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Postoperative analgesia with quadratus lumborum blockade for elective caesarean delivery: A retrospective study
Abstract Number: T2B-1
Abstract Type: Original Research
Pain control remains a challenge following caesarean delivery (CD) despite multimodal analgesia regimens that include intrathecal morphine (ITM). Recently, a more posterior approach to transverse abdominis plane (TAP) block, the quadratus lumborum block (QLB), has been found promising following lower abdominal surgery for pain control. However, there is limited evidence regarding its effectiveness in the CD population. The aim of this study was to assess outcomes associated with QLB when used in combination with ITM and multimodal analgesia for CD.
This retrospective cohort study was conducted among women undergoing elective CD. Women with history of opioid tolerance were excluded since this was identified a priori as a significant confounder. After institutional Research Ethics Board approval, 50 women receiving QLB (in addition to ITM) were identified, and 100 women who did not receive QLB (i.e., ITM only) were frequency matched to the QLB group by body mass index, parity, previous CD, and maternal age. All women received identical postoperative multimodal analgesic regimes of scheduled naproxen/acetaminophen, and oxycodone on request. The primary outcome was cumulative 24h oxycodone consumption. Differences between groups were assessed using the Mann-Whitney U test and reported as medians with interquartile range (IQR, i.e., the 25th and 75th percentiles). The study was powered to detect a 50% reduction in cumulative 24h opioid consumption with 80% power and 5% significance level.
There was no difference in group demographics. Median 24h oxycodone consumption was similar between groups (QLB 0.0mg (IQR 0.0-6.3) vs non-QLB 2.5mg (IQR 0.0-10.0), p=0.462). A delay in median time to first oxycodone request was observed (QLB 10.6h (3.9-22.4) vs non-QLB 2.9h (1.8-18.6), p=0.009). No secondary outcome differences were found between the QLB and non-QLB group for cumulative 48h oxycodone consumption, median and highest pain scores, and antiemetic use. There were no adverse events or complications. When grouped post hoc by those women who received any opioid within 24h vs none, differences in previous CD (41.3% vs 58.7%, p=0.008) and median maternal age (32.6 (IQR 29.3, 34.8) vs 35.0 (IQR 32.3, 37.7), p=0.002) were observed.
Adding QLB to multimodal analgesic regimens, inclusive of ITM, was associated with increased time to first opioid use; QLB was not associated with reduced analgesia use, pain scores or reduction in side effects. The retrospective design and small sample size limits the ability of this study to detect smaller outcome effect sizes. Until evidence from ongoing RCTs becomes available, this study informs clinicians regarding the utility of QLB for postoperative pain management in women who receive ITM and multimodal analgesia for CD.