Background & Aims
Surgery is a lifesaving medical intervention; however, it is not free of complications and one of the inevitable complications is pain. Pain affects the length of hospital stay, patient satisfaction, outcome (morbidity, mortality including chronic postsurgical pain), and overall health-related quality of life (1-4). Hence, relieving pain is one of the main pillars of medicine to enhance the short and long-term outcomes of surgery, and quadratus lumborum block (QLB) is found to be an option in abdominal surgical pain management (5-9). However, due to the lack of trained human power in the specialty of regional anesthesia, access to ultrasound, and other resources in low and middle-income countries (LMICS) like Ethiopia the practice is limited. Thus, we aim to introduce a nostrum of QLB for flank incision surgery with a case study that will provide a contextual understanding of the technique, with in-depth insight into patient selection, safety, efficacy, challenges, and opportunities.
Methods
This is a case study of 4 consecutive patients who have undergone open kidney surgery and retroperitoneal mass surgery under general anesthesia and received landmark approaches of superior anterior QLB (SAQLB). Anterior QLB is among the variant approaches of QLB which involves depositing local anesthetic between the fascial planes of the psoas & quadratus lumborum(QL) muscle and those muscles will be exposed and become visible in flank incision surgery. Thus, QLM, psoas, arcuate ligaments, and adjacent transverse process are used as landmarks in SAQLB, and 30-40 ml of 0.25% bupivacaine was injected under direct visualization of the fascial planes of those muscles. Patients were followed till the day of discharge for pain and any block-related complications beyond the usual care. Global assessment of pain management done on discharge from the hospital which encompasses pain severity, block-related complications, satisfaction with pain control, and overall care.
Results
Mild pain was reported at 34, 36, and 48 hours for cases 1,2, and 3 respectively. Case I stated its efficacy “I am a nurse working in the operation theatre and I know how much pain after surgery is unbearable, I feel it works not only for the 1st two days rather I can cascade the pain intensity until 5th day, and I believe it works till the 4th postoperative day. Please do it for others you will get from Allah.” The 4th case reported mild dull pain immediately after surgery that was relieved with 50 mg of tramadol iv and diclofenac 75 mg IM injections. Except with case IV (severe pain during ambulation downstairs), there were no reports of severe postoperative pain during their hospital stay. Reported side effects were a slight decrement in Blood pressure after 20-30 minutes of the block, discomfort from airway management and urinary catheter as well symptoms of paralytic ileus due to concomitant administration of opioids with overall good pain control and patient satisfaction.
Conclusions
Collaborative efforts between anesthesia providers (anesthetists, anesthesiologists), nurses, surgeons, and researchers can enhance the understanding and implementation of tailored postsurgical pain management in retroperitoneal surgery. As the use of USG-QLB in resource-limited settings like Ethiopia has been influenced by regional factors; introducing a landmark approach of SAQLB in the clinical practice is the accession. The finding in this case study shows a promising effect with feasibility for low-resource settings for open retroperitoneal surgeries. However, its widespread adoption requires additional investigation with a robust methodology to establish the safety and efficacy of the technique as well as optimal dosing, timing, and long-term outcomes.
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Presenting Author
Gebrehiwot Asfaw Tegu
Poster Authors
Gebrehiwot Asfaw Tegu
MSc
Bahir Dar University
Lead Author
Topics
- Treatment/Management: Interventional Therapies – Injections/Blocks