Caesarean Section, Spinal Anesthesia, Quadratus Lumborum Block, Analgesia
Conditions
Keywords
Caesarean Section, Spinal anesthesia, Quadratus lumborum block, Postoperative pain, Intrathecal morphine
Brief summary
Cesarean section commonly induces moderate to severe pain for 48 hours. These patients have additional compelling reasons to provide adequate pain relief as early mobilization is a key factor to prevent the risk of thromboembolic event which is increased during pregnancy. Beside these, patients need to be pain free to takecare for their newborn and breastfeed them. Poorly controlled pain after cesarean section also increases risk of chronic pain and postpartum depression. Intrathecal morphine is considered the gold standard for postoperative pain relief after cesarean delivery. The duration of analgesic effect of morphine extend to 12-24 hours. Its widespread use is due to its favorable pharmacokinetic profile, ease of administration and low cost. Although intrathecal morphine is highly effective, its use is associated with undesirable adverse effect particularly nausea, vomiting and pruritus which reduce overall patients' satisfaction. More serious complication is the risk of delayed maternal respiratory depression. The Quadratus Lumborum block was first described in 2007 which demonstrates a spread to the paravertebral space, thus leads to a more extensive block to T5-L1 nerve branches and a long lasting block with the potential to provide visceral pain relief. Therefore, this block has an evolving role in postoperative analgesia for many lower abdominal surgeries. As the safety is concerned, there has been one report of a patient with unilateral hip flexion and knee extension weakness leading to unplanned overnight admission following lateral quadratus lumborum block after laparoscopic gynaecological operation. If the result favors effective, it will have the advantage of a combination with intrathecal opioid to prolong the pain free period after cesarean section which has about 4,000 cases per year.
Interventions
DRUGIntrathecal morphine
0.5% Hyperbaric bupivacaine 2 ml add morphine 0.2 mg for spinal anesthesia
0.25% Bupivacaine 25 ml each side for quadratus lumborum block without spinal morphine
DRUGIntrathecal morphine with bilateral Quadratus Lumborum Block
0.5% Hyperbaric bupivacaine 2 ml add morphine 0.2 mg for spinal anesthesia and 0.25% Bupivacaine 25 ml each side for quadratus lumborum block
Sponsors
Mahidol University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* All singleton pregnant women with gestation of at least 37 weeks scheduled for elective cesarean section with American Society of Anesthesiologists (ASA) physical status 1 or 2
Exclusion criteria
1. refuse to receive spinal block 2. allergy to drugs used in research: morphine, local anesthetic drug and paracetamol 3. abnormal coagulopathy: congenital coagulopathy or who used anticoagulants 4. platelet dysfunction or thrombocytopenia 5. distorted anatomical structures of lumbar spines 6. systemic infection or local infection at both flank areas which are the punctures sites for quadratus lumborum block 7. unable to comprehend or use the verbal rating pain scoring system or patient-controlled analgesia
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Time to first analgesic request (PCA morphine) | 48 hours postoperatively | Whether bilateral quadratus lumborum block can increase pain free period of patients undergo cesarean section under spinal block with intrathecal morphine or not |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Requirement of rescue pain | 48 hours postoperatively | Requirement of pain control medication |
| Pain score | 48 hours postoperatively | Pain score at rest and on movement rating by numerical rating scale in 48-hr postoperative |
| Adverse effect | 48 hours postoperatively | Incidence of side effects e.g. nausea and vomiting, itching and sedation |
| Satisfaction score | 48 hours postoperatively | Satisfaction score rated from 0-100 |
Countries
Thailand
Outcome results
None listed