Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter May 21, 2019

Quadratus lumborum block for postoperative analgesia after full abdominoplasty: a randomized controlled trial

Thor W. Bjelland, Thomas G.R. Yates, Morten W. Fagerland, Jan K. Frøyen, Karl R. Lysebråten and Ulrich J. Spreng

Abstract

Background and aims

The quadratus lumborum block (QLB) provides regional analgesia of the anterior abdominal wall, theoretically matching the postoperative pain after postbariatric standard full abdominoplasty. We investigated the effectiveness of a QLB as an addition to the current multimodal analgesia regimen in postbariatric patients treated with standard full abdominoplasty.

Methods

Randomized, placebo-controlled, triple blinded study (n = 50). All patients received perioperative paracetamol and intraoperative local anesthetic infiltration. QLB was administered bilaterally before induction of general anesthesia with 2 × 20 mL of either ropivacaine 3.75 mg/mL (n = 25) or placebo (saline 9 mg/mL) (n = 25). Patients received intravenous patient controlled opioid analgesia postoperatively. The primary endpoint was opioid use during the first 24 postoperative hours. Secondary endpoints were acute and chronic postoperative pain, postoperative nausea and vomiting, and other side effects.

Results

Patient characteristics were similar between groups. The primary endpoint in morphine equivalent units was similar between groups during the first 24 h with mean (SD) of 26 (25) vs. 33 (33) mg (p = 0.44) in the ropivacaine and placebo group, respectively. The observed effect was smaller, and SD larger than assumed in the sample size estimation. Linear mixed effects modeling indicated a minimal inter-group difference. No differences were found for secondary endpoints.

Conclusions

The QLB did not provide significant additional benefit in terms of reduced opioid requirements or secondary endpoints when administered as part of a multimodal pain regimen to postbariatric patients undergoing standard full abdominoplasty. A minimal difference of little clinical importance the first 12 postoperative hours may have been missed.

Implications

Including the QLB in the current multimodal pain regimen cannot be recommended based on these findings. The study does not preclude QLB use in individual cases where the multimodal regimen is inadequate or contraindicated. The effectiveness of the QLB for supraumbilical pain remains undocumented.


Corresponding author: Karl R. Lysebråten, MD, Department of Anesthesia, Intensive Care and Emergencies, Baerum Hospital, Sogneprest Munthe-kaas vei, Vestre Viken HT, 1346 Sandvika, Norway, Phone: +47 67809326

Acknowledgements

Pain nurses Helena Blom and Bjørg Farup (patient follow up, 24-h recordings); Research nurse Elisabet Anderson (patient inclusion and data verification/plotting); The nurse anesthetists at Bærum hospital (perioperative recordings); The post-anesthesia care unit nurses at Bærum hospital (postoperative recordings); The nurses at the ward for gynecology and plastic surgery at Bærum hospital, with a special thanks to Kersti Gerner (12 and 24-h recordings); Torill M. Skudal, Jarle B. Haugland and Cecilie S. Lootsma at the hospital pharmacy for providing blinded study drugs.

  1. Authors’ statements

  2. Research funding: The study was funded by a grant from Vestre Viken Hospital Trust, Norway.

  3. Conflict of interest: The authors have no conflicts of interest.

  4. Informed consent: Informed consent has been obtained from all individuals included in this study.

  5. Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and was approved by The South East Regional Ethics Committee, Postboks 1130, Blindern, 0318 Oslo, Norway, under the protocol number 2016/1307, on Oct 10, 2016.

References

[1] Araco A, Pooney J, Araco F, Gravante G. Transversus abdominis plane block reduces the analgesic requirements after abdominoplasty with flank liposuction. Ann Plast Surg 2010;65:385–8.10.1097/SAP.0b013e3181cc2a24Search in Google Scholar PubMed

[2] Fiala T. Tranversus abdominis plane block during abdominoplasty to improve postoperative patient comfort. Aesthet Surg J 2015;35:72–80.10.1093/asj/sju019Search in Google Scholar PubMed

[3] Sforza M, Andjelkov K, Zaccheddu R, Nagi H, Colic M. Transversus abdominis plane block anesthesia in abdominoplasties. Plast Reconstr Surg 2011;128:529–35.10.1097/PRS.0b013e31821e6f51Search in Google Scholar PubMed

[4] 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;117:387–94.10.1093/bja/aew224Search in Google Scholar PubMed

[5] Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med 2016;41:146–50.10.1097/AAP.0000000000000349Search in Google Scholar PubMed

[6] American Society of Anesthesiologists. ASA Physical status classification system. Available at: https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed: 28 Dec 2017.Search in Google Scholar

[7] R Development Core Team. R: a language and environment for statistical computing. Version 3.4.3 ed. Vienna, Austria: R Foundation for Statistical Computing, 2017.Search in Google Scholar

[8] Boker A, Brownell L, Donen N. The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety. Can J Anaesth 2002;49:792–8.10.1007/BF03017410Search in Google Scholar PubMed

[9] American College of Physicians. Dosing and conversion chart for opioid analgesics. 2004. Available at: http://www.acpinternist.org. Accessed: 28 Nov 2015.Search in Google Scholar

[10] Pierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia Critical Care and Pain 2013;13:28–32.10.1093/bjaceaccp/mks046Search in Google Scholar

[11] Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, Haythornthwaite JA, Jensen MP, Kerns RD, Ader DN, Brandenburg N, Burke LB, Cella D, Chandler J, Cowan P, Dimitrova R, Dionne R, Hertz S, Jadad AR, Katz NP, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9:105–21.10.1016/j.jpain.2007.09.005Search in Google Scholar PubMed

[12] Brant R. Inference for means: comparing two independent samples. Available at: https://www.stat.ubc.ca/~rollin/stats/ssize/n2.html. Accessed: 27 Nov 2015.Search in Google Scholar

[13] Fagerland MW, Lydersen S, Laake P. The ordered 2×C table. In: Calver R, editor. Statistical Analysis of Contingency Tables. 1st ed. Boca Raton, FL: Chapman and Hall/CRC, 2017:223–74.10.1201/9781315374116-6Search in Google Scholar

[14] Silverman DG, O’Connor TZ, Brull SJ. Integrated assessment of pain scores and rescue morphine use during studies of analgesic efficacy. Anesth Analg 1993;77:168–70.10.1213/00000539-199307000-00033Search in Google Scholar

[15] Krohg A, Ullensvang K, Rosseland LA, Langesaeter E, Sauter AR. The analgesic effect of ultrasound-guided quadratus lumborum block after cesarean delivery: a randomized clinical trial. Anesth Analg 2018;126:559–65.10.1213/ANE.0000000000002648Search in Google Scholar PubMed

[16] Oksuz G, Bilal B, Gurkan Y, Urfalioglu A, Arslan M, Gisi G, Oksuz H. Quadratus lumborum block versus transversus abdominis plane block in children undergoing low abdominal surgery: a randomized controlled trial. Reg Anesth Pain Med 2017;42:674–9.10.1097/AAP.0000000000000645Search in Google Scholar PubMed

[17] Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlled trial. Eur J Anaesthesiol 2015;32:812–8.10.1097/EJA.0000000000000299Search in Google Scholar PubMed

[18] Abrahams M, Derby R, Horn JL. Update on ultrasound for truncal blocks: a review of the evidence. Reg Anesth Pain Med 2016;41:275–88.10.1097/AAP.0000000000000372Search in Google Scholar PubMed

[19] Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011;66:1023–30.10.1111/j.1365-2044.2011.06855.xSearch in Google Scholar PubMed

[20] 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;125:303–12.10.1213/ANE.0000000000001922Search in Google Scholar PubMed

[21] Kumar A, Sadeghi N, Wahal C, Gadsden J, Grant SA. Quadratus lumborum spares paravertebral space in fresh cadaver injection. Anesth Analg 2017;125:708–9.10.1213/ANE.0000000000002245Search in Google Scholar PubMed

[22] Tamura T, Kitamura K, Yokota S, Ito S, Shibata Y, Nishiwaki K. Spread of quadratus lumborum block to the paravertebral space via intramuscular injection: a volunteer study. Reg Anesth Pain Med 2018;43:1–6.10.1097/AAP.0000000000000735Search in Google Scholar PubMed

[23] Lenz H, Sandvik L, Qvigstad E, Bjerkelund CE, Raeder J. A comparison of intravenous oxycodone and intravenous morphine in patient-controlled postoperative analgesia after laparoscopic hysterectomy. Anesth Analg 2009;109:1279–83.10.1213/ane.0b013e3181b0f0bbSearch in Google Scholar PubMed


Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/sjpain-2019-0013).


Received: 2019-01-14
Revised: 2019-04-07
Accepted: 2019-04-15
Published Online: 2019-05-21
Published in Print: 2019-10-25

©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.

Scroll Up Arrow