Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Patients Undergoing Left Hemicolectomy

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Patients Undergoing Left Hemicolectomy: A Randomized Controlled Trial

The enhanced recovery after surgery and laparoscopic approach have been proven beneficial in surgery of the colon. However, patients have still pain, nausea and vomiting postoperatively. Postoperative pain is an expected but undesirable effect after an operation. This study will compare Transabdominis Plane (TAP) Block and Quadratus Lumborum (QL) Block with the common postoperative treatment with enteral and parenteral analgesics.

Study Overview

• Status: Unknown
• Conditions: Pain, Postoperative; Surgery; Colon Neoplasm
• Intervention / Treatment: Procedure: Left hemicolectomy, laparoscopic technique

Detailed Description

TAP is a recommended multimodal method of reducing postoperative pain in laparoscopic and open surgery. TAP block seems to be feasible and effective in postoperative pain control without increasing morbidity in colon resections. QL block is also performed as one of the perioperative pain management procedures in abdominal surgery. It is regarded as an effective analgesic tool. The dermatomal effects of QL block reach higher than the TAP block, and might explain the better effect of the QL block than TAP blocks on postoperative pain after caesarean delivery. For this study the investigators standardize the type of surgery to be left hemicolectomy. This is the most common procedure on colon.

Power and Sample Size Calculator:

The number of patients required for the study was calculated on the basis of opioid consumption. We were interested in a reduction by 20% in the group given QLB. Assuming α=0,05, we calculated that we need 69 patients (23 in each group) to achieve a power of 80% (β=0.2).

75 adult patients scheduled for left hemicolectomy have to be included.

Subcutaneous wound infiltration at the end of surgery in all patients with ropivacaine 2 mg/ml, 20 ml. Maximum allowed dosis of Ropivacain is 3 mg/kg bodyweight (BW), dosis reduction if BW<70 kg Premedication: Paracetamol 2 g and Diklofenak 100 mg orally. General anaesthesia: TCI: Propofol and Remifentanil Ondansetron 4 mg, dexamethasone 8 mg and Oxycodone 5 mg intravenously at the end of surgery.

Postoperatively:

Oral paracetamol and codeine-fixed combination up to 1000 mg and 60 mg, respectively, every 6 h In case of insufficient analgesia, as judged by the patient, oxycodon 2 - 5 mg IV.

When nausea and vomiting occure postoperatively, ondansetron 4 mg IV administers as the drug of first choice followed by droperidol 0,625 mg IV if the nausea/vomiting persists.

Collected data:

Postoperative pain at rest and during activity evaluated by a 4-points verbal pain score (VPS; with no pain=0, slight pain = 1, Moderate pain = 2, and severe pain = 3) on admission to recovery, and every hour until discharge.

Rescue analgesic consumption during 0 to 4, 4 to 24 and 24 to 48 h. Sedation, nausea and vomiting record by the same 0 - 3 scale (none, slight, moderate, strong) during recovery Time of postoperative mobilization with corresponding pain score. Time of discharge-to-home or ward readiness according to standard criteria, including stable vital signs, no bleeding from the surgical site, ability to void, absence of excessive nausea and pain, and ability to dress and walk without support.

Side effects including nausea and/or vomiting (0 to 4, 4 to 24, and 24 to 48 h), antiemetics administered (0 to 24 and 24 to 48 H), grade of sedation (0 to 10 scale, where 0 = awake, and 10 = aroused on stimulation), and other side effects and symptoms of LA toxicity.

Telephone interview at 24 h, 48 h and 7 days, with questions:

Pain during rest and activity using the VPS Total need of analgesics Sedation Nausea Level of activity Overall satisfaction with the per- and postoperative period on a 0 - 3 scale: not satisfied, slight, moderate or highly satisfied.

• Study Type: Interventional
• Enrollment (Anticipated): 75
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Norway
  • Ostfold
    • Grålum, Ostfold, Norway, 1714
      • Recruiting
      • Ostfold Hospital Trust, Moss
      • Contact: Jan Sverre Vamnes, MD, Ph.D.; Phone Number: +47 91608896; Email: janvam@so-hf.no
      • Contact: Knut Inge Solbakk, md; Phone Number: +47 90933106; Email: knisol@so-hf.no

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age 18-80 Years
• BMI 20-35
• ASA physical status I-II

Exclusion Criteria:

• Allergy to LA
• Chronic pain requiring opioid analgesics
• Patients with atrioventricular block II
• Patients treated with class III antiarrhythmics
• Patients with severe renal and/or hepatic disease
• A coagulation disorder
• An infection at the LA injection place

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Left hemicolectomy without nerve blocks; Left hemicolectomy, laparoscopic technique Enteral and parenteral analgesics such as paracetamol and oksykodon	Procedure: Left hemicolectomy, laparoscopic technique; Left hemicolectomy, Laparoscopic technique; Other Names: QL block bilateral with ropivacain 3,75 mg/ml (2 x 20 ml); TAP block with ropivacain 3,75 mg/ml (2 x 20 ml); Traditional analgesics such as paracetamol and oksycodon
Active Comparator: Left hemicolectomy with TAP block; Left hemicolectomy, laparoscopic technique TAP block bilateral with Naropin 3,75 mg/ml, 2 x 20 ml	Procedure: Left hemicolectomy, laparoscopic technique; Left hemicolectomy, Laparoscopic technique; Other Names: QL block bilateral with ropivacain 3,75 mg/ml (2 x 20 ml); TAP block with ropivacain 3,75 mg/ml (2 x 20 ml); Traditional analgesics such as paracetamol and oksycodon
Active Comparator: Left hemicolectomy with QL block; Left hemicolectomy, laparoscopic technique QL block bilateral with Naropin 3,75 mg/ml, 2 x 20 ml	Procedure: Left hemicolectomy, laparoscopic technique; Left hemicolectomy, Laparoscopic technique; Other Names: QL block bilateral with ropivacain 3,75 mg/ml (2 x 20 ml); TAP block with ropivacain 3,75 mg/ml (2 x 20 ml); Traditional analgesics such as paracetamol and oksycodon

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Use of analgesics - "change" is being assessed	Amount of analgesics used postoperative	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain at the incision site - "change" is being assessed	VPS (Verbal Pain Score): No pain = 0, Slight pain = 1, Moderate pain= 2, Severe pain = 3	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)
Deep pain and pain on coughing - "change" is being assessed	VPS (Verbal Pain Score): No pain = 0, Slight pain = 1, Moderate pain= 2, Severe pain = 3	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)
Nonsteroidal anti-inflammatory drug consumption - "change" is being assessed	Amount of different medicaments in mg	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)
Postoperative nausea and vomiting - "change" is being assessed	0 - 3 score where None = 0, Little nausea = 1, Can not eat = 2, Vomiting = 3	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)
Antiemetic administered - "change" is being assessed	Amount of different medicaments in mg	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)
Sedation scores - "change" is being assessed	Sleepy or active. Score: Awake = 0, Tired = 1, Falls asleep = 2, Asleep all the time = 3	1 week (0-4 hrs) (4-24 hrs) (24-48 hrs) (48 - 168 hrs)

Collaborators and Investigators

• Sponsor: Ostfold Hospital Trust
• Investigators: Principal Investigator: Jan Sverre Vamnes, MD, Ph.D., Senior consultant

Publications and helpful links

General Publications

• El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, Kapral S, Marhofer P. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 2009 Jun;102(6):763-7. doi: 10.1093/bja/aep067. Epub 2009 Apr 17. Erratum In: Br J Anaesth. 2009 Oct;103(4):622.
• Blanco R, Ansari T, Riad W, Shetty N. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial. Reg Anesth Pain Med. 2016 Nov/Dec;41(6):757-762. doi: 10.1097/AAP.0000000000000495. Erratum In: Reg Anesth Pain Med. 2018;43:111.
• Borglum J, Gogenur I, Bendtsen TF. Abdominal wall blocks in adults. Curr Opin Anaesthesiol. 2016 Oct;29(5):638-43. doi: 10.1097/ACO.0000000000000378.
• Murouchi T, Iwasaki S, Yamakage M. Quadratus Lumborum Block: Analgesic Effects and Chronological Ropivacaine Concentrations After Laparoscopic Surgery. Reg Anesth Pain Med. 2016 Mar-Apr;41(2):146-50. doi: 10.1097/AAP.0000000000000349.
• Ueshima H, Otake H, Lin JA. Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques. Biomed Res Int. 2017;2017:2752876. doi: 10.1155/2017/2752876. Epub 2017 Jan 3.
• Pirrera B, Alagna V, Lucchi A, Berti P, Gabbianelli C, Martorelli G, Mozzoni L, Ruggeri F, Ingardia A, Nardi G, Garulli G. Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surg Endosc. 2018 Jan;32(1):376-382. doi: 10.1007/s00464-017-5686-7. Epub 2017 Jul 1.

Study record dates

Study Major Dates

• Study Start (Actual): February 28, 2018
• Primary Completion (Anticipated): December 31, 2020
• Study Completion (Anticipated): December 31, 2020

Study Registration Dates

• First Submitted: February 28, 2018
• First Submitted That Met QC Criteria: March 7, 2018
• First Posted (Actual): March 8, 2018

Study Record Updates

• Last Update Posted (Actual): March 13, 2019
• Last Update Submitted That Met QC Criteria: March 12, 2019
• Last Verified: March 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Neoplasms; Neoplasms by Site; Postoperative Complications; Pain; Neurologic Manifestations; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Colonic Diseases; Intestinal Diseases; Intestinal Neoplasms; Colorectal Neoplasms; Pain, Postoperative; Colonic Neoplasms; Physiological Effects of Drugs; Peripheral Nervous System Agents; Sensory System Agents; Analgesics
• Other Study ID Numbers: 1813

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No