Erector Spinae Plane Block vs Quadratus Lumborum Block for paediatric lower abdominal surgery.
This study is a double blinded, prospective, randomized trial. The study compared the Erector Spinae Plane Block (ESPB) against the Quadratus Lumborum Block (QLB) in paediatric patients presenting for lower abdominal surgery.
Children aged 1 – 7 years, classified as ASA I-II and undergoing lower abdominal surgery were randomized to either an ESPB or QLB. An anaesthetist blinded to the intervention was assigned to manage the case and all blocks were performed by 2 anaesthetists that were blinded to the data collection. Bupivacaine 0.25% 0.5ml/ kg (max 20mL) was used for the blocks. Additional analgesia administered during the surgery included 1microg/ kg of fentanyl at induction, N2O maintenance and 15mg/ kg paracetamol IV at the end of surgery.
Post-operatively, FLACC scores were measured at 1, 3 and 6 hours, by a pain nurse blinded to the study. Rescue analgesia was in the form of Paracetamol (15mg/kg) if FLACC 2-4 & Tramadol (1mg/kg) if FLACC greater than 4. Discharge analgesia was paracetamol & Ibuprofen, although Ibuprofen was only at 7mg/kg and only if FLACC >4. Analgesic consumption was recorded by an author blinded to group allocation. Parental satisfaction was measured on a 1-10 scale, with 10 the highest level of satisfaction.
There was no significant difference between the ESPB & QLB FLACC scores at any time point and parental satisfaction was 9.7 for the ESPB & 9.5 for the QLB. No block related complications were noted in either group. The authors commented that ESPB and QLB both provided effective analgesia for paediatric lower abdominal surgery with similar and low additional analgesic requirements immediately post-operatively. The authors conclude that both blocks are equally effective in the first 24hours and that clinicians should choose either block based on their clinical expertise.
Take home message:
Lower abdominal surgical procedures are common in children 1-7 years of age. Pain is generally worst in the first 24-36 hours and regional anaesthesia is useful to reduce the initial post-operative pain. Frequently caudal analgesia is used but there is some evidence in the literature to suggest that caudals do not have an insignificant failure rate. Similarly there is evidence to suggest that TAP blocks, while easy to perform, may not be as effective in controlling post-operative pain.
One of the weaknesses of this study is that it compares 2 regional techniques that are likely to be of interest to people that perform regular regional anaesthesia. The fact that these 2 blocks provide similar analgesic quality & that either can be performed is unlikely to change current practice. Had either block been shown to improve analgesia over a caudal then perhaps it would have had more of a practice changing effect. This study is however applicable to our general paediatric surgical population. With an increasing frequency of day case surgical procedures being performed regional techniques can add to our post-operative pain control armamentarium. This study increasies the knowledge base in paediatric regional anaesthesia and provides evidence for alternative strategies for pain control in our patients.
Reviewed by : Dr Neil Hauser