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

Mohammad Ali Abduallah, Sameh Abdelkhalik Ahmed, Mohamed Shebl Abdelghany, Mohammad Ali Abduallah, Sameh Abdelkhalik Ahmed, Mohamed Shebl Abdelghany

Abstract

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.

Keywords: Elderly patients; hip arthroplsaty; patients' satisfaction; post-operative analgesia; quadratus lumborum block.

Conflict of interest statement

There are no conflicts of interest.

Copyright: © 2020 Indian Journal of Anaesthesia.

Figures

Figure 1
Figure 1
Ultrasound-guided quadratus lumborum block (transmuscular approach). (a) Cross-sectional sonoanatomy of the lateral abdominal wall showing from anterior to posterior EO – External oblique; QL – Quadratus lumborum; PM – Psoas major; TP – transverse process; VB – vertebral body; LD – latissimus dorsi; ES – Erector spinae. (b) Shamrock sign with the quadratus lumborum, psoas major and erector spinae muscles as leaves of the Shamrock and the transverse process as the stem. (c) Trajectory of the needle (yellow arrows) from the posterior to the anterior through the latissimus dorsi and the quadratus lumborum muscles, notice the needle tip (white arrow) in the fascial plane between the quadratus lumborum and the psoas major muscles. (d) Deposition of the local anaesthetic – LA; in the fascial plane between the quadratus lumborum and the psoas major muscles.
Figure 2
Figure 2
CONSORT flowchart of the study
Figure 3
Figure 3
Patients' satisfaction in the two groups. Control group (n = 30 patients) quadratus lumborum group (n = 30 patients). QL = Transmuscular quadratus lumborum block. Control group = sham group where we inject saline through transmuscular quadratus lumborum needle. Data were expressed as patients' number

References

    1. Rao AR, Lakshmanan A, Ajith A, Rao SM. Centenarians: Hip fractures and peripheral lower limb nerve blocks. Indian J Anaesth. 2010;54:268.
    1. Capdevila X, Macaire P, Dadure C, Choquet O, Biboulet P, Ryckwaert Y, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: New landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002;94:1606–13, table of contents.
    1. Biboulet P, Morau D, Aubas P, Bringuier-Branchereau S, Capdevila X. Postoperative analgesia after total-hip arthroplasty: Comparison of intravenous patient-controlled analgesia with morphine and single injection of femoral nerve or psoas compartment block. A prospective, randomized, double-blind study. Reg Anesth Pain Med. 2004;29:102–9.
    1. Cuvillon P, Ripart J, Lalourcey L, Veyrat E, L'Hermite J, Boisson C, et al. The continuous femoral nerve block catheter for postoperative analgesia: Bacterial colonization, infectious rate and adverse effects. Anesth Analg. 2001;93:1045–9.
    1. Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth. 2016;117:387–94.
    1. La Colla L, Uskova A, Ben-David B. Single-shot quadratus lumborum block for postoperative analgesia after minimally invasive hip arthroplasty: A new alternative to continuous lumbar plexus block? Reg Anesth Pain Med. 2017;42:125–6.
    1. Jagtap S, Chhabra A, Dawoodi S, Jain A. Comparison of intrathecal ropivacaine-fentanyl and bupivacaine-fentanyl for major lower limb orthopaedic surgery: A randomised double-blind study. Indian J of Anaesth. 2014;58:442.
    1. Talawar P, Tandon S, Tripathy D, Kaushal AJ. Combined pericapsular nerve group and lateral femoral cutaneous nerve blocks for surgical anaesthesia in hip arthroscopy. Indian J Anaesth. 2020;64:638.
    1. Blanco R. TAP block under ultrasound guidance: The description of a 'non pops technique'. Reg Anaesth Pain Med. 2007;32:130.
    1. Chakraborty A, Goswami J, Patro VJ, Practice A. Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient. A A Practice. 2015;4:34–6.
    1. Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block-an alternative to transversus abdominis plane block. Paediatr Anaesth. 2013;23:959–61.
    1. Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol. 2013;29:550–2.
    1. 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;41:757–62.
    1. Ueshima H, Otake H, Lin JA. Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques. Biomed Res Int. 2017;2017:2752876.
    1. Ueshima H, Yoshiyama S, Otake H. The ultrasound-guided continuous transmuscular quadratus lumborum block is an effective analgesia for total hip arthroplasty. J Clin Anesth. 2016;31:35.
    1. Kadam VR, Howell S. Ultrasound-guided continuous transmuscular quadratus lumborum block- L4 or L2 level catheter insertion for analgesia in open abdominal surgery: Case series. Indian J Anaesth. 2018;62:555–7.
    1. Dam M, Moriggl B, Hansen CK, Hoermann R, Bendtsen TF, Borglum J. The pathway of injectate spread with the transmuscular quadratus lumborum block: A cadaver study. Anesth Analg. 2017;125:303–12.
    1. Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani N, Nixon AM, Chin KJ. A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Anaesthesia. 2017;72:73–9.
    1. Elsharkawy H, El-Boghdadly K, Kolli S, Esa WA, DeGrande S, Soliman LM, et al. Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block. Eur J Anaesthesiol. 2017;34:587–95.
    1. Carvalho R, Segura E, Loureiro MD, Assuncao JP. Quadratus lumborum block in chronic pain after abdominal hernia repair: Case report. Rev Brasileira de Anaestesiol. 2017;67:107–9.
    1. Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015;32:812–8.
    1. Krohg A, Ullensvang K, Rosseland LA, Langesæter E, Sauter AR. The analgesic effect of ultrasound-guided quadratus lumborum block after cesarean delivery: A randomized clinical trial. Anesth Analg. 2018;126:559–65.
    1. Hockett MM, Hembrador S, Lee A. Continuous quadratus lumborum block for postoperative pain in total hip arthroplasty: A case report. A & A case reports. 2016;7:129–31.
    1. La Colla L, Ben-David B, Merman R. Quadratus lumborum block as an alternative to lumbar plexus block for hip surgery: A report of 2 cases. A & A case reports. 2017;8:4–6.
    1. Tulgar S, Ermis MN, Ozer Z. Combination of lumbar erector spinae plane block and transmuscular quadratus lumborum block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture. Indian J of Anaesth. 2018;62:802.
    1. Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol Reanim. 2016;63:141–8.
    1. Tulgar S, Kose HC, Selvi O, Senturk O, Thomas DT, Ermis MN, et al. Comparison of ultrasound-guided lumbar erector spinae plane block and transmuscular quadratus lumborum block for postoperative analgesia in hip and proximal femur surgery: A prospective randomized feasibility study. Anesth Essays Res. 2018;12:825–31.
    1. Kukreja P, MacBeth L, Sturdivant A, Morgan CJ, Ghanem E, Kalagara H, et al. Anterior quadratus lumborum block analgesia for total hip arthroplasty: A randomized, controlled study. Reg Anesth Pain Med. 2019;44:1–5.
    1. Kukreja P, MacBeth L, Potter W, Buddemeyer K, DeBell H, Elsharkawy H, et al. Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: A comparative study. Einstein (São Paulo) 2019;17:eA04905.
    1. Green MS, Hoffman CR, Iqbal U, Ives OO, Hurd B. Transmuscular quadratus lumborum block reduces length of stay in patients receiving total hip arthroplasty. Anesth Pain Med. 2018;8:E80233.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit