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

Abstract

Background: Achieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (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, with IT morphine and bilateral QLB, or only bilateral QLB.Methods: Parturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared.Results: Eighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period is significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04-3.96) in Group IT vs. 7.75 (5.67-9.83) in IT+QLB vs. 1.75 (0.75-2.75) in QLB (p<0.001)]. The median (min, max) amount of morphine required during 24 hours was 5.5 (0-25) in Group IT vs. 5.0 (0-36) in IT+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 (1.23-3.77) hours (95%CI) in Group IT (n=27) vs. 8.02 (5.96-10.07) in IT+QLB (n=28). (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 can provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta‐analysis of randomised controlled trials

“…We included 114 trials (8730 women) in our final network analysis, 73 (64%) of which reported the primary outcome of morphine equivalent dose in the first 24 postoperative hours for 5126 (59%) women (Fig. 1 and online Supporting Information, Table S1) [14–127]. Placebo vs. transversus abdominis plane injection in 11 trials was the most common direct comparison.…”

Different Doses of Intrathecal Morphine on Postoperative Analgesia and Pruritus after Cesarean Section: a Prospective Randomized Triple-Blinded Trial

“…23 Hence, morphine is recommended, rather than short-acting opioids, to be added to spinal bupivacaine for providing postoperative analgesia after Cesarean section. Although, the quadratus lumborum block might be a technique to replace, and avoid ITM-induced side effects in Cesarean delivery, evidence showed that it did not have additive analgesic effects when combined with ITM; additionally, it was inferior to ITM when used alone in patients undergoing Cesarean section [24][25] Although, we could not eliminate intrathecal morphine-induced side effects to zero, we could reduce them as much as possible by reducing the dose of ITM. However, this will reduce the analgesic effects as well.…”

Quadratus Lumborum Block for Analgesia after Cesarean Section with Spinal Anesthesia: A Randomized Controlled Study

“…However, a number of studies compared QLB with intrathecal morphine and demonstrated that the analgesia provided by intrathecal morphine is superior to QLB (15,20,21) . Moreover, QLB provides no benefit compared to sham procedure when intrathecal morphine is used as part of postoperative multimodal analgesia (20)(21)(22) .…”

“…The original lateral approach (QLB-I) (23) is now not used after CS. (12) Most of the current studies have utilized the posterior approach (QLB-II) (12,13,(15)(16)(17)(19)(20)(21)(22) , however, other studies have successfully utilized the transmuscular approach (QLB-III) (14,18) .…”