RevBrasAnestesiol.2017;67(4):418---421
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Ultrasound
guided
quadratus
lumborum
block
for
analgesia
after
cesarean
delivery:
case
series
Ilana
Sebbag
∗,
Fatemah
Qasem,
Shalini
Dhir
WesternUniversity,SchulichSchoolofMedicineandDentistry,DepartmentofAnesthesia,London,Ontario,Canada
Received23October2015;accepted24November2015 Availableonline21April2016
KEYWORDS
Quadratuslumborum
block;
Cesareandelivery; Multimodalanalgesia
Abstract
Introduction:Themajorityofwomenhavingplannedcesareansectionreceivespinalanesthesia fortheprocedure.Typically,spinalopioidsareadministeredduringthesametimeasa compo-nentofmultimodalanalgesiatoprovidepainreliefinthe16---24hperiodpostoperatively.The quadratuslumborumblockisaregionalanalgesictechniquethatblocksT5-L1nervebranches andhasanevolvingroleinpostoperativeanalgesiaforlowerabdominalsurgeriesandmaybe apotentialalternativetospinalopioids. Iffound effective,itwillhavetheadvantageofa reductioninopioidassociatedadverseeffectswhileprovidingsimilarqualityofanalgesia.
Methods:Weperformedbilateralquadratuslumborumblockin3womenwhoreceivedaspinal anestheticforacesareandeliveryandevaluatedtheirpost-operativeopioidconsumptionand patientsatisfaction.
Results:Inall3patients,therewasnoadditionalopioidconsumptionduringthefirst24hafter theblock.NumericRatingScale(NRS)forpainwaslessthan6forthefirst24h.Womenwere allverysatisfiedwiththequalityofpainrelief.
Discussion: Quadratus lumborum block may be a promising anesthetic adjuvant for post-cesareananalgesia.Furtherrandomizedcontrolledtrialsareneededtocomparetheefficacy ofthequadratuslumborumblockwithintrathecalopioids.
©2016SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:ilana.sebbag@gmail.com(I.Sebbag).
http://dx.doi.org/10.1016/j.bjane.2015.11.005
Quadratuslumborumblockforpost-cesareananalgesia 419
PALAVRAS-CHAVE Bloqueiodoquadrado lombar;
Cesariana;
Analgesiamultimodal
Bloqueiodoquadradolombarguiadoporultrassomparaanalgesiapóscesariana: sériedecasos
Resumo
Introduc¸ão: Amaioriadasmulheresagendadasparacesarianarecebeanestesiaraquidianapara oprocedimento.Tipicamente,osopioidesadministradosporviaespinhal(VE)sãoadministrados aomesmotempocomoumcomponentedaanalgesiamultimodalparaproporcionaralíviodador noperíodopós-operatóriode16-24horas.Obloqueiodoquadradolombar(QL)éumatécnicade analgesiaregionalquebloqueiaosramosnervososT5-L1etemumpapelcrescentenaanalgesia pós-operatóriadecirurgiasabdominaisinferiores,podendoserumapotencialalternativapara osopioidesVE.Seforconsideradoeficaz,essebloqueioteráavantagemdeumareduc¸ãonos efeitosadversosassociadosaosopioides,proporcionandoqualidadesemelhantedeanalgesia.
Métodos: Obloqueiobilateraldoquadradolombarfoirealizadoemtrêsmulheresque rece-beram raquianestesia para parto cesário, e o consumo de opioides no pós-operatório e a satisfac¸ãodaspacientesforamavaliados.
Resultados: Emtodosastrêspacientes,não houveconsumoadicional deopioideduranteas primeiras24horasapósobloqueio.Aescaladeavaliac¸ãonumérica(EAN)paradorfoiinferior a6duranteasprimeiras24horas.Todasasmulheresficarammuitosatisfeitascomaqualidade doalíviodador.
Discussão: ObloqueiodoQLpodeserum adjuvantepromissorpara analgesiapós-cesariana. Estudosrandomizadosecontroladossãonecessáriosparacompararaeficáciadobloqueiodo quadradolombarcomopioidesadministradosporviaintratecal.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Intrathecal morphine is considered the ‘‘gold standard’’ for postoperative pain relief after cesarean delivery. Its widespreaduseisduetoitsfavorablepharmacokinetic pro-file,easeofadministration(duringspinalblockforsurgical anesthesia)andlowcost.1,2
Nevertheless, subarachnoid use of morphine is not deprived of adverse effects. While dose-dependent respi-ratorydepressionisthemostdreadedcomplication,other minorsideeffectssuchaspruritus,nausea,vomitingand uri-naryretentioncanbebothersomeduringearlypuerperium. The TransversusAbdominis Plane (TAP) blockhas been usedfor postoperativeanalgesiafor abdominalandpelvic surgical procedures, includingcesarean deliveries. Never-theless,theanteriorapproachtotheTAPblockhasshown limited analgesic effect due to its short duration (up to 10h)andmostlyparietalpainreliefprofile.3,4Theposterior
approach,orquadratuslumborum(QL)block,firstdescribed in2007byBlanco,demonstratedaspreadtothe paraverte-bralspace,thusleadingtoamoreextensiveandlonglasting block,withthepotentialtoprovidevisceralpainrelief.5
As we strive toprovide optimal post-operative analge-siawithminimumsideeffects,weperformedtheQLblock inthreewomenundergoingcesareandeliveryunderspinal anesthesia in order to provide analgesia that would last beyondthedurationofspinalopioids.
Methods
Writteninformedconsentforpublicationwasobtainedfrom allwomen.
Subjectsreceivedstandardcareaccordingtoroutine hos-pitalprotocols.
Afterthesurgery, thepatients weretransferredtothe recoveryroomandplacedinthelateralposition.The skin waspreparedwithclorhexidine2%inasterilefashion.Under ultrasoundguidance(aSonoSiteM-Turboultrasoundmachine usingacurvilinear5---2MHzsteriletransducer (SonoSite M-Turbo, Bothell,WA, USA), the lateralabdominal wall was scanned posteriorly and superiorly to the ipsilateral iliac crest(Fig.1),followingthetransversalisfasciauntil quadra-tus lumborummuscle was identified(Fig. 2).Ropivacaine 0.25% 30mL was injected through an 18G Tuohy needle (Fig.2), 15mLonthe anterioraspect of themuscle (Bor-glumapproach)6and15mLontheposterioraspect(QLtype
2, Blanco approach).2 The same procedure was repeated
onthe contralateral side, withthe same volume of local anesthetic.
All patients received multimodal analgesia with acetaminophen 650mg every 6h and Ketorolac 15mg q6h.Oralmorphine5mgwasprescribedonaperrequest basis.
NumericRatingScale(NRS)forpainwasrecordedevery hourinthefirst24h aftersurgeryandpatientsatisfaction wasrecorded24hpostoperatively.
Inaddition,opioidconsumptionduringthefirst24hwas recorded.
Case1
420 I.Sebbagetal.
Anterior
Posterior
Figure1 Surface anatomyofthe posterior abdominal wall andflank.CB,(sub)Costalborder;IC,iliaccrest.
EO
IO
TA
QL
Needle
Figure2 Sonoanatomyofthequadratuslumborumblock.EO, externaloblique;IO,internaloblique;TA,transversus abdomi-nis.
monitoringrevealedspontaneousfetalheartrate decelera-tionsto50s.Abiophysicalprofilerevealed2/8forfluid.A cesareandeliverywasrecommendedandperformedwithin 1h fromarrival to the hospital.Neuraxial block was per-formedwitha25gWhitacreneedleinthesittingposition. Afterclear cerebrospinalfluid was visualized, intrathecal hyperbaricbupivacaine 0.75% 10.5mg,fentanyl 15gand
morphine150gwere injected.Afterthe surgeryhas
fin-ished,shewasofferedtheQLblockasshewasconcerned aboutpostoperativeneed forparenteralopioidsaswellas aprevious badexperience withparenteral opioid induced nauseaandvomiting.
Case2
A 36year-old G3P2woman witha singletonpregnancyat 39+4 weeks of gestation presented for elective repeat cesarean delivery. Neuraxial block was performed with a 25g Whitacre needle in the sitting position. After clear cerebrospinal fluid was visualized, intrathecal hyperbaric bupivacaine 0.75% 10.5mg, fentanyl 15g and morphine
150gwere injected. After the surgery has finished, she
wasofferedtheQLblockasanadjuvantforpost-operative analgesia.
Case3
A 33year-old G3P2woman witha singletonpregnancyat 39+2 weeks of gestation presented for elective repeat cesarean delivery. Neuraxial block was performed with a 25g Whitacre needle in the sitting position. After clear cerebrospinal fluid was visualized, intrathecal hyperbaric bupivacaine 0.75%11.25mg,fentanyl 15gand morphine
150gwere injected. After the surgery has finished, she
wasofferedtheQLblockasanadjuvantforpost-operative analgesia.
Results
NRSforpain(1---10)andpatientsatisfactionwiththequality oftheanalgesiaobtained(Unsatisfied/Satisfied/Very Satis-fied)wasrecorded,asdescribedinTable1.
Noneofthepatientsreceivedfurtheropioidsduringthe first24haftersurgery.
Discussion
Post-cesarean analgesiacan bechallenging duetovarious reasons, including cultural factors and patients’ expec-tations. Although intrathecal morphine is widely used successfully in most cases, the scientific community has been recently looking into chronic pain associated with intrathecalopioiduse.Recentevidenceshowsthatgenetic polymorphismof the-receptormayleadto
pharmacoge-neticvariability,ultimatelyalteringtheanalgesicresponse tointrathecalmorphineandpossiblydetermining suscepti-bilitytoopioidinducedhyperalgesia.7,8Woundhyperalgesia
is a known risk factor for developing chronic postsurgical pain,andhasbeen reportedin upto10%of womenafter cesareandelivery.9---11
Inaddition,durationofanalgesiawithintrathecal mor-phine is unclear. Previous studies in the obstetric and non-obstetric surgical population failed todemonstrate a linearrelationshipbetweenmorphinedoseanddurationof analgesia.1,2 Despite the intrathecal morphinedose, most
womeninadose-findingRandomizedControlledTrial(RCT) continuedtouseIVPatientControlledAnalgesia(PCA)pump ofmorphineataslowbutsteadyrate.1Thesefindings
sug-gestthatintrathecalopioidadministrationmaynotprovide sufficientanalgesia.
Quadratuslumborumblockforpost-cesareananalgesia 421
Table1 NRSforpain(1---10)andpatientsatisfaction.
NRS
T=1
NRS
T=2 NRS
T=3 NRS
T=4 NRS
T=5
NRS
T=6
NRS
T=9
NRS
T=12 NRS
T=18 NRS
T=21 NRS
T=24
Patient satisfaction
Case1 0 0 0 ---b 1 1 0---2a 0 2---3a ---b 4---6a Verysatisfied
Case2 0 0---2a 2---3a 2---3a 2---3a 2---3a ---b ---b 1 ---b 2 Verysatisfied
Case3 0 0 0 0 ---b 0 0 0---4a 0 ---b ---b Verysatisfied
NRS,NumericRatingScale(0---10);T,numberofhourspostquadratuslumborumblock.
a Firstnumberindicatespainatrest;secondnumberindicatespainatmovement.Onthetimepointsthatindicateonenumber,only
painatrestwasrecorded.
b Patientasleepornotavailableintheirroom.
Arecentcase reportof theuseof theQLblockfor the treatmentofchronicabdominalpainhighlightitspotential use for preventing and even treating chronic pain in the obstetricpopulation.12
When Blanco first described the QL block as a vari-ation of the more anterior TAP block, he recommended placementofthelocalanesthetic(LA)laterallytothe mus-cle(QLtype1).Nevertheless,magneticresonanceimaging (MRI) looking into local anesthetic spread demonstrated thatparavertebralspreadisbetterwithposteriorinjection of the LA (QL type 2).5 In fact, his group recently
pub-lishedanRCTcomparingopioidconsumptionaftercesarean delivery in 25 patients that received a QL block with bupivacaine 0.125% 0.2mL.kg−1 versus 23 patients that
received a sham block.13 They found that morphine
con-sumption was significantly lower in the QL group during the first 6 and 12h after the block, but the pain scores weresignificantlydifferentupto48hpost-procedure. Exter-nal validity in this study is questionable as they used parenteral morphine patientcontrolledanalgesia, instead of comparing the QL block with intrathecal morphine, consideredthe‘‘gold standard’’forpost-cesarean analge-sia.
In addition,Borglum etal.MRI studiesrevealed that a major portionof the LAadministered on the lateral bor-deroftheQLmusclespreadsinanantero-lateraldirection, divergingfromtheinjectionpointanddefeatingthepurpose ofobtainingparavertebralspread.14Furthermore,hisgroup
suggested a transmuscular approach, with the LA placed anteriorly to the QL muscle. This approach was associ-atedwithlessredundantantero-lateralspreadandachieved extensivethoracolumbarspread.6Tothebestofour
knowl-edge, the Borglum approach has not yet been studied in obstetricpatients.
Inallthreeofourcases,wedepositedhalfoftheLAon theanterior(Borglum)andremaininghalfontheposterior (QL2,Blanco) aspectsofthe muscleinordertooptimize bothcephalo-caudalandparavertebralspread.
Our results showed that thistechnique was associated withminimal painduring thefirst 24h postoperatively. In addition,wefound thattheQLblockanalgesiawaslonger lastingthanthepublisheddurationofintrathecalmorphine analgesia.Ourpatients didnotrequireany opioidsduring thefirst24haftersurgery.
Randomized controlled trials comparing QL block with intrathecalmorphinewillbeneededtoconfirmourfindings ofprolongedanalgesicefficacyofQLblockforpost-cesarean analgesia.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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