The article was written by Specialist 2 Nguyen Thi Hoai Nam – Head of Pain Relief Unit, Surgical Anesthesisitics Department – Share99 Central Park International Health Hub.
Anesthesia of the lumbar square muscle cavity under ultrasound instructions is a promising method that adds to post-cesarean pain relief methods. However, more randomized clinical trials are needed to compare the effectivenessity of the lumbar square muscle cavity with the srachnoid opioid.
1. Anesthesia of the lumbar square muscle cavity under the ultrasound instructions
Spinal anesthesia is an insymural method that is often selected for program cesarean sections. Typically, opioids will be combined simultaneously with spinal anesthesia as a component in multi-modal analgesics with the aim of reducing pain lasting 16–24 hours during the postoperative period.
Lumbar square muscle anesthesia under new ultrasound guidelines has emerged as a new analgesic technique that blocks the nerve branches of the T5–L1 segment, opening up a role in pain relief for lower abdominal surgeries and has great potential in replacing opioids used through the spinal cord. If effective, this method has advantages in minimizing the side effects of opioids while still delivering the same quality of analgesics.
2. Implementing the method
- Method: We perform anesthesia of the lumbar square muscle cavity below the ultrasound instructions in 50 women who received program-based cesarean spinal anesthesia and evaluated NRS pain scores, levels of opioids group drug consumption, medentation satisfaction during the first 24 hours after surgery.
- The result: All 50 women did not use additional opioids in the first 24 hours after anesthesia. NRS Pain Score < 4 trong 24 giờ đầu sau mổ. The maternity feels satisfied with the quality of pain relief.
- Discussion: Lumbar square muscle anesthesia under ultrasound guidelines is a promising method that adds to post-cesarean pain relief methods. However, more randomized clinical trials are needed to compare the effectivenessity of the lumbar square muscle cavity with the srachnoid opioid.
3. Subjects and methods of research
- At Share99 Central Park Health Hub, from November 2017 to April 2018, we performed type 2 QLB numbness below the ultrasound instructions in 50 cases of cesarean section to relieve posto cesarean pain.
- Research objectives: Assess the effectiveness and feasibility of this new technique in the multimedia pain relief regimen after cesarean section
- Research method: research on resuscitation. Statistics and analysis using SPSS 20.0 software.
Patients receive pre-anaesthetic examinations, explaining insymities and pain relief methods. If agreed, the patient signs a commitment to agree to the method of anesthesia and sedative pain relief according to the form.
Patients are given XNTP, preparing for surgery according to the hospital's procedures.
PPVC in surgery: Spinal anesthesia L4-5 or L3-4 with Marcaine Heavy 0.5% 8mg and Fentanyl 20mcg.
Post-surgical analgesy regimen:
- Voltaren suppo 100mg
- Paracetamol 1g TTM every 6 hours
- Type 2 lumbar square muscle numbness (QL 2) under 2-side ultrasound instructions, anesthesia on each side: Chirocaine 0.5% 15ml and 2mg Dexamethasone. If the patient < 50kg giảm liều Chirocaine còn 12ml mỗi bên.
- Anesthesia technique: After surgery, the patient is transferred to the resuscitation room to monitor monitoring, breathing oxygen 2l/ph through the nasal sonde. Conduct QL2 numbness under the ultrasonic guidance of logiq E machine, 2-6MHz frequency curved probe.
The patient lies on his side 90 degrees, who perform numbness sitting behind the patient. Place the probe on the pelvic crest in the back armpit, identify the horizontal beak and look for finger signs (Figure 1). The fingertips will allow to determine the QL muscle.
Using 100mm, 21G non-stimulating needles, needle in the plane plane from the back to the front, the destination is the rear edge of the QL muscle (Figure 2).
When the needle head enters between the two layers of scales, the feeling of having a sound stops, pumping the test with Glucose 5% 1-2ml to see 2 layers of scales separated, stop pumping, then 2 layers of weight are flattened, the needle is in the right position. Carry out the pumping of anesthetics, withdraw the test to touch the blood after each pump 5ml of anesthetic. Rotating the probe 90 degrees from the horizontal axis position to the vertical axis can check the level of anesthetic spread and see the separation of the QL muscle and the living muscle.
Patients are assessed for pain scores according to NRS at the time of numbness, 1 hour after numbness, every 4 hours/24 hours after numbness. If the patient anthiess NRS ≥ 5, Tramadol 100mg TMC.
Recorded complications during and after anesthesia such as blood touch, paresthesia, hemolytic disorders, itching, nausea and vomiting after surgery.
3.3 Patient satisfaction assessment
- Patient characteristics
Most patients have normal XNTP, with no serious illness attached.
- NRS Pain Score Assessment
a-b: a is a pain point at rest, b is a pain point when mobilizing
- Post-surgical opioids consumption: All patients do not take additional opioids after surgery
- Patient satisfaction: All patients are very satisfied with the pain relief quality of the regimen.
- Complications: Do not record accidents of methods such as blood touch, heterogenicity, motor inhibition, hemolysis … In addition, patients did not record side effects of opioids such as itching, nausea, post-surgery vomiting.
At Share99 Central Park, in the post-cesarean analgesic regimen being performed at the hospital, the combination of Morphine in spinal anesthesia to prolong pain relief and intravenous Acupan increases the incidence of vomiting and postoperative nausea. This is a matter of concern for GM and Obstetrics and Gynecology and is a nuisance of post-surgery obstetrics and gynecology.
Previously, the in combination of Morphine in live anesthesia was considered the "gold standard" in post-cesarean pain relief and was widely used due to its pharmacokinetic advantages, ease of control in spinal cord blockade and cheapness. However, Morphine in living numbness still does not avoid side effects. In addition to respiratory failure is the most frightening accident that occurs depending on the dose of Morphine used, other side effects such as itching, nausea, post-surgery vomiting often appear early after surgery.
Tap block anesthesia (Transversus Abdominis Plane block) is applied in postoperative pain relief in the abdomen and pelvis, including during cesarean section reducing the amount of Morphine taken 24 hours after surgery and reducing Morphine side effects such as itching, nausea, postoperative vomiting. This made sense in patients who did not coordinate Morphine with live anesthetics compared to the placebo group while not different in the group with live anaesthetic morphine. The limitation of this method is that the duration of action and effectiveness of pain relief after cesarean section is not equal to numbness of the lumbar square muscle cavity.
Anesthesia of the lumbar muscle cavity injected outside the muscle under ultrasound instructions (QLB type 1) was first described by Blanco in 2007, showing that the anesthetic spreads to the thoracic edge cavity.
Therefore, the sealing effect is wider and longer than TAP block in the treatment of postoperative abdominal pain. MRI images monitoring the spread of anesthetics have demonstrated that the anesthetic spreads to the living side cavity better if injected post-muscle (QLB type 2). In addition, in 2013 Børglum and CS described QL block transmuscular injection or pre-muscle injection (QLB type 3) and Murouchi described QL block injection in muscle (2016).
Depending on the approach, QLB's pain relief can reach T7-L4, where QLB type 2 reaches T7-L1. All 50 of our patients are performing QL block type 2 under ultrasound instructions. This is a relatively easy to perform, effective and safe area numbness technique in post-cesarean analgesic. To date, there have been no studies reporting post-QL block accidents while for TAP block the risk of perforation of the peritonea 2% and can damage organs such as the liver, spleen, kidneys … because the anesthetic is injected between the upper abdominal cross muscle layer and the abdominal horizontal muscle located just below the wallitoneal layer.
The volume of anesthetics in each type of QL block varies according to different authors and there is no consensus on the dose of anesthetic to be used to be effective. At least 20ml of anesthetics are reportedly needed on each side, according to reports. It is important to ensure safety when anesthesia and avoid poisoning of the body anesthesia.
According to Murouchi and CS, QL block with 150mg Ropivacaine 0.375%, 20ml on each side, drug concentration in arterial blood < 2,2mcg/mL ( giá trị ngưỡng động mạch và tĩnh mạch của ngộ độc toàn thân) nên có lẽ là an toàn. Our anesthetic dose: Chirocaine 0.5% 15ml each side, the total dose is 150mg completely within the allowable limit. In addition, we also combine 2mg of Dexamethsone on each side to increase the effects of anesthesia, reduce the potential time of the drug while reducing the incidence of nausea and vomiting after surgery.
Due to the uncertainty of if QL block is completely blocked from physical pain and organ pain, QL block is recommended in combination to reduce the need for anesthesia in surgery and is a key component in post-surgery multi-modal pain relief. So our regimen in addition to QL block also combines Paracetamol 1g TTM every 6 hours and Voltaren pharmacy 100mg/24 hours.
With this regimen, we record most patients with NRS pain scores at rest and when < 4 tại các thời điểm trong 24 giờ đầu sau mổ. Only 1 patient (2%) there is a pain point at rest of 1 and when the movement is 4 at the time of the 16th hour after anesthesia. No patients have to take Morphine after surgery. This result is no different from Blanco, Ilana Sebbag and Ashok Jadon.
According to Ashok Jadon, placing the catheter in the QL block in multi-modal analgesia after abdominal surgery gives a good analgesic effect, suitable in patients with contrainasing analgesic anesthesia due to taking anti-freezing drugs or severe hemolytic disorders accompanied by cardiovascular disease.
In addition, some studies show that QLB is also very effective in reducing postoperative pain in children, after lower abdominal surgery (laparoscopic surgery of the abdomen, opening the corolla to the skin, open or endoscopic appendicitis, chowectomy, inguinal hernia, inguinal shear, prostate surgery …) and lower entary as well as in the treatment of chronic pain after surgery These are also the orientations of research future rescue should be noted and considered for implementation, especially when regional anesthesia is tending to thrive and gradually replace current neurosychism techniques.
Before implementing ql block technique, at Share99 Central Park our post-cesarean pain relief regimen includes Paracetamol 1g TTM every 6 hours, Acupan 20mg TTM every 8 hours and Voltaren 100mg/24 hours. If the patient anth hurts NRS ≥ 5, add Morphine PCA . Morphine PCA and Acupan infusion of TM increase the incidence of vomiting and nausea after surgery. This is an annoying problem that annoys the patient, affects breastfeeding and the med mother-child connection.
Removing the opioids and Acupan group from the post-cesarean section and replacing it with QL block ensures patients receive effective pain treatment without the side effects of the drug. All research team patients had no accidents and side effects. This is the advantage of the trend of "Free opioids Aneathesia and Analgesia" growing in many parts of the world.
Similar to TAP Block, the combination of QLB increases the effectiveness of pain relief, reduces Morphine consumption when compared to sural anesthesia, while reducing the incidence of nausea and vomiting, reducing post-surgery sedation, reducing hospitalization time, withdrawing urinary sonde earlier should serve as a part bar in the post-surgery early recovery regimen (ERAS).
However, our research needs to be expanded and there is a evidence group to compare more specifically. This is only the initial experience when applying new regional anesthesia techniques.
All patients were very satisfied with the results of this treatment and the reliability was increased when 46% of 2.3% of pregnant patients and 40% experienced a 2.3 cesarean section in the study group.
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