QLB vs. Wound Infiltration in Cesarean Section
Condition: Analgesia; Cesarean Section
Study type: Interventional

Summary: 
      Effective postoperative analgesia after cesarean section (CS) is important because it enables
      early ambulation and facilitates breast-feeding. A 2009 Cochrane review concluded that wound
      infiltration with local analgesic after CS reduced opioid consumption. In addition, two
      regional anesthetic techniques, the transversus abdominis plane (TAP) block and the quadratus
      lumborum block (QLB), have been shown in multiple studies to reduce post-operative opioid
      consumption after CS. A recent randomized controlled trial showed that QLB is more effective
      in reducing morphine consumption post-CS compared to TAP. No randomized controlled trial to
      date, however, compared the analgesic effect of QLB with infiltration of the wound after CS.
      The objective of the study is to compare the analgesic effect of QLB type 2 with wound
      infiltration after CS.
    

Detailed description: 
      Effective postoperative analgesia after cesarean section (CS) is important because it enables
      early ambulation and facilitates breast-feeding. Post-CS analgesia is usually multimodal. At
      our hospital, patients are routinely given a combination of parenteral paracetamol,
      metamizole and tramadol at fixed intervals with additional intravenous piritramide on demand.
      The well-known side effects of piritramide (nausea, vomiting, and sedation) may interfere
      with interaction between mother and child, breast-feeding and post-partum experience in a
      dose-dependent manner. Alternative strategies to reduce rescue opioid analgesic consumption
      post-CS section are, therefore, required.

      A 2009 Cochrane review concluded that wound infiltration with local analgesic after CS
      reduced opioid consumption. In addition, two regional anesthetic techniques, the transversus
      abdominis plane (TAP) block and the quadratus lumborum block (QLB), have been shown in
      multiple studies to reduce post-operative opioid consumption after CS. A recent randomized
      controlled trial showed that QLB is more effective in reducing morphine consumption post-CS
      compared to TAP.

      Telnes et al. compared TAP block with wound infiltration with local anesthetic following CS.
      They found no reduction in cumulative morphine consumption and more pronounced sedation
      associated with TAP block. No randomized controlled trial to date, however, compared the
      analgesic effect of QLB with infiltration of the wound after CS.

      The objective of the study is to compare the analgesic effect of QLB type 2 with wound
      infiltration after CS.
    

Intervention name(s): Quadratus Lumborum Block type 2; Wound Infiltration
Intervention type(s): Drug; Drug
Intervention description(s): The obstetrician (multiple, experienced clinicians) will infiltrate the wound (Pfannenstiel incision) subcutaneously at the end of surgery with 20 ml normal saline. Subsequently, a US-guided QLB using a linear/convex transducer will be performed by the anesthesiologist using 30 ml levobupivacaine 0.18% (20 ml 0.25% levobupivacaine + 10 ml normal saline) bilaterally (60 ml in total).; Participants will receive 20 ml levobupivacaine 0.25% infiltration in the surgical wound and US-guided QLB with 30 ml normal saline bilaterally (60 ml in total).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Single-center, randomized, double-blind trial
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Analgesia; Cesarean Section; Quadratus Lumborum Block type 2; Wound Infiltration