Quadratus Lumborum Block for Total Abdominal Hysterectomy
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Procedure specific postoperative pain management (PROSPECT) guidelines for abdominal
      hysterectomy published in 2006 recommended laparoscopic or vaginal hysterectomy as a
      preferred surgical technique. Multimodal postoperative pain management plane includes
      cyclooxygenase-2 (COX-2) selective inhibitors, and/or conventional non-steroidal
      antiinflammatory drugs (NSAID) in combination with strong opioids for high-intensity pain or
      with weak opioids for moderate- or low-intensity pain. Paracetamol also was recommended in
      combination with COX-2 inhibitors or conventional NSAIDs. Epidural analgesia was recommended
      for high-risk patients. PROSPECT guidelines updated in 2018 discuss only perioperative
      approach for laparoscopic hysterectomy. However, hysterectomy technique has been switched
      from total abdominal to laparoscopic approach. In low resources settings, laparoscopic
      technique is nor well developed neither available to many patients. Furthermore, the majority
      of patients undergo total abdominal hysterectomy (TAH), that is very painful procedure.
      Quadratus lumborum block (QLB) is a regional analgesic technique described by Blanco in 2007.
      Society for Obstetric Anesthesiology and Perinatology (SOAP) and European Society for
      Regional Anaesthesia and Pain Therapy (ESRA) recommended QLB for post-Cesarean pain
      management in cases where intrathecal morphine could not be used or for breakthrough pain.
      Previous reports have shown that QLB is effective in providing pain relief after various
      abdominal operations. The effects of QLB for laparoscopic hysterectomy is controversial. We
      would like to see if QLB can provide analgesic benefits in multimodal pain management after
      TAH in our clinical settings.
    

Detailed description: 
      Participants will be randomly allocated into two groups. Experimental group will have QLB
      type 2 at the end of surgery, before emergence from general anesthesia. Control group will
      not have QLB.

      All cases will be done under general anesthesia. During the surgery, the patients will be
      monitored with 5-lead electrocardiography, pulse oximetry, non-invasive blood pressure and
      end-expiratory CO2.

      Standardized general anesthesia include induction with a propofol bolus of 1.5-2.5mg/kg and
      rocuronium 0.6mg/kg. Fentanyl 2 mcg/kg will be given at induction, and repeated to keep the
      blood pressure and heart rate changes up to 20% of baseline. Sevoflurane in a 50% air/50%
      oxygen mixture with an end-tidal of 1.5 vol% will be used as the maintenance agent.
      Mechanical ventilation will be maintained to keep the end-expiratory CO2 values between 34
      and 36 mmHg. Incremental dose of rocuronium (0.15 mg/kg) will be given every 30 min or when
      needed. At the end of the surgery, after partial recovery from neuromuscular blockade,
      patients will receive atropine 0.01 mg/kg and neostigmine: 0.02mg/kg before tracheal
      extubation. Participants will be referred to the post-anesthesia recovery room after
      extubation and adequate hemodynamic and respiratory recovery.

      Postoperative pain management will include ketoprofen and morphine.
    

Intervention name(s): QLB
Intervention type(s): Procedure
Intervention description(s): QLB is ultrasound-guided injection of 30 ml bupivacaine 0.25% into quadratus lumborum plane posterior to the end of internal oblique muscle.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Quadratus lumborum block; Postoperative analgesia