Analgesia for Laparotomy in Cancer Patients: Quadratus Lumborum Block
Condition: Cancer
Study type: Interventional

Summary: 
      Regional anesthesia of the abdomen significantly reduce postoperative pain, spare the
      systemic opioids and decrease postoperative nausea and vomiting. Multiple regional techniques
      can be performed at the neuro-axis (epidural), the nerve root (paravertebral) and the
      peripheral nerve (transversus abdominis plane).

      Quadratus lumborum (QL) block is an addition into the league of truncal nerve block
      techniques that has been found to provide analgesia for abdominal surgeries. Several case
      reports have shown that local anesthetic injection around the quadratus lumborum muscle is
      effective in providing pain relief after various abdominal operations and in patients with
      chronic pain.

      The study hypothesis is that quadratus lumborum block in single shot may be more superior to
      transversus abdominus plane block as regard intra-operative and the post-operative analgesia.
    

Detailed description: 
      This is a prospective randomized controlled study conducted at Oncology Center-Mansoura
      University.

      102 patients were randomly allocated by closed envelope method into 2 equal groups:

        -  Quadratus lumborum block Group (Q) (n= 51): patients received 15 ml of 0.5% isobaric
           bupivacaine + 10 ml saline + 50 ug dexmedetomidine + epinephrine (1:100,000) for each
           side.

        -  Transversus abdominis plane Group (T) (n= 51): patients received 15 ml of 0.5% isobaric
           bupivacaine + 10 ml of saline + 50 ug dexmedetomidine + epinephrine (1:100,000) for each
           side.

      All blocks were performed after induction of general anesthesia and approximately 15 min
      before the skin incision.

        -  Technique of ultrasound guided quadratus lumborum Block: patient lie in lateral position
           to obtain appropriate view of quadratus lumborum and transversus abdominins plane
           extension of lateral abdominal muscles. In this approach, a high-frequency linear
           transducer (7-12 MHZ) attached to ultrasound machine was placed in anterior axillary
           line to visualize the typical triple abdominal layers. At the junction of the tapered
           ends of abdominal muscles and quadratus lumborum, a 21 G cannula needle was inserted in
           plane and confirmed its position by injecting saline. Under ultrasound guidance, saline
           separating thoracolumbar fascia from muscle is observed then local anesthetic is
           injected.

        -  Technique of ultrasound guided Transversus abdominis plane Block: Patient lie in supine
           position and high-frequency linear transducer (7-12 MHZ) attached to ultrasound machine
           placed in anterior axillary line between costal margin and iliac crest to visualize the
           typical triple abdominal layers. A 21 G cannula needle is then moved forward from an
           anteromedial position in a posterior and lateral direction using an in-plane technique
           with the entry point in the skin being separated from the probe in order to improve
           needle visibility in the long axis. The needle tip is inserted between transversus
           abdominis muscle and internal oblique muscle then local anesthetic is injected to
           produce separation between the two muscle.
    

Intervention name(s): Quadratus lumborum block; Transversus abdominis plane block
Intervention type(s): Other; Other
Intervention description(s): 15 ml of 0.5% isobaric bupivacaine + 10 ml saline + 50 micro gram dexmedetomidine + epinephrine (1:100,000) for each side.; 15 ml of 0.5% isobaric bupivacaine + 10 ml of saline + 50 micro gram dexmedetomidine + epinephrine (1:100,000) for each side.
Other intervention name(s): Group Q; Group T
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Supportive Care