Ultrasound Guided Subcostal Transversus Abdominis Plane Block Versus Quadratus Lumborum Block for Pediatrics Undergoing Pyeloplasty.
Condition: Pain Management; Pediatrics; Anesthesia
Study type: Interventional

Summary: 
      The aim of this work to compare the analgesic efficacy of preoperative ultrasound guided
      subcostal TAP block and Quadratus lumborum block in pediatric patients undergoing pyeloplasty
      surgeries.
    

Detailed description: 
      This randomized, controlled study is designed to:

        -  Assess the quality of perioperative analgesia (intraoperative hemodynamics,
           postoperative pain score and analgesic consumption) provided by ultrasound guided
           subcostal TAP and quadratus lumborum blocks in pediatrics undergoing pyeloplasty
           surgeries.

        -  Compare the efficacy and safety of both blocks in pediatrics undergoing pyeloplasty
           surgery.

      Hypothesis

      Following approval from research and ethics committee of anesthesia department, Faculty of
      Medicine, Cairo University, children will be pre-medicated by intramuscular injection of
      atropine 0.02 mg/Kg, midazolam 0.2 mg/Kg and ketamine 2 mg/ Kg before admission to operation
      theater (OR).

      Upon arrival to OR; continuous electrocardiography (ECG), pulse oximetry, non-invasive
      arterial blood pressure will be applied and baseline readings will be recorded, then general
      anesthesia will be induced by 8% sevoflurane and 50% air in oxygen. Peripheral venous cannula
      will be inserted after loss of consciousness. If a patient had an intravenous (IV) cannula,
      induction will be performed using 1.5-2.5 mg/kg propofol, in both situations atracurium at a
      dose of 0.5 mg/kg will be given intravenously to facilitate endotracheal intubation and
      fentanyl at a dose 2 µg/kg will be given to abolish stress response of intubation. Anesthesia
      will be maintained by using 1-1.5% isoflurane in a mixture of oxygen and air (50/50) and
      atracurium top ups at a dose of 0.1mg/kg every 30 minutes.

      Patient positioning and preparation for the block:

      For the (sTAP) group (n=39): patients will be in the supine position; after preparing the
      skin with with povidone iodine, a high frequency (5-10 MHz) ultrasound probe will be placed
      obliquely on the upper abdominal wall, along the surgical site subcostal margin near the
      midline. After identifying the rectus abdominis muscle, we will gradually move the ultrasound
      probe laterally along the subcostal margin until we identify the transversus abdominis muscle
      lying posterior to the rectus muscle. A 22 G echogenic needle using the in-plane technique
      will be inserted medially near the xiphoid process aiming towards the iliac crest, then 1
      mL/Kg of bupivacaine 0.25% will be injected in the plane between rectus abdominis and
      transversus abdominis muscles. The patient will then be positioned for the procedure if other
      than supine position is chosen.

      For the (QLB) group (n=39): patients will be positioned in the lateral decubitus position so
      that the blocked side will be the uppermost one. After skin sterilization with povidone
      iodine the ultrasound probe will be positioned between the iliac crest and the costal margin
      at the level of the anterior axillary line to identify the three thin parallel muscles of the
      anterolateral abdominal wall. The probe will be moved posteriorly following the narrowing of
      the muscles until the muscle fibers of transversus abdominis muscles taper off into its
      aponeurosis at the level of the posterior axillary line where the quadratus lumborum muscle
      is identified. The posterior aspect of the QL muscle is confirmed and a 22 G echogenic needle
      will be inserted using an in-plane technique from anterolateral to posteromedial towards this
      posterior aspect of the QL muscle. 1 mL/Kg of bupivacaine 0.25% will be injected behind the
      QL muscle on the lateral border of the erector spinae muscle. The patient will then be
      positioned for the procedure if other than lateral decubitus position is chosen.

      Vital signs (heart rate (HR) and non-invasive blood pressure) will be recorded at the onset
      of the block then every 15 minutes intraoperatively, and every 4 hours postoperatively for a
      period of 24 hours. Fentanyl 0.5 µg /kg as rescue analgesia will be given intraoperatively if
      HR and or systolic BP increased >20% of baseline up to maximum 5 µg/ kg.

      After skin closure, inhalational anesthesia will be discontinued and reversal of muscle
      relaxation with atropine (0.02 mg/Kg) and neostigmine (0.05 mg/Kg) will be administered IV
      after return of patient's spontaneous breathing. Patients will then be transferred to post
      anesthesia care unit (PACU) for 60 min to complete recovery and monitoring.

      Postoperative assessment and analgesic regimen:

      The Face, Legs, Activity, Cry, Consolability scale (FLACC) (table 1) will be assessed
      immediately postoperative in the PACU and every 4 hours in the ward for 24 hours. The time to
      the first request of rescue postoperative analgesic will be: "the time interval between the
      local anesthesia injection and the first request to postoperative analgesia (patients first
      complain of pain and or FLACC score ≥4)". an intravenous paracetamol 15mg/kg will be given
      immediately postoperative and will be repeated every 6 hours. Persistent or breakthrough pain
      will be managed with incremental intravenous morphine at a dose of 0.05-0.1mg/kg to maintain
      resting FLACC scale ˂ 4 (maximum dose 0.3mg/kg). Cumulative 24 hours analgesic consumption
      will be recorded.
    

Intervention name(s): Bupivacaine Hydrochloride 0.25% Injection Solution [MARCAINE]
Intervention type(s): Drug
Intervention description(s): preoperative ultrasound guided subcostal TAP block and Quadratus lumborum block using 1 ml/kg of Bupivacaine Hydrochloride 0.25%in pediatric patients undergoing pyeloplasty surgeries.
Intervention MeSH terms: Bupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention
Keywords: ultrasound; quadratus lumborum; subcostal TAP; pediatrics; pyeloplasty