Epidural Versus Quadratus Lamborum Block in Adult Open Nephrectomies

Study Overview
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Brief Summary
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Our primary objective is to compare the effectiveness of bilateral QLB and epidural analgesia for postoperative management using VAS measured in PACU until 24 hours after surgery in patients undergoing elective open nephrectomies under GA. The secondary outcomes include: The 1st time to rescue analgesia and total amount of opioid consumption throughout the first postoperative day. hemodynamic variables. Any complications as postoperative nausea and vomiting (PONV) and sedation. The sensory block coverage & the Bromage score at 2, 6, 12, and 24 hours after anesthesia recovery and duration of urinary catheter usage. Duration of PACU stay and postoperative duration of hospitalization and Patients' satisfaction.

Detailed Description
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Open surgery remains basic surgery for patients requiring radical or partial nephrectomy and is associated with a high incidence of intense immediate postoperative pain and chronic pain the months following surgery. The physiopathology of acute pain is explained as it is mediated by inflammatory cell infiltration, activation of the pain pathways in the spinal cord, and reflexive muscle spasm. All these three mechanisms of acute pain are typically ameliorated during the postoperative recovery. Regional anesthesia techniques are commonly enhanced for pain management in open nephrectomy as they decrease parenteral opioid requirements and improve patient satisfaction. QLB has been introduced as a component of multimodal analgesia for thoracic and abdominal surgeries as: cesarean section, hip arthroplasty, inguinal hernia repair and nephrectomies. It provides a great spread of local anesthesia which allows anesthesia from T6 - L2 and provides loss of somatic and visceral pain. The QLB was initially described by R.Blanco where the local anesthetic (LA) was injected at the anterolateral aspect of the QL muscle (type 1 QLB). Later, J. Børglum used the posterior transmuscular approach by detecting Shamrock sign and injecting the LA at the anterior aspect of the QL (type 3 QLB). Recently, R. Blanco described another approach by injecting the LA at the posterior aspect of the QL muscle (type 2 QLB), which may be easier and safer as the LA is injected in a more superficial plane, so the risk of intra-abdominal complications and lumbar plexus injuries is less. Finally, the intramuscular QLB (type 4 QLB) was done by injecting LA directly into the QL muscle. QLBs may be particularly useful in nephrectomy as it lacks the adverse effects associated with patient controlled analgesia including nausea, vomiting, sedation, and respiratory depression, as well as side effects of patient controlled epidural analgesia such as pruritus hypotension, and urinary retention. Our hypothesis is that performing ultrasound guided QLB will be more superior or equal to epidural block in providing postoperative analgesia for patients undergoing open nephrectomy under general anesthesia

Official Title
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Epidural Versus Quadratus Lamborum Block for Postoperative Analgesia in Adult Open Nephrectomies : A Randomized Double Blind Controlled Trial

Conditions
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Post Operative Analgesia

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients of American Society of Anesthesiologists (ASA) class I or II physical status. Age:20-60 years old. Patients scheduled for open nephrectomies . Gender: both Exclusion Criteria: Patient refusal. Significant organ dysfunctions (e.g., cardiac, respiratory, renal, or liver disorders). Morbid obesity (BMI >35). Patient with known hypersensitivity to amide local anesthetics or morphine. Patient with any contraindication for intrathecal anesthesia, e.g. coagulopathy. Psychiatric disorders, which will make observational pain intensity assessment difficult. Pregnancy. Skin lesions or wounds at the puncture site of the proposed block .

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Epidural Block<br>Epidural block for the control group will be done before induction of general anesthesia. Patients will be positioned in the sitting position, an 18-gauge Tuohy needle will be inserted into epidural space of Th 11-12 intervertebral space under aseptic condition. In the medial approach, the site of the insertion of the needle is between the spaces created by the vertebral spinous processes. Upon locating the desired spot, lidocaine 1% must be injected into the skin and underlying tissues to decrease the discomfort with the advancement of the epidural needle | |
| Quadratus Lumborum Block<br>Bilateral QL block type 3 (anterior) for the intervention group will be performed on both sides of the patient after induction of general anesthesia. Patient will be positioned in semi-lateral decubitus and using low-frequency ultrasonography (USG) guidance attached to inferior lumbar region (Petit's triangle) that is consisted of inferior iliac crest and bordered by two muscles such as latissimus dorsi muscle in the posterior, abdominal external oblique muscle in the anterior. The USG will display the Shamrock sign, where the transverse process of vertebrae L4 role as the trunk, erector spinae muscle on the posterior side, psoas major (PM) on the anterior side, and QL muscle on the lateral side. After the visualization of QL and PM muscles, the Contiplex R needle will be directed parallel to the posterior side of the ultrasound probe until the tip of needle is confirmed in the border of QL and PM muscle | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| compare the effectiveness of bilateral QLB and epidural analgesia | postoperative pain management using visual analog scale measured in postanesthesia care unit | 24 hours |