Systematic Review and Meta-Analysis of Quadratus Lumborum Block Postoperative Analgesic Efficacy Courtney
1 Pina Oonagh
Dowling and Ezra Kassin
2
1Donald
and Barbara Zucker School of Medicine at Hofstra/Northwell 2Long Island Jewish Medical Center- Department of Anesthesiology
Background
Results
Results
There has been increasing interest in the Quadratus Lumborum Block (QLB) as a safe and effective treatment for postoperative pain following abdominal and hip surgical procedures (1). There are 4 different types of QLB which differ by site of drug application. These are QLB 1 (lateral), QLB 2 (posterior), QLB 3 (anterior/transmuscular) and QLB 4 (intramuscular) (2). The primary objective of this systematic review and meta-analysis, was to determine the postoperative analgesic efficacy of any type of QLB used for hip, cesarean, and abdominal surgeries.
Outcome 1PONV *1PONV 2Postoperative opioid use 24hrs
Effect Size 0.79 1.01 -1.534
95% Cl 0.39-1.63 0.55-1.87 -2.30- -0.77
P-Value 0.03 0.97 0.0001
I2 59.28 36.2 96.51
*2Postoperative
-1.09
-1.83- -0.35
0.004
94.20
opioid use 24hrs
Conclusions 1.
2.
Hypothesis
Future Direction 1. 2. 3.
Adult patients undergoing abdominal or hip surgery who receive QLB compared to no block or a placebo will require a reduced amount of postoperative opioid and demonstrate a lower incidence of post-operative nausea and vomiting (PONV) in the first post-operative 24 hours.
4.
Redefine the search terms to provide more focused data collection Conduct a subgroup analysis to examine different types of QLB Conduct a subgroup analysis to examine efficacy of QLB in different types of surgeries. Perform a thorough risk of bias assessment.
Resources
Methods This systematic review used the search terms; quadratus AND lumborum AND (cohort OR randomized) NOT children in PubMed producing 128 articles. Of the 128, 38 studies were included based on matching criteria. Data extracted included means, standard deviations (opioid use) and frequencies (PONV). For the 24 hour opioid use outcome standardized mean differences (Hedge’s G) between groups was estimated and for the PONV outcome, log odds Ratios were estimated. Heterogeneity of the effect sizes was assessed using Q and I2 statistics. If heterogeneity was present or the degree of heterogeneity (I2) was greater than 25%, estimates were determined using a random-effects model. Sensitivity analysis was also conducted when I2 > 25%. Publication bias was assessed using the Egger test.
While QLB was shown to be related to reduced post-operative opioid use compared to no block or placebo the high degree of heterogeneity poses interpretive challenges. QLB did not have a significant decrease in post-operative nausea and vomiting compared to no block or placebo
A reduction in 24hr postoperative opioid use was observed in the QLB group versus no block group (effect size (Hedge’s G) = -1.53 (95% CI -2.30 to -0.77 p= 0.0001, table 1 and figure 1). For this comparison, studies were shown to have very high heterogeneity (I2=96.51%). Egger test for this outcome was significant (p<0.0001). Sensitivity analysis performed excluding hip procedures still demonstrated a significant reduction in opioid use for the QLB group versus no block group (Table 1) 2 also remained high (94.20%).The odds ratio for PONV was 0.79 (95% CI: 0.39 while I Figure 7: Independent CRISPR knockout of CDK4 or CDK6 - 1.63) QLB versus block group (table 1 and figure 2). For this comparison does notfor cause dropout in most the breastno cancer cell lines studied. studies were found to have a high degree of heterogeneity, with an I2 of 59.28% (p=0.03) while the Egger test for this outcome was not significant (p=0.14). Sensitivity analysis with the exclusion of study utilizing QLB for hip surgery (He et al 2020) found similarly no significant effect of QLB on PONV and an I2 of 36.2% (table 1)
1. Elsharkawy, Hesham, et al. “Quadratus Lumborum BlockAnatomical Concepts, Mechanisms, and Techniques.” Anesthesiology, American Society of Anesthesiologists, 1 Feb. 2019,pubs.asahq.org/anesthesiology/article/130/2/322/20073/Quadratus -Lumborum-BlockAnatomical-Concepts. A Review of the Quadratus Lumborum Block and ERAS. 2. Akerman M, Pejčić N, Veličković I. Front Med (Lausanne). 2018 Feb 26;5:44. doi: 10.3389/fmed.2018.00044. eCollection 2018. 3.Picture-https://www.nysora.com/regional-anesthesia-for-specific-surgicalprocedures/abdomen/ultrasound-guided-transversus-abdominis-planequadratus-lumborum-blocks/