• Int J Obstet Anesth · Nov 2019

    A triple-blinded randomized trial comparing spinal morphine with posterior quadratus lumborum block after cesarean section.

    What did they do?

    Tamura and team randomised 176 elective CS patients to spinal anaesthesia with or without morphine, in addition to placebo or ultrasound-guided quadratus lumborum block (QLB).

    And they found

    Only intrathecal morphine significantly improved analgesia, not QLB whether performed with or without spinal morphine. Thus QLB probably does not improve analgesia further beyond current best practices.

    Not so fast...

    While this modest-sized RCT concluded that QLB did not improve pain after caesarean section, the conclusion is i) somewhat inconsistent with earlier studies that did show benefit, and ii) the adjuvant analgesic regime1 used may not be applicable to practice outside Japan.


    1. The researchers administered the remaining 90 mcg fentanyl IV, along with droperidol 1.25 mg and acetaminophen/paracetamol 15mg/kg after baby delivery. An NSAID (diclofenac 50mg) was only provided when breakthrough pain was requested. 

    summary
    • T Tamura, S Yokota, M Ando, Y Kubo, and K Nishiwaki.
    • Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan. Electronic address: takahiro@med.nagoya-u.ac.jp.
    • Int J Obstet Anesth. 2019 Nov 1; 40: 32-38.

    BackgroundThis study aimed to compare the postoperative analgesic effects of ultrasound-guided posterior quadratus lumborum block with spinal morphine, after cesarean section, using the visual analogue scale pain score.MethodsOne-hundred-and-seventy-six pregnant women scheduled for elective cesarean section with spinal anesthesia were randomly allocated into four groups to receive spinal morphine 0.1 mg (group M+); spinal saline (M-); posterior quadratus lumborum block using either 0.3% ropivacaine (0.45 mL/kg each side, maximum 150 mg) group pQ+); or saline (pQ-). All patients received 11-13 mg hyperbaric bupivacaine 0.5% and 10 μg fentanyl. Intravenous droperidol, fentanyl and acetaminophen were administered during surgery. Bilateral posterior quadratus lumborum block was performed immediately after surgery. Postoperative pain was assessed at 0.5, 1, 2, 4, 6, 18 and 24 h after surgery, and the pain score 6 h after surgery was the primary endpoint.ResultsOne-hundred-and-forty-six patients were included in the final analysis. Pain scores 6 h after surgery, both at rest and when moving, were significantly different when comparing the M+pQ+ group with the M-pQ+ or M-pQ- groups, and when comparing the M+pQ- group with the M- pQ+ or M- pQ- groups (all P <0.05). There was no significant difference between the M+pQ+ and M+pQ- groups, or between the M-pQ+ and M-pQ- groups.ConclusionSpinal morphine improved postoperative analgesia but the combination of posterior quadratus lumborum block with spinal morphine did not lead to further improvement.Copyright © 2019 Elsevier Ltd. All rights reserved.

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    This article appears in the collection: The quadratus lumborum block for Caesarean section.

    Notes

    summary
    1

    What did they do?

    Tamura and team randomised 176 elective CS patients to spinal anaesthesia with or without morphine, in addition to placebo or ultrasound-guided quadratus lumborum block (QLB).

    And they found

    Only intrathecal morphine significantly improved analgesia, not QLB whether performed with or without spinal morphine. Thus QLB probably does not improve analgesia further beyond current best practices.

    Not so fast...

    While this modest-sized RCT concluded that QLB did not improve pain after caesarean section, the conclusion is i) somewhat inconsistent with earlier studies that did show benefit, and ii) the adjuvant analgesic regime1 used may not be applicable to practice outside Japan.


    1. The researchers administered the remaining 90 mcg fentanyl IV, along with droperidol 1.25 mg and acetaminophen/paracetamol 15mg/kg after baby delivery. An NSAID (diclofenac 50mg) was only provided when breakthrough pain was requested. 

    Daniel Jolley  Daniel Jolley
     
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