To compare pain relief provided by either Quadratus lumborum nerve block or Psoas Compartment nerve block in patients undergoing hip replacement surgery under general anaesthesia
- Conditions
- Osteoarthritis of hip,
- Registration Number
- CTRI/2017/03/008134
- Lead Sponsor
- All India Institute of Medical Sciences New Delhi
- Brief Summary
Total hip arthroplasty (THA) is a commonly performed procedure for irreversible hip joint damage. Post-operative analgesia in patients undergoing THA remains a challenge with up to 50% patients undergoing this procedure complaining of severe pain after the surgery.(1) According to a recent meta-analysis currently there is no proven best method of providing post-operative analgesia for these patients.(2) Systemic opioids are routinely used for providing perioperative analgesia for patients undergoing THA, but their use is limited by side effects such as nausea, vomiting, sedation constipation and respiratory depression. All these side effects are especially undesirable as a number of patients undergoing THA are elderly.
In our institute most THAs are performed under central neuraxial block. A combined spinal epidural technique is usually used, a bolus of 10-15mg hyperbaric 0.5% bupivacaine is administered initially in the sub arachnoid space followed by epidural boluses of local anaesthetic as and when required to extend surgical anaesthesia. For providing postoperative analgesia 30-50 mcg/kg epidural morphine in 10 ml normal saline is administered via the epidural catheter every 8 to 12 hourly. The use of epidural morphine in saline avoids the motor block that is caused by epidural local anaesthetics but its use is associated with exaggerated side effects of systemic opioids, as well as unwanted urinary retention and pruritus in 15-30% patients. (3) In addition performing central neuraxial blocks is not possible in all patients necessitating administration of general anaesthesia at times.
Regional anaesthesia techniques such as ipsilateral psoas compartment block (PCB), fascia iliaca or femoral nerve block have all been used for providing perioperative analgesia, minimising opioid use and aiding in early mobilisation and rehabilitation of patients undergoing THA. (4-7)
The psoas compartment block is a posterior approach to lumbar plexus block that can anaesthetise the areas supplied by the femoral, obturator and lateral femoral cutaneous nerves. (8) The block was traditionally performed using anatomical landmarks and more recently ultrasound guided PCB has been described by a number of authors. (9, 10) The block was traditionally performed using anatomical landmarks and more recently ultrasound guided PCB has been described by a number of authors. (9, 10) The depth at which the lumbar plexus is present usually varies from 7 to 8.5 cm and it lies between the anterior two third and posterior one third of the psoas muscle at this level. (6) The depth at which the plexus is present and the proximity of the kidney and major vessels in this area makes this a technically challenging block to perform.
The Quadratus lumborum block (QLB) is a relatively new ultrasound (USG) guided plane block wherein local anaesthetic is deposited between the quadratus lumborum (QL) and adjoining muscles. Various techniques of the block have been described and local anaesthetic is deposited either between QL and internal oblique muscle anteriorly (QLB1) or between QL and latissimus dorsi (QLB2) or in another technique between QL and psoas major muscle posteriorly (QLB3). (12-14) Irrespective of the site of injection it has been postulated that proximal migration of the drug to the ipsilateral paravertebral space occurs, resulting in anaesthesia of nerves emerging from the lumbar intervertebral foramen akin to a lumbar plexus block. However this block is technically simpler to perform than a PCB and may be associated with fewer side effects. A single bolus of local anaesthetic administered in QLB1 as compared to compared to a single bolus femoral nerve block has been shown to reduce opioid requirements in the first 24 hours in patients undergoing hemi- hip arthroplasty following femoral neck fracture.(15) The use of continuous QLB3 has also been found to be effective for providing perioperative analgesia following hip arthroplasty in two cases as reported by Ushima and colleagues. (16) In a cadaveric study, the QLB3 technique or transmuscular approach to QL block as described by Borglum has been demonstrated to result in more consistent spread of dye to the lumbar nerve (L1-3) roots as compared to QLB 1 and QLB 2 techniques. (17)
The hypothesis of this study is that an ipsilateral, continuous transmuscular Quadratus lumborum block would be non-inferior to an ipsilateral continuous Psoas compartment block, both block performed under ultrasound guidance for providing perioperative analgesia in patients undergoing unilateral total hip arthroplasty under general anaesthesia.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Completed
- Sex
- All
- Target Recruitment
- 60
60 patients of ASA physical status I to III aged 18 to 70 years undergoing unilateral THA under general anaesthesia at AIIMS, New Delhi.
- Patient refusal to participate 2.
- Those who are unable to denote pain using a VAS scale(0-100mm) 3.
- Bleeding diasthesis or anticoagulant use 4.
- Bilateral THA done in the same sitting 5.
- BMI >30kg/m2 6.
- Local infection at the site of the proposed block.
Study & Design
- Study Type
- Interventional
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method Primary objective: to compare pain scores post-operatively, at rest and on mobilisation using visual analog scale (VAS, 0-100mm) between patients receiving either continuous ipsilateral transmucular QL block or PCB for perioperative analgesia following unilateral total hip arthroplasty under general anaesthesia 6 hours post-operatively
- Secondary Outcome Measures
Name Time Method Sensory dermatomes blocked Motor dermatomes blocked 30 min following injection preoperatively and at, 6, 12 and 24 hours post-operatively Pain scores at rest using (0-100mm VAS) at 0, 1, 2, 4, 6, 12 and 24 hours post-operatively Pain scores on movement (plantar and dorsal ankle flexion) (0-100mm VAS) at 0, 1, 2, 4, 6, 12 and 24 hours post-operatively Total analgesic requirement intraoperative and 24 hour postoperative PCA fentanyl and rescue Quality of Recovery score 24 hours postoperatively
Trial Locations
- Locations (1)
Orthopaedics Operation thetre complex All India Institute of Medical Sciences
🇮🇳Delhi, DELHI, India
Orthopaedics Operation thetre complex All India Institute of Medical Sciences🇮🇳Delhi, DELHI, IndiaDr Anjolie ChhabraPrincipal investigator01126546691anjolie5@hotmail.com