Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy

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.

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.

Percutaneous Gastrostomy Tube Placement under Quadratus Lumborum Block: A Case Report

The quadratus lumborum block is a technique that is not widely applied in abdominal surgery. The influence of the mode of anesthesia on the outcome of polymorbid patients is a controversial issue in the medical literature. We report a case in which we performed a quadratus lumborum block type 2 on a woman who was admitted to Riga's 1st hospital in need of gastrostomy, due to difficulty swallowing solid foods and liquids caused by hypopharynx carcinoma. On account of the patient's difficult airway, general anesthesia was deemed unsafe for the patient, with a risk of patient death. Percutaneous gastrostomy tube placement under a quadratus lumborum block type 2 was performed successfully.

Motor-sparing peripheral nerve blocks for hip and knee surgery

PURPOSE OF REVIEW

To summarize the recent literature describing and comparing novel motor-sparing peripheral nerve block techniques for hip and knee surgery. This topic is relevant because the number of patients undergoing same day discharge after hip and knee surgery is increasing. Preserving lower extremity muscle function is essential to facilitate early physical therapy for these patients.

RECENT FINDINGS

Distal peripheral nerve blocks may allow for preserved quadriceps motor strength and comparable analgesia to traditional techniques. However, few studies in hip and knee populations include strength or function as primary outcomes. For hip surgeries, studies have failed to show analgesic differences between regional blocks and periarticular infiltration. Similarly for knee arthroplasty in the absence of periarticular infiltration, recent evidence suggests adding combinations of blocks (ACB plus iPACK or genicular nerve blocks) may balance pain control and early ambulation.

SUMMARY

The use of motor-sparing peripheral nerve block techniques enables early ambulation, adequate pain control, and avoidance of opioid-related side effects facilitating outpatient/ambulatory lower extremity surgery. Further studies of these techniques for continuous peripheral nerve block catheters are needed to assess if extended blockade continues to provide motor-sparing and opioid-sparing benefits.

Effect of Quadratus Lumborum Block on Pain and Stress Response after Video Laparoscopic Surgeries: A Randomized Clinical Trial

Background: There are many surgical and anesthetic factors that affect pain and the endocrine–metabolic response to trauma. The ability of anesthetic agents and neuronal blockade to modify the response to surgical trauma has been widely studied in the last few years. Objective: To evaluate if the anterior quadratus lumborum block contributes to improved surgical recovery, using as parameters analgesia, pulmonary function and neuroendocrine response to trauma. Methods: We carried out a prospective, randomized, controlled, and blinded study, in which 51 patients scheduled for laparoscopic cholecystectomy. Patients were randomly selected and assigned to 2 groups. The control group received balanced general anesthesia and venous analgesia, and the intervention group was treated under general, venous analgesia and anterior quadratus lumborum block. The parameters evaluated were: demographic data, postoperative pain, respiratory muscle pressure and inflammatory response to surgical stress with the plasma dosage of IL-6 (Interleukin 6), CRP (C-Reactive protein) and cortisol. Results: Anterior quadratus lumborum block induced the slowing of IL-6 cytokine production and a decrease in cortisol release. This effect was accompanied by the significant reduction of postoperative pain scores. Conclusion: Anterior quadratus lumborum block is an important strategy for analgesia in abdominal laparoscopic surgery and contributes to reducing the inflammatory response to surgical trauma with an early return of preoperative baseline physiological functions.

Comparison of ultrasound-guided quadratus lumborum block-2 and quadratus lumborum block-3 for postoperative pain in cesarean section: A randomized clinical trial

INTRODUCTION

The aim of this study was to compare the postoperative analgesic effects of ultrasound-guided quadratus lumborum block-2 (QLB-2) and quadratus lumborum block-3 (QLB-3) after cesarean section (C/S) under general anesthesia.

METHOD

This was a prospective, randomized, double-blind study. A total of 143 term pregnant women with American Society of Anesthesiologists II status, who were scheduled for elective C/S under general anesthesia were randomly separated into QLB-2 and QLB-3 groups. After surgery under standardized general anesthesia, QLBs were performed with 0.3 mL.Kg-1 0.25% bupivacaine in both groups. Patient-controlled analgesia (PCA) devices were used for additional analgesia. The primary outcomes were pain scores evaluated at 0, 2, 6, 12, and 24 hours. In addition, PCA demands, actual delivered tramadol doses, rescue analgesic requirements, anesthesia time, and patient satisfaction were recorded.

RESULTS

A total of 104 patients were analyzed statistically. Pain scores were statistically lower in the QLB-3 group at 2, 6, 12, and 24 hours postoperatively (P = .001). Anesthesia time was longer in the QLB-3 group. Patients who received QLB-3 block demonstrated significantly fewer PCA demands and lower consumption of tramadol (P = .003). Moreover, the first analgesic requirement time was longer along with higher patient satisfaction. In addition, all procedures were performed without any complications and side effects due to PCA were negligible.

CONCLUSIONS

This study demonstrated that, although both QLBs were safe and reliable, QLB-3 provides more effective analgesia and patient satisfaction than QLB-2 in C/S.

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

Background

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

Methods

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

Results

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

Conclusions

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

Elevated serum TLR4 level as a potential marker for postsurgical chronic pain in pediatric patients with different approaches to analgesia

Introduction

The perioperative period of any surgery is accompanied by immune suppression. The level of Toll-like receptor 4 (TLR4) is known to increase in inflammation and after nerve injury and contributes to the development of neuropathic pain. The interaction of TLRs in response to the effect of opioids results in paradoxical hyperalgesia. Regional anesthesia techniques are the standard of care for perioperative pain management in children.

Aim

The aim of the study was to determine and evaluate the indicators of TLR4 for different methods of pain relief in anesthetic management of hernia repair in children and their effect on pain chronification.

Materials and methods

There were examined 60 children with inguinal hernia during 2020-2022. Children were divided into 3 groups: Group I included 20 children who underwent surgery under general anesthesia using the block of the anterior abdominal wall-transversalis fascia plane block (TFPB), combined with the quadratus lumborum block (QLB-4) via a single intramuscular injection; Group II included 20 children who underwent surgery under general anesthesia using the TFPB; Group III comprised 20 children who underwent surgery under general anesthesia using opioid analgesics. The levels of TLR4 were evaluated at a discharge from the hospital, 3 and 6 months after surgery.

Results

There was no difference in age and body weight among all groups. In Group II, boys prevailed. In Group III, the length of hospital stay was the longest (3.28 ± 0.24 days, p < 0.05, t = 4.09) as compared to children of Group II and Group I (3.0 ± 0.30 (p < 0.05, t = 2.647) and 2.1 ± 0.16 days, respectively). While staying in the surgical department, children of Group III demonstrated significantly higher FLACC and VAS scores. The prevalence of chronic pain was the highest among children of Group III (35%) as compared to those in Group II and Group I (20 and 15%, respectively). The highest increase in the level of TLR4 was found in the group of opioid analgesia on the third and sixth months after surgery (68.86 + 10.31 pg/ml and 143.15 + 18.77 pg/ml (p < 0.05, t = 6.33), respectively) as compared to patients who received regional anesthesia.

Conclusions

There were confirmed the following advantages of the transversalis fascia plane block combined with the quadratus lumborum block (QLB + TFPB) via a single intramuscular injection: ease of use; adequate perioperative pain control as evidenced by the FLACC and VAS pain assessment scales; reduced perioperative use of opioid analgesics; shortening the length of hospital stay.

Comparative Study between Ultrasound-Guided Quadratus Lumborum Block Type 2 Versus Lumbar Epidural Analgesia as a Perioperative Analgesic Technique for Pelvic Cancer Surgeries

Background: The effect of the quadratus lumborum block (QLB) is believed to result from a spread of LA from its lumbar deposition cranially into the thoracic paravertebral space.The aim of this study is to compare the analgesic efficacy of an Ultrasound-guided quadrates lumborum type II block versus lumbar epidural analgesia or conventional analgesia after pelvic cancer surgeries regarding intraoperative fentanyl consumption, postoperative pain scores and morphine consumption in the first 24 hours.Methods: This study was conducted on 90 patients of American Society of Anesthesia (ASA) physical status II scheduled for elective pelvic cancer operations. Patients were randomized into three equal groups of 30 patients: Group Q: received bilateral QLB by 20ml of 0.25% bupivacaine in each side, Group E: received continuous lumbar epidural block analgesia ((0.125 % bupivacaine at infusion rate of 6ml/hour for 24 hours). Group C (Control group): were transferred to operation room without further intervention.Results: End tidal sevoflurane was significantly decreased in group Q than group C and in group E than group C at all time measurements. VAS at 0.5, 1, 8. 16 and 24 hours was significantly increased in group C than Group Q and group E. Time to first rescue dose of morphine was significantly increased in Group E than Group Q (P1 <0.001) and was significantly decreased in group C than Group Q (P2 <0.001) and was significantly decreased in group C than Group E (P3 <0.001). Total dose of morphine in 1st 24 hours was significantly increased at group C than group Q and group E (P <0.001) but there was an insignificant difference between Group Q and E.Conclusion: When compared to the control group, QLB and epidural block resulted in decreased VAS, intraoperative sevoflurane and fentanyl use and postoperative morphine consumption with a greater level of patient satisfaction. Epidural block, on the other hand, resulted in less intraoperative sevoflurane usage than QLB.

Ultrasound-Guided Quadratus Lumborum Block Versus Caudal Block for Pain Relief in Children Undergoing Lower Abdominal Surgeries: A Randomized, Double-Blind Comparative Study

Background

The quadratus lumborum (QL) block, also known as the abdominal truncal block, was developed to provide visceral and somatic analgesia during abdominal procedures.

Objectives

This study aimed to assess pain alleviation, the incidence of complications in lower abdominal procedures, and hemodynamic stability between the caudal block and ultrasound-guided QL block.

Methods

Fifty-two patients aged 1 to 7 years old from both genders scheduled for unilateral lower abdominal surgery were randomly assigned to 2 study groups: group QL, unilateral QL block (n = 26), and group C, caudal block (n = 26). In group C, children received caudal block. In group QL, an ultrasound-guided QL block was performed. The time to first rescue analgesia was evaluated as a primary outcome. The quality of analgesia was determined using the face, legs, activity, cry, consolability scale (FLACC scale), hemodynamic parameters, and incidence of complications because hemodynamic instability was recorded under ultrasound guidance. Signs of local anesthetics toxicity and the parents' satisfaction were secondary outcomes.

Results

The time until the first demand for analgesia postoperatively was statistically longer in group QL compared to group C. A non-significant difference was observed between the 2 groups (P > 0.05) regarding age, weight, gender, duration of surgery, type of surgery, FLACC scale, and hemodynamics (SBP, systolic blood pressure), except at 30 minutes, which was significant in QL block. Also, a non-significant difference was observed in the severity of postoperative pain up to 1 day postoperatively. Group QL showed more satisfaction than group C. No intraoperative complications were detected.

Conclusions

Compared to caudal block, QL block produced sustained and adequate analgesia time postoperatively, with higher satisfaction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE

 To review our experience with quadratus lumborum block (QLB) in pediatric urology.

MATERIALS AND METHODS

 This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry.

RESULTS

 There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction.

CONCLUSION

 Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Comparative efficacy analysis of ultrasound-guided quadratus lumborum block and lumbar plexus block in hip arthroscopy: a pilot prospective randomized controlled trial

Controlled trials assessing quadratus lumborum block (QLB) for post-operative analgesia in hip surgery are scarce. This study aimed to compare ultrasound-guided QLB and lumbar plexus block (LPB) for clinical efficacy in hip arthroscopy. Patients undergoing hip arthroscopy in Beijing Jishuitan Hospital in January–June 2019 were randomized to the lumbar plexus (L) and quadratus lumborum (Q) groups (n = 25/group). After either ultrasound-guided block for 30 min, both groups were prepared for surgery after muscle strength measurement in the affected limbs. Opioid doses for patient-controlled analgesia (PCA), visual analog scale (VAS) scores in the resting and active states, upon leaving the post-anesthesia care unit (PACU), and at 2–48 h post-surgery were recorded, and post-operative complications were also recorded. Muscle strength in the affected limbs was significantly higher in the Q group compared with the L group (4.0 versus 2.0, P &lt; 0.001). VAS scores were similar in both groups post-surgery (P &gt; 0.05). One patient had epidural spread in the L group, with no other complications. Compared with ultrasound-guided LPB, ultrasound-guided QLB provides similar and good post-operative analgesia after hip arthroscopy, with less impact on muscle strength and fewer complications. These results should be confirmed in larger trials.

Supra-Arcuate Ligament Blocks: Anatomy, Mechanisms, and Techniques

Quadratus lumborum block (QLB) is clinically used for postoperative analgesia of abdominal or hip surgery, which can reduce the dose of general anesthetic, inhibit postoperative pain, and promote postoperative rehabilitation. However, accumulated studies have shown several drawbacks of QLB, such as only a small portion of local anesthetic spread into the thoracic paravertebral space, relatively longer onset time, and easily-influenced block effect by the integrity of lumbar fascia, etc. Therefore, on the basis of traditional anterior QLB, our group proposed the techniques of a supra-arcuate ligament block, which include a paramedian short-axis scanning approach, paramedian long-axis scanning approach, infra-lateral arcuate ligament QLB with the apposition zone between diaphragm and quadratus lumborum as drug diffusion target and supra-arcuate ligament block under direct laparoscopic visualization. Recent studies have demonstrated that the supra-arcuate ligament blocks have the advantages of clear anatomy, are easy to perform, and have rapid onset, which avoid some drawbacks of the conventional QLB techniques. This article reviews the anatomical basis, sonoanatomy, technical points, and clinical considerations of supra-arcuate ligament blocks.

Efficacy of quadratus lumborum block for analgesia in adult participants undergoing hip surgery: A meta-analysis of randomized controlled trials

STUDY OBJECTIVE

This study aimed to identify the benefits of quadratus lumborum block (QLB) in terms of postoperative analgesic effects in adult participants undergoing hip surgery.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Previous randomized controlled trials that evaluated the analgesic effect of QLB compared to that of no block.

PATIENTS

Nine studies including 616 participants.

INTERVENTIONS

Participants in the treatment group received QLB, whereas those in the control group received no block.

MEASUREMENTS

Outcomes were postoperative 24-h opioid consumption (primary), 12-h/24-h visual analog scale (VAS) or numeric rating scale (NRS) pain scores, postoperative nausea and vomiting (PONV), and satisfaction. The effect size was estimated using the standardized mean difference (SMD), mean difference (MD), or risk ratio (RR) with a 95% confidence interval (CI). We used the risk of bias tool (RoB 2) to assess the risk of bias of the included studies and the GRADE approach to determine the level of certainty of the evidence.

MAIN RESULTS

Compared to no block, the QLB group has less opioid consumption (SMD -1.69, 95% CI -2.54 to -0.84; low level of certainty of the evidence). Estimated MD for morphine consumption was 24 mg. The QLB group had a lower 12-h VAS/NRS pain score (MD -1.16, 95% CI -1.82 to -0.51; moderate level of certainty of the evidence) and 24-h VAS/NRS pain score (MD -0.92, 95% CI -1.42 to -0.43; moderate level of certainty of the evidence). QLB decreased the incidence of PONV (RR 0.43, 95% CI 0.24 to 0.79; moderate level of certainty of the evidence) and increased participants' satisfaction (SMD 1.15, 95% CI 0.63 to 1.67; moderate level of certainty of the evidence). Estimated MD for satisfaction was 1.74 points of Likert scale. There were no significant adverse events associated with the QLB in any of the included trials.

CONCLUSION

Our meta-analysis showed that QLB when compared to no block clinically decreased opioid requirements, reduced PONV, and improved participants' satisfaction. QLB also seems to be significantly superior to no block in terms of pain score, but its clinical importance remains unclear.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis.

METHODS

We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the  grading of recommendations, assessment, development, and evaluation system.

RESULTS

Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr.

CONCLUSIONS

Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr.

TRIAL REGISTRATION

PROSPERO (CRD42021238916); registered 25 February 2021.

A Modified Approach for the Ultrasound-Guided Quadratus Lumborum Block in Dogs: A Cadaveric Study

Simple Summary

This study describes a modified approach for the ultrasound-guided quadratus lumborum block in dogs. Previous studies carried out in canine cadavers describe the needle insertion following a ventro-lateral to dorso-medial approach. Our modified technique follows a dorso-lateral to ventro-medial direction. We aimed to have the same success with this approach as previous studies in dogs but to minimise the potential complications. After performing the modified technique bilaterally in nine canine cadavers and administering contrast, we assessed the contrast distribution with computed tomography (CT) and dissection. Potential complications were also assessed. Our dissection results showed similar distribution to previous studies, although CT results showed a more caudal contrast spreading. No contrast was found in the abdomen or epidural space. This study shows that our modified approach is safe and has at least the same distribution as the previous studies published in dogs.

Abstract

Ultrasound-guided quadratus lumborum block (QLB) is a locoregional technique described in canine cadavers. The aim of this study was to assess a modified approach to QLB to minimise potential complications such as abdominal organ puncture. Nine canine cadavers were included and were positioned in lateral recumbency. An ultrasound-guided QLB was performed on each side. The probe was placed in the transverse position over the lumbar muscles just caudal to the last rib, and a needle was advanced in-plane from a dorso-lateral to a ventro-medial. A volume of 0.2 mL kg⁻¹ of a mixture of iomeprol and methylene blue was injected. Computed tomography (CT) and dissection were performed to evaluate the spreading. Success was defined as staining of the nerve with a length of more than 0.6 cm. Potential complications such as intra-abdominal, epidural, or intravascular spreading of the mixture were also assessed. The CT images showed a T13 to L7 vertebra distribution, with a median of 5 (3–6). Dissection showed staining of the nerves from T13 to L4, with a median of 3 (2–5). No complications were found. This modified approach to QLB is safe and shows similar results to the previous studies in canine carcass.

Ultrasound-Guided Anterior Quadratus Lumborum Block Reduces Postoperative Opioid Consumption and Related Side Effects in Patients Undergoing Total Hip Replacement Arthroplasty: A Propensity Score-Matched Cohort Study

Quadratus lumborum block (QLB) has been shown to be effective for pain relief after hip surgery. This study evaluated the efficacy of ultrasound-guided anterior QLB in pain control after total replacement hip arthroplasty (TRHA). A total of 115 patients receiving anterior QLB were propensity score-matched with 115 patients who did not receive the block. The primary outcome was opioid consumption at 24, 24-48, and 48 postoperative hours. Secondary outcomes included pain scores at the post-anesthesia care unit (PACU), 8, 16, 24, 32, 40, and 48 h length of hospital stay, time to first ambulation, and the incidence of opioid-related side effects. Postoperative opioid consumption 48 h after surgery was significantly lower in the QLB group. Resting, mean, worst, and the difference of resting pain scores compared with preoperative values were significantly lower in the QLB group during the 48 postoperative hours. The length of hospital stay was shorter in the QLB group. The incidence of postoperative nausea and vomiting was significantly lower in the QLB group during the 48 postoperative hours, except at the PACU. This study suggests that anterior QLB provides effective postoperative analgesia for patients undergoing THRA performed using the posterolateral approach.

Effect of Subcostal Anterior Quadratus Lumborum Block vs. Oblique Subcostal Transversus Abdominis Plane Block after Laparoscopic Radical Gastrectomy

OBJECTIVE

To evaluate the analgesic effect of ultrasound-guided subcostal anterior quadratus lumborum block (QLB) for laparoscopic radical gastrectomy surgery.

METHODS

Patients (aged 20-65 years, ASA I - II, and weighing 40-75 kg) scheduled for elective laparoscopic radical gastrectomy were enrolled in the current study. Sixty patients were randomly assigned to two groups by computer-generated randomization codes: an ultrasound-guided oblique subcostal transversus abdominis plane block (TAPB) group (group T, n=30) or an ultrasound-guided subcostal anterior QLB group (group Q, n=30). In both groups, bilateral ultrasound-guided oblique subcostal TAPB and subcostal anterior QLB were performed before general anesthesia with 0.25% ropivacaine 0.5 mL/kg. For postoperative management, all patients received patient-controlled intravenous analgesia (PCIA) with nalbuphine and sufentanil after surgery, maintaining visual analogue scale (VAS) scores ≤4 within 48 h. The intraoperative consumption of remifentanil, the requirement for sufentanil as a rescue analgesic, and the VAS scores at rest and coughing were recorded at 1, 6, 12, 24 and 48 h after surgery. The recovery (extubation time after surgery, first ambulation time, first flatus time and length of postoperative hospital stay) and the adverse events (nausea and vomiting, skin pruritus, respiratory depression and nerve-block related complications) were observed and recorded. The primary outcome was the perioperative consumption of opioids.

RESULTS

Compared with group T, the intraoperative consumption of remifentanil, requirement for sufentanil and the frequency of PCIA were reduced in group Q. Meanwhile, VAS scores at all points of observation were significantly lower in group Q than in group T. Patients in group Q were also associated with shorter time to first out-of-bed activity and flatus, and shorter length of postoperative hospital stay than group T (P<0.05). There were no skin pruritus, respiratory depression or nerve-block related complications in both groups.

CONCLUSION

Compared with ultrasound-guided oblique subcostal TAPB, ultrasound-guided subcostal anterior QLB provided greater opioid-sparing effect, lower visual analogue scores, and shorter postoperative hospital stay for laparoscopic radical gastrectomy.

Effect of Ultrasound-Guided Quadratus Lumborum Block Preemptive Analgesia on Postoperative Recovery of Patients with Open Radical Colon Cancer Surgery: A Retrospective Study

Purpose

To evaluate the effect of ultrasound-guided quadratus lumborum block (QLB) preemptive analgesia on recovery in colon cancer patients undergoing open radical surgery and provide reference for its clinical application.

Methods

From July 2019 to June 2020, according to the anesthesia method, 56 patients who received open radical colon surgery were divided into two groups: Group Q (n=27), which received QLB combined general anesthesia, and Group C (n=29), which received general anesthesia only. Both groups were given self-controlled intravenous analgesia pump after surgery. The primary outcome is a series of parameters representing postoperative recovery. The secondary outcome was VAS scores and opioid consumption.

Results

The first time of getting up, flatus, taking semi-liquid diet and the postoperative hospital stay in Group Q were significantly reduced (P<0.01). The rest and active VAS scores were significantly lower in Group Q (P<0.01). The opioids consumption was significantly decreased in Group Q (P<0.05).

Conclusion

The application of ultrasound-guided QLB preemptive analgesia in open radical colon cancer surgery can significantly enhance the postoperative analgesia effect, reduce opioid consumption, and accelerate the postoperative recovery of the patients.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-2000034824).

Postoperative pain treatment with transmuscular quadratus lumborum block and fascia iliaca compartment block in patients undergoing total hip arthroplasty: a randomized controlled trial

Background

Patients often suffer moderate or even severe pain after total hip arthroplasty; such pain seriously affects early postoperative recovery. This study aimed to investigate the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block combined with fascia iliaca compartment block for elderly patients undergoing total hip arthroplasty.

Methods

Fifty-four patients scheduled for total hip arthroplasty were included in this randomized controlled study. The patients were randomly assigned to receive only transmuscular quadratus lumborum block (group Q) or transmuscular quadratus lumborum block combined with fascia iliaca compartment block (group QF) with ultrasound guidance. Postoperatively in both groups, paracetamol 1 g was regularly administered at 6 h intervals and patient-controlled intravenous analgesia was administered. The primary outcome was cumulative sufentanil consumption via patient-controlled intravenous analgesia 24 h postoperatively. The secondary outcomes included pain degree, time to the first analgesic requirement, joint range of motion, quality of recovery, and the incidence of postoperative complications.

Results

Fifty patients were included, and their data were analyzed. The cumulative sufentanil consumption in group QF was significantly lower during the first 24 h after surgery than that in group Q, and the cumulative sufentanil consumption in group QF was reduced at 6–12 and 12–18 h after surgery. The postoperative pain intensity was lower in group QF than in group Q (linear mixed-effects model, the main effect of treatment: P < 0.001). Compared with group Q, group QF had higher quality of recovery and joint range of movement. The time to the first analgesic requirement was longer in group QF than in group Q (log-rank, P < 0.001). There was no statistically significant difference in complications postoperatively between the two groups.

Conclusions

Our study provides a multimodal, opioid-sparing analgesic regimen for elderly patients undergoing total hip arthroplasty. The combination of transmuscular quadratus lumborum block and fascia iliaca compartment block provides a significant advantage for early postoperative functional recovery. Further studies are required to confirm the minimum effective dose.

Trial registration

The study was registered on the 21st December 2020 (retrospectively registered) on the Chinese Clinical Trial Registry: ChiCTR2000038686.

Randomized controlled trial of a quadratus lumborum block with liposomal bupivacaine for postoperative analgesia in laparoscopic donor nephrectomy

Perioperative pain management is an important consideration in early recovery and patient satisfaction following laparoscopic donor nephrectomy. Transmuscular quadratus lumborum block has been described to reduce pain and opioid usage following several abdominal surgeries. In this prospective single‐blind randomized controlled trial, we compared 52 patients who adhered to our institutional donor nephrectomy Early Recovery After Surgery pathway, which includes a laparoscopic‐guided transversus abdominus plane block, to 40 patients who additionally received a transmuscular quadratus lumborum block with liposomal bupivacaine. Compared to control patients, those who received the block spent longer in the operating room prior to the surgical start (65.4 vs. 51.6 min, P < .001). Both groups had similar total hospital length of stay (33.3 h vs. 34.4 h, P = .61). Pain scores from postoperative days 0–30, number of patients requiring opioids, postoperative nausea, and pain management satisfaction were similar between both groups. Patients who received the block consumed less opioid on postoperative day 1 compared to controls (P = .006). No complications were attributable to the block. The quadratus lumborum block provides a safe pain management adjunct for some patients, and may reduce opioid use in the early postoperative period when combined with our standard institutional protocol for kidney donors.

Paraspinous Quadratus Lumborum Block: A New Analgesic Option for a Thigh Sarcoma Resection With Reconstruction-A Case Report

Efficient pain management is essential for postoperative rehabilitation in patients undergoing a tumor resection with an immediate reconstructive surgery. Ultrasound-guided quadratus lumborum block has been described for abdominal or hip surgery, but not for concomitant surgery in the abdomen and the thigh. The paraspinous transmuscular approach has easy landmarks to perform this block. We present a case of a patient undergoing a resection of a sarcoma in the lower limb with an immediate reconstruction with a pedicled vertical designed deep inferior epigastric perforator flap, in whom a successful paraspinous transmuscular quadratus lumborum block for postoperative analgesia was performed.

Comparison of ropivacaine plasma concentration after posterior Quadratus Lumborum Block in Cesarean Section with ropivacaine with epinephrine vs plane

BACKGROUND

The posterior Quadratus Lumborum Block (pQLB) has been used in postoperative pain management after Cesarean Section (CS). However, clinicians have no data about pQLB safety in pregnants, at increased risk of local anesthetic systemic toxicity (LAST). The purpose of the present study was to explore the efficacy and the safety of adding epinephrine to ropivacaine for bilateral pQLB vs. bilateral pQLB performed with ropivacaine alone in CS.

METHODS

in this prospective trial 52 pregnants, ASA 2 physiological status, were consecutively allocated to one of 2 groups, e-pQLB and pQLB; e-pQLB group received 0.375% ropivacaine+100 mcg epinephrine, 20 ml each side; pQLB received 0.375% ropivacaine alone, 20 ml each side. The primary and secondary outcomes were to evaluate if the adjunct of epinephrine to ropivacaine increases efficacy and safety of pQLB, respectively.

RESULTS

Authors found in e-pQLB group vs. p-QLB group: a total mean morphine consumption statistically lower during the first 24 postoperative hours (5.08±3.12, vs 9.11±4.67 SD mg, p=0.0002); NRS values statistically lower at 6 hours from block, both at rest (1,73±1,88 SD vs. 2,88±2,53, p=0.03) and with movement (3,03±1,98 SD vs. 4,23±2,87, p=0.04); a longer time between block and the first opioid request (5.92±2.48 vs 3.78±2.68 SD hrs, p< 0.003); venous ropivacaine concentrations significantly lower at any time of samples but at 120 minutes.

CONCLUSIONS

Adding epinephrine to ropivacaine increases efficacy and duration of pQLB. Moreover it increases block safety, reducing peak and mean venous ropivacaine concentration.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of ultrasound-guided quadratus lumborum block for post-operative analgesia in unilateral laparoscopic renal surgeries - A randomised controlled trial

Background and Aims:

Quadratus lumborum block (QLB) is a novel anaesthetic technique for abdominal wall block providing excellent post-operative analgesia. The primary objective of this study was to evaluate the duration of post-operative analgesia with QLB in unilateral laparoscopic renal surgeries. The secondary objectives were to assess total morphine consumption during the first 24 h postoperatively and observe for complications.

Methods:

Sixty patients undergoing unilateral laparoscopic renal surgeries were randomly divided into two groups, with patients receiving QLB (Group A) or no block (Group B) at the end of surgery. General anaesthesia was standardised in both the groups. The pain was assessed by a Visual Analogue Scale (VAS) of 1–10. The duration of analgesia was taken as time from extubation to VAS of ≥3. Morphine was administered in patient-controlled analgesia pump with a bolus of 1 mg and a lockout interval of 10 min (min). The total morphine consumption was recorded. The statistical analysis was performed with the Student's t-test and Chi-square test.

Results:

The duration of post-operative analgesia was significantly prolonged in Group A (1288 ± 288.92 min) than Group B (138 ± 54.92 min). Morphine consumption was also less in Group A (3.1 ± 0.87 mg) than Group B (10.46 ± 1.8 mg). There was a significant difference in the VAS score from 16 to 20 h. No complications were recorded.

Conclusions:

Ultrasound-guided QLB after laparoscopic renal surgery is safer to perform, effective with an increased post-operative duration of analgesia, reduces the consumption of opioids and is associated with fewer side effects.

To evaluate the effect of quadratus lumborum block on the tramadol sparing effect in patients undergoing open inguinal hernia surgery: A randomised controlled trial

Background and Aims

An ultrasound-guided quadratus lumborum (QL) block provides both somatic and visceral analgesia in abdominal surgeries. We aimed to evaluate the postoperative tramadol sparing effect of single-shot anterior QL block in inguinal hernia surgery patients.

Methods

This prospective, randomised controlled trial was conducted in a single tertiary care centre over a period of 1 year. A total of 50 patients, American Society of Anaesthesiologists (ASA) physical status I-II of both sexes aged 18-80 years with body mass index (BMI) ≥20 to ≤35 kg/m² undergoing uncomplicated unilateral inguinal hernia surgery under spinal anaesthesia (SA) were randomly allocated to either of the two groups. The block group (n = 25) received single-shot anterior QL block with 20 ml of 0.5% ropivacaine and the control group (n = 25) received no block. Postoperatively, patients received intravenous (IV) paracetamol 1g every 6 h and tramadol patient-controlled analgesia up to 24 h. Primary outcome was total tramadol consumption at 24 h postoperatively.

Results

The total tramadol consumption mean ± SD [95% CI (range)] at 24 h in the block group was 84.00 ± 37.86 [68.37-99.63 (20-160)] mg versus 93.60 ± 34.99 [79.16-108.04 (20-160)] mg in control group, (p value = 0.36). Postoperative VAS score, haemodynamics, and patient satisfaction score were similar in both the groups. No adverse events were reported.

Conclusion

A single-shot anterior QL block did not establish a postoperative tramadol-sparing effect at 24 h as compared to no block in patients undergoing inguinal hernia surgery under SA.

The effect of post-operative ultrasound-guided transmuscular quadratus lumborum block on post-operative analgesia after hip arthroplasty in elderly patients: A randomised controlled double-blind study

BACKGROUND AND AIM

The best analgesic technique after hip surgeries is a matter of debate. This clinical trial aimed to assess the effect of transmuscular ultrasound-guided quadratus lumborum (QL) block on post-operative analgesic consumption after hip arthroplasty in elderly patients.

METHODS

This prospective randomised double-blind study was carried out on 60 patients aged 60-80 years presented for total hip replacement under unilateral spinal anaesthesia. Patients were randomly allocated to one of two groups: A control group, receiving sham transmuscular QL block (QLB) (1 ml of normal saline), and a QL group, receiving real transmuscular QLB (30 ml of plain bupivacaine 0.25%). Post-operative morphine consumption (primary outcome), post-operative pain score (secondary outcome), time to the first request of rescue analgesia, patient's satisfaction and the occurrence of post-operative complications were measured.

RESULTS

Compared to the control group, the use of QLB in the second group significantly decreased intravenous morphine consumption postoperatively from 8.50 ± 3.06 mg to 5.60 ± 3.22 mg (P = 0.0007) with a significant prolongation of the time to the first call for analgesia (P < 0.0001). It also decreased the post-operative visual analogue score 4 h, 6 h and 8 h postoperatively (P < 0.05). However, there was no difference between both the groups regarding patient's satisfaction and the occurrence of complications (P > 0.05).

CONCLUSION

The use of transmuscular QLB in patients undergoing total hip replacement decreased post-operative analgesic consumption and post-operative pain score and prolonged post-operative analgesia. It did not affect patients' satisfaction and occurrence of post-operative complications.

Retrospective study of quadratus lumborum block for postoperative analgesia in patients undergoing percutaneous nephrolithotomy

Background

The postoperative analgesic effect of transmuscular quadratus lumborum block (QLB-TM) in patients following lower abdominal surgeries has been identified; however, the efficacy of QLB using the lateral approach (QLB-L) is still in debate. Therefore, this retrospective study was conducted to investigate the effect of a single-shot block with QLB-L on postoperative analgesia for patients undergoing percutaneous nephrolithotomy (PCNL).

Methods

The medical information of the patients undergoing PCNL was retrieved from the electronic charter system (Medisystem, Suzhou, China) in our Nanjing Drum Tower Hospital during the period of Jan/2019 to Jun/2019. Among the total of 57 patients, there are 17, 18, and 22 patients subjected to QLB-L, QLB-TM, or routine treatment, respectively. The primary observational parameter was to assess postoperative pain with visual analog scales (VAS) at rest 30 min after extubation, 24 h, and 48 h after surgery, respectively. The secondary observatory endpoints, including the consumption of intraoperative opioids, the cumulative dose of non-steroid anti-inflammatory drugs (NSAIDs) and the incidence of adverse events related to postoperative analgesia, were evaluated as well.

Results

The static VAS score at 24 h after surgery and the intraoperative consumption of sufentanil were significantly lower in patients receiving either intervention of QLB-L or QLB-TM as compared with those receiving routine treatment. However, one shot of QLB had no impact on VAS scores at 30 min post-extubation, 48 h after PCNL procedure compared with the patients receiving routine treatment. The percentage of non-ambulatory patients within 24 h post-PCNL was significantly higher in the QLB-TM group compared with the routine treatment group (P = 0.04). There were no significant differences in the incidence of postoperative nausea and vomit (PONV), itches, respiratory depression, the time for the first defecation, and the length of hospital stay (LOS) among the three groups.

Conclusions

QLB-L procedure may exert as equivalent as QLB-TM in terms of abrogating postoperative pain within 24 h post-surgery and decreasing intraoperative sufentanil consumption in patients undergoing PCNL procedure as well. The caution should be taken to avoid lower extremities weakness in the patients after QLB-TM within the first 24 h post-PCNL procedure.

Quadratus Lumborum 2 Block as the Sole Anesthetic Technique for Open Hernia Repair in Multimorbid Patients

Ultrasound-guided quadratus lumborum (QL, QL1-3) blocks have been used extensively for perioperative pain control for patients undergoing abdominal procedures. These blocks provide a more widespread and longer-lasting analgesic effect compared to the transversus abdominis plane (TAP) block. While QL blocks have been used as an adjunct in multimodal postoperative pain control, they are rarely used as the sole anesthetic technique for abdominal surgeries.

We report the cases of two high-risk multimorbid patients requiring urgent open umbilical hernia repairs secondary to incarceration or obstruction. Bilateral QL2 blocks were utilized as the sole anesthetic technique to reduce anesthetic risk, with positive outcomes. 

Utilization of the QL2 block technique for our patients enabled avoidance of general anesthesia in these high-risk patients because of the extensive area of anesthesia they provide when compared with the TAP and QL1 block techniques. The advantages of the QL2 block for high-risk patients include immediate perioperative pain control, reduced use of muscle relaxants, reduced opioid analgesic requirement for postoperative pain management, and enhanced postoperative recovery. Disadvantages include potential for local anesthetic toxicity, neural injury, or failure of the block. While regional anesthetic techniques may be beneficial options for those patients who are not candidates for general anesthesia, more studies in which these techniques are used need to be performed to determine the widespread efficacy and adequacy of this method.

The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after cesarean section with vertical incision: a randomized, double-blinded placebo-controlled study

PURPOSE

Quadratus lumborum block (QLB) has recently been used for postoperative analgesia after abdominal surgery. Although there are several approaches to QLB, the effectiveness of intramuscular QLB (QLBi) remains controversial. The aim of the present study was to examine the effectiveness of QLBi for postoperative analgesia after cesarean section with a vertical midline incision.

METHODS

In this single-center, randomized, double-blinded placebo-controlled study, 36 women who were scheduled for elective cesarean section were randomly divided into a QLBi group (n = 18) and a placebo group (n = 18). In both groups, spinal anesthesia was performed with 10-11 mg hyperbaric bupivacaine and 15 µg fentanyl. After the surgery, in the QLBi group, 0.4 mL/kg of 0.25% ropivacaine was injected into the bilateral quadratus lumborum muscle under ultrasound guidance (the total volume was 0.8 mL/kg). In the placebo group, instead of ropivacaine, the subjects were injected with the same amount of normal saline. The primary outcome measure was elapsed time to first analgesic use from the QLBi block after cesarean section.

RESULTS

The data from all 36 patients were analyzed. There were no significant differences between the QLBi and placebo groups regarding elapsed time to first postoperative analgesic use [mean 230 (standard deviation 103) vs 194 (89) min; 95% confidence interval - 101 to 30; p = 0.27].

CONCLUSIONS

QLBi with the concentration and amount of local anesthetic used in the present study was clinically slightly effective, and the effect was limited for postoperative analgesia after cesarean section.

Ultrasound-Guided Transmuscular Quadratus Lumborum Block Reduces Postoperative Pain Intensity in Patients Undergoing Total Hip Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

Methods

Eighty-eight patients undergoing THA were randomized to receive 0.33% ropivacaine (Group QLB, n = 44) or saline (Group Con, n = 44) for QL3 block. Spinal anesthesia was then performed. Pain intensity was assessed using the visual analog scale (0: no pain to 10: worst possible pain). The primary outcome was pain scores recorded at rest at 3, 6, 12, 24, 36, and 48 h and on standing and walking at 24, 36, and 48 h postoperatively. Secondary outcomes were analgesic consumption, side effects, the 10-meter walking speed on day 6, and patient satisfaction after surgery.

Results

Postoperative pain intensity was significantly lower in Group QLB compared to Group Con at rest after 3, 6, 12, 24, 36, and 48 h (p < 0.001) and during mobilization after 24, 36, and 48 h (p < 0.001). Morphine use was significantly lower in Group QLB compared to Group Con during 0–24 h (16.0 ± 7.1 vs. 34.1 ± 7.1 mg, p < 0.001) and during 24–48 h (13.0 ± 4.0 vs. 17.4 ± 4.6 mg, p < 0.001) postoperatively. The 10-meter walking speed was higher in Group QLB compared to Group Con, both at comfortable (0.79 ± 0.13 vs. 0.70 ± 0.14 m/s, p=0.012) and at maximum speeds (1.18 ± 0.26 vs. 1.06 ± 0.22 m/s, p < 0.001). Incidences of nausea (7.3% vs. 31%, p=0.006), vomiting (7.3% vs. 26.2%, p = 0.022), and urinary retention (9.8% vs. 28.6%, p=0.030) were lower in Group QLB than in Group Con.

Conclusions

Ultrasound-guided QL3 block is an effective pain management technique after THA.

Analgesic effects and distribution of cutaneous sensory blockade of quadratus lumborum block type 2 and posterior transversus abdominis plane block: an observational comparative study

Background

The posterior transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) were developed for postoperative pain control after lower abdominal surgery. However, there is little data regarding their effects. Their analgesic effects and the distribution of the cutaneous sensory blockade were observed in patients undergoing laparoscopic gynecologic surgery.

Methods

After an induction of general anesthesia, patients alternately received bilateral ultrasound-guided QLB type 2 (QLB2) or posterior TAPB using 20 ml of 0.375% levobupivacaine on each side. The measurements included visual analogue pain scores (VAS), cutaneous sensory blockade in each dermatome, demands for postoperative analgesics, and complications for up to 48 h after the block. Our primary endpoint was VAS at 24 h after the block.

Results

Forty patients completed the study. The VAS at rest was significantly lower after QLB2 than that after TAPB at 48 h, but not at 24 h. Neither group differed in VAS when coughing at any point in time. Postoperative demands for fentanyl and other analgesics also did not differ for either block. The majority of injections produced a cutaneous sensory blockade in the T11 and T12 dermatomes in both groups. The median number of dermatomes blocked was limited to three dermatomes after either block. No severe complication related to either block was observed.

Conclusions

The analgesic effects of QLB2 and posterior TAPB did not differ in patients undergoing laparoscopic gynecologic surgery. The cutaneous sensory blockade produced was limited to three dermatomal levels in the majority of patients. However, these findings need to be confirmed through a larger comparative study.

Anterior quadratus lumborum block analgesia for total hip arthroplasty: a randomized, controlled study

BACKGROUND AND OBJECTIVES

Quadratus lumborum (QL) block is a new regional analgesic technique for upper and lower abdominal surgeries as part of a multimodal analgesic regime. It has also been reported to relieve pain after total hip arthroplasty (THA). In this prospective, randomized, double-blind study, we compared QL block with control (no block) in patients undergoing primary THA.

METHODS

Eighty patients undergoing primary THA surgery under spinal anesthesia were randomized into two groups, one with and one without QL block. The patients in both groups were randomized after sedation, positioning and ultrasound scanning. Both the patient and the researcher collecting data were blinded to the patient's group assignment. Opioid consumption and visual analog scores (VAS) pain scores were measured at 12, 24, and 48 hours after surgery. Also, the ambulation distance, patient satisfaction, and length of stay were recorded.

RESULTS

The study analysis included 36 patients in the QL group and 35 patients in the control group. Both VAS pain score at 24 hours (difference -1.76, 95% CI -2.87 to -0.64) and cumulative opioid consumption were significantly lower in the QL group at 12, 12-24, 24, 24-48, and 48 hours after surgery as compared with the control group (difference at 48 hours -36.13, 95% CI -62.89 to -9.37) (p<0.05). However, there was no difference in pain score at 12 and 48 hours, nor in the ambulation distance and duration of hospital stay between the two groups. The patient satisfaction score was significantly higher in the QL group.

CONCLUSIONS

Our preliminary data show that the QL block provided effective analgesia and decreased opioid requirements up to 48 hours after primary THA.

TRIAL REGISTRATION NUMBER

NCT03408483.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound-guided quadratus lumborum block for postoperative pain control in patients undergoing unilateral inguinal hernia repair, a comparative study between two approaches

BACKGROUND

Early postoperative ambulation and reduction of hospital stay necessitate efficient postoperative analgesia. Quadrates Lumborum Block (QLB) has been described to provide adequate postoperative analgesia after abdominal surgery. This randomized comparative trial was designed to compare the duration of analgesia provided by two different QLB approaches; the posterior QLB (QLB-2) and transmuscular QLB (QLB-3) in patients undergoing surgical repair of unilateral inguinal hernia.

METHODS

Forty patients, aged from 18 to 50 years, ASA physical status I or II, scheduled for unilateral inguinal hernia repair were enrolled. At the end of the surgical procedure and before recovery from general anesthesia, Patients were randomly assigned into two groups to receive either posterior QLB (Group QLB-2) or transmuscular QLB (Group QLB-3) using 20 ml 0.25% bupivacaine. Duration of analgesia, postoperative VAS and postoperative opioid consumption were recorded.

RESULTS

Duration of block was significantly longer in QLB-3 group when compared to QLB-2 group (20.1 + 6.2 h versus 12.0 + 4.8 respectively) with P value of < 0.001. A statistically significant lower VAS score was recorded in QLB-3 group immediately and 12 h postoperative. QLB-3 group showed a statistically significant delayed time of first analgesic request and less postoperative morphine consumption with P value of < 0.001 and 0.001 respectively.

CONCLUSIONS

Ultrasound guided postsurgical transmuscular approach of QLB (QLB-3) using 20 ml 0.25% bupivacaine produces more postoperative analgesic effect and less postoperative opioid consumption when compared to posterior QLB approach (QLB-2) in patients underwent unilateral inguinal hernia repair under general anesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03526731 - on 16 May 2018.

Comparison of transversus abdominis plane block and quadratus lumborum block for post-caesarean section analgesia: A randomised clinical trial

Background and Aims:

Effective post-operative analgesia after caesarean section (CS) is important because it facilitates early amelioration, ambulation and expedites breastfeeding. Quadratus lumborum (QL) block is an interfascial block providing effective visceral and somatic analgesia. We conducted this study to compare the analgesic efficacy of QL block and transversus abdominis plane (TAP) block after CS.

Methods:

In this single hospital-based, prospective double-blind study, 60 patients scheduled for an elective CS between December 2018 and January 2019 were randomised to receive ultrasound-guided TAP block (n = 30) or QL block (n = 30) bilaterally with 0.2% ropivacaine postoperatively. The primary objective was to measure the time for rescue analgesic requirement and secondary objectives included the total number of analgesic dose required over a period of 72 hours and severity of post-operative pain assessment via visual analogue scale (VAS) score at rest and with movement. Statistical analysis was done using SPSS version 21. Data were compared using the Chi-square test and students' t-test.

Results:

Time for rescue analgesic requirement was higher in the QL group than the TAP group (mean ± SD: 68.77 ± 1.74 h vs. 13.3 ± 1.21 h) (P < 0.001). The QL group had significantly less analgesic demand (P < 0.001) at 2, 4, 6, 12, 24, 36, 48 and 72 h post-CS. The VAS at rest and movement was significantly reduced in the QL group at all times.

Conclusion:

The QL block provided prolonged and effective analgesia in comparison to TAP block up to 72 hours post-CS.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study

Objective

To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block.

Methods

The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block.

Results

For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block.

Conclusion

Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III

Applications and critical evaluation of fascia iliaca compartment block and quadratus lumborum block for orthopedic procedures

Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.

Effect of posterior quadratus lumborum blockade on the quality of recovery after major gynaecological laparoscopic surgery: A randomized controlled trial

Bilateral quadratus lumborum blockade (QLB) using ultrasound guidance has been introduced as an abdominal truncal block to improve postoperative analgesia and quality of recovery (QoR) after abdominal surgery, but efficacy remains controversial. The primary aim of this study was to evaluate the efficacy of posterior QLB on the postoperative QoR, and secondarily to evaluate postoperative pain after gynaecological laparoscopic surgery (LS). This study was a single-centre randomized controlled trial. QLB group patients underwent bilateral posterior quadratus lumborum injections with 25–30 mL of 0.25% levobupivacaine after induction of general anaesthesia; the control group underwent no block. Both groups were administered fentanyl-based intravenous patient-controlled analgesia postoperatively. The postoperative QoR was measured using the Quality of Recovery 40 (QoR-40) questionnaire score; postoperative pain was evaluated using the visual analogue scale (VAS) and the cumulative postoperative fentanyl dose. Thirty-one and 29 patients were randomised to the QLB and control groups, respectively. The intraoperative remifentanil dosage was significantly less in the QLB group. The median (interquartile range) for the QoR-40 score was not different between the groups: 154 (133–168) in the QLB group and 158 (144–172) in the control group. There were no statistically significant differences in secondary outcome variables. Single-shot QLB did not improve the QoR or postoperative pain in patients managed by multimodal analgesia after gynaecological LS.

Comparison of IL-6 and CRP Concentration Between Quadratus Lumborum and Epidural Blockade Among Living Kidney Donors: A Randomized Controlled Trial

Background

An adequate anesthesia technique generates appropriate postoperative analgesic properties and decreases the patient’s stress response. This will lead to decreased morbidity and mortality associated with immunology disturbances, such as infection, prolonged wound healing, and sepsis.

Objectives

The aim of this study was to compare interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, as the markers of the stress response, between continuous epidural and quadratus lumborum (QL) block as postoperative analgesia techniques among living kidney donors.

Methods

Sixty-two patients were randomly divided into two equal groups: continuous epidural and QL block. A group received bilateral QL block with 20 mL of bupivacaine 0.25% and the other received 6 mL/hour of bupivacaine 0.25% continuously via an epidural catheter. Prior to extubation, the QL block group received bilateral QL block with the same dose and the continuous epidural group was administered with 6 mL/hour of bupivacaine 0.125%. Blood samples were drawn to compare IL-6 and CRP concentrations after intubation (preoperatively), directly after surgery, 24 hours postoperatively, and 48 hours postoperatively. Postoperative pain was measured with the numerical rating scale (NRS). Morphine requirement and duration of catheter usage were also measured postoperatively. Side effects within 24 hours postoperatively were noted. Data were analyzed with independent t-test or Mann-Whitney test.

Results

No difference was observed between the groups in the plasma concentration of IL-6 either after surgery or 24 hours postoperatively (P = 0.785 and P = 0.361, respectively) although the mean IL-6 concentration 24 hours postoperatively was lower in the QL block group than in the continuous epidural group. CRP concentration was not significantly different between the groups either after surgery or 48 hours postoperatively (P = 0.805 and P = 0.636, respectively).

Conclusions

There was no significant difference in IL-6 and CRP concentrations between continuous epidural and QL block among living kidney donors. Both continuous epidural and QL block techniques showed comparable postoperative analgesic properties among living kidney donors undergoing laparoscopic nephrectomy.

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

Background

Adequate pain control after cesarean section (CS) is crucial for mothers caring for newborns, and early ambulation to avoid thromboembolism and chronic abdominal and pelvic pain. This randomized controlled trial compared the efficacy of quadratus lumborum block (QLB) and intrathecal morphine (ITM) for analgesia after CS.

Methods

Ninety women at ≥ 37 weeks pregnancy scheduled for elective CS were enrolled. All patients received spinal anesthesia and post-operative QLB. They were randomly allocated to Control (anesthesia: 0.1 ml saline, QLB: 24 ml saline), ITM (anesthesia: 0.1 mg morphine, QLB: 24 ml saline), or QLB groups (anesthesia: 0.1 ml saline, QLB: 24 ml 0.375% ropivacaine). Integrated analgesia score (IAS) and numerical rating scale (NRS) scores at rest and during movement, morphine requirements in the first 48 h, time to first morphine dose and morphine-related side effects were recorded.

Results

IASs and NRS scores at rest and during movement were significantly lower in QLB and ITM group than in Control group. Moreover, IASs and NRS scores at rest and during movement were lower in QLB group than in ITM group. Time to first morphine dose was significantly longer in QLB group than in ITM and Control group. Furthermore, morphine requirements in the first 48 h were significantly lower in QLB group than ITM and Control group. Incidence of morphine-related side effects was significantly higher in ITM group than in QLB and Control group.

Conclusions

QLB and ITM are effective analgesic regimens after CS. However, QLB provides better long-lasting analgesia and reduced total postoperative morphine consumption.