Quadratus Lumborum Block Versus Perioperative Intravenous Lidocaine for Postoperative Pain Control in Patients Undergoing Laparoscopic Colorectal Surgery:A Prospective, Randomized, Double-blind Controlled Clinical Trial

OBJECTIVE: To investigate the comparative analgesic efficacy of systemic lidocaine and quadratus lumborum (QL) block in laparoscopic colorectal surgery.BACKGROUND: Although epidural analgesia is the standard to control pain in patients undergoing open colorectal surgery, optimal analgesic management in laparoscopic surgery is less well-defined. There is need for effective and efficient alternatives to epidural analgesia for pain management in patients undergoing laparoscopic colorectal surgery.METHODS: A total of 125 patients undergoing laparoscopic colorectal surgery were included in this randomized, double-blind controlled clinical trial. Patients randomly received an intravenous infusion with placebo plus a QL-block with placebo, a QL-block with ropivacaine 0.25% plus intravenous placebo, or intravenous lidocaine plus a QL-block with placebo. Postoperatively, all patients received patient-controlled intravenous anesthesia (PCIA) with morphine. Primary outcome parameter was the opioid consumption during the first 24 hours postoperatively. Secondary endpoints included severity of postoperative pain, time to return of intestinal function, incidence of postoperative nausea and vomiting, and length of hospital stay.RESULTS: The QL-block was not superior to systemic lidocaine for the reduction of morphine requirements in the first 24 hours postoperatively {QL-group: 37.5 (28.4) mg [mean (standard deviation)] vs lidocaine group: 40.2 (25) mg, P = 0.15}. For the majority of secondary outcome parameters, no significant differences were found between the groups. Morphine consumption in the postanesthesia care unit, the number of PCIA-boli demanded by the patient, and the number of PCIA-boli delivered by the PCIA-pump during the first 24 hours postoperatively were lower in the placebo group.CONCLUSIONS: In our trial, the QL-block did not provide superior postoperative analgesia when compared to systemic lidocaine in laparoscopic colorectal surgery.TRIAL REGISTRATION: Eudra CT: 2014-001499-73; 31/7/2014.</p

The continuous search for new approaches improving postoperative outcomes

For further improvements of postoperative outcome, prevention of postoperative nausea and vomiting and adequate pain control are crucial, as these two entities remain the most frequent postoperative complications and hence also most important complaints of patients after surgery. The reduction of PONV and postoperative pain will thus have a large impact on patient well-being and satisfaction. The overall incidence of PONV after general anesthesia is still 20-30% (when no adequate prophylaxis has been administered), and can reach up to 80% in high risk patients. Occasionally, PONV can lead to aspiration pneumonia, wound dehiscence, surgical bleeding and esophageal rupture and dehydration. The real burden of PONV is the impairment of patients’ comfort. Moreover, PONV can lead to prolonged post anesthesia care unit (PACU) stay, necessitates an increase in nursing care and results in unanticipated hospital admissions following ambulatory surgery. As a result, PONV and its associated complications do increase costs. 80% of the patients experience acute postoperative pain after surgery, of which less than 50% receive adequate pain relief. Insufficient pain management might lead to clinical and psychological sequelae that can drastically reduce quality of life and impair recovery. Traditionally, opioids are still considered the gold standard for postoperative analgesia, but their use can cause clinically relevant, dose-limiting side effects including respiratory depression, sedation, constipation, itching, ileus, urinary retention and PONV. In an attempt to reduce opioid-related side effects, the concept of multi-modal analgesia for postoperative pain has been introduced. The overall aim of this thesis was to investigate and develop new therapeutic approaches with which the incidence of the above-mentioned two major postoperative complications (i.e., PONV and pain) could be reduced and postoperative outcome be improved. We evaluated the efficacy of two established drugs (alizapride and lidocaine) and of a relatively new peripheral nerve block (quadratus lumborum block) for the prevention of PONV and treatment of postoperative pain. We studied in a randomized placebo-controlled clinical trial whether 100 mg alizapride is non-inferior to 4 mg ondansetron for the prevention of PONV in patients undergoing laparoscopic gynecological surgery. Primary endpoint was the incidence of nausea and the incidence of vomiting on the PACU. Non-inferiority was tested separately for both outcomes. With respect to the incidence of nausea and to the incidence of vomiting during PACU-stay alizapride failed to show non-inferiority in comparison to ondansetron. Also regarding the incidence of PONV in the PACU and the overall incidence of PONV during 24 hours alizapride failed to demonstrate non-inferiority. Ondansetron-treated patients required significantly less rescue medication than placebo-treated patients. From this study, we concluded that there is no evidence that 100 mg alizapride is non-inferior in comparison to 4 mg ondansetron for the prophylaxis of PONV. Unfortunately, the low adherence to and the limited knowledge of clinical guidelines is a well-known medical problem. We studied the incidence of PONV and the compliance to the departmental guidelines for the prevention of PONV in our institution in an uncontrolled before-and-after study using a quasi-experimental design. In a first audit, we investigated the compliance with the departmental algorithm for PONV prevention. The results of this audit revealed that the adherence to our institutional guidelines for PONV-prevention was very low. The results of this audit prompted us to simplify our institutional algorithm for the prophylaxis of PONV. All female patients now receive a triple prophylaxis (consisting of dexamethasone, ondansetron plus either a target controlled infusion with propofol or droperidol) and all male patients obtain double prophylaxis with dexamethasone and ondansetron. This simplification of our algorithm for the prevention of PONV resulted in a significant reduction of the PONV-incidence and in a better compliance with the algorithm. Lidocaine is an amide local anesthetic with analgesic, anti-inflammatory and antihyperalgesic properties. Systemic lidocaine has been successfully used as a co-analgesic for the treatment of acute postoperative pain, especially in abdominal surgery. We studied in a randomized placebo-controlled trial the effect of systemic lidocaine on postoperative pain in patients undergoing laparoscopic sterilization in day-case surgery. Patients received an intravenous bolus injection of lidocaine 1.5 mg kg-1 at induction of anesthesia followed by a continuous infusion of 1.5 mg kg-1h-1 until 30 minutes after arrival on the PACU. The proportion of patients with a numeric rating scale >3, the mean numeric rating scales for pain and the opioid consumption could not be reduced by an intravenous lidocaine infusion. The median time to meet the criteria for hospital discharge were lower in patients receiving systemic lidocaine, a finding with statistical significance but questionable clinical relevance for which we were unable to elucidate the underlying mechanisms. Plasma levels of lidocaine measured when stopping the lidocaine infusion were all under the toxic dose of 5 µg ml-1. From this study, we concluded that systemic lidocaine shortens time to discharge readiness, but has no additional analgesic value in laparoscopic sterilization. In addition, we studied the effect of systemic lidocaine on postoperative morphine requirements in patients undergoing posterior spinal arthrodesis in a randomized placebo-controlled trial. The patients received a bolus of lidocaine (1.5 mg kg-1) and an intravenous lidocaine infusion (1.5 mg kg-1h-1) until 6 hours after arrival on the PACU. Systemic lidocaine had no influence on morphine consumption during the first 24 postoperative hours. Regarding the numeric rating scores for postoperative pain, PONV-incidence, return of intestinal function, length of hospital stay and inflammatory properties no effect of systemic lidocaine could be shown. We concluded from this trial that systemic lidocaine has no analgesic efficacy and place in multimodal pain management in spinal surgery. A transversus abdominis block or quadratus lumborum block is a rather new peripheral nerve block providing analgesia to the skin and muscles of the anterior abdominal wall. It is known from the literature that a quadratus lumborum block can reduce cumulative opioid consumption in the first 24 postoperative hours after laparoscopic colorectal surgery. The same effects are reported for systemic lidocaine in the literature. We studied the superiority of a quadratus lumborum block in comparison with perioperative systemic lidocaine for postoperative analgesia after laparoscopic colorectal surgery in a randomized placebo-controlled trial. Patients received either a quadratus lumborum block preoperatively, a systemic lidocaine infusion perioperatively until four hours after arrival on the PACU or placebo. There was no significant difference between the quadratus lumborum group and the lidocaine group in morphine requirements during the first 24 hours. Significant differences were however observed for total morphine requirements on the PACU, for the total number of PCIA-boli demanded by the patients and the number of PCIA-boli delivered by the pump the first 24 postoperative hours between the three groups: Interestingly, the placebo-group received less morphine compared to the quadratus lumborum and lidocaine group. PONV and postoperative pain remain two important complaints with a great impact on postoperative outcome. We investigated new approaches to prevent PONV and postoperative pain. In summary, our studies revealed that these new approaches, i.e., the use of alizapride for PONV prophylaxis, the use of systemic lidocaine and the quadratus lumborum block in concepts of multimodal analgesia, had not the hypothesized efficacy. In contrast, following the introduction of the new PONV algorithm we observed an improved compliance of anesthetic care providers with the departmental PONV guidelines.status: publishe

Response to Comment on "Borglom, Gogenur and Bendtsen''

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Acute rhabdomyolysis in dystrophinopathies during anesthesia: a systematic review

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Transversus abdominis plane block versus perioperative intravenous lidocaine versus patient-controlled intravenous morphine for postoperative pain control after laparoscopic colorectal surgery: study protocol for a prospective, randomized, double-blind controlled clinical trial

Despite the laparoscopic approach becoming the standard in colorectal surgery, postoperative pain management for minimally invasive surgery is still mainly based on strategies that have been established for open surgical procedures. Patient-controlled epidural and intravenous analgesia are considered standard postoperative analgesia regimens in colorectal surgery. Epidural analgesia provides excellent analgesia, but is increasingly scrutinized in laparoscopic surgery since postoperative pain after the laparoscopic approach is significantly reduced. Moreover, epidural analgesia can be associated with numerous complications. Therefore, epidural analgesia is no longer recommended for the management of postoperative pain in laparoscopic colorectal surgery. Likewise, patient-controlled intravenous analgesia is subject to significant side effects. Given these important limitations of the traditional strategies for postoperative analgesia, effective and efficient alternatives in patients undergoing laparoscopic colorectal surgery are needed. Both the transversus abdominis plane block and systemically administered lidocaine have already been reported to effectively reduce pain after laparoscopic colorectal surgery. We hypothesize that the transversus abdominis plane block is superior to perioperative intravenous lidocaine.status: publishe

The role of intravenous lidocaine in modern anesthesia

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In search of the Holy Grail: Poisons and extended release local anesthetics

Regional anesthesia has been advocated as adjunct to a multimodal analgesia regimen. The limited duration of the action of available local anesthetics limits their application. Catheters, perineural or IV adjuvants, or repetition of blocks are modalities available to prolong the analgesic benefit of LRA. All of these approaches have their shortcomings. New extended release local anesthetic formulations may provide time-efficient and longer duration of analgesia with a single injection. Available data on liposomal bupivacaine are promising, and more recently, it has been FDA approved for use in interscalene brachial plexus block but not for other nerve blocks at this time. Several other new formulations and compounds, such as HTX-011, Neosaxitoxin, and SABER-Bupivacaine, are also being developed and tested for their safety and analgesic potential.status: publishe

Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial

Background: It is inconclusive whether the perioperative administration of systemic lidocaine provides effective postoperative analgesia and enhances recovery in major orthopaedic surgery. We hypothesised that in adolescent and adult patients undergoing posterior spinal arthrodesis, a perioperative lidocaine infusion would reduce opioid requirements during the first 24 postoperative h. Methods: 70 patients undergoing posterior arthrodesis were enrolled in this prospective, randomised, double-blind, placebo-controlled clinical trial. Patients received total i.v. anaesthesia with propofol and remifentanil and were randomized to an adjuvant therapy with either lidocaine [i.v.-bolus injection of 1.5 mg kg -1 at induction of anaesthesia, followed by an infusion of 1.5 mg kg -1 h -1 which was continued until six h after arrival at the post-anaesthesia care unit] or placebo (equal volumes of saline). Postoperative pain was treated with patient-controlled i.v. morphine. Primary endpoints of this study were morphine requirements in the first postoperative 24 h. Results: Systemic lidocaine did not decrease morphine requirements in the first 24 postoperative h [lidocaine-group: 48 (23) mg (mean( sd )) vs placebo-group: 51(19) mg, P  = 0.22]. Likewise, groups were not different with respect to the severity of postoperative pain, morphine consumption after 48 and 72 h, incidence of postoperative nausea and vomiting, perioperative inflammation, time to recovery of intestinal function, hospital length of stay, and quality of life (assessed preoperatively and one month postoperatively using the SF-12 physical and mental composite scores). Conclusions: In our study, systemic lidocaine had no analgesic benefits in posterior arthrodesis when added to an opioid-based anaesthetic regimen. Clinical trial registration: Eudra CT 2012-005264-98.status: publishe

A double-blind placebo controlled trial comparing alizapride and ondansetron in the prevention of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynaecological surgery

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