Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial

Efficacy of quadratus lumborum block in the treatment of acute and chronic pain after cesarean section: A systematic review and meta-analysis based on randomized controlled trials

BACKGROUND

This analysis aimed to explore the analgesic effects of quadratus lumborum block on acute and chronic postoperative pain among patients undergoing cesarean section.

METHODS

PubMed, Cochrane, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP databases for Randomized Controlled Trials (RCTs) that focused on the use of quadratus lumborum block in cesarean section procedures were searched from the inception of the databases until December 2022. Studies were screened based on inclusion and exclusion criteria, and were then conducted for quality assessment and data extraction. Meta-analysis was performed using Stata 15.0 software. Two researchers independently screened the studies, extracted data, and evaluated the risk of bias for the included studies. In case of any disagreements, it was resolved by consultation with a third party opinion.

RESULTS

A total of 21 studies involving 1976 patients were finally included, with an overall acceptable study quality level. Compared to the control group, the administration of Quadratus Lumborum Block (QLB) resulted in significant reduction in the postoperative 24-hour visual analog scale (VAS) score (WMD = -0.69, 95% CI: -1.03 ~ -0.35, P < .001) and the consumption of opioid analgesics within 24 hours after surgery (WMD = -2.04, 95% CI: -2.15 ~ -1.92, P = .002). The incidence of chronic pain 3 months QLB (OR = 0.41, 95% CI: 0.09 ~ 1.88, P = .253) and 6 months (OR = 0.83, 95% CI: 0.33 ~ 2.07, P = .686) after surgery were observed to increase as compared with the control group.

CONCLUSIONS

The use of QLB for postoperative analgesia after cesarean section, particularly in the relief of acute postoperative pain, had been proven to significantly decrease the VAS score and morphine consumption within the first 24 hours after surgery. However, further studies are needed to determine its impact on managing chronic postoperative pain.

Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

The effectiveness of erector spina plane, quadratus lumborum blocks, and intrathecal morphine for analgesia after cesarean: a randomized study

OBJECTIVE

This prospective randomized study was conducted at Ataturk University Medical Faculty Hospital, Department of Anesthesia and Reanimation, from June 2022 to May 2023. The aim of this study was to compare the effectiveness of ultrasound-guided erector spinae plane block, quadratus lumborum block, and intrathecal morphine to decrease postoperative pain after cesarean section.

METHODS

Sixty-term pregnant women who were scheduled for elective cesarean sections with spinal anesthesia were included. Patients were randomly divided into three groups (n=20 for each group): Group 1: Patients were administered intrathecal morphine during spinal anesthesia; Group 2: Patients performed bilateral erector spinae plane block postoperatively; and Group 3: Patients performed bilateral quadratus lumborum block postoperatively. In the postpartum care unit, patients received intravenous Patient-Controlled Analgesia. The Patient-Controlled Analgesia devices were set to administer an intravenous bolus of 25 μg fentanyl, with a lockout interval of 10 min. Opioid consumption and maximum pain score in the 24 postoperative hours were recorded.

RESULTS

Patients in Group 1 had a longer time to first analgesic requirement compared to Group 2 (p=0.017). Opioid consumption and resting and moving visual analog score scores in the first 24 h postoperatively were similar between groups.

CONCLUSION

All three methods, including intrathecal morphine, erector spinae plane block, and quadratus lumborum block, are efficacious and comparable in providing postoperative analgesia after cesarean under spinal anesthesia.

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients

Introduction

With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section.

Methods

A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate.

Results

In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population.

Conclusion

Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.

Efficacy of Different Approaches of Quadratus Lumborum Block for Postoperative Analgesia After Cesarean Delivery: A Bayesian Network Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Various approaches to quadratus lumborum block (QLB) have been found to be an effective analgesic modality after cesarean delivery (CD). However, the evidence for the superiority of any individual approach still needs to be demonstrated. Therefore, we conducted this network meta-analysis to compare and rank the different injection sites for QLB for pain-related outcomes after CD.

MATERIALS AND METHODS

PubMed, EMBASE, SCOPUS, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) evaluating the role of any approach of QLB with placebo/no block for post-CD pain. The primary outcome was parenteral consumption of morphine milligram equivalents in 24 postoperative hours. The secondary end points were early pain scores (4 to 6 h), late pain scores (24 h), adverse effects, and block-related complications. We used the surface under cumulative ranking probabilities to order approaches. The analysis was performed using Bayesian statistics (random-effects model).

RESULTS

Thirteen trials enrolling 890 patients were included. The surface under cumulative ranking probability for parenteral morphine equivalent consumption in 24 hours was the highest (87%) for the lateral approach, followed by the posterior and anterior approaches. The probability of reducing pain scores at all intervals was highest with the anterior approach. The anterior approach also ranked high for postoperative nausea and vomiting reduction, the only consistent reported side effect.

DISCUSSION

The anterior approach QLB had a superior probability for most patient-centric outcomes for patients undergoing CD. The findings should be confirmed through large RCTs.

Randomized Clinical Trial Comparing Quadratus Lumborum Block and Intrathecal Morphine for Postcesarean Analgesia

OBJECTIVE

 To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia.

METHODS

 Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded.

RESULTS

 Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group.

CONCLUSION

 Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.

Anterior Quadratus Lumborum block area comparison in the three different volumes of Ropivacaine: a double-blind, randomized controlled trial in healthy volunteers

BACKGROUND

In abdominal surgery, ultrasound-guided anterior quadratus lumborum blocks (QLB) are performed to induce analgesia. However, no study reported suitable volumes of the anterior QLB for the different postoperative analgesia regions. Therefore, this prospective randomized controlled study assessed the dermatomal spread and analgesic effects of the three different volumes of a local anesthetic for anterior QLB.

METHODS

Ultrasound-guided anterior QLB was performed at the L2 level on 30 healthy volunteers. The volunteers were randomized to receive 20 ml (n = 10), 30 ml (n = 10), and 40 mL (n = 10) of 0.375% ropivacaine. The cutaneous sensory blocked area (CSBA), the number of block dermatomes, and the block duration time were measured by determining the extent of the cold sensation.

RESULTS

The CSBA was significantly larger in the 40 ml group than in the 30 (P = 0.001; 1350.6 ± 234.4 vs. 1009.5 ± 151.6 cm²) and 20 ml groups (P < 0.001; 1350.6 ± 234.4 vs. 808.1 ± 120.5 cm²). Similarly, the number of blocked dermatomes was significantly higher in the 40 ml group than in the 30- and 20-ml groups. However, no significant difference was observed in block duration among the groups.

CONCLUSIONS

No difference was observed in block duration with the various volumes of 0.375% ropivacaine. However, the larger volume for anterior QLB contributed to a larger area of cutaneous sensory blockade. Appropriate volumes in anterior QLB can create suitable postoperative analgesia levels for the different operative sites.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registration Center on www.chictr.org.cn on 27th April 2018 (registration number: ChiCTR-IOR-17010853).

Comparison of the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block versus thoracic erector spinae block for postoperative analgesia in caesarean section parturients under spinal anaesthesia-A randomised study

Background and Aims

Truncal blocks play an important role in multimodal analgesia regimens to manage the postoperative pain after lower segment caesarean section (LSCS). This study was aimed to compare the analgesic efficacy of ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) and thoracic erector spinae plane block (TESPB) in parturients of LSCS done under subarachnoid block (SAB).

Methods

In a randomised and double blind study, 60 parturients scheduled for LSCS under spinal anaesthesia were randomly divided into two equal groups: group E (n = 30) and group Q (n = 30). After surgery, each parturient received either US guided bilateral TQLB (group Q) or TESPB (group E) with 20 ml 0.375% ropivacaine and 4 mg dexamethasone on each side. Assessments were done at 2, 4, 6, 8, 10, 12 and 24 h. The primary objective was to compare the duration of analgesia (first request to rescue analgesia) and the secondary objectives were to compare pain scores [numerical rating score (NRS)], total amount of tramadol consumption, incidence of nausea-vomiting, parturient satisfaction and other adverse effects in 24 hours postoperatively.

Results

The duration of analgesia (mean ± standard deviation) was comparable in group E (11.90 ± 2.49 h) and group Q (12.56 ± 3.38 h), P = 0.19. Pain scores (NRS) at rest and on movement were comparable at all time points of 2, 4, 6, 8, 10, 12, and 24 h (P > 0.05). The amount of tramadol used was comparable in group E and group Q (P = 0.48).

Conclusion

TESPB and TQLB are equally efficacious to provide postoperative analgesia after LSCS done under SAB when used as a part of multimodal analgesia.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis

The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.

Ultrasound-Guided Posterior Quadratus Lumborum Block for Acute Postoperative Analgesia in Adult Patients: A Meta-Analysis of Randomized Controlled Trials

Objective

The quadratus lumborum block provides postoperative analgesia for patients undergoing abdominal surgery, although there are three common approaches to perform this block. The present meta-analysis investigated the effectiveness of posterior quadratus lumborum block (QLB2) after surgery.

Methods

PubMed, Embase, and the Cochrane Central Register were searched from inception to 26 August 2021 for randomized controlled trials that evaluated the analgesic efficacy of QLB2 vs control (placebo or no block). The primary outcomes were pain scores at 6 h, 12 h, and 24 h after surgery. The secondary outcomes were morphine consumption at 24 h after surgery and the postoperative complications.

Results

The present meta-analysis included 14 studies conducted with a total of 1001 patients. In comparison to control group, the QLB2 group presented significantly lower rest pain scores at 6 h (SMD -0.59; 95% CI: -1.05, -0.12; p = 0.01, I2 = 84%; GRADE = moderate), 12 h (SMD: -0.83; 95% CI: -1.47, -0.19; p = 0.01; I2 = 88%; GRADE = low), and 24 h (SMD: -0.37; 95% CI: -0.71, -0.03; p = 0.03; I2 = 80%; GRADE = moderate) after surgery. The dynamic pain scores were significantly reduced, compared to control, in the QLB2 group at 12 h (SMD: -0.93; 95% CI: -1.52, -0.33; p = 0.002; I2 = 83%; GRADE = low) and 24 h (SMD: -0.52; 95% CI: -0.93, -0.11; p = 0.01; I2 = 83%; GRADE = moderate) after surgery. In addition, the QLB2 group presented reduced postoperative opioid consumption at 24 h (SMD: -0.45; 95% CI: -0.86, -0.03; p = 0.03; I2 = 78%; GRADE = moderate). The subgroup analyses revealed that the analgesic benefit of QLB2 did not persist beyond 24 h when the patients were under spinal anesthesia.

Conclusion

Ultrasound-guided QLB2 could provide effective analgesia for patients under general anesthesia by decreasing the intensity of pain and opioid requirement when used within 24 h after abdominal surgery.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

Impact of Transversus Abdominis Plane Block With Bupivacaine or Ropivacaine Versus Intrathecal Morphine on Opioid-related Side Effects After Cesarean Delivery: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Intrathecal morphine (ITM) is frequently associated with side effects such as postoperative nausea and vomiting (PONV) and pruritus. The aim of this meta-analysis was to compare the impact of transversus abdominis plane (TAP) block versus ITM on side effects following cesarean delivery.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and CENTRAL were searched for randomized controlled trials that compared TAP with ITM for cesarean delivery. The primary outcomes were opioid-related side effects. The secondary outcomes included pain scores, opioid consumption, patient satisfaction, and time to the first analgesia request.

RESULTS

Seven studies involving 660 patients were included. TAP blocks were performed with bupivacaine or ropivacaine. There was less PONV with TAP versus ITM (risk ratio [RR]=0.45, 95% confidence interval [CI]: 0.33-0.63, P<0.001; I2=0%), but no significant difference in pruritus (RR=0.76, 95% CI: 0.49-1.18, P=0.22; I2=78%) and sedation (RR=0.44, 95% CI: 0.19-1.00, P=0.05; I2=0%). TAP had a greater morphine consumption in 24 hours (mean difference: 5.80 mg; 95% CI: 1.38-10.22 mg, P=0.01; I2=89%) and higher pain score at rest at 6 hours (mean difference: 0.70, 95% CI: 0.39-1.02, P<0.001; I2=56%), but similar pain at rest at 24 hours and on movement compared with ITM. No differences were found in time to first analgesia and patient satisfaction.

DISCUSSION

Compared with ITM, TAP block is associated with less PONV but inferior early analgesia after cesarean delivery. However, the heterogeneity among the studies highlights the need for more well-designed studies to obtain more robust conclusions.

Transparency considerations for describing statistical analyses in research

Researchers who use the results of statistical analyses to draw conclusions about collected data must write a statistical analysis section in their manuscript. Describing statistical analyses in precise detail is as important as presenting the dosages of drugs and methodology of interventions. It is also essential for scientific accuracy and transparency in scientific research. We evaluated the quality of the statistical analysis sections of clinical research articles published in the Korean Journal of Anesthesiology between February 2020 and February 2021. Using a Likert scale where 1, 2, and 3 represented “not described at all,” “partially described,” and “fully described,” respectively, the following 6 items were assessed: 1) stating of the statistical analysis methods used, 2) rationale for and detailed description of the statistical analysis methods used, 3) parameters derived from the statistical analyses, 4) type and version of the statistical software package used, 5) significance level, and 6) sidedness of the test (one-sided vs. two-sided). The first 3 items evaluate issues directly related to the statistical analysis methods used and last 3 are indirectly related items. In all the included articles, the statistical analysis methods used were stated (score of 3). However, only 4 articles (12.9%) fully described the sidedness of the test (score of 3). Authors tend not to describe the sidedness of statistical analysis tests in the methodology section of clinical research articles. It is essential that the sidedness be described in research studies.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Quadratus lumborum block for postoperative analgesia after cesarean section: a meta-analysis of randomized controlled trials with trial sequential analysis

The aim of this study was to assess the analgesic efficacy of QLB versus controls in women undergoing cesarean section (CS). We systematically searched Cochrane Library, PUBMED, EMBASE, VIP, WANFANG, and China National Knowledge Infrastructure. Trials were eligible if parturients received QLB during CS. GRADE system was used to assess the certainty of evidence and Trial sequential analyses (TSA) were performed to determine whether the results are supported by sufficient data. Thirteen studies involving 1269 patients were included. Compared to controls, QLB significantly reduced the cumulative postoperative intravenous opioid consumption (in milligram morphine equivalents) at 24 h (MD, - 11.51 mg; 95% CI - 17.05 to - 5.96) and 48 h (MD, - 15.87 mg; 95% CI - 26.36 to - 5.38), supported by sufficient data confirmed by TSA. The postoperative pain scores were significantly reduced by QLB at 4 h, 6 h, 12 h, 24 h, and 48 h postoperatively by QLB compared with control. Moreover, the time to first request for rescue analgesic and the incidence of PONV were also significantly reduced by QLB. The quality of evidence of most results were low and moderate assessed by GRADE.

Effect of Bilateral Quadratus Lumborum Block Type I on Patient Satisfaction and Incidence of Chronic Postsurgical Pain Following Cesarean Section-A Randomized Controlled Trial

BACKGROUND

Quadratus lumborum block (QLB) provides a reduction in pain scores and opioid consumption after cesarean section (CS). Intrathecal morphine (ITM) is still considered as the gold standard of acute postoperative pain therapy, but it does have some significant side effects. The aim of this clinical study was to evaluate whether performing the quadratus lumborum block type I in patients undergoing CS would be associated with an increased satisfaction of pain therapy and a decreased incidence of chronic postsurgical pain (CPSP).

METHODS

Sixty patients scheduled for elective CS were enrolled. All patients received spinal anesthesia and were randomly allocated to either the QLB group (received bilateral quadratus lumborum block type I with the use of 24 m mL 0.375% ropivacaine) or the control group (received no block). The level of satisfaction was evaluated using a three-step scale and the answers provided in a questionnaire regarding the patients' satisfaction with the method of postoperative pain treatment in the first 48 h. After a 6-month period, all patients were interviewed to evaluate the incidence and possible severity of CPSP.

RESULTS

Satisfaction scores were significantly lower in the QLB group than in the control group (p = 0.0000). There were no significant differences between the QLB and control groups regarding the occurrence of chronic postsurgical pain after 6 months following CS (p = 0.102). No statistical differences between the groups were recorded when we compared the results of the questionnaire after a period of 48 h from CS (the number of participants were limited in number).

CONCLUSIONS

QLB type I is an analgetic option that increased the satisfaction of parturients with pain therapy after CS compared to patients who did not receive the block, and there is a tendency for a lower incidence of CPSP.

Quadratus lumborum or transversus abdominis plane block for postoperative analgesia after cesarean: a double-blinded randomized trial

Background

Multimodal analgesia (MMA) is the current standard practice to provide post-cesarean analgesia. The aim of this study was to compare the analgesic efficacy of quadratus lumborum (QL) block and transversus abdominis plane (TAP) block as an adjunct to MMA.

Methods

Eighty mothers undergoing cesarean delivery under spinal anesthesia were randomized to receive either TAP or transmuscular QL block (QLB) with 20 mL 0.375% ropivacaine on each side. Postoperatively, all the subjects were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcomes were the pain scores during rest and movement, number of doses of tramadol, postoperative nausea-vomiting, sedation, and mother’s satisfaction with the pain management.

Results

The median (IQR) time to first analgesic request was 12 (9.25, 13) hours in the QL group and 9 (8.25, 11.37) hours in the TAP group (p = 0.0008). Patients in QL group consumed less doses of tramadol than those in TAP group (p < 0.0001). Pain scores were significantly lower in the QL group at all time points (p < 0.0001) except at 8^th hour when at rest, p = 0.0024, and on movement, p = 0.0028. The maternal satisfaction was significantly higher in the QL group (p = 0.0017).

Conclusion

Our study showed the significant delay in time to first analgesic request in QL group patients. Patients in the QL group had lower pain scores, required fewer analgesic supplements, and had more satisfaction. Nausea-vomiting and sedation were comparable.

The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Objective

Cesarean section (CS) is one of the most frequently performed major surgical interventions. Local anesthetic techniques, a universal component of perioperative multimodal analgesia, are reportedly effective in reducing pain scores and opioid requirements. However, the optimal local anesthetic technique for postoperative CS pain remains unclear.

Methods

Six databases were searched, and a Bayesian network meta-analysis was performed. The outcomes included cumulative morphine consumption and pain scores at four time points, time to first analgesic request, postoperative nausea and vomiting, pruritus, and sedation.

Results

Sixty-eight studies with 5039 pregnant women were included. Six local anesthetic techniques were involved, including transversus abdominis plane block (TAPB), ilioinguinal and iliohypogastric nerve block, quadratus lumborum blocks, transversalis fascia plane block, erector spinae block, and wound infiltration. Compared to inactive controls, TAPB reduced cumulative morphine consumption at 6, 12, 24, and 48 h, pain scores at 6, 12, and 24 h (with the exception of 24 h at rest), the risk of postoperative nausea and vomiting, and sedation. Compared with inactive controls, ilioinguinal and iliohypogastric nerve block reduced cumulative morphine consumption at 6 and 24 h and pain scores at 6, 12, and 24 h during movement. Compared with inactive controls, quadratus lumborum blocks reduced cumulative morphine consumption at 24 and 48 h and pain scores at 6 and 12 h and lengthened the time to first analgesic request. Compared with inactive controls, wound infiltration reduced cumulative morphine consumption at 12 and 24 h, pain scores at 12 and 24 h during movement, and risk of sedation. Compared with inactive controls, erector spinae block reduced pain scores at 6 and 12 h. Transversalis fascia plane block was found to have similar outcomes to inactive controls.

Conclusion

TAPB is the most comprehensive local anesthetic technique for postoperative CS analgesia in the absence of intrathecal morphine.

Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial

BACKGROUND

Achieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine, with IT morphine and bilateral QLB, or only bilateral QLB.

METHODS

Parturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared.

RESULTS

Eighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period was significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04-3.96) in Group IT vs. 7.75 (5.67-9.83) in IT+QLB vs. 1.75 (0.75-2.75) in QLB (p < 0.001)]. The median (min, max) amount of morphine required during 24 h was 5.5 (0-25) in Group IT vs. 5.0 (0-36) in IT+QLB vs. 17.5 (1-40) mg in Group QLB (p < 0.001). In the final analysis the median pain-free period was 2.50 (1.23-3.77) hours (95%CI) in Group IT (n = 27) vs. 8.02 (5.96-10.07) in IT+QLB (n = 28). (p = 0.027).

CONCLUSION

US-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB could provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period.

TRIAL REGISTRATION

ClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.

The principles of presenting statistical results: Table

General medical journals such as the Korean Journal of Anesthesiology (KJA) receive numerous manuscripts every year. However, reviewers have noticed that the tables presented in various manuscripts have great diversity in their appearance, resulting in difficulties in the review and publication process. It might be due to the lack of clear written instructions regarding reporting of statistical results for authors. Therefore, the present article aims to briefly outline reporting methods for several table types, which are commonly used to present statistical results. We hope this article will serve as a guideline for reviewers as well as for authors, who wish to submit a manuscript to the KJA.

Ultrasound-guided quadratus lumborum block for postoperative analgesia: A systematic review and meta-analysis

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB) is a truncal block with several technique variations. It has been reported as providing effective analgesia for postoperative pain.

OBJECTIVES

The aim of this review was to evaluate the efficacy and safety of QLB for postoperative analgesia. The primary outcome was cumulative opioid consumption at 24 h postoperatively. The main secondary outcomes were the time to the first rescue opioid analgesic, pain scores at 24 h postoperatively and the incidence of postoperative nausea and vomiting (PONV).

DESIGN

This was a systematic review and meta-analyses of observational studies and randomised controlled trials (RCTs). PRISMA-P guidelines were followed, and the review was registered in PROSPERO. GRADE was used to assess the quality of evidence.

DATA SOURCES

The search was performed from several databases (Ovid MEDLINE, PubMed, Scopus, Web of Science, CINAHL and the Cochrane CENTRAL) from inception up to June 2019.

ELIGIBILITY CRITERIA

RCTs and prospective observational studies that investigated the postoperative analgesic properties of US-guided single shot QLB in adult patients undergoing abdominal or hip surgery were included. QLB was compared with other analgesics.

RESULTS

Twenty-seven studies constituting 1557 patients were reviewed. Twelve studies with 803 patients were included in the meta-analysis on the primary outcome. Overall opioid consumption at 24 h postoperatively was reduced [mean difference, -11.15 (95% CI, -15.33 to -6.97) mg, I2 = 99%, moderate certainty in GRADE] and the time to the first opioid analgesic was longer in patients with QLB: 7 studies with 499 patients, mean difference, 189.32 (95% CI, 114.4 to 264.23) min, I2 = 98%. There were no differences in pain grades. The incidence of PONV was lower in patients with QLB [11 studies with 744 patients, OR 0.40 (95% CI, 0.27 to 0.58), I2 = 7%]. Reported complications and adverse effects of QLB were minimal.

CONCLUSION

QLB reduced postoperative opioid consumption, prolonged the time to the first rescue opioid analgesic and diminished the incidence of PONV. QLB appears to be an applicable option for postoperative analgesia after abdominal and hip surgery.

REGISTRATION NUMBER

PROSPERO, https://www.crd.york.ac.uk/prospero/, CRD42016039921.

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia

BACKGROUND

Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine.

METHODS

Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects.

RESULTS

Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (-2 to 1) and -0.1 cm (-0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (-2 to 15) and 0.6 cm (-0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of -18 mg (-28 to -7) and -1.5 cm (-2.4 to -0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by -4.4 cm · h (-5.0 to -3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons.

CONCLUSIONS

Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spinal morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used.

EDITOR’S PERSPECTIVE

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

The analgesic efficacy of quadratus lumborum block in caesarean delivery: a meta-analysis and trial sequential analysis

PURPOSE

Quadratus lumborum block (QLB) has recently gained popularity for postoperative analgesia after cesarean delivery (CD) as it provides both visceral and somato-sensory blockade of the abdomen. Aim of this meta-analysis was to evaluate the analgesic potential of QLB after CD.

METHODS

Electronic database from inception to December 2019 was searched systematically for randomized-controlled trials comparing QLB with injection of inactive solution in women undergoing CD. Primary outcome was consumption of morphine at 24 h. Morphine consumption at 48 h, dynamic and static pain scores at various time intervals were the secondary outcomes studied.

RESULTS

Seven trials met the inclusion criteria. Morphine consumption was reduced significantly with QLB in comparison to sham or no block at 24 h (mean difference [MD] - 9.84 mg; 95% confidence interval [CI] - 18.16, - 0.50; p = 0.04; I² = zero). Adequate "information size" for above outcome was confirmed with trial sequential analysis, ruling out any possibility of a false-positive result. QLB significantly reduced pain scores at rest (MD - 1.13; 95% CI - 1.75, - 0.56; p = 0.00) and on movement (MD - 1.48; 95% CI - 2.5, - 0.46; p = 0.01) at 6 h. However, statistically significant difference in pain scores persisted only for dynamic pain at 24 h (MD - 0.55; 95% CI - 1.04, - 0.06; p = 0.03). QLB does not provide any additional analgesic benefit to the parturient receiving intrathecal morphine.

CONCLUSION

QLB significantly reduces opioid requirements in CD and may have analgesic effects lasting 24 h.

Effects of transversus abdominis plane block versus quadratus lumborum block on postoperative analgesia: a meta-analysis of randomized controlled trials

Background

Trunk block technique has been used in postoperative analgesia for patients undergoing surgery, specifically, transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have been proved effective. The purpose of this meta-analysis is to evaluate the effects of TAPB and QLB in postoperative analgesia.

Methods

Online databases, including MEDLINE, EMBASE, Cochrane Library (&Trail), Web of Science, CNKI, Wanfang and QVIP were applied to collect the randomized controlled trials (RCTs) from inception to Dec. 9th, 2019. Twenty-two studies were finally included containing 777 patients in the TAPB group and 783 cases in QLB group. RCTs comparing TAPB and QLB in postoperative analgesia were included in this meta-analysis. The indicators including total analgesia consumption postoperatively, operative time, duration of anesthesia, visual analogue scale (VAS) score at 24 h postoperatively, duration of postoperative analgesia, the number of patients requiring analgesia postoperatively and adverse reactions were analyzed.

Results

our findings showed that morphine consumption (mg) (WMD = 3.893, 95%CI: 2.053 to 5.733, P < 0.001), fentanyl consumption (μg) (WMD = 23.815, 95%CI: 15.521 to 32.109, P < 0.001), VAS score at 24 h postoperatively (WMD = 0.459, 95%CI: 0.118 to 0.801, P = 0.008), the number of patients requiring analgesia postoperatively (WMD = 3.893, 95%CI: 2.053 to 5.733, P < 0.001), and the incidence of dizziness (WMD = 2.691, 95%CI: 1.653 to 4.382, P < 0.001) in TAPB group were higher than in QLB group.

Conclusions

QLB is superior to TAPB in reducing morphine consumption, fentanyl consumption, VAS score at 24 h postoperatively, the number of patients requiring analgesia postoperatively, and the incidence of dizziness.

Interfascial plane blocks

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.