Postoperative analgesic effects of the quadratus lumborum block III and transversalis fascia plane block in paediatric patients with developmental dysplasia of the hip undergoing open reduction surgeries: a double-blinded randomised controlled trial

Abstract

Objective: To evaluate the analgesic effectiveness of two novel regional nerve blocks in paediatric patients with developmental dysplasia of the hip (DDH) after open reduction surgeries.

Design: Prospective, double-blinded, randomised controlled trial.

Setting: 2 tertiary teaching hospitals in China between August 2017 and July 2018.

Participants: 110 paediatric patients aged 2-10 years with DDH undergoing open reduction surgeries were recruited, 95 were randomised and 90 were included in the final analysis.

Interventions: Random assignment to quadratus lumborum block III (QLB III) group, transversalis fascia plane block (TFPB) group and the control (no region nerve block) group.

Primary and secondary outcome measures: The primary outcome was the Face, Legs, Activity, Cry and Consolability (FLACC) Scale Scores. Secondary outcomes included perioperative opioid consumption, the time until first press of nurse-controlled analgesia/patient-controlled analgesia (NCA/PCA) pump and the total counts number of pressing, length of postanaesthesia care unit (PACU) stay, length of hospital stay, parental satisfaction with pain management and adverse events.

Results: Mean FLACC Scores were significantly lower in QLB III group and TFPB group while in the PACU and for 48 hours postoperatively, compared with control group (p<0.0001, p<0.0001, respectively). No differences were found for FLACC Scores between QLB III group and TFPB group, neither at rest (p=0.0402) nor while posture changing (p=0.0306). TFPB prolonged the first-time request for NCA/PCA analgesia, and decreased the total number of pressing counts, compared with QLB III (22.5 (16.2 to 28.7) vs 11.7 (6.6 to 16.8), p<0.0001; 2.4 (1.3 to 3.6) vs 3.8 (2.8 to 4.8), p=0.0111, respectively). No patient experienced any adverse events.

Conclusions: We suggested that both ultrasound-guided QLB III and TFPB should be considered as an option for perioperative analgesia in children with DDH undergoing open reduction surgeries. TFPB was superior to the QLB III because it prolonged the first-time request for NCA/PCA analgesia and decreased the total counts number of pressing.

Trial registration number: NCT03189966/2017.

Keywords: paediatric anaesthesia; paediatric plastic & reconstructive surgery; pain management; ultrasound.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Ultrasonic images showing the ultrasound-guided QLB III and TFPB. (1A) The ultrasound image of QLB III illustrates the osseous structure and muscular structure, which seems like a ‘Shamrock’. The triangular quadratus lumborum (QL, red dash line) muscle is adherent to the apex of the transverse process (white dash line) of vertebral body. (1B) The needle (white arrow) penetrates the QL muscle with an in-plane approach from the posterior side of the ultrasound probe. ES: erector spinae; PM: psoas major; LA: local anaesthetic (yellow dash line). (2A) An ultrasound image of the external oblique, the internal oblique and the transversus abdominis (TA) tapering off posteriorly into their common aponeurosis adjacent to the QL (red dash line). Transversalis fascia (the orange shadow) is deep in the aponeurosis of the TA muscle and right against the peritoneum. (2B) The needle tip (white arrow) is positioned just in the transversalis fascia (the orange shadow). LA: local anaesthetic (yellow dash line). QLB III, quadratus lumborum block III; TFPB, transversalis fascia plane block.

Figure 2

A Consolidated Standards of Reporting Trials flow diagram of this study. A standard flow diagram shows all steps of this clinical trial. QLB, quadratus lumborum block; TFPB, transversalis fascia plane block.

Figure 3

Transverse diagram of TFPB and QLB III. The course of the subcostal nerve (SCN) is indicated, including the lateral cutaneous branch (LCB) and the anterior cutaneous branch (ACB). The needle (N-TFPB) passing through anterolateral abdominal wall to posterior abdominal wall can be showed clear and pointed to lumbar vertebrae (L3) closely above the peritoneum (P). The location of the local anaesthetic (LA-TFPB) across the anterior surface of the quadratus lumborum (QL) and behind the transversalis fascia (TF) is shown. The needle (N-QLB III) penetrated the QL from back. The target point (LA-QLB III) is the interfascial plane between the QL and the psoas major (PM) muscle just deep to the TF. lumbar plexus (LP), erector spinae (ES), transversus abdominis (TA), internal oblique (IO) and external oblique (EO). QLB III, quadratus lumborum block III; TFPB, transversalis fascia plane block.