Truncal Blocks for Pediatric With Developmental Dysplasia of the Hip Undergoing Open Reduction
Condition: Developmental Dysplasia of the Hip (DDH)
MeSH terms: Developmental Dysplasia of the Hip; Hip Dislocation, Congenital; Hyperplasia
Study type: Interventional

Summary: 
      The aim of the study is to evaluate the effectiveness of ultrasound-guided transversalis
      fascia plane block (TFPB) and quadratus lumborum block (QLB) on post-operative analgesia in
      pediatric patients with Developmental Dysplasia of the Hip (DDH)under going open reduction
      surgeries（Salter acetabular osteotomy，combined with proximal femoral rotation osteotomy）.The
      effectiveness of TFPB/QLB for perioperative analgesia in lumbar nerves (L1) innervated
      surgery have been demonstrated in recent studies. However, this regional technique rarely
      applied to children.The objective of our research is to assess the quality of postoperative
      analgesia in pediatric patients who had received a preoperative TFPB/QLB for hip surgery.
    

Detailed description: 
      90 pediatric patients(age 2-10years) in the BeiJing Ji Shui Tan Hospital and The Second
      Affiliated Hospital of Wen Zhou Medical University with American Society of Anesthesiologists
      (ASA) physical status I or II, who are scheduled to undergo open reduction surgeries （Salter
      acetabular osteotomy，combined with proximal femoral rotation osteotomy）are selected and
      divided into 3 equal groups with 30 subjects.The consent forms are approved by the
      institutional Ethics Committee.

      Inclusion Criteria: Pediatric patients between 2 years to 10 years with DDH, scheduled for
      unilateral open reduction surgeries（Salter acetabular osteotomy，combined with proximal
      femoral rotation osteotomy）.

      Exclusion Criteria:Patients will be excluded if participants meet any of the following
      criteria:patients with known allergy to local anaesthetics, mental disability, peripheral
      neuropathy, a coagulopathy disorder,localized infection in the area, and any reason cause
      reoperation.

      Electrocardiogram, non-invasive blood pressure, pulse oximetry, temperature,capnography, and
      end tidal anesthetic concentration values are monitored in patients Parental presence will be
      allowed if requested for the induction of anesthesia. Pediatrics without vein access will
      receive general anesthesia which induces with 8% sevoflurane in 70% nitrous oxide and 30%
      oxygen, via a facemask. When loss of consciousness is achieved,investigators need to
      establish vein access routinely.Intravenous induction for general anesthesia with
      endotracheal intubation is commenced using intravenous propofol 3 mg/kg, cis-atracurium 0.2
      mg/kg,fentanyl 2. ug/kg. Anesthesia will be maintained using remifentanyl, and a volatile
      anesthetic(sevoflurane). The inhaled concentration of sevoflurane will be adjusted to
      maintain hemodynamic stability, which is defined as a change in systolic blood pressure and
      heart rate of no more than 20% of baseline parameters. The use of opioids during the
      perioperative periods at the discretion of the anesthetist. Some anesthetists administer
      opioids preemptively, however, in the majority of cases the decision is based on the
      cardiovascular response to stimulation; an increase in heart rate of 10% from baseline is
      usually interpreted as insufficient analgesia and is treated with opioids. Patients will be
      given either fentanyl in doses of 1-2mcg/kg, remifentanil as continuous infusion 0.01-0.03
      mcg/ (kg.min) or a combination of these.

      TFPB group Patients in transversalis fascia plane block group(Group T) will receive
      ultrasound-guided transversalis fascia plane block using0.3% ropivacaine(0.8 ml/kg) after
      general anesthesia. A high-frequency probe (Sono-Site HFL50x, 15- 6 MHz, 55-mm broadband
      linear array) connected to an S-nerve ultrasound machine((Sonosite Inc,Bothell, WA, USA) was
      positioned with a transverse orientation, between iliac crest and costal margin.With the
      patient in a supine position, the needle is advanced from the anterior using an in-plane
      technique. A linear ultrasound probe is orientated transversely over the lateral abdomen
      between the iliac crest and the costal margin. The external oblique, internal oblique,and
      transversus abdominis muscles are imaged, and the more posterior transversus aponeurosis is
      isolated from these muscles.The reflection of the peritoneum curving away from the muscles
      from anterior to posterior, and the perinephric fat, which lies behind the peritoneum and
      deep to the transversalis fascia, are both identified. The perinephric fat is generally more
      prominent closer to the iliac crest. The quadratus lumborum is identified medial to the
      aponeurosis of the transversus abdominis. The end point is more visible if the needle is
      passed through the posterior''tail'' of the transversus muscle, as the transversus
      aponeurosis is thinner and less distinct as a separate layer. After passing through the deep
      surface of transversus abdominis muscle, local anesthetic is injected to separate the
      transversalis fascia from the transversus muscle. The correct needle position was confirmed
      by injection of 2 ml of normal saline solution that was spreading anterio-posteriorly between
      the anterior border of QLM and its fascia, in addition to a minimal anterior spread in TAP
      plane. After negative aspiration, 0.8 ml/Kg of ropivacaine 0.3%was injected.

      QLB group Patients in quadratus lumborum block group（Group Q） will receive ultrasound-guided
      quadratus lumborum block using 0.3% ropivacaine(0.8 ml/kg).after general anesthesia.The TFPB
      is performed with the patient in the lateral position using a curvilinear low-frequency
      ultrasound probe.This is orientated transversely at the posterior axillary line between the
      iliac crest and the costal margin using a 22G 100-mm needle.The needle is directed in the
      posterior to anterior orientation with the practitioner standing behind the patient. The
      triangular quadratus lumborum (QL) muscle is adherent to the apex of the transverse process
      of L3 vertebra.Using the Shamrock method, a new transmuscular quadrates lumborum block
      technique, developed by Børglum (British Journal of Anaesthesia, 2013), the needle penetrates
      the QL muscle with an in-plane approach from the posterior side of the ultrasound probe. The
      target point is the interfascial plane between the QL and the psoas major muscle just deep to
      the transversalis fascia, in order to lessen the risk of unintentional penetration of the
      peritoneal cavity contrary to the technique. The correct needle position was confirmed by
      injection of 2 ml of normal saline solution that was spreading antero-posteriorly between the
      QL and the psoas major muscle. After negative aspiration, 0.8 ml/Kg of ropivacaine 0.3%was
      injected.

      Control group Patients in the third group as control (Group C) receive no nerve
      block.Patients will be extubated based on clinical criteria.

      Patients will then be transported to the post-operative anesthesia care unit (PACU) after
      extubation.All pediatric patients will receive 6-hourly paracetamol post-operatively for two
      days and receive sufentanyl via nurse-controlled analgesia (NCA) or patient-controlled
      analgesia (PCA). The prescription of post-operative NCA/PCA is also at the discretion of the
      anesthetist. Children under the age of 6 years will receive sufentanyl via NCA continuously
      at a rate of 2 mcg/(kg.48h) with a bolus option of 0.01 mcg/kg every 15 minutes.Older
      children will receive sufentanyl via PCA continuously at a rate of 2 mcg/( kg.48h) with a
      bolus option of 0.01 mcg/kg every 15 minutes.

      Data collection will include the type of procedure, age, weight, type of truncal block (QLB
      group vs TFPB vs control).Primary outcome was the FLACC (ie, the Face, Legs, Activity,
      Consolability Scale) score of patients in the PACU and at 2h, 4h, 8h, 12h, 24h, 48h
      postoperatively. Secondary outcomes included intraoperative MBP and HR at the endpoints of
      Salter acetabular osteotomy(T1), femoral rotation osteotomy (T2), and anterior superior iliac
      spine osteotomy (T3) during the surgery; intraoperative opioid consumption (i.e., fentanyl
      and remifentanil); duration of the surgery; postoperative fentanyl consumption in the PACU,
      postoperative morphine consumption in the ward; the length of PACU stay; the time until first
      press of NCA/PCA pump and the total counts number of pressing the pump; length of hospital
      stay; complications (e.g., immediate complications such as vessel puncture and possible
      undesirable effects such as hypotension, bradycardia, epidural local anesthetic spread, or
      postoperative nausea and vomiting). The number of doses of rescue analgesics (morphine 0.05
      mg/kg) in the postoperative period (48 h) will be recorded. Rescue treatment of postoperative
      nausea and vomiting,will be treated with ondansetron (0.1 mg/kg) if needed.Side effects such
      as pruritus will also be noted.
    

Intervention name(s): transversalis fascia plane block; quadratus lumborum block
Intervention type(s): Procedure; Procedure
Intervention description(s): With the patient in a supine position, the needle is advanced from the anterior using an in-plane technique. A linear ultrasound probe is orientated transversely over the lateral abdomen between the iliac crest and the costal margin. Local anesthetic is injected to separate the transversalis fascia from the transversus muscle. The correct needle position was confirmed by injection of 2 ml of normal saline solution that was spreading anterio-posteriorly between the anterior border of QLM and its fascia, in addition to a minimal anterior spread in TAP plane. After negative aspiration, 0.8 ml/Kg of ropivacaine 0.3%was injected.; The needle is directed in the posterior to anterior orientation with the practitioner standing behind the patient. The triangular quadratus lumborum (QL) muscle is adherent to the apex of the transverse process of L3 vertebra. Using the Shamrock method, the needle penetrates the QL muscle with an in-plane approach from the posterior side of the ultrasound probe. The target point is the inter fascial plane between the QL and the psoas major muscle just deep to the transversalis fascia, in order to lessen the risk of unintentional penetration of the peritoneal cavity contrary to the technique. The correct needle position was confirmed by injection of 2 ml of normal saline solution that was spreading anterio-posteriorly between the QL and the psoas major muscle. After negative aspiration, 0.8 ml/Kg of ropivacaine 0.3%was injected.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: transversalis fascia plane block; quadratus lumborum block; ultrasound-guided; Developmental Dysplasia of the Hip; postoperative analgesia