Quadratus Lumborum Block Versus Caudal Block for Pediatric Postoperative Analgesia

Overview

The aim of this study is to compare between two regional analgesic techniques; caudal block and ultrasound guided quadratus lumborum block as regard degree of pain relief, accuracy of block, effect on hemodynamic stability and incidence of complications.

Full Title of Study: “Ultrasound Guided Quadratus Lumborum Block Versus Caudal Block for Pain Relief in Children Undergoing Lower Abdominal Surgeries”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Prevention
    • Masking: Double (Participant, Outcomes Assessor)
  • Study Primary Completion Date: August 1, 2020

Detailed Description

Regional anesthesia and analgesia techniques are commonly used during pediatric surgical practice to facilitate pain control, decrease parenteral opioid requirements and improve the quality of post-operative pain control and patient-parent satisfaction. The most commonly used technique is caudal anesthesia, which is generally indicated for urologic surgery, inguinal hernia repair and lower extremity surgery. The quadratus lumborum (QL) block is a recently introduced abdominal truncal block, used for somatic and visceral analgesia of both the upper and lower abdomen. It was first described by Blanco in 2007 . Currently, the QL block is performed as one of the perioperative pain management procedures for all generations (pediatrics, pregnant, and adult) undergoing abdominal surgery . QL block allows the local anesthetics to spread between the posterior aspect of the quadratus lumborum muscle and the medial layer of the thoracolumbar fascia, which is close to the thoracic paravertebral space . The ultrasound (US) has gained popularity among anesthesiologists performing regional anesthesia. Block success, and hence the efficacy would depend on the patient's anatomical variations and the anesthesiologist's skill level . The use of ultrasound-guidance for peripheral nerve blocks (PNBs) offers many advantages. Direct visualization of the nervous and surrounding structures decreases the incidence of complications e.g. inadvertent intraneural or intravascular injection. Direct real-time observation of the local anesthetics spread ensures more accurate deposition .This leads to faster onset and longer duration of block, thus improves block quality. It also allows dose reduction of local anesthetics . It has been shown that when peripheral nerves are adequately imaged by ultrasound, the simultaneous use of the nerve stimulator offers no further advantages. Following ethical committee approval of Anesthesia department, Fayoum University and obtaining informed consent from parents of each patient, fifty two patients will be randomized into 2 study groups. Each group contains 26 patients. Methodology: Preoperative Assessment: All patients will be assessed clinically and investigated for exclusion of any of the above mentioned contraindications. Operating Room Preparation & Equipment: The ultrasound used will be Sonosite M Turbo (USA), the scanning probe will be the linear multi-frequency 13-6 MHz transducer (L25x13-6 MHz linear array). The needle used will be the stimuplex D needles manufactured by B Braun (Germany). Perioperative Management: All patients will be premedicated with IM midazolam 0.2 mg/kg and atropine 0.02 mg/kg. Perioperative monitoring will include continuous ECG, pulse oximetry, non-invasive arterial blood pressure, and temperature monitoring. Inhalational induction of general anesthesia (GA) will be performed with a face mask using sevoflurane 8% and 50% oxygen in air, and then an intravenous (IV) cannula will be inserted. Fentanyl will be administered intravenously at 1 μg/kg, and a laryngeal mask airway (Intavent – Orthofix, Maidenhead, United Kingdom) will be used to secure the upper airway, with the patient kept spontaneously breathing. Anesthesia will be maintained with Isoflurane and 50% oxygen in air. Surgery will be allowed to begin 10 minutes after block application. At the end of surgery, acetaminophen 15 mg/kg IV will be administered to all patients. Any complications occurring during the procedure will be recorded. After completion of surgical procedure and emergence from anesthesia the patient will be referred to PACU. Quality of analgesia will be assessed using a FLACC scale at 30 minutes and at 1, 2, 4, 6, 12, and 24 hours postoperatively. Diclofenac sodium 1 mg/kg rectally will be given as rescue analgesia for patients in all study groups in PACU if FLACC scale > 4. Parents will be informed about the pain evaluation, and when patients had pain at home, parents will be instructed to give oral paracetamol 30 mg/kg. The anesthesiologist will record data received from the parents over the phone. Statistical Analysis Sample size was calculated using the G* Power software version 3.1.7 analysis program (Heinirch Heine University, Dusseldorf, Germany) before the study. Depending on previous similar research with calculated effect size (d) 0.85, two tails (two sided), type 1 error 0.05 and increasing power of study to 90%, it was determined that each group should include at least 26 subject to obtain significant statistical value. Collected data will be computerized and analyzed using statistical package for social science (SPSS) version 16. The results will be expressed as number and percentages for qualitative variables, mean, standard deviation and range for continuous data, median and inter-quartile range for quantitative discrete variables and scores. To compare between groups, the chi-square will be used for qualitative variables, student t rest for comparing quantitative continuous variables between 2 groups, Mann Whitney U test to compare scores between 2 groups. Probability (P) value of less than 0.05 will be considered statistically significant.

Interventions

  • Procedure: Quadratus Lumborum Block
    • Posterior or QL block type 2 , a bolus of 0.5 ml/Kg bupivacaine 0.25%
  • Procedure: Caudal Block
    • caudal block with 1 ml/kg of bupivacaine 0.25%.

Arms, Groups and Cohorts

  • Active Comparator: Quadratus Lumborum Block (QL)
    • Patients will be placed in the lateral position,The high-frequency linear probe will be placed on the lateral abdomen, slightly cephalic to the iliac crest. Once the QL muscle will be observed, the probe will be tilted slightly to the caudal direction, to show the largest slice of the QL muscle, to confirm its posterior aspect. A 22-G block needle (Stimuplex D, Braun, Hongo, Bunkyo-ku, and Tokyo) will be inserted in-plane, ~1 cm ventral to the probe. The needle tip will be advanced until it penetrates the posterior fascia of the QL muscle. A small amount of saline will be injected to confirm the correct position of the tip, between the QL muscle and the erector spinae and latissimus dorsi muscles (Posterior or QL block type 2), then a bolus of 0.5 ml/Kg bupivacaine 0.25% will be injected.
  • Active Comparator: Caudal block (C)
    • After induction of general anesthesia, a lateral position is obtained with the upper hip flexed 90⁰ and the lower one only 45⁰. A line is drawn to connect the posterior superior iliac spines bilaterally and used as one side of an equilateral triangle; then the location of the sacral hiatus should be approximated. By palpating the sacral cornua as 2 bony prominences, the sacral hiatus could be identified as a dimple in between. A 22 gauge needle is inserted at 45 degrees to the sacrum and redirected if the posterior surface of sacral bone is contacted. Children will receive caudal block with 1 ml/kg of bupivacaine 0.25%.

Clinical Trial Outcome Measures

Primary Measures

  • Time at which the first analgesia required
    • Time Frame: 24 hours after procedure
    • in hours

Secondary Measures

  • Pain assessment by the aid of FLACC score
    • Time Frame: 30 minutes after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 1 hour after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 2 hours after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 4 hours after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 6 hours after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 12 hours after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • Pain assessment by the aid of FLACC score
    • Time Frame: 24 hours after operation
    • F:Face ,L:Legs, A:Activity, C:Cry, C:Consolability score
  • number of analgesic doses for each patient
    • Time Frame: 24 hours after operation
    • by oral paracetamol 30 mg/kg given by parents
  • The general satisfaction score of parents
    • Time Frame: 24 hours after operation
    • measured on a 5-point scale of 1.Extremely dissatisfied 2.Dissatisfied 3.Not satisfied, nor dissatisfied 4.Satisfied 5.Completely satisfied.
  • Preoperative heart rate
    • Time Frame: 5 minutes before operation
    • in beat per minutes measured by electrocardiogram
  • Preoperative systolic blood pressure
    • Time Frame: 5 minutes before operation
    • in mm mercury measured by non-invasive blood pressure measurement
  • Preoperative diastolic blood pressure
    • Time Frame: 5 minutes before operation
    • in mm mercury measured by non-invasive blood pressure measurement
  • Intraoperative systolic blood pressure
    • Time Frame: every 15 minutes till end of operation
    • in mm mercury measured by non-invasive blood pressure measurement
  • Intraoperative diastolic blood pressure
    • Time Frame: every 15 minutes till end of operation
    • in mm mercury measured by non-invasive blood pressure measurement
  • Intraoperative heart rate
    • Time Frame: every 15 minutes till end of operation
    • in beat per minutes measured by electrocardiogram
  • Incidence of hypotension
    • Time Frame: within one hour of the intervention
    • drop of blood pressure more than 20 % of baseline blood pressure
  • Incidence of bradycardia
    • Time Frame: Within one hour of the intervention
    • Heart rate below 50 beat per minute by electrocardiogram
  • Incidence of vascular puncture
    • Time Frame: Within one hour of the intervention
    • as signs of local anesthetics toxicity
  • Incidence of convulsions
    • Time Frame: Within one hour of the intervention
    • as signs of local anesthetics toxicity
  • Incidence of arrhythmias
    • Time Frame: Within one hour of the intervention
    • as signs of local anesthetics toxicity
  • Incidence of paresthesia
    • Time Frame: Within one hour of the intervention
    • as signs of local anesthetics toxicity
  • Incidence of hematoma formation
    • Time Frame: Within one hour of the intervention
    • Recorded under ultrasound guidance
  • Incidence of injury to the underlying structures
    • Time Frame: Within one hour of the intervention
    • Injury to the liver or a viscous

Participating in This Clinical Trial

Inclusion Criteria

  • Age 1-7 years – American Society of Anesthesiologists physical status I-II – Lower abdominal surgery Exclusion Criteria:

  • History of developmental delay or mental retardation – Parent refusal – History of allergic reactions to local anesthetics – Rash or infection at the injection site – Anatomical abnormality – Bleeding disorders. – History of cardiac, neurological, renal, hepatic diseases.

Gender Eligibility: All

Minimum Age: 1 Year

Maximum Age: 7 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Fayoum University Hospital
  • Collaborator
    • Cairo University
  • Provider of Information About this Clinical Study
    • Principal Investigator: Doaa Lotfy, Assistant Lecturer of Anesthesiology – Fayoum University Hospital
  • Overall Official(s)
    • Kareem M Nawwar, MD, Study Director, Kasr ElAini Hospital, Faculty Of Medicine, Cairo Univerisity

References

Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001 Jul;87(1):62-72. doi: 10.1093/bja/87.1.62. No abstract available.

Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia: anatomy, function and clinical considerations. J Anat. 2012 Dec;221(6):507-36. doi: 10.1111/j.1469-7580.2012.01511.x. Epub 2012 May 27.

Chakraborty A, Goswami J, Patro V. Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient. A A Case Rep. 2015 Feb 1;4(3):34-6. doi: 10.1213/XAA.0000000000000090.

Liu SS, Ngeow J, John RS. Evidence basis for ultrasound-guided block characteristics: onset, quality, and duration. Reg Anesth Pain Med. 2010 Mar-Apr;35(2 Suppl):S26-35. doi: 10.1097/AAP.0b013e3181d266f0.

Griffin J, Nicholls B. Ultrasound in regional anaesthesia. Anaesthesia. 2010 Apr;65 Suppl 1:1-12. doi: 10.1111/j.1365-2044.2009.06200.x.

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