative and postoperative images. One out of ten dogs needed intraoperative rescue analgesia. Pain score was less than 4/24 in all the animals until four hours after surgery. TT showed significative increase in all the areas tested apart from the elbow 30 min after the recovery. The QLB provides additional analgesia for canine ovariohysterectomy.

Abstract

Quadratus lumborum block (QLB) is used to provide analgesia for abdominal surgery in humans. The aim of this study was to assess an anaesthetic protocol involving the QLB for canine ovariohysterectomy. Ten dogs were included. Anaesthetic protocol consisted of premedication with IM medetomidine (20 μg kg⁻¹) and SC meloxicam (0.1 mg kg⁻¹), induction with propofol to effect, and maintenance with sevoflurane in oxygen/medical air. QLB was performed injecting 0.4 mL kg⁻¹ of 0.25% bupivacaine/iohexol per side. Computed Tomography (CT) was performed before and after surgery. Fentanyl was administered as rescue analgesia during surgery. The Short Form of The Glasgow Composite Pain Scale and thermal threshold (TT) at the level of the elbow, T₁₀, T₁₃ and L₃ were assessed before premedication and every hour postoperatively. Methadone was given as rescue analgesia postoperatively when pain score was >3. A Yuen’s test on trimmed means for dependent samples was used to analyse the data (p < 0.05). CT images showed spreading of the contrast/block for a median (range) of 3 (2–5) vertebrae, without differences between preoperative and postoperative images. One dog needed rescue analgesia during surgery. Pain score was less than 4/24 in all the animals during the first 4 h after surgery. TT showed a significant increased signal in all the areas tested, apart from the humerus, 30 min after surgery. The QLB may provide additional analgesia for canine ovariohysterectomy. Further studies are needed to assess the specific contribution of the QLB in abdominal analgesia.