Quadratus Lumborum Block (Transmuscular Approach) VS. TransversusAbdominus Plane Block(Unilateral Posterior Approach) for Perioperative Analgesia in Patients Undergoing Flank Incision Surgeries.
Condition: Anesthesia, Local
Study type: Interventional

Summary: 
      Severe perioperative pain experienced after surgical procedures performed by flank incision
      is mainly related to incision of many muscles. Postoperative pain affects patient comfort,
      satisfaction, prolongs the duration of hospital stay and increases post-procedure
      complications. This study is designed to compare the success rate of Unilateral Ultrasound
      Guided Transmuscular Quadratus Lumborum Block with Unilateral posterior Ultrasound Guided
      TransversusAbdominus Plane block in providing perioperative analgesia in Patients undergoing
      Flank Incision surgeries in the Urosurgery Theater at KasrAlainy University Hospitals.
    

Detailed description: 
      Patients aged from 20-60 years old, scheduled for flank surgery procedure will be included in
      the study. Patients will be randomly allocated using concealed closed envelope method into
      one of three groups:

      Group A (n=16): will receive USG TransmuscularQLB after induction of general anesthesia.

      Group B (n=16): will receive unilateral USG posterior TAP Block after induction of General
      anesthesia.

      Group C (n=16): (control group) will not receive any blocks.general anesthesia will be
      induced using propofol 2-3 mg/kg over 20-30 seconds, fentanyl 2 µg/kg, and atracurium 0.5
      mg/kg to facilitate endotracheal intubation. Anesthesia will be maintained using isoflurane
      1.5 %, atracurium at a dose of 0.1 mg/kg every 20 minutes. For all patients, fluid management
      will be strict according to body weight and blood loss will be adequately estimated and
      replaced. In the three groups, the observing anesthetist will be advised to give fentanyl
      increment doses (0.5 µg/kg) when mean blood pressure, heart rate or both increased by more
      than 20% from the baseline, lacrimation or sweating (signs of inadequate analgesia).

      Postoperatively, all patients will receive IV paracetamol 1gm every 8 hours. As a rescue
      analgesic, meperidine (0.5 mg/kg) will be used when VAS score > 4. The following data will be
      recorded1- Duration of the surgery 2- Time required to perform the blocks in minutes 3-
      Intraoperative mean blood pressure and heart rate will be recorded in all groups immediately
      after induction, at the surgical incision and every 15 minutes till the end of the procedure.

      4- Total amount of intraoperative fentanyl consumption will be recorded 5- Immediate
      postoperative blood pressure and heart rate will be recorded 6- Visual Analogue scale (VAS)
      for pain will be applied postoperatively at rest and during movement. Pain will be assessed
      with a 10-cm ruler ranging from no pain (0) to severe pain (10). Evaluation will be performed
      immediately postoperative, at 30 minutes, 1 hour, 2 hours, 4 hours, 6hours and 12 hours
      postoperatively.

      7- The time of the first analgesic request (rescue analgesia) in the postoperative period
      will be recorded (defined as the time between the end of surgery and the request of the first
      dose of postoperative analgesics). As a rescue analgesic, meperidine (0.5 mg/kg) will be used
      when VAS score > 4.

      8- Postoperative nausea and vomiting
    

Intervention name(s): transmuscular QL block; Transversus Abdominus Plane block
Intervention type(s): Procedure; Procedure
Intervention description(s): Ultrasound device will be used; The probe is placed in the mid-axillary line cranially to the iliac crest to identify the three muscles of the anterior abdominal wall. Then, scan dorsally keeping the transverse orientation until observing that the transversusabdominus muscle becomes aponeurotic, and this aponeurosis is followed until the QL muscle is clearly visualized with its attachment to the lateral edge of the transverse process of the L2 vertebral body and visualize the thoracolumbar fascia at the lateral edge of the QL muscle.
The view of the psoas major muscle (PM) anteriorly, the erector spinae muscle (ESM) posteriorly and the QL muscle adherent to the apex of the transverse process result in a well recognizable pattern of a Shamrock with three leaves (trifoliate).; Posterior TAP block will be performed on the same side of surgery (unilateral) under ultrasonographic guidance with a with broadband (7-13MHz) linear probe covered with a sterile plastic sheath. Probe will positioned transversely midway between the iliac crest and the costal margin at level of mid axillary line.
Once the external oblique muscle (EOM), internal oblique muscle (IOM) and transversus abdominis muscle (TAM) are visualized at the level of the mid axillary line between the 12th rib and the iliac crest, the puncture area and the ultrasound probe were prepared in a sterile manner. After identification of the neuro-facial plane between IOM and TAM, block was performed with 20G spinal needle. The needle will be directed to approach the TAP with "in-plane" USG-guided technique. Once the tip of the needle placed in the space between the IOM and TAM, Inject a 1 ml test dose of lidocaine 2% for hydrovisualization of needle-tip position and confirming its correct postioning.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research