A review of peripheral nerve blocks for cesarean delivery analgesia

Mitchell, Kelsey D; Smith, Conrad; Mechling, C.; Wessel, Charles B.; Orebaugh, Steven L.; Lim, Grace

doi:10.1136/rapm-2019-100752

Cited by 50 publications

(73 citation statements)

References 88 publications

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“…A meta-analysis reported that using high-dose IT morphine >100-250 mcg resulted in a range of mean times (13.8-39.5 h) to rst analgesic request. 6 In our study, the Kaplan-Meier curve showed a median pain-free period or median time to rst request for IV-PCA morphine of 2.50 h in the Group IT morphine. Similarly, a previous study at our center reported a median time to rst request for IV-PCA morphine of 2.1 h when adding IT morphine 0.2 mg. 19 There was an improvement in the pain-free period and opioid consumption during the early postoperative period when QLB was combined with IT morphine.…”

Section: Discussionsupporting

confidence: 50%

“…[1][2][3][4] Intrathecal (IT) morphine is the standard method for postoperative pain control following spinal anesthesia for cesarean delivery 3,5 but increases the risk of maternal pruritus, nausea and vomiting and rare devastating respiratory depression. 1,[6][7] As a result of recent advances in ultrasound (US)-guided regional anesthesia, the popularity of abdominal wall block has dramatically increased during the last decade. US-guided transversus abdominis plane block (TAPB) has been shown to be an effective component of multimodal analgesia in parturients who are unable to receive neuraxial opioids or whose pain is not adequately controlled.…”

Section: Introductionmentioning

confidence: 99%

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Bilateral Posterior Quadratus Lumborum Block for Pain Relief after Cesarean Delivery: A Randomized Controlled Trial

Pangthipampai

Dejarkom

Poolsuppasit

et al. 2020

Preprint

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Background: Achieving optimal abdominal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal morphine is the current standard but ultrasound guided quadratus lumborum block (US-QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine 0.2 mg, with IT morphine 0.2 mg and bilateral QLB, or only bilateral QLB.Methods: Parturients having elective cesarean delivery with a low transverse incision under spinal block were randomized to three groups. Subjects were allocated into IT morphine 0.2 mg with sham QLB (Group IT morphine), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml and adrenaline 1:250,000 in each side (Group IT morphine with QLB), or bilateral QLB with 0.25% bupivacaine 25 ml and adrenaline 1:250,000 in each side (Group QLB). A PCA pump was connected to each parturient after completion of the QLB or sham block. The first time to PCA morphine requirement when parturients experienced pain was recorded and compared.Results: Eighty parturients were included. Analysis of Group QLB was terminated early because Kaplan-Meier survival analysis showed the median pain-free period to be significantly shorter in Group QLB at the second interim analysis; [2.50 hours (95% CI: 1.04-3.96) in Group IT morphine vs. 7.75 (95% CI: 5.67-9.83) in Group IT morphine with QLB vs. 1.75 (95% CI: 0.75-2.75) in Group QLB (overall p<0.001)]. The median (min, max) amount of morphine required during 24 hours was 5.5 (0-25) in Group IT morphine vs. 5.0 (0-36) in Group IT morphine with QLB vs. 17.5 (1-40) mg in Group QLB (p<0.001). In the final analysis the median pain-free period was 2.50 hours (95%CI: 1.23-3.77) in Group IT morphine (n=27) and 8.02 (95%CI: 5.96-10.07) in Group IT morphine with QLB (n=28). (Gehan-Breslow p=0.027).Conclusion: US-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB may provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period.Trial registration: ClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.

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Section: Discussionsupporting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

Bilateral Posterior Quadratus Lumborum Block for Pain Relief after Cesarean Delivery: A Randomized Controlled Trial

Pangthipampai

Dejarkom

Poolsuppasit

et al. 2020

Preprint

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“…The secondary analgesic outcomes included difference in area under the curve of the weighted pooled rest pain scores at five predesignated time points (in recovery room [0 to 2 h], and at 4 to 6, 12, 24, and 48 h postoperatively); postoperative rest pain severity (VAS pain scores) in recovery room and at 4 to 6, 12, 24, and 48 h postoperatively; time to first analgesic request (hours); requirement for breakthrough analgesia in recovery room; any indicators of postoperative function and quality of recovery such as time to ambulation (hours), time to voiding (hours), time to breastfeeding (hours); patient satisfaction with pain relief; and block performance time (minutes). Secondary safety outcomes included opioid-related side effects (i.e., postoperative nausea and vomiting, excessive sedation, respiratory depression, pruritis, hypotension, and urinary retention) and block-related complications 19 (i.e., hematoma, organ injury, local anesthetic systemic toxicity, and block failure).…”

Section: Primary and Secondary Outcomesmentioning

confidence: 99%

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia

Hussain¹,

Brull²,

Weaver³

et al. 2020

Anesthesiology

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Background Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine. Methods Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects. Results Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (−2 to 1) and −0.1 cm (−0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (−2 to 15) and 0.6 cm (−0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of −18 mg (−28 to −7) and −1.5 cm (−2.4 to −0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by −4.4 cm · h (−5.0 to −3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons. Conclusions Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spinal morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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“…A recent review of post-CD regional analgesia techniques discusses each of these approaches in detail. 2 In this issue of the Journal, Sultan et al present a network meta-analysis (NMA) comparing single-shot TAP block, single-dose wound infiltration (WI), and continuous wound catheter (WC) with a primary outcome of 24-hr opioid consumption after CD. 3 At first glance, it may be unclear from this study which technique is superior.…”

mentioning

confidence: 99%

“…Un article de revue récent s'intéressant aux techniques d'analgésie régionale postcésarienne décrit chacune de ces approches en détail. 2 Dans ce numéro du Journal, Sultan et coll. présente une méta-analyse en réseau (MAR) comparant les blocs TAP à injection unique, les infiltrations de l'incision en dose unique, et les infiltrations continues via cathéter.…”

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Management of pain after Cesarean delivery without intrathecal morphine: networking for the best answer

Barry

Uppal

2020

Can J Anesth/J Can Anesth

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A review of peripheral nerve blocks for cesarean delivery analgesia

Cited by 50 publications

References 88 publications

Bilateral Posterior Quadratus Lumborum Block for Pain Relief after Cesarean Delivery: A Randomized Controlled Trial

Bilateral Posterior Quadratus Lumborum Block for Pain Relief after Cesarean Delivery: A Randomized Controlled Trial

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia

Management of pain after Cesarean delivery without intrathecal morphine: networking for the best answer

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