Effect of Pre-incisional Ultrasound-guided Quadratus Lumborum

Block on Perioperative Analgesia and Inflammatory Responses in

Transperitoneal Laparoscopic Nephrectomy: A Single-blinded,

Randomised Control Trial

Dita Aditianingsih

, Besthadi Sukmono

, Erika Sasha Adiwongso

and Chaidir Arif Mochtar

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Department of Urology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Keywords: Quadratus Lumborum Block, Laparoscopic Nephrectomy, Pre-incisional.

Abstract: A Quadratus lumborum (QL) block produces an effective lower abdominal surgery perioperative analgesia,

which has been reported to improve perioperative pain intensity and inflammatory responses. This prospective

randomised-control study evaluates the efficacy of a pre-incisional ultrasound-guided QL block in providing

perioperative analgesia following a transperitoneal laparoscopic nephrectomy. Forty-four adult patients were

randomly assigned into the control group or QL block group. Intraoperative fentanyl, post-operative

Numerical Rating Scale (NRS) at rest and during movement and additional tramadol in the first 24 hours were

recorded. Blood samples for interleukin-6 (IL-6) and hemodynamic profiles were recorded after anaesthesia

induction, after two hours of surgery and two hours post-operation. The QL block group had lower

intraoperative fentanyl (P < 0.05), lower post-operative NRS at rest and during movement (P < 0.001), lower

IL-6 level (P < 0.05) and lower additional post-operative tramadol demand with a relative risk of 3.00 (1.43–

6.29, P < 0.05). The intraoperative hemodynamic profiles and after-surgery were significantly changed,

compared to the baseline in the control group (P < 0.001), while the QL block group showed more stable

profiles (P > 0.05). The pre-incisional QL block with 0.25% bupivacaine reduced the need for intraoperative

opioid, showed more stable intraoperative hemodynamic changes and lowered inflammatory response, post-

operative pain and the need for additional opioids following transperitoneal laparoscopic nephrectomy.

1 BACKGROUND

Laparoscopic living donor nephrectomy (LLDN) is

the preferred method for kidney donation that is

routinely performed under general anaesthesia

(Hayden and Cowman, 2011). Several studies have

reported that solely using general anaesthesia leads to

a risk factor of developing greater acute post-

operative pain and persistent pain one year after the

surgery. The higher doses of intravenous opioids have

the potential to increase post-operative hyperalgesia,

a higher pain score and additional opioid demands

(Barreveld et al., 2013; Richebe et al., 2013; Méleine

et al., 2012).

Pre-incisional block analgesia is administered

before surgical manipulation to provide analgesia

during and after surgery. The approach aims to

prevent intraoperative pain by activating the

excessive release of cytokines as the inflammatory

response because it is associated with post-operative

morbidity (De Oliviera et al., 2011).

Our study aimed to evaluate the efficacy of pre-

incisional bilateral Quadratus lumborum (QL) block

in reducing intraoperative opioid consumption as the

primary outcome, when compared with a non-

receiving pre-incisional QL block on patient who

underwent LLDN. Secondary outcomes were the

inflammatory response of interleukin-6 (IL-6) and

early post-operative pain intensity.

2 METHOD

2.1 Study Design

This was a single-blinded, prospective, randomised

control study that involved two groups of adult

patients who underwent transperitoneal laparoscopic

Aditianingsih, D., Sukmono, B., Adiwongso, E. and Mochtar, C.

Effect of Pre-incisional Ultrasound-guided Quadratus Lumborum Block on Perioperative Analgesia and Inﬂammatory Responses in Transperitoneal Laparoscopic Nephrectomy: A

Single-blinded, Randomised Control Trial.

DOI: 10.5220/0009387900260032

In Proceedings of the 4th Annual International Conference and Exhibition on Indonesian Medical Education and Research Institute (The 4th ICE on IMERI 2019), pages 26-32

ISBN: 978-989-758-433-6

donor nephrectomy under general anaesthesia and

kidney extraction via a Pfannenstiel incision. This

study was part of the clinical trial approved by the

university and hospital Ethics Committee of Medical

Research on June 19

, 2017 (protocol number 17-06-

0619), and registered on ClinicalTrials.gov

(identification number: NCT03879980). We

conducted the study between March 2019 and May

2019 and followed good clinical practice guidelines.

2.2 Sample Size

A preliminary study estimated intraoperative fentanyl

consumption was 305 µg (SD 79.7) on the QL block

group and 435 µg (SD 159.9) on the control group.

Based on opioid consumption that was lower in QL

block with a combined SD of 97.6, we calculated a

sample size of 20 in each group could be given 90%

power to detect a difference of 100 µg fentanyl

between the groups with ⍺ = 0.05. We recruited a total

of 44 patients to anticipate missing data or dropouts.

2.3 Research Protocol

Forty-four healthy patients with American Society of

Anesthesiologists (ASA) classification I or II gave

written consent to participate and were randomly

allocated into either a QL block group or a control

(non-QL block) group. Randomisation used blocks of

4 into 2 groups using a list of random numbers and

was performed by sealed envelopes. The surgeries

were performed by 3 urology surgeon consultants

with comparable distributions. Patients and principal

investigators were blinded to group allocation.

Patients who had a body mass index (BMI) >30, age

<18 or >65 years old, chronic use of analgesics or

anti-inflammatory drugs, neuropathy, allergy to local

anaesthetic, surgery <4 or >6 hours and/or duration of

anaesthesia <5 or >7 hours were excluded. All

patients received midazolam 2 mg IV and ranitidine

50 mg IV as premedication. Monitoring of heart rate,

electrocardiography, non-invasive blood pressure,

pulse oxygen saturation and end-tidal carbon dioxide

was conducted. Anesthesia was induced with propofol

1–2 mg/kg IV and fentanyl 1 µg/kg IV, and intubation

was facilitated with atracurium 0.5 mg/kg IV.

For the QL block group, after anaesthesia

induction, the anaesthesiologist consultant performed

the ultrasound-guided lateral QL block (type I) before

the surgical incision. The patients were in the semi-

lateral supine position to present the side to be

blocked. Using GE LOGIQ



P7 (GE Healthcare,

Chicago, Illinois), and 1–6 MHz convex transducer

placed in the transverse plane above the iliac crest at

the level of the umbilicus, a Stimuplex

(BBraun,

Germany) 20G 100-mm needle was advanced in the

anteroposterior direction toward the junction of the

tapered abdominal muscle layer and QL muscle, and

20 mL of 0.25% bupivacaine was deposited in the

anterolateral border of QL muscle at the junction

where the transversalis fascia reaches outside the

anterior layer of transversalis fascia. The lateral

approach QL blocks were performed on both sides of

patients, and the total amount of bupivacaine was 100

mg for each patient (Figure 1).

Figure 1: QL type I block technique. The arrow represents

the needle tip on lateral border of the QL muscle. TAP,

transversus abdominis plane; QL quadratus lumborum.

General anaesthesia was maintained using

sevoflurane with end-tidal sevoflurane (ETS) target of

1.5–2% using the Aisys C2 monitor (GE Healthcare,

Chicago, Illinois) to keep the bispectral index (BIS



Covidien, Minneapolis) in the range between 40 and

50, and maintenance of atracurium 0.005 mg/kg/min

IV to achieve train of four (TOF) between 0.15 and

0.25 (TOF-Watch, Organon, Ireland) intraoperatively.

Both groups received fentanyl boluses 1 µg/kg IV if

their heart rate or blood pressure increased ≥ 20%

while BIS was 40–50, and the TOF range was 0.15–

0.25; this was assessed by the anaesthesiologist as the

pain response during the surgical stimulations. Venous

blood samples were collected from brachial veins at the

time: before the anaesthesia induction as the baseline,

two hours of surgical stimulation and gas insufflation

intraoperatively and two hours after recovery from

anaesthesia. Inflammatory response IL-6 was analysed

by the ELISA method (Quantikine, R&D system,

USA) following the manufacturer’s instructions, and

every sample was run in duplicates. Perioperative

hemodynamic profiles were represented by heart rate,

systolic pressure, diastolic pressure and mean arterial

pressure and were recorded using the Philips IntelliVue

MP70 monitor (Philips Healthcare, Amsterdam,

Netherlands) at the same time as blood samples were

collected.

All patients received combination neostigmine

1.5–2.5 mg IV (0.03–0.04 mg/kg) and atropine 0.5

mg IV when the TOF ratio was 0.4–0.9 to reverse

neuromuscular blockade post-operatively, and they

were extubated after confirming recovery of

Effect of Pre-incisional Ultrasound-guided Quadratus Lumborum Block on Perioperative Analgesia and Inﬂammatory Responses in

Transperitoneal Laparoscopic Nephrectomy: A Single-blinded, Randomised Control Trial

awareness. Both groups immediately received basic

post-operative analgesia regimen paracetamol 1 gr IV

hourly. A combination of omeprazole 20 mg IV

and ondansetron 4 mg IV 8

hourly was given to

prevent post-operative nausea and vomiting (PONV).

The Numerical Rating Scale (NRS) was observed

between two and 24 hours after the surgery. During

the observation, when the NRS began to increase to

>3 at rest, the intermittent tramadol 50 mg IV boluses

were given 8

hourly. If the NRS persisted >3, the

intermittent tramadol 50 mg IV boluses were

administered more frequently up to 4

hourly. If the

pain relief was still inadequate after increasing

tramadol boluses, the extra fentanyl 1 µg/kg IV boluses

were given every 15 to 30 minutes until the NRS ≤3.

The analgesic effect of the intraoperative QL

block and control groups was evaluated by measuring

intraoperative fentanyl consumption as the primary

outcome. Intraoperative fentanyl consumption was

recorded as total consumption in µg and calculated

into mean consumption per hour in µg/kg/h, based on

the influence of the patients’ body weight and the

duration of surgery to the given dose of fentanyl

boluses. Secondary outcomes were hemodynamic

profiles, perioperative inflammation response of IL-

6, immediate pain level at rest and during movement

(coughing) by measuring NRS from 0 = no pain to

10 = worst pain at two hours and 24 hours after

anaesthesia recovery. All patients received the NRS

information during their preoperative visits and

repeated explanations during the pain service team

visit after their surgery. The additional opioid

administration during the first 24 hours after surgery

was also recorded.

The research assistant was not involved in the

patient care that was randomly assigned to the

patients. The anaesthesiologist consultant who

performed the QL block was aware of the

randomisation. Each patient, the intraoperative

anaesthesiologist, the pain service team and the

nurses were blind to group allocation. The primary

investigator received the randomisation numbers

after all measurements and calculations of the patients

had been entered into the database collections.

Statistical analyses were performed using the

Statistical Package for the Social Sciences (SPSS)

version 20 (IBM Corp, Armonk, NY) application.

Patient characteristics were presented in tabular form

to assess data distribution. Numerical data were

analysed using the Mann-Whitney U test or estimated

as log-normal distributed, then the comparison

between the groups were analysed with an unpaired t-

test and post hoc analysis with the generalised linear

model (GLM) in log-transformed data. A comparison

with the baseline in each group was analysed with

repeated ANOVA. Categorical data were tested with

the Chi-square test. Data were presented as means ±

standard deviation (SD), or median (range), or mean

of log-transformed data (minimum–maximum) and

95% confidence intervals.

3 RESULTS

The study CONSORT flowchart shows 44 patients

were enrolled, randomly allocated into QL block group

(22 patients) and control group (22 patients) and

analysed (Figure 2). The baseline characteristics of

both groups were comparable, except that there were

more male subjects in the control group (Table 1).

Figure 2: CONSORT flowchart.

Table 1: Baseline characteristics: Categorical data are

presented as percentage, numerical data are presented as

mean ± SD, median (minimum–maximum). QL, quadratus

lumborum.

Variable

Control group

(n=22)

QL block

group

(n=22)

Gender

Male (%) 17 (77) 11(50)

Female (%) 5 (28) 11(50)

Age (years) 31 (25–54) 32 (21–63)

Weight (kg) 65.46 ± 9.40 62.79 ± 13.34

Height (cm) 162.68 ± 7.82 161.66 ± 9.34

Body mass index

(kg/m

)

24.51 ± 3.20 24.20 ± 2.90

Duration of

surgery (minutes)

273 (258–288) 270 (210–360)

Pneumoperitoneum

pressure (mmHg)

10.00 (8–14) 12.00 (10–14)

Duration of

anaesthesia

(minutes)

295 (245–385) 300 (230–390)

The 4th ICE on IMERI 2019 - The annual International Conference and Exhibition on Indonesian Medical Education and Research Institute

The mean and total intraoperative fentanyl

consumption of the QL block group were

significantly less than the control group (Table 2).

The NRS scores at two hours after recovery, at rest

and during movement were significantly lower in the

QL block group (P < 0.001), compared to the control

group. The NRS scores at 24 hours after QL block

were performed at rest and during movement and

were significantly lower (P < 0.001), compared to the

control group. The additional intravenous tramadol

IV was needed less in the QL block group, as

compared to the control group (P < 0.05) (Table 2).

The control group needed more additional

intravenous tramadol within 24 hours, with the

relative risk of this being three times higher than the

QL block group [RR 3.00 (1.43–6.29), P < 0.05].

None of the patients needed additional fentanyl

boluses during the observation.

The trends of perioperative hemodynamic profiles

and IL-6 levels as the inflammatory response during

and after surgery showed significant group

differences (Table 3). The QL block group showed

significantly higher systolic (P < 0.001), diastolic

(P = 0.002), mean arterial pressure (P < 0.001) and

heart rate (P = 0.037) intraoperatively, but lower

values after surgery, compared to the control group.

The perioperative hemodynamic profiles were

significantly changing during and after surgery,

compared to the baseline (P < 0.001) in the control

group, while the QL block group showed more stable

profiles (P > 0.05), except in terms of the heart rate.

In addition, we analysed the hemodynamic

difference between time points (Table 4). The control

group showed significant higher systolic (P < 0.001),

diastolic (P = 0.005) and mean arterial pressure

(P = 0.001) changes between intraoperative and post-

operative time points, compared to QL block group;

while the QL block group showed significant higher

Table 2: Patient’s perioperative data: Numerical data were analysed with unpaired t-test and presented as mean ± SD or with

Mann-Whitney U test and presented as median (maximum–minimum); categorical data were analysed with the Chi-square

test and presented as a number of patients (percentage), P < 0.05 is significant.

Control group

(n=22)

QL Block group

(n=22)

P-value

Mean intraoperative fentanyl consumption (µg/kg/h) 1.46 ± 0.28 1.16 ± 0.36 0.002

Total intraoperative fentanyl consumption (µg) 430 ± 105.08 322 ± 89.36 0.016

Numerical Rating Scale (NRS)

2 hours after recovery at rest 1.00 (0.00 – 3.00) 0.00 (0.00 – 2.00) < 0.001

2 hours after recovery in movement 2.00 (1.00 – 4.00) 1.00 (0.00 – 3.00) < 0.001

24 hours at rest 2.00 (1.00 – 4.00) 1.00 (0.00 – 3.00) < 0.001

24 hours in movement 4.00 (2.00 – 5.00) 2.00 (1.00 – 4.00) < 0.001

Additional intravenous tramadol in 24 hours (n%)

Yes 15 (34) 9 (20) 0.001

No 7 (15) 13 (30)

Table 3: Perioperative hemodynamic response.

Parameters Control group (n=22) P value† QL block group (n=22) P

value†

value*

CI 95%

Systolic blood pressure (mmHg)

baseline 100.72 (94.49–106.95) 112.16 (106.07–118.24) 0.05 11.44 (2.79–20.09)

intraoperative 106.76 (102.09–111.43) <0.001 115.89 (109.70–122.09) 0.326 0.016 9.13 (1.77–16.50)

post-operative 118.84 (112.91–124.77)

111.42 (105.30–117.54) 0.082 -7.42 (-15.82–0.98)

Diastolic blood pressure (mmHg)

baseline 59.84 (54.83–64.85) 70.26 (66.53–73.99) 0.05 10.42 (3.98–16.86)

intraoperative 63.00 (59.40–66.60) <0.001 70.89 (65.69–76.10) 0.437 0.010 2.94 (1.96–13.83)

post-operative 70.40 (65.68–75.12)

66.68 (61.69–71.68) 0.273 -3.72 (-10.46–3.03)

Mean arterial pressure (mmHg)

baseline 73.47 (68.34–78.59) 84.23 (80.48–87.98) 0.05 10.76 (4.20–17.32)

intraoperative 77.59 (73.97–81.20) <0.001 85.89 (81.02–90.76) 0.410 0.006 8.31 (2.56–14.06)

post-operative 86.55 (81.82–91.27)

81.60 (77.05–86.15) 0.134 3.24 (-11.48–1.58)

Heart rate (beats/min)

baseline 69.50 (64.12–75.51) 71.12 (66.99–75.68) 0.658 1.02 (0.92–1.13)

intraoperative 75.16 (69.66–81.10)

<0.001 84.33 (80.72–88.10) <0.001 0.009 1.12 (1.03–1.22)

post-operative 82.03 (74.47–90.16)

88.31 (83.18–93.97) 0.179 1.08 (0.96–1.20)

*Data were analysed with unpaired t-test, are presented as mean of log-transformed data (maximum–minimum), P < 0.05 is significant.

†Data were analysed with repeated ANOVA, post hoc analysis, P < 0.05 is significant.

QL = quadratus lumborum.

Effect of Pre-incisional Ultrasound-guided Quadratus Lumborum Block on Perioperative Analgesia and Inﬂammatory Responses in

Transperitoneal Laparoscopic Nephrectomy: A Single-blinded, Randomised Control Trial

Table 4: Hemodynamic changes between time points comparison.

Parameters Control group (n=22) QL block group (n=22) P

value*

CI 95%

Systolic blood pressure changes (mmHg)

Baseline–intraoperative 6.04 ± 16.12 3.74 ± 13.56 0.618 -2.30 (-11.56–6.96)

Intraoperative–post-operative 12.08 ± 14.23 -4.47 ± 13.35 <0.001 -16.55 (-25.07– -8.04)

Diastolic blood pressure changes (mmHg)

Baseline–intraoperative 3.16 ± 12.26 0.63 ± 14.82 0.539 -2.53 (-10.77–5.71)

Intraoperative–post-operative 7.40 ± 10.48 -4.21 ± 15.37 0.005 -11.61 (-19.48–-3.74)

Mean arterial pressure changes (mmHg)

Baseline–intraoperative 4.12 ± 13.09 1.67 ± 12.99 0.540 -2.46 (-10.47–5.56)

Intraoperative–post-operative 8.96 ± 11.12 -4.30 ± 13.62 0.001 -13.26 (-20.78–-5.73)

Heart rate changes (beats/min)

Baseline–intraoperative 5.56 ± 9.23 13.05 ± 6.96 0.005 7.49 (2.37–12.61)

Intraoperative–post-operative 7.84 ± 12.67

4.26 ± 11.20 0.335 -3.58 (-10.87–3.71)

*Data were analysed with unpaired t-test, are presented as mean ± SD, P < 0.05 is significant.

QL = quadratus lumborum.

heart rate changes (P = 0.005) between the baseline

and intraoperative, compared to the control group.

The variability of the IL-6 levels from the baseline

to the post-operative level was significantly different

between the control and the QL block groups. In each

group, the IL-6 level was significantly increased

intra- and post-operatively, compared to the baseline

level (P < 0.001). The trend of inflammatory response

IL-6 plasma level from baseline to after surgery

increased significantly higher (P = 0.002) in the

control group, compared to the QL block group

(Figure 3).

Figure 3: Inflammatory response of interleukin-6. Data are

presented in log transform data (minimum–maximum); the

horizontal lines indicate the medians; boxes indicate

interquartile ranges; whiskers indicate ranges; P < 0.05 is

significant. GLM = general linear model. QL = quadratus

lumborum block. Non-QL, control group.

4 DISCUSSION

Laparoscopy surgery is increasingly performed

because it promotes early mobilisation, minimises

post-operative complications and reduces hospital

stay, compared to open surgery. Therefore, efforts to

optimise the safety of the procedure, peri-operative

pain management and early daily functioning are

important (Hayden and Cowman, 2011).

In 2007, Blanco first introduced the US-guided

QL block technique as a posterior extension of the

TAP block. It represents a more extensive abdominal

analgesia by placing a curvilinear transducer in a

transverse orientation slightly above the iliac crest in

the posterior axillary line and uses the QL muscle as

its basic sonographic landmark (Chakraborty et al.,

2016; Anders et al., 2018).

The lateral QL (type I) block refers to the injection

of a local anaesthetic at the lateral border of QL

muscle with the spread of local anaesthetic at the

junction of QL and transversalis fascia plane; QL

block produces effective post-operative analgesia in

lower abdominal surgery due to its spread to the

thoracic paravertebral space and thoracolumbar fascia

nerves. The QL block is the extension of the posterior

transversus abdominis plane (TAP) block deep in the

transversus abdominis aponeurosis and generates

sensory blockade from T7–L1 (Ueshima et al., 2017).

We performed the lateral QL (type I) block prior to

the surgical incision. Although the QL (type I) block

produces the local anaesthetic spread and has no

visceral pain relief L1 (Ueshima et al., 2017), our

findings showed that it reduced intraoperative

fentanyl consumption up to 25%, which was

significantly less than without the QL block.

The laparoscopy technique is sometimes

associated with longer operation time, and the peak

level of pain in a laparoscopy procedure is mostly

during trocar port insertion, gas insufflation and the

first two hours after surgery (Warle et al., 2013).

Administering the pre-incisional QL block before the

surgery produced a sufficient intraoperative opioid-

sparing effect and reduced pain intensity 24 hours

The 4th ICE on IMERI 2019 - The annual International Conference and Exhibition on Indonesian Medical Education and Research Institute

post-operative in our study. The result was similar to

the previous pre-incisional TAP-block studies in

reducing intraoperative fentanyl requirements

(Bhattacharjee et al., 2014). This is in line with

animal studies, which have strongly suggested that

peripheral nerve block reduced post-operative

hyperalgesia and exposure to a higher dose of opioids

during general anaesthesia and enhanced central pain

sensitisation that led to reducing the effect of

peripheral nerve block in preventing post-operative

pain (Méleine et al., 2012).

Reducing catheter-related bladder discomfort

(CRBD) incidence could also reduce a bias that

obscures post-operative pain assessment. Post-

operative CRBD is common, due to voluntary or

involuntary detrusor muscle contraction of the

bladder stimulated by acetylcholine on the muscarinic

receptor. Pain during bladder catheterisation needs a

sensory blockade of S3 that is outside of the QL block

coverage. Tramadol is a synthetic opioid analgesic

that inhibits detrusor muscle activity through

inhibition of type-1 muscarinic (M1) and type-3

muscarinic (M3) receptors. Rather than using

morphine, we used tramadol, because it produces an

adequate analgesic effect with less urinary retention

and has no impact on voiding function despite an

increase in compliance of the bladder (Agarwal et al.,

2008). From the urologist’s perspective, it is

important to have satisfactory post-operative

analgesia with less of an effect on urinary retention

and reduced CRBD to promote early mobilisation in

LLDN patients.

The QL block group showed lower plasma IL-6

levels two hours after surgery, compared to the

control group. During laparoscopy surgery,

pneumoperitoneum by gas insufflation and surgical

procedure produces visceral pain and somatic pain.

IL-6 is one of the earliest pro-inflammatory responses

induced during pain stimuli and injury, such as in

surgery. Surgical stress enhances the pro-nociceptive

effects of a pro-inflammatory cytokine such as IL-6,

a potential mediator of stress-induced effects on

nociception that is involved in the modulation of pain

and contributes to hyperalgesia. In healthy

volunteers, there is a correlation between pain and

systemic IL-6 in response to stress and injury

(Moeller-Bertram et al., 2012).

Pre-incisional analgesia is a pre-emptive

treatment strategy that focuses on the prevention of

central sensitisation by administering analgesia

before the surgical incision to improve perioperative

pain control. It becomes a part of multimodal

analgesics before the stimulus arises and appears to

be effective in reducing pain and consumption of

analgesics during and after the surgery (De Oliviera

et al., 2011; Vadivelu et al., 2014). Surgical stress

induces the release of inflammatory cytokines and

proteins. Patients taking a pre-emptive oral analgesic

regimen one hour before surgical incision

demonstrated a suppressed plasma hs-CRP level as

the inflammatory mediator response in nociceptive

pain (Jianda et al., 2016). However, there are various

factors that influence the pre-emptive analgesia

effect, such as type and duration of surgery, analgesic

agents used, individual inflammation and physical

responses to the extent of the injury (Farouk, 2008).

A pre-incisional TAP block could demonstrate its

efficacy in reducing the hemodynamic response to a

surgical stimulus (Bhattacharjee et al., 2014). We

expected that the QL block would blunt the

hemodynamic response during surgical procedures.

However, the QL block group showed higher

intraoperative hemodynamic systolic pressure,

diastolic pressure, mean arterial pressure and heart

rate, compared to the control group. These

hemodynamic responses between the groups could be

the result of higher consumption of intraoperative

fentanyl in the control group. However, we found that

the control group had higher perioperative

hemodynamic changes in systolic, diastolic and mean

arterial pressure, compared to the QL block group;

while the QL block group showed a more stable

perioperative hemodynamic variability, compared to

the control group. While we ensured adequate muscle

relaxation and monitored the depth of anaesthesia

with BIS and ETS monitoring, it was difficult to

define the level of intraoperative analgesia based on

hemodynamic parameters (Bhattacharjee et al.,

2014).

There are a few limitations to this study. The

control group may have been more appropriate to

perform QL block using normal saline to improve

blinding, but our institution ethic board recommended

that we avoid invasive intervention using the placebo.

When the NRS started to increase >3, the tramadol

was given by intermittent boluses 8

hourly by ward

nurses, but not by PCA based on patient need. The

level of sedation due to tramadol consumption was

not assessed. We could not assess nausea and

vomiting between the groups because antiemetics

were routinely given post-operative, but we were able

to eliminate bias in evaluating post-operative pain by

reducing nausea and vomiting. We excluded patients

with BMI >30; therefore further research of the QL

block on obese patients is needed. Additional

research in pre-emptive analgesia is warranted to

optimise perioperative pain management following

transabdominal laparoscopic surgery.

Effect of Pre-incisional Ultrasound-guided Quadratus Lumborum Block on Perioperative Analgesia and Inﬂammatory Responses in

Transperitoneal Laparoscopic Nephrectomy: A Single-blinded, Randomised Control Trial

5 CONCLUSIONS

The pre-incisional bilateral QL block using 100 mg

of 0.25% bupivacaine resulted in less intraoperative

opioid consumption and a lower post-operative

inflammatory response. It reduced the 24-hour post-

operative pain intensity and additional opioid

consumption following transperitoneal laparoscopic

nephrectomy.

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The 4th ICE on IMERI 2019 - The annual International Conference and Exhibition on Indonesian Medical Education and Research Institute