Ultrasound-guided Techniques for Perioperative Analgesia in Pediatric Lower Abdominal Surgeries: Quadratus Lumborum Block with Bupivacaine versus Caudal Bupivacaine and Neostigmine

Abstract

BACKGROUND: Ultrasound-guided regional anesthesia techniques for perioperative analgesia in pediatric patients scheduled for lower abdominal surgeries can be achieved either by quadratus lumborum block (QLB) or caudal block (CB). Neostigmine was co-administered with caudal bupivacaine to shorten the onset and extend the duration of analgesia. OBJECTIVES: This study aimed to compare between 2 ultrasound-guided techniques used for perioperative analgesia (QLB with bupivacaine vs. CB with bupivacaine/neostigmine) regarding the total amount of rescue analgesic (acetaminophen mg/kg) used for pain relief at 24 hours postsurgery in pediatric patients undergoing lower abdominal surgeries in a developing country and to discuss existing barriers during the implementation of both techniques. STUDY DESIGN: A randomized, double-blind, prospective, single-center study. SETTING: Ain-Shams University Hospitals METHODS: Eighty pediatric patients scheduled for lower abdominal surgeries under general anesthesia were randomly allocated to receive either ultrasound-guided QLB using bupivacaine or ultrasound-guided CB using a bupivacaine/neostigmine mixture. The total amount of rescue analgesic (acetaminophen mg/kg) 24 hours postsurgery was considered as the primary outcome while the time to first rescue analgesia, pain score, postoperative nausea and vomiting, bradycardia, hypotension, and urinary retention were considered as secondary outcomes. RESULTS: In the QLB group, the time to first rescue analgesia was longer whereas the total analgesic dose (mg/kg) was lower than the CB group (P < 0.001, P = 0.007, respectively). While, on the other hand, in CB group, the time to perform the block was shorter and Parents Satisfaction Score 24 h postsurgery was lower than the QLB group (P < 0.001, P < 0.001, respectively). Side effects were infrequent and comparable between the study groups. LIMITATIONS: First, the researchers did not assess the dermatomal level before or after the operation in either group. Second, the investigators should have noticed the first voiding time to demonstrate accurately the incidence of urine retention. Third, a cost-effectiveness analysis of perioperative costs (drugs, staff, resources being used) of these regional anesthesia techniques when applied in an ambulatory setting should have been done, which would be helpful for those in resource-limited settings. CONCLUSIONS: Postoperative analgesia for pediatric patients undergoing lower abdominal surgeries can be safely and effectively achieved by QLB with bupivacaine and a CB with a bupivacaine/neostigmine mixture with priority given to CB, especially in resource-limited settings. KEY WORDS: Quadratus lumborum, caudal, bupivacaine, neostigmine, ultrasound, pediatric, postoperative, pain