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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 242-250

Clinical comparison between three regional analgesic modalities using ultrasound guidance for postoperative pain relief in children undergoing unilateral lower abdominal surgery


Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission22-Jan-2019
Date of Decision14-Feb-2019
Date of Acceptance25-Mar-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Mostafa M Sabra
Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Cairo, 112273
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_10_19

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  Abstract 


Objective Many regional techniques have been developed as safe and practical methods for adequate postoperative analgesia for unilateral lower abdominal surgery in children. The aim of the study was to compare the effectiveness of analgesia by using quadratus lumborum (QL) block, transversus abdominis plane (TAP) block, and caudal analgesia in children undergoing unilateral lower abdominal surgery.
Patients and methods This prospective, randomized, single-blinded study was conducted at Al-Hussein Hospital. Two hundred and forty pediatric patients aged 2–7 years were enrolled to undergo lower abdominal surgeries and were allocated into four groups (60 each). Group A : received QL block, group B: received TAP block, group C: received caudal block, with ultrasound guidance in the three groups, and group D: the control group. The primary outcome was postoperative pain control which was assessed by using Children’s Hospital Eastern Ontario Pain Scale and objective pain score. Intraoperative hemodynamics, postoperative complication, satisfaction of the parents, and postoperative analgesic requirements were the secondary outcomes.
Results There was no significant difference between groups in mean intraoperative arterial blood pressure and heart rate. There was significant difference between groups A and C in pain scores assessment (P<0.05), but no significant difference between groups A and B. Postoperative analgesia requirements were significantly higher in group B compared with group A (P<0.05). Parent satisfaction was markedly observed in groups A and B.
Conclusion This study’s outcomes demonstrated that for pediatric patients who are experiencing unilateral lower abdominal surgery, QL block and TAP block under ultrasound guidance proved to be safe with no recorded complications either intra- or postoperatively, with QL block superiority as evidenced by decreased rescue postoperative analgesia and lower pain scores. The QL block offered more effective for postoperative analgesia than the TAP block and caudal block.

Keywords: caudal block, pediatric, postoperative pain, quadratus lumborum block, transversus abdominis plane block


How to cite this article:
Sabra MM, Abotaleb UI. Clinical comparison between three regional analgesic modalities using ultrasound guidance for postoperative pain relief in children undergoing unilateral lower abdominal surgery. Al-Azhar Assiut Med J 2019;17:242-50

How to cite this URL:
Sabra MM, Abotaleb UI. Clinical comparison between three regional analgesic modalities using ultrasound guidance for postoperative pain relief in children undergoing unilateral lower abdominal surgery. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 8];17:242-50. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/242/271671




  Introduction Top


After unilateral lower abdominal surgeries in pediatric patients, the main source of pain is the abdominal wall [1],[2]. For instance, lower abdominal surgeries is a relatively minor operation; however, it may be accompanied with risk of severe pain, which is experienced by ∼12% of patients [3]. Failure to control preoperative pain causes significant clinical effects on the pediatric patient’s daily activities [4]. This has made regional analgesic approaches to gain tremendous popularity as crucial elements of postoperative analgesia regimens [5].

Unilateral lower abdominal surgeries (including unilateral hernia repair, unilateral orchiopexy, unilateral hydrocelectomy) are the most common surgical cases performed, with prevalence of 38% among the pediatric operations in our hospital.

Because of children and family anxiety, it is challenging to overcome postoperative pain incurred after pediatric surgical procedures. Therefore, proper pain control is significant to minimize unnecessary hospital admissions and reduce any emotional disturbance that is experienced by the patients and their families. Likewise, successful postoperative pain management encourages rehabilitation and quickens recovery from surgery [6].

Compared with conventional landmark-based approaches, ultrasound-guided blocks are associated with reduced volume of the local anesthetic required as well as a higher rate of success [5]. Regional anesthesia and analgesia procedures are frequently used for facilitation of proper pain control during unilateral lower abdominal surgeries; the most commonly used techniques are: quadratus lumborum (QL) block, transversus abdominis plane (TAP) block, and caudal analgesia [7].

An abdominal truncal block known as QL has emerged and it is applied for somatic analgesia both for lower and upper abdomen. With the QL block, it is possible for the local anesthetic to spread from the quadratus muscles’ posterior aspect to the thoracolumbar fascia’s medial layer, situated closer to the thoracic paravertebral space [7],[8].

Transversus abdominis, and internal and external obliques are the three muscle layers of the abdominal wall. In between the internal oblique muscles and transversus abdominis are mixed somatic nerves that facilitate innervation [9]. Currently, TAP block is considered as an effective approach that reduces morphine consumption as well as postoperative pain intensity after a patient undergoes lower abdominal surgery [10].

Although caudal analgesia together with local analgesics is considered effective, besides being short lived, it is linked to unwanted motor blockade as well as other complications [11].

The aim of the current study was to compare the effectiveness and safety of postoperative analgesia by using ultrasound guidance for the QL block, TAP block, and caudal block in children undergoing unilateral lower abdominal surgery.


  Patients and methods Top


This prospective, randomized, single-blinded, controlled study was carried out at Al-Hussein Hospital on pediatric patients enrolled to undergo lower abdominal surgeries over 10 months, from March 2018 to December 2018. Patients were eligible for this study if they aged from 2 to 7 years, American Society of Anesthesiologists physical status I and II presenting for elective surgery.

After obtaining our Research/Ethics Committee approval, a written informed consent was obtained from the parents of children, and received clarification to the aim of the study; 262 children were studied for illegibility for this study, and only 240 pediatric patients were enrolled in the study.

We excluded: patients whose parents refused regional block, patients requiring emergency surgeries, contraindications to regional anesthesia (bleeding disorders, skin lesions at the site of needle insertion point, or cutaneous anomalies), and patients with hepatomegaly or liver disease.

Preprocedural assessment included assurance, history taking, physical examination, and laboratory work such as complete blood picture, liver and kidney function tests, and coagulation profile.

All patients fasted for at least 6 h before the surgery, and received EMLA cream (Rocipharm Kariskoga AB; AstraZeneca, Södertälje, Sweden) to an appropriate site for cannulation 1 h before induction. An intravenous line was secured with a 22 G cannula, and the patients were premedicated with intravenous midazolam 0.05 mg/kg and atropine 0.01 mg/kg, 30 min before admission to the operating room.

On entry to the operating room, standard monitoring was applied (ECG, automated noninvasive blood pressure monitoring, peripheral nerve stimulation, and pulse oximetry). Baseline blood pressure (BP) and heart rate (HR) were recorded; mean HR (HR1) and mean BP (BP1) were calculated (Datex Ohmeda-GE, S5, patient monitor, USA). Lactated Ringer’s solution was infused (5–6 ml/kg/h).

Randomization was done by utilizing a computer-produced randomization chart (www.randomization.com). Furthermore, the participants were randomly allocated to four study groups (60 in each) as follows: group A (60) received ultrasound-guided QL block, group B (60) received TAP block, group C (60) received ultrasound-guided caudal block; and group D (60) the control group received standard anesthesia protocol.

The random group assigned was enclosed in a sealed envelope to guarantee concealment of assignment sequence. After transferring the patient to the operation theater, the sealed envelope was opened by an anesthesiologist, not engaged in the study.

Anesthetic technique

Preoxygenation was applied for 4 min utilizing a facemask and 100% oxygen. Anesthesia was induced by intravenous fentanyl (2 µg/kg) and propofol (2.5 mg/kg) over 30 s; then a ProSeal laryngeal mask airway (LMA North America, San Diego, California, USA) was used to secure the upper airway. Anesthesia was maintained by: isoflurane (1.2%) in 100% oxygen and atracurium maintenance dose according to time and nerve stimulator response. Intraoperative fluid therapy using lactated Ringer’s solution according to the weight of the child (4-2-1 formula) with care for replacement of losses (blood loss and third space).

All blocks (QL, TAP, and caudal) were performed by the same anesthesiologist to avoid inconsistent results, after placement of appropriate size of ProSeal laryngeal mask airway, and before surgery, while the patients were placed in supine position in group A, and lateral position in groups B and C; the site of the ultrasound and needle entry was scrubbed with povidone iodine (Povidone Iodine 10%; Nile Company, Egypt). Ultrasound machine (SonoSite M-Turbo, USA) and scanning probe were covered with a sterile sheath (linear multifrequency 13–6 MHz) was used in this study.

In group A (received quadratus lumborum block)

Placement of the probe was anterior and superior to the iliac crest, and the three abdominal wall muscles were recognized. The posterior border of the external oblique muscle was identified by following the muscle posterolaterally. At the point when the probe was tilted to the connection site of both internal oblique muscle and external oblique muscle over the QL, a bright hyperechogenic line was seen which is the midline of the thoracolumbar fascia. Then the local anesthetic was injected as a bolus of 0.5 ml/kg levobupivacaine 0.25% (chirocaine injection, 5 mg/ml, 0.5% 10 ml vial, AbbVie), using (B. Braun’s Stimuplex, 22 G, 80 mm insulated echogenic needle) in-plane technique as a bolus of 0.5 ml/kg levobupivacaine HCL 0.25%, between the QL muscles and the thoracolumbar fascia, after negative aspiration test.

In group B (receiving TAP block), placement of the probe was laterally between the iliac crest and anterolateral abdominal wall, then the external oblique, internal oblique, and transversus muscles were determined ([Figure 1]). The plane between the internal oblique and transversus abdominis was recognized around the midaxillary line with the probe transverse to the abdomen, then levobupivacaine HCL 0.25% was injected as a bolus of 0.5 ml/kg, using the in-plane technique, between transversus abdominis and internal oblique muscles, after negative aspiration test.
Figure 1 Local anesthetic distribution in TAP block. TAP, transversus abdominis plane.

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In group C (received caudal block): left lateral position was obtained with the upper hip flexed 90° and the lower one only 45°. Placement of the probe was at the level of the coccyx in the transverse plane just cephalic to the point of injection, then the probe was placed in a longitudinal plane between the sacral cornua, then the local anesthetic was injected as a bolus of 1.0 ml/kg levobupivacaine 0.25% using 25 G graduated special caudal needle ([Figure 2]).
Figure 2 Needle inside caudal space before injection.

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After 10 min of blocks, the operation began. Inadequate block was considered if there was more than 20% increase in HR or BP from the baseline in response to surgical stimulation. So intravenous fentanyl (1 µg/kg) was given and the patient was excluded from the study.

Group D (control group): intravenous paracetamol 15 mg/kg (Injectamol 10 mg/ml; Al-Amreya, Alexandria, Egypt) was used before skin incision.

Intraoperative mean arterial BP and mean HR were recorded at skin incision, then every 5 min till 15 min, then every 15 min to the end of surgery, and any complications (hemodynamic instability, visceral injury, and formation of hematoma) were recorded.

The patient was referred to the postanesthesia care unit (PACU) after completion of surgery and emergence from anesthesia.

CHEOPS score, which is obtained by analyzing the postoperative pain in children by observation of the behavior of the child, includes six forms of pain behavior: cry, facial, verbal, torso, touch, and legs. Each type has 3–4 grades with a minimal score of four points (no pain) and the maximum is 13 points (most awful pain). Additionally, onset and dose of rescue analgesia were recorded. Objective pain score relies on five criteria: arterial BP, crying, movement, agitation, and verbal evaluation; every criterion is given a score of 0–2, with 2 being the worst, making the total worst possible score of 10 were used to assess pain level at the following times: 30 min postoperatively and at 2, 4, 6, 8, and 12 h postoperatively by an anesthetist who was blind to group assignment [12].

All patients received postoperative diclofenac suppositories (Dolphin; Delta Pharma, Egypt) every 8 h (12.5 mg for patients <3 years and 25 mg for those above 3 years).

Paracetamol intravenous 15 mg/kg was given as rescue analgesia for patients in all the study groups if the CHEOPS pain score was more than 6 or the objective pain score was more than 5. Any child who received the maximum daily dose of intravenous paracetamol (75 mg/kg per day) was given pethidine at a dose of 1 mg/kg intravenous and was excluded from the study.

Pain assessment was performed by an anesthesia resident blinded to the type of regional anesthetic technique used.

Statistical analysis

Data were analyzed using the statistical package SPSS, version 21 (SPSS; SPSS Inc., Chicago, Illinois, USA). Data were presented as mean, SD, median, interquartile range, minimum and maximum for quantitative variables and frequencies (number of cases) and relative frequencies (%) for categorical variables. Comparisons between groups were done using one-way analysis of variance followed by post-hoc test (using Tukey’s adjustment) were used for comparison of parametric data. Kruskal–Wallis test was used to compare nonparametric data while Mann–Whitney was used to compare between two groups. For comparing categorical data, χ2 test was performed. Exact test was used instead when the expected frequency is less than 5. P values less than 0.05 were considered as statistically significant ([Figure 3]).
Figure 3 Consort flowchart of the study.

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  Results Top


Two hundred and forty pediatric patients aged between 2 and 7 years were enrolled to undergo unilateral lower abdominal surgery, and these patients were divided into four groups randomly using closed envelop method of randomization. Neither demographic data of the patients nor the type and duration of operation showed statistical significance between the four groups ([Table 1] and [Table 2]).
Table 1 Comparison between groups according to demographic data

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Table 2 Comparison between groups according to the type and duration of surgery

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As regards intraoperative hemodynamic measurement, there was no statistically significant difference (P>0.05) in mean arterial BP or HR among the four groups ([Figure 4] and [Figure 5]).
Figure 4 Line chart showing intraoperative MAP (mmHg) variations between groups over time. MAP, mean arterial blood pressure.

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Figure 5 Line chart representing intraoperative HR (beat/min) variations. HR, heart rate.

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As regards postoperative pain scores:

The intergroup comparison showed high statistically significant difference (P<0.001) between groups according to CHEOPS (median, range, and interquartile range) as shown in [Table 3].
Table 3 Comparison between groups according to CHEOPS

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At arrival to the PACU and in the 12 h postoperative period, group D showed a less pain score, with statistically significant difference than the other three groups but at times 2 and 6 h postoperatively. group C showed less pain score, with high statistically significant difference than the other three groups (P<0.001), while at times 4 and 8 h postoperatively, both groups B and D showed less pain score, with significant difference than groups A and C (P<0.05).

Objective pain score

The intergroup comparison showed high statistically significant difference (P<0.001) between groups (median, range, and interquartile range) ([Table 4]).
Table 4 Comparison between groups according to objective pain score

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At arrival to PACU and 8 h postoperative: group D showed less pain score, with high significant difference than the other three groups, while 2 h postoperatively group C showed less pain score, with high significant difference than the other three groups. At 4 h postoperatively groups B and D showed less pain score, with significant difference than groups A and C, but 6 h postoperatively group C was significant more than the other three groups, and 12 h postoperatively groups C and D were significant than groups A and B.

Regarding time to first rescue analgesia: groups C and D showed decreased time to first rescue analgesic with high statistically significant difference (P<0.001) than groups A and B. The time interval to give first rescue dose of analgesia was shorter in groups C and D (while group A population showed longest duration to receive their first rescue dose of analgesia). Regarding the number of rescue doses and total dose of analgesia: there is high statistically significant difference between groups. Groups C and D have received a number of rescue doses and also total doses higher than that for groups A and B ([Table 5]).
Table 5 Comparison between groups according to time to first, number of doses, and total dose of rescue analgesia (intravenous paracetamol 15 mg/kg)

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As regards total rescue analgesia consumption, group A has the least consumption of total rescue analgesia among the four groups while group D patients have received the highest amounts. Group B patients received amounts more than group A but less than those of groups C and D.

Regarding parent satisfaction

Data from our study showed high statistically significant difference (P<0.001) between groups according to the degree of parents and/or patients’ satisfaction. Group A (QL) patients showed highest degrees of satisfaction than group B, while group D patients has expressed most degrees of dissatisfaction ([Table 6]).
Table 6 Comparison between groups according to satisfaction

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There were no recorded complications in all groups either intraoperatively or postoperatively in the form of hemodynamic instability, injury to underlying structures, hematoma formation, infection, and postoperative nausea and vomiting.


  Discussion Top


This single-blind, clinical, randomized, prospective study compared QL, TAP with caudal blocks for postoperative pain relief in children following unilateral lower abdominal surgery.

In children, lower abdominal surgery, for instance, hydrocelectomy, hernia repair, and for orchiopexy several methods that have been used involved the TAP block, QL block; wound infiltration, carried out by the surgeon; as well as ilioinguinal block, caudal block, carried out by the anesthesiologist [6].

Levobupivacaine was used in this study, because it is a long-acting local anesthetic with a much safer pharmacoclinical profile in comparison to its parent compound bupivacaine [13].

The study revealed that TAP block and QL offer extra benefits to multimodal analgesia in children who are experiencing lower abdominal surgery with QL block superiority as demonstrated by better parent satisfaction, reduced rescue postoperative analgesia, and lower pain scores determined by the number of patients that require analgesia in the first 24 h; and parent satisfaction; and at 1, 2, 4, 6, 12, and 24 h. The QL block was determined to have a longer duration of efficiency. These outcomes were perceived to be in line with those of Blanco et al. [14].

The QL block refers to a procedure that could be used in upper and lower abdominal surgery. Blanco and colleagues recounted that the QL block was more superior as compared with the TAP block pertaining to the period of the success of the block, opioid consumption as well as pain relief. TAP block affected from T10 to T12 dermatomes while the QL block covered from T7 to T12 dermatomes. This extensive spread with the QL block produced analgesia for somatic and visceral pain [15].

In pediatric lower and upper abdominal operations, the TAP block refers to a technique that is regularly applied for postoperative analgesia. Under ultrasound guidance, the reliability and ease of use have augmented its popularity [16].

Murouchi and colleagues examined the correlation between the level of local anesthetics of blood and the efficacy of the QL and TAP blocks and indicated that the blood levels of local anesthetic patients were higher when they were given the TAP block as compared with when the QL block was applied; the QL block was however more operational, whereas the level of local anesthetic in the blood was lower in the QL block than the TAP block. The QL block could be more trustworthy; this might be the rationale behind choosing the QL block for children. Comprehensibly, the QL block offers analgesia at the visceral level as well as in the abdominal muscle plane [17].

In comparing the efficacy of QL block with that of TAP block in abdominal surgery, there exist some theories concerning the QL block mechanism linked to the scope of paravertebral local anesthetic area [14].

Although a paravertebral block offers excellent unilateral analgesia, there are related risks of vascular puncture and hypotension, as with the outcomes of Blanco [18], which was related to the paravertebral spread.The QL block could as well be used in both lateral and supine position, and in children, it could be easily used with a linear probe, which might upsurge its use in multimodal analgesia in patients who are experiencing abdominal surgery [17].

In the literature that explains the use of a QL block for postoperative analgesia in children, there is little information. The first to report that analgesia was given a catheter with the use of a QL block in pediatric colostomy repair in a lateral position were Visoiu and Yakovleva [19].

Normally, caudal anesthetics offer analgesia for about four to six hours. Its complications however comprise the danger of an increase in blood concentration, intestinal damage, and bone marrow puncture, and these difficulties could result in systemic poisonousness [20].

In the three groups, postoperative analgesia’s efficiency was evaluated, which considerably revealed lower median pain scores when groups A and B were compared at all points of time. When groups B and C were however compared concerning the two pain scores, it is only in the first 6 h points of valuation where there was difference. During the first 6 h postoperatively, groups A and B were comparable, and afterwards group A revealed pain scores that are considerably lower.


  Conclusion Top


This study’s outcomes demonstrated that for pediatric patients who are experiencing orchiopexy or unilateral inguinal hernia, the QL block offered more effective and longer postoperative analgesia than the TAP block, and the caudal block which has been used for many years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V et al. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology. Paediatr Anaesth 2018; 28:493–506.  Back to cited text no. 1
    
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Alsadek WM, Al-Gohari MM, Elsonbaty MI, Nassar HM, Alkonaiesy RM. Ultrasound guided TAP block versus ultrasound guided caudal block for pain relief in children undergoing lower abdominal surgeries. Egypt J Anaesth 2015; 31:155–160.  Back to cited text no. 2
    
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Shanthanna H, Singh B, Guyatt G. A systematic review and meta-analysis of caudal block as compared to noncaudal regional techniques for inguinal surgeries in children. 2014 2014; 2014:890626.  Back to cited text no. 3
    
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Elbahrawy K, El-Deeb A. Transversus abdominis plane block versus caudal block for postoperative pain control after day-case unilateral lower abdominal surgeries in children: a prospective, randomized study. Res Opin Anesth Intensive Care 2016; 3:20.  Back to cited text no. 4
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Blanco R, Ansari T, Riad W, Shetty N. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial. Reg Anesth Pain Med 2016; 41:757–762.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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