Quadratus Lumborum Block Type 2 Versus Posterior Transversus Abdominus Plane Block

Study Overview
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Brief Summary
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This patient population are at risk of adverse effects secondary to inadequate pain management such as inadequate maternal bonding and late ambulation. Regional analgesia is preferred due to their opioid sparing effects and reduction in related adverse effects but the analgesia from these blocks is not known which one is superior to the other in the context of cesarean section

Detailed Description
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The aim of this study is to compare the effect of posterior transversus abdominus plane block and quadratus lumborum type 2 for cesarean delivery. The transversus abdominus plane(TAP) block provides sensory block from T6 to L1 for lower abdominal surgeries. Quadratous lumborum type 2 block, the injection is posterior to the quadratus lumborum muscle. This method has the advantage of a more superficial point of injection with better ultrasonographic resolution. Only one RCT was done in this context by Kalpana Verma and his colleagues comparing quadratus lumborum type 2 and posterior transversus abdominus plane block. That shows marked discrepancy with time to first analgesic request from the quadratus lumborum block in other abdominal surgeries

Official Title
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A Comparative Study Between Quadratus Lumborum Block Type 2 and Posterior Transversus Abdominus Plane Block for Analgesia After Cesarean Delivery Under Spinal Anesthesia

Conditions
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Regional Block

Intervention / Treatment
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* Procedure: Posterior transversus abdominus plane block
* Procedure: Quadratus lumborum block type 2


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: American Society of Anesthesiologists physical status II parturient. Singleton pregnancies with a gestation of at least 37 weeks. Patients undergoing spinal anesthesia for cesarean deliveryvia a Pfannenstiel incision with exteriorization of the uterus. Exclusion Criteria: Age < 19 or > 40 years. Height<150 cm, weight < 60 kg, body mass index (BMI) ≥35 kg/m2. Inability to comprehend or participatein pain scoring system. Contraindications to spinal anesthesia (Coagulopathy, increased intracranial pressure, or local skin infection). Hypersensitivity to any drugused in the study. Hypertensive disorders of pregnancy. Renal impairment or other contraindication to non-steroidal anti-inflammatory drugs. Significant cardiovascular, renal or hepatic abnormalities. Patients with history of opoid intake, drug abusers, psychiatric patients.

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: patients will be randomly allocated via sealed opaque envelop into 2 groups of 50 patients each; Posterior transversus abdominus block (TAP) group and Quadratus lumborum block type 2 is the second group (QLB)group
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Posterior transversus abdominus block<br>After the surgery end and while the patient in the supine position, with the side to be blocked is elevated A 12-14 MHz linear array transducer will be placed transversely between the iliac crest and costal margin then slided from medial-lateral to visualize the posterior most part of the external oblique, internal oblique, and transversus abdominus muscles Then 20 mL of bupivacaine0.25% will be injected between the transverses abdominus muscle and the fascia deep to the internal oblique muscle The same steps will be repeated on the other side | Procedure: Posterior transversus abdominus plane block<br>* Twenty mL of bupivacaine 0.25% will be injected in the plane between the transverses abdominus muscle and the fascia deep to the internal oblique muscle on each side<br>|
| Active Comparator: Quadratus lumborum block type 2<br>After the surgery end and while the patient in the supine position, with the side to be blocked is elevated A2-5 MHz curved array transducer will be placed at the level of the antero-superior iliac spine then the external oblique muscle will be followed posterolaterally until its posterior border will be visualized The probe will be tilted down to identify a bright hyperechoic line After that 20 mL of bupivacaine 0.25% will be injected under direct visualization on the posterior surface of quadrates lumborum muscle The same steps will be repeated on the other side | Procedure: Quadratus lumborum block type 2<br>* Twenty mL of bupivacaine 0.25% will be injected on the posterior surface of quadrates lumborum muscle on each side<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The analgesic duration | the time measured from finishing the block till the first request of analgesia by the patient | within 24 hours after the surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative pain at rest | 100 centimetres visual analog scale (VAS) for pain, where zero is equal to no pain and hundred indicates the worst possible pain | immediately and 1,2,3,4hour at postanesthesia care unit, then in the surgical ward at 6,8,10,12,18 and 24 h | 
| Postoperative pain on movement (attempted hip flexion) or coughing | 100 centimetres visual analog scale (VAS) for pain, where zero is equal to no pain and hundred indicates the worst possible pain | immediately and 1,2,3,4hour at postanesthesia care unit, then in the surgical ward at 6,8,10,12,18 and 24 h | 
| Patient satisfaction | poor= 1, fair = 2, good = 3, excellent = 4 | 24 hours after surgery | 
| Heart rate | beat per minute | at 1st, 2nd, 3rd, 4th, 10th, 16th and 22nd hours postoperatively | 
| Non-invasive blood pressure | mmHg | at 1st, 2nd, 3rd, 4th, 10th, 16th and 22nd hours postoperatively | 
| Total postoperative analgesic consumption of of ketolac, paracetamol and fentanyl | Patients with visual analog scale more than 30 will receive 30 mg of intravenous ketolac in addition to 1gm paracetamol which will be repeated every 8 hours intravenous infusion of every 8 hours. Intravenous administration of fentanyl bolus doses of 0.5 µg per kg per dose will be given if the visual analog scale remains more than 30 | within the first 24 hours after surgery | 
| Postoperative nausea and vomiting | 0= none, 1= mild, 2= moderate and 3= sever | within 24 hours after surgery | 
| Postoperative lower limb weakness | reported by the patient during her first walk after surgery | within 24 hours after surgery |