Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Analgesia in Children
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The aim of the present study is to evaluate and compare the analgesic effect of
      ultrasound-guided Quadratus Lumborum Block with ultrasound-guided Transversus Abdominis plane
      block in pediatric Laparoscopic lower abdominal surgeries
    

Detailed description: 
      90 male and female patients aged from 1 to 7 years old from ASA class I to II undergoing
      elective laparoscopic lower abdominal surgery will be randomly divided into three equal
      groups of thirty patients each by using computer generated random table.

      Technique of the study After insertion of venous access, all children received premedication
      in the form of atropine at a dose of 0.01-0.02 mg/kg. Perioperative monitoring included
      continuous ECG, pulse oximetry and non-invasive arterial blood pressure. Baseline reading of
      heart rate, mean arterial blood pressure was recorded after monitor attachment. General
      anesthesia will be induced using propofol 1.5-2.5 mg/kg over 20-30 sec. as tolerated,
      atracurium 0.5 mg/kg to facilitate endotracheal intubation and fentanyl 1 µg/kg. Anesthesia
      will be maintained using isoflurane (1 MAC) and atracurium 0.1 mg/kg supplements will be
      given to maintain muscle relaxation.

      TAP block or quadratus lumborum block will be performed in all patients immediately after
      induction and before starting of surgery. patients will be allocated randomly into three
      equal groups , 30 patients in each as the following :-

      Group C "Control group" will receive regular analgesics (1 µg /kg fentanyl with induction and
      15mg/kg paracetamol before extubation).

      Group TAP "TAP group" will receive bilateral TAP block using (0.5 ml/ kg bupivacaine 0.25%)
      in each side + regular analgesics.

      Group QL"quadratus lumborum group" will receive bilateral quadratus lumborum block using (0.5
      ml/ kg bupivacaine 0.25%) in each side + regular analgesics.

      TAP block procedure

      With the patient in the supine position, the site of the ultrasound and needle entry was
      sterilized. The TAP block will be performed laterally behind the midaxillary line between the
      iliac crest and the most inferior extent of the ribs. The plane between the internal oblique
      and transversus abdominis muscle located around the midaxillary line with the probe
      transverse to the abdomen. Anteriorly, the needle passes to come perpendicular to the
      ultrasound beam and placed between transversus and internal oblique posterior to the
      midaxillary line. Then, the local anesthetic will be injected. QL block prcedure

      bilateral ultrasound guided transmuscular quadrates lumborum (TQL) block was given SONOSITE
      NANOMAX; the scanning probe was the linear 25N multifrequency 13-6 MHz transducer (L25x13-6
      MHz linear array) made in USA. In lateral position, the side to be blocked was kept up and
      probe was placed in the midaxillary line in the transverse plane immediately above the iliac
      crest and then it was slided dorsally till the Shamrock sign was clearly identified. In
      "Shamrock sign" The quadratus lumborum (QL) muscle is seen as a superior leaf of the Shamrock
      at the apex of the transverse process (TP) of L4, erector spinae (ES) muscles make up the
      posterior leaf, psoas major (PM) muscle makes the anterior leaf and the transverse process
      (TP) represents the stem connecting the 3leaves. A 22-G 90-mm spinal needle was inserted from
      the posterior end of the probe and directed for the fascial plane between the QL and PM
      muscles through the QL muscle. Once needle was confirmed at correct location the drug was
      injected. Other side was also injected in similar manner. The parents were not aware of group
      allocation as the block was done after induction of anesthesia. An independent
      anesthesiologist conducted postoperative assessments and was not aware of group allocation

      The surgical intervention was started 15 min after QL block. Pneumoperitoneum was maintained
      at a flow rate of 0.5 L/min and a pressure of 8-12 mm Hg with CO2 insufflation.

      After completion of surgical procedure anesthesia was discontinued, muscle relaxant reversed
      using atropine 0.02 mg/kg and 0.05 mg/kg of prostigmine. Paracetamol infusion (15 mg/kg) will
      be given by intravenous infusion before extubation. After extubation transfer the children to
      PACU.

      Postoperatively pain will be assessed using FLACC score (face, leg, activity, cry and
      consolability) as shown in the table below. Acetaminophine (perfalgan) 15 mg/kg IV will be
      given as rescue analgesia for patients if FLACC score >4.

      Parameters will be assessed

      A. Preoperative and intraoperative measurements:

        1. Hemodynamic parameters: HR, MAP and SaO2 were recorded before and immediately after
           induction of anesthesia, at the time of puncture of the prop and then every 5 min
           intervals until the end of the operation.

        2. Analgesic requirement: all through the procedure (by measuring the analgesic need intra
           operative in the form of fentanyl 0.5 µg/kg) in case of increase in intraoperative mean
           arterial blood pressure or heart rate of more than 20% of baseline for longer than 5
           minutes.

        3. Incidence of complications: in the form of hemodynamic instability, injury to the
           underlying structures, and hematoma formation as recorded under ultrasound guidance.

      B. Postoperative measurement:

      1. The number of patients who require rescue analgesia in the first 24 h. 2. Quality of
      analgesia: it will be assessed immediately postoperatively, every 30min in the PACU and then
      at 4, 6, 8, 10, 12, 18, and 24 h postoperatively using FLACC score.

      3. Time to the first analgesic requirement: Duration of analgesia was defined as the time
      interval from completion of local anesthetic administration till first need of rescue
      analgesic (FLACC>4) in the form of IV paracetamol 15mg/kg.

      Each category is scored on the 0-2 scale, which results in a total score of 0-10. 0 Relaxed
      and comfortable 1-3 Mild discomfort Behaviour 0 1 2 Face No particular expression or smile

      Occasional grimace or frown, withdrawn, disinterested

      Frequent to constant quivering chin, clenched jow Legs Normal position or relaxed

      Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position,
      moves easily

      Squirming, shifting, back and forth, tense

      Arched, rigid or jerking Cry No cry (awake or asleep)

      Moans or whimpers; occasional complaint

      Crying steadily, screams, sobs, frequent complaints Consolability Content, relaxed Reassured
      by touching, hugging or being talked to, distractible Difficult to console or comfort 4-6
      Moderate pain 7-10 Severe discomfort or pain or both (Merkel, et al., 1997) 4. Total amount
      and the numbers of analgesic doses in 24h. 5. Hemodynamic data: HR, MAP and SaO2 were
      recorded up to 120 min.

      6. length of hospital stay and patients or parents satisfaction assessed on a 5point scale.
      1-completely dissatisfied, 2-dissatisfied, 3-not satisfied nor dissatisfied, 4- satisfied
      5-completely satisfied 7. Postoperative complication: including postoperative hypotention or
      bradycardia (decrease in MAP or HR by more than 20% of baseline value), postoperative nausea
      and vomiting (PONV).
    

Intervention name(s): regional nerve block
Intervention type(s): Other
Intervention description(s): Abdominal field blocks have been used in anesthesia for surgery involving the anterior abdominal wall with ultrasound-guided technique. TAP block is a regional anesthetic technique that blocks neural afferents of the anterolateral abdominal wall. Using anatomical landmark guidance or with the aid of ultrasound (US), local anesthetic is injected into the transversus abdominis fascial plane, where the nerves from T6 to L1 are located. Ultrasound-guided quadratus lumborum (QL) block is considered now as one of the novel truncal abdominal blocks, as it is effective in preventing somatic pain associated with upper and lower abdominal surgeries.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment