|Year : 2022 | Volume
| Issue : 2 | Page : 203-207
The efficacy of ultrasound-guided transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia in lower-segment cesarean section with low-dose bupivacaine: A randomized controlled trial
Roshni Benedicta, M Karthik Jain, Nischala Dixit, Vikram M Shivappagoudar
Department of Anaesthesiology, St. John's Medical College, Bengaluru, Karnataka, India
|Date of Submission||17-May-2022|
|Date of Decision||11-Jul-2022|
|Date of Acceptance||15-Jul-2022|
|Date of Web Publication||06-Sep-2022|
Dr. Vikram M Shivappagoudar
Department of Anaesthesiology, St. John's Medical College, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: The study sought to compare the postoperative analgesia after ultrasonography (USG)-guided bilateral transversus abdominis plane (TAP) block versus quadratus lumborum (QL) 1 block with lower concentration of bupivacaine in patients undergoing lower-segment cesarean section (LSCS). Materials and Methods: A randomized controlled trial was conducted at a tertiary hospital, Bengaluru, from 2019 to 2021. Fifty-six patients belonging to the American Society of Anesthesiologists physical status Class I and II aged 20–40 years posted for LSCS under subarachnoid block were divided into two groups. Patients in Group I were given bilateral TAP block and patients in Group II were given bilateral QL1 block under USG guidance at the end of surgery using 0.125% bupivacaine (20 ml) and 4 mg dexamethasone. Patients were monitored for postoperative pain with Numerical Pain Intensity Scale (NPIS) at 0, 1, 4, 8, 12, and 24 h. Rescue analgesic was given if NPIS score was 6 or more. Time to first dose of rescue analgesic was noted. NPIS scores and time to rescue analgesic were compared using independent t test. P < 5% was considered statistically significant. Results: Average NPIS scores were less at 0, 1, and 4 h (<6) and higher at 8, 12, and 24 h in both the groups postoperatively. NPIS scores at 8 h were significantly higher in Group I compared to Group II (P = 0.02). Time to first dose of rescue analgesic was 7.32 h in Group I and 9.07 h in Group II (P < 0.001). Conclusions: Postoperative analgesia was better with USG-guided QL1 block versus USG-guided TAP block with 0.125% bupivacaine and 4 mg dexamethasone in patients undergoing LSCS.
Keywords: Bupivacaine, cesarean section, postoperative pain, ultrasonography
|How to cite this article:|
Benedicta R, Jain M K, Dixit N, Shivappagoudar VM. The efficacy of ultrasound-guided transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia in lower-segment cesarean section with low-dose bupivacaine: A randomized controlled trial. Anesth Essays Res 2022;16:203-7
|How to cite this URL:|
Benedicta R, Jain M K, Dixit N, Shivappagoudar VM. The efficacy of ultrasound-guided transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia in lower-segment cesarean section with low-dose bupivacaine: A randomized controlled trial. Anesth Essays Res [serial online] 2022 [cited 2023 Jan 30];16:203-7. Available from: https://www.aeronline.org/text.asp?2022/16/2/203/355667
| Introduction|| |
Multimodal analgesia is the standard of care in any acute postoperative pain relief regimen. Regional blocks have become the mainstay of perioperative pain management. Transversus abdominis plane (TAP) block and quadratus lumborum (QL) block provide effective postoperative pain relief and minimize opioid intake in patients undergoing major abdominal surgery. There are many studies published comparing TAP and QL blocks using 0.25% bupivacaine in abdominal surgeries. There is a need to understand the efficacy of these blocks in terms of postoperative analgesia using lower concentration of local anesthetic agents to reduce the total dose used and thereby its side effects.
We conducted a study to compare the efficacy of ultrasonography (USG)-guided bilateral QL1 block versus USG-guided bilateral TAP block with lower concentration of bupivacaine (0.125%) and dexamethasone for postoperative analgesia in patients undergoing lower-segment cesarean section (LSCS) using the Numerical Pain Intensity Scale (NPIS) and compare the time to rescue analgesia. The secondary objective was to compare the adverse outcomes of both the procedures.
| Materials and Methods|| |
A prospective randomized controlled trial was conducted at a tertiary care hospital, Bengaluru, after obtaining the institutional ethical committee clearance (IEC Study Ref No: 345/2019) and registered under the Clinical Trials Registry-India with the registration number of CTRI/2020/07/026739. The study was conducted between December 2019 and November 2021. To study the effectiveness of analgesia in reducing Visual Analog Scale score at 10 h postsurgery with 5% level of significance and 80% power of the study, the required sample size was 28 patients in each arm.
After obtaining clearance from the institutional ethics committee, 56 patients belonging to the American Society of Anesthesiologists physical status (ASA-PS) Class I–II aged between 20 and 40 years posted for LSCS under subarachnoid block were included in the study. Patients with history of hypersensitivity to local anesthetics, coagulopathy, on anticoagulants, local site infection were excluded from the study.
Written informed consent was taken from all the patients for participation in the study and the use of the data for research and educational purposes. The procedures followed in the study were according to the guidelines laid down in Declaration of Helsinki (2008). Twenty-eight patients were randomly allocated into each group (Groups I and II) using the computerized randomization technique. Standard anesthesia monitors, including ECG, NIBP, and pulse oximeter, were connected. Patients were given spinal anesthesia with 2 ml of injection bupivacaine heavy 0.5% according to the standard protocol. Once the surgery was over and the sensory level of spinal block receded to T10 dermatome, ultrasound-guided TAP block or QL1 block was administered under strict aseptic precautions using S Series Ultrasound, Fujifilm Sonosite, with a 6–12-MHz high-frequency linear probe.
In patients belonging to Group I, ultrasound-guided TAP block was performed with patients in supine position. A linear transducer was positioned in the midaxillary line, in a transverse plane, between the iliac crest and the costal margin. The ultrasound probe was moved anteriorly and the structures (external oblique, internal oblique, and transversus abdominis muscles) were identified. Under strict aseptic precautions, a 22-G lumbar puncture needle was introduced anteriorly, in plane, under real-time ultrasound guidance to lie in the fascial planes between the internal oblique muscle and the transversus abdominis muscle. The position of the needle was confirmed, following which 20 ml of 0.125% bupivacaine + 4 mg dexamethasone was injected after negative aspiration. Spindle-shaped echo lucent shadow in the space between the two muscles confirmed a successful injection. Similar procedure was performed on the other side.
In patients belonging to Group II, type 1 QL block was performed with a wedge placed under the patient's flank. A linear transducer was placed in the transverse plane in the midaxillary line and moved posteriorly until the posterior aponeurosis of the transversus abdominis muscle becomes visible. At the lateral boundary of the QL muscle, the target is deep to the aponeurosis of the transversus abdominis but superficial to the fascia transversalis. The needle was inserted from either the anterior or the posterior end of the transducer and advanced until the needle tip penetrated the posterior aponeurosis of the transversus abdominis muscle. The position of the needle was confirmed, following which 20 ml of 0.125% bupivacaine + 4 mg dexamethasone was injected after negative aspiration. Similar procedure was performed on the other side.
Postoperatively, all patients were observed in the recovery room after the procedure for vital parameters (HR, NIBP, and SPO2), NPIS scores, and spinal blockade. The endpoint of the spinal blockade was noted when the patient starts to move the lower limb along gravity. The patients were monitored postoperatively in surgical ward after being shifted from recovery room. All patients were monitored for pain with NPIS scale at 0, 1, 4, 8, 12, and 24 h. Patients were asked to rate the pain they experience on a NPIS from 0 to 10, 0 being “no pain” and 10 being “very severe pain.” Patients received rescue analgesic (injection pethidine 25 mg intravenous [i.v.]) according to the institutional multimodal analgesia protocol. The first rescue dose was given when NPIS was 6 or more. The time of receiving first rescue dose of i.v. pethidine 25 mg was noted. Patients were monitored postoperatively for complications such as abdominal pain, swelling, perioral numbness, restlessness, nausea, vomiting, or seizures for 24 h. The results were compared and tabulated on an Excel sheet and analyzed using SPSS software version 25 (IBM, USA).
Descriptive statistics were reported using mean with SD, number, and percentages. Chi-square test was used to test the association between duration of spinal block categories by study groups. NPIS scores at 0, 1, 4, 8, 12, and 24 h were compared between the TAP and QL groups using independent t-test. The first dose of pethidine requirement was compared between the study groups using independent t-test. P < 5% was considered statistically significant. All the analyses were carried out using SPSS version 25.0.
| Results|| |
[Table 1] depicts the distribution of age, sex, and ASA-PS class in both the groups. There was no significant difference in age, sex, and ASA-PS class between the groups.
[Table 2] depicts the duration of spinal block in both the groups. There was no significant difference between the groups with respect to the duration of spinal block.
[Figure 1] reveals the average NPIS scores at 0, 1, 4, 8, 12, and 24 h. The difference in the average NPIS scores in 0, 1, 4, 12, and 24 h was not statistically significant. At 8 h, the average NPIS score in Group I was 6.534 and in Group II was 4.143 (P = 0.020); it was found to be statistically significant.
|Figure 1: Bar diagram representing the comparison of the average NPIS scores between the groups. NPIS: Numerical Pain Intensity Scale|
Click here to view
[Figure 2] depicts the average time for the first rescue analgesic (injection pethidine). The first dose of pethidine requirement was at 7.321 h in Group I and 9.071 h in Group II; it was found to be statistically significant (P < 0.001). There were no complications noted postoperatively in either of the groups.
|Figure 2: Bar diagram depicting comparison of the average time for the first rescue analgesic|
Click here to view
| Discussion|| |
Management of perioperative pain is a significant challenge for anesthesiologists. Opioid analgesic therapy has been considered the gold standard to treat immediate postoperative pain for a long time. However, opioid-related morbidity has prompted an increased call for more significant research into developing pain treatment regimens that highlight the use of a multimodal strategy. Even though multimodal analgesic techniques are advised to be used to treat postoperative pain, there is no guidance on the best analgesic combinations for various procedures. Postoperative ambulation and rehabilitation are facilitated with appropriate perioperative pain management, which is considered a requirement for a faster recovery and to shorten hospital stay. It also minimizes the risk of adverse physiologic and psychological effects associated with uncontrolled intense pain. Multimodal analgesia has become the only way to reduce perioperative pain.
Abdominal field blocks including TAP block and QL block are proven in providing effective intraoperative and postoperative analgesia, thereby decreasing the opioid requirement. However, there are reported consequences, including intraperitoneal injection of local anesthetic and visceral injury. Furthermore, locating anatomical landmarks may be problematic in obese patients. Therefore, the use of real-time USG to visualize the needle in this plane improves the precision and effectiveness of these blocks.
It had been hypothesized that QL blocks provide better analgesia as they block both somatic and visceral components, whereas TAP blocks provide only somatic block. The studies done till now comparing QL and TAP blocks have used a higher concentration of local anesthetic agent (0.25% bupivacaine, 0.25% ropivacaine, or 0.375% bupivacaine). We wanted to compare the analgesic efficacy between both the blocks with a dilute concentration of local anesthetic to reduce the total dose used.
This study compared the efficacy of USG-guided bilateral QL1 block versus bilateral USG-guided TAP block for postoperative analgesia in patients undergoing LSCS (with 20 ml of 0.125% bupivacaine + 4 mg dexamethasone on each side) using the NPIS and time to rescue analgesia. Our study was conducted on 56 adults (ASA I-II) randomized into two equal groups (TAP and QL groups). Each patient was administered spinal anesthesia. At the end of surgery, bilateral TAP block or bilateral QL1 block was given using a linear probe of high-frequency and 22-G spinal needle.
In this study, the NPIS scores of patients in both the groups were compared. The NPIS scores were less in both the groups at 0, 1, and 4 h and did not require any rescue analgesic. The NPIS scores at 8, 12, and 24 h were higher in both the groups. We found that the NPIS scores at 8 h were significantly higher in Group I (TAP block) in comparison with Group II (QL1 block). At other times (0, 1, 4, 12, and 24 h), the NPIS scores were similar. Furthermore, time to first rescue analgesic was longer in Group II (9.1 h in QL1 block) in comparison with Group I (7.3 h in TAP block). Therefore, it was concluded that QL1 block offered better analgesia than transversus abdominis block.
The better analgesic efficacy as shown in our study for QL1 block could be due to better spread of local anesthetic agent as elicited by Carline et al. and Dam et al. Carline et al. performed a cadaveric study on dye injection techniques of various types of QL blocks. Under the QL1 block approach, the iliohypogastric and ilioinguinal nerves, subcostal nerves, T11 to T12 and L1 nerve roots, and cross-sections of the arcuate ligaments and T9 to L2 nerve roots were involved. Variable staining of higher thoracic nerve root was visible. Dam et al. also conducted a cadaveric dye injection technique to learn about the spread of analgesic in QL1 block. The QL1 block reliably stained lumbar nerve roots and nerves. Dermatomal distribution of dye spread ranged from T6-T7 to L1-L2.
The longer lasting analgesic effect of QL1 block as shown in our study could be due to delayed clearance of the drug compared to the TAP block as elicited by Hironobu et al. in a cadaveric study.
Patients were monitored for complications like abdominal pain, postoperative nausea and vomiting, hematoma formation and symptoms of local anesthetic toxicity. There were no complications noted postoperatively in either of the groups
Yousef, Kumar et al., and Utsav conducted similar studies comparing QL block and TAP block. They also found that the duration of analgesia was longer in the QL group similar to our study. Yousef conducted a similar study on 60 adult female patients (ASA-PS Class I–II) scheduled for total abdominal hysterectomy. The duration of analgesia in the group that received TAP block was found to be 8.33 h and the group that received QL block was found to be 15.1 h. Kumar et al. conducted a prospective, randomized, double-blinded study on 70 adult patients. The time for the first rescue analgesic in the TAP group was 243.00 min and in the QL1 group was 447.00 min. The total analgesic consumption (morphine) was 5.65 mg in the TAP group and 3.25 mg in QL1 block.
Furthermore, the meta-analysis by Utsav et al. involved 5 studies comparing QL1 block with TAP block for postoperative pain management in various abdominal surgeries. Postoperative analgesia, time to rescue analgesia, adverse effects, and morphine consumption were studied. A significant reduction in postoperative pain was identified with QL1 blockade. Therefore, it was concluded that QL1 blockade is likely a preferable regional analgesic technique to TAP blockade.
The duration of analgesia in some of these studies was found be longer than our study probably because they used higher concentration of local anesthetic agent in their studies. This is the first study to evaluate the efficacy of fascial plane blocks using dilute concentration of local anesthetic. The study has the following limitations: technical difficulties such as positioning patients and visualization of structures in QL block were much more challenging than TAP block. This could be a confounding factor. The intensity of postoperative pain is not the same in different surgeries. The results of this study cannot to be extrapolated to other abdominal surgeries with different intensities of pain. Further studies may be needed to confirm the findings of our study.
Both ultrasound-guided TAP block and ultrasound-guided QL1 block proved to be safe and effective in prolonging the duration of postoperative analgesia in LSCS with lower concentration of local anesthetic agent (0.125% bupivacaine + 4 mg dexamethasone). Both the blocks substantially reduced the opioid consumption, thus reducing opioid-related adverse effects. Ultrasound-guided QL1 block provided better analgesic efficacy and duration when compared to ultrasound-guided TAP block in patients undergoing LSCS with these doses.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Shibata Y, Sato Y, Fujiwara Y, Komatsu T. Transversus abdominis plane block. Anesth Anal 2007;105:883.
Bartels K, Mayes LM, Dingmann C, Bullard KJ, Hopfer CJ, Binswanger IA. Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One 2016;11:e0147972.
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al
. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131-57.
Joshi GP, Kehlet H. Postoperative pain management in the era of ERAS: An overview. Best Pract Res Clin Anaesthesiol 2019;33:259-67.
Gan TJ. Poorly controlled postoperative pain: Prevalence, consequences, and prevention. J Pain Res 2017;10:2287-98.
McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg 2007;104:193-7.
Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008;106:674-5.
Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2.
] [Full text]
Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth 2016;117:387-94.
Dam M, Moriggl B, Hansen CK, Hoermann R, Bendtsen TF, Børglum J. The pathway of injectate spread with the transmuscular quadratus lumborum block: A cadaver study. Anesth Analg 2017;125:303-12.
Hironobu U, Hiroshi O, Jui-An L. Ultrasound-guided quadratus lumborum block: An updated review of anatomy and techniques. Biomed Res Int 2017;2017:2752876.
Yousef NK. Quadratus lumborum block versus transversus abdominis plane block in patients undergoing total abdominal hysterectomy: A randomized prospective controlled trial. Anesth Essays Res 2018;12:742-7.
] [Full text]
Kumar GD, Gnanasekar N, Kurhekar P, Prasad TK. A comparative study of transversus abdominis plane block versus quadratus lumborum block for post operative analgesia following lower abdominal surgeries: A prospective double-blinded study. Anesth Essays Res 2018;12:919-23.
] [Full text]
Utsav M. Transversus abdominis plane block versus quadratus lumborum block for post operative pain in abdominal surgery: A systematic review and meta-analysis. Arch Anesth Crit Care 2018;4:542-6.
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