Ultrasound-guided Two Different Type Blocks for Pain Relief in Totalabdominal Hysterectomy
Condition: Ultrasonography
Study type: Interventional

Summary: 
      Effective analgesia after total abdominal hysterectomy is important for faster recovery and
      preventing complications which depend to pain. A multimodal and preventive approach is
      preferred to ensure adequate analgesia and to avoid side effects due to high doses of
      analgesics. The hypothesis was that the Quadratus Lumborum block (application of local
      anesthetics to the side of the abdomen) would be superior to Transversus Abdominis Plane
      block (application of local anesthetics in front of the abdomen) for analgesia before
      abdominal incision in total abdominal hysterectomy. The primary goal of the study was to
      evaluate the feasibility of ultrasound-guided Transversus Abdominis Plane block and Quadratus
      Lumborum block. The secondary goal was to evaluate postoperative adverse effects and patient
      satisfaction.
    

Detailed description: 
      The study protocol was approved by the Local Ethics Committee. Written informed consent was
      obtained from each patient. The study was carried out in accordance with The Code of Ethics
      of the Declaration of Helsinki. The study was conducted between April 2017 - July 2017 with a
      prospective, randomized, double-blind design on 62 patients who had undergone total abdominal
      hysterectomy with Pfannenstiel incision. American Society of Anesthesiologist (ASA) II-III,
      patients between the ages of 18-75 were included in the study. The participants with bleeding
      diathesis, those who could not communicate (mental disorder, language problem, etc.), those
      with allergies to the drugs used, those who did not wish to participate in the study, and
      those who had an infection in the block area were excluded from the study. The participants
      were divided into 2 groups with the sealed envelope technique preoperatively Transversus
      Abdominis Plane Block Procedure Before the surgical procedure, the muscles were screened at
      the umbilicus plain/mid-axillary line with the ultrasound using a linear probe while the
      participants in the supine position. The skin, subcutaneous adipose tissue, external oblique
      muscle, internal oblique muscle, transversus abdominis muscle, and peritoneum were
      visualized. The block needle was advanced in the posterolateral direction with the in-plain
      approach. 0.3 ml/kg of 0.25% bupivacaine was administered bilaterally into the space between
      the internal oblique muscle and the transversus abdominis muscle.

      Transmuscular Quadratus Lumborum Block Procedure Quadratus lumborum muscle could be
      recognized with ultrasound via the convex probe was transversally attached above iliac crest
      at the midaxillary line while the patients were in the lateral decubitus position. The point
      of injection with a block needle in transmuscular Quadratus Lumborum Block is between the
      anterior border of Quadratus lumborum muscle and psoas major muscles. A transmuscular
      Quadratus Lumborum Block was performed bilaterally with 0,3 ml/kg 0.25% bupivacaine solution
      injection on each side.
    

Intervention name(s): PCA (patient controlled analgesia)
Intervention type(s): Device
Intervention description(s): Intravenous Patient-Controlled Analgesia was used for postoperative pain control with a bolus dose of 25 mg Tramadol and a lockout interval of 20 min. The pain was evaluated at different times after the operation, both at rest and movement (Dynamic VAS) at the 0., 2., 6., 12. hours and 24h later. All patients received 1 g iv paracetamol 8 hourly intervals regularly. 75 mg im diclofenac sodium was given as rescue analgesic.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention
Keywords: Nerve block; analgesia; pain management