Posteromedial quadratus lumborum block versus wound infiltration after caesarean section

Abstract

BACKGROUND Reducing pain and minimising the use of opioids after caesarean section are crucial to enhancing maternal recovery and promoting mother-newborn interaction. Various techniques have been implemented to improve analgesia. We compared the analgesic efficacy of posteromedial quadratus lumborum block with that of wound infiltration following elective caesarean section. OBJECTIVE We hypothesised that within a multimodal analgesia approach, posteromedial quadratus lumborum block would, due to its potential to relieve visceral pain, result in a 15% reduction in 24-h postoperative opioid consumption compared with wound infiltration. DESIGN A double-blind, randomised, placebo-controlled clinical study. SETTING A single-centre study between August 2019 and May 2020. PATIENTS One hundred and sixteen women were randomly allocated into two groups. In the quadratus lumborum group, 20 ml 0.9% saline was injected into the surgical wound followed by bilateral posteromedial quadratus lumborum block using 20 ml 0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25% levobupivacaine was injected into the surgical wound followed by a bilateral posteromedial quadratus lumborum injection with 20 ml 0.9% saline per side. MAIN OUTCOME MEASURES The primary outcome was opioid (piritramide) consumption at 24 h. Secondary outcomes were piritramide consumption at 48 h, time-to-first analgesic request, pain scores at rest and with movement, surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation, pruritus and complications. RESULTS Piritramide consumption in 24 h was significantly lower with posteromedial quadratus lumborum block (1.5 ± 1.8 mg) than with wound infiltration (2.2 ± 1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI -1.3 to -0.03). In those who required piritramide, time-to-first analgesic request was significantly longer with posteromedial quadratus lumborum block 11 [7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scores were low, with no differences recorded at rest and with movement. There were no differences in time-to-ambulation and time-to-breastfeed between the groups. CONCLUSION As a component of multimodal post-caesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioid consumption compared with wound infiltration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04000308

Anterior Quadratus Lumborum Block at the Lateral Supra-Arcuate Ligament versus Transmuscular Quadratus Lumborum Block for Analgesia after Elective Cesarean Section: A Randomized Controlled Trial

“…Third, we did not administer intrathecal opioids after CD to avoid interfering with the interfascial plane blocks. The issue of whether the addition of QLB to parturients receiving neuraxial morphine results in additional analgesic benefit compared with neuraxial morphine alone is still a point of discussion in meta-analyses and clinical studies [22,32,33]. Fourth, all parturients in the current study received the Joel-Cohen incision, but not Pfannenstiel incision.…”

“…The pain experienced after CD is complex and consists of somatic pain originating from the abdominal wall incision located in the cutaneous segment area innervated by the anterior branch of the T12~L1 spinal nerves and the rectus abdominis dissected in the surgical area innervated by the anterior branches of the T6~T7 thoracic nerves [22]. The pain also has a visceral component due to uterine exteriorization and stretching innervated by the T5~T10 thoracic sympathetic nerve [23].…”

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

“…The effectiveness of the QLB for postoperative analgesia after CS has been studied utilizing spinal anesthesia with and without intrathecal morphine. Without intrathecal morphine, many studies have demonstrated the effectiveness of the QLB to decrease the pain scores and decrease the total dose of postoperative rescue analgesic compared to sham procedure (12)(13)(14)(15) , TAP block (16)(17)(18) , or wound infiltration (19) .…”

“…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) .…”

Vpliv multimodalne analgezije na samostojnost otročnic pri osebni higieni, skrbi za novorojenčka in dojenja po carskem rezu

“…Koncept multimodalne analgezije vključuje načrtno kombiniranje področnih tehnik lajšanja bolečine s sistemskimi analgetiki, različne farmakodinamične in farmakokinetične lastnosti z namenom doseganja sinergističnih analgetičnih učinkov (Holland et al, 2019;Smith, Young, Blosser, & Poole, 2019: Bornstein et al, 2021. Z multimodalnimi režimi analgezije lahko po carskem rezu pomembno zmanjšamo uporabo opioidnih analgetikov, ob tem pa še vedno zagotovimo ustrezno obvladovanje bolečine (Stopar-Pintarič et al, 2021;Višić, Stopar Pintarič, Albreht, Blajić, & Lučovnik, 2021).…”