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Implementation of a quadratus lumborum regional block protocol with assessment of effectiveness for patients with appendicitis: a quality improvement project

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Abstract

Purpose

This study analyzes the implementation of the routine use of quadratus lumborum blocks (QLBs) on postoperative pain and opioid consumption among children undergoing laparoscopic appendectomy compared to those not receiving regional anesthesia.

Methods

Children undergoing laparoscopic appendectomy within a multi-hospital children’s healthcare system were retrospectively reviewed from 2017 to 2021. Patients were stratified by appendicitis type (uncomplicated vs. complicated). Pain scores and opioid consumption in the post-anesthesia care unit (PACU) and within the first 24 h postoperatively were compared by block status (no block [NB] vs. QLB) and appendicitis type.

Results

2033 patients were reviewed, and 610 received a QLB. The frequency of rescue opioid use was reduced in the PACU (uncomplicated: QLB 46.6% vs. NB 54.6%, p = 0.005; complicated: QLB 28.5% vs. NB 39.9%, p = 0.01) and postoperatively (complicated: QLB 33.7% vs. NB 52.9%, p < 0.001) for those who received a QLB. This resulted in reduced opioid consumption as measured by morphine milligram equivalents per kilogram postoperatively.

Conclusion

QLBs can be safely administered in children and provide improvements in opioid consumption postoperatively. QLBs should remain a strongly favored regional anesthetic technique because of their wide applicability for abdominal surgeries to minimize rescue opioid analgesic use.

Type of study

Retrospective comparative study.

Level of evidence

Level III.

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Data availability

The data that support the findings of this study are available on request from the corresponding author (DP).

Abbreviations

ASA:

American Society of Anesthesiologists

CA:

Complicated appendicitis

EO:

External oblique

ERAS:

Enhanced recovery after surgery

HLOS:

Hospital length of stay

IO:

Internal oblique

IQR:

Interquartile range

kg:

Kilograms

LA:

Local anesthetic

LOS:

Length of stay

MME:

Morphine milligram equivalents

NB:

No block

NRS:

Numeric rating scale

NSAIDs:

Non-steroidal anti-inflammatory drugs

NSQIP:

National Surgical Quality Improvement Program

OR:

Operating room

PACU:

Post-anesthesia care unit

QL:

Quadratus lumborum

QLB:

Quadratus lumborum block

TA:

Transversus abdominis

TAP:

Transversus abdominis plane

UA:

Uncomplicated appendicitis

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Funding

No funding was received to complete this study.

Author information

Author notes

  1. Devon Pace

    Present address: Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 613, Philadelphia, PA, 19107, USA

Authors and Affiliations

  1. Division of Pediatric Surgery, Nemours Children’s Health, Wilmington, DE, USA

    Devon Pace, Brian Burke, Keith Fishlock & Loren Berman

  2. Department of Anesthesiology and Perioperative Medicine, Nemours Children’s Health, Wilmington, DE, USA

    Kesavan Sadacharam & Robert S. Lang

  3. Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA

    Devon Pace, Shale J. Mack, Kesavan Sadacharam, Robert S. Lang & Loren Berman

Authors
  1. Devon Pace
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  2. Shale J. Mack
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  3. Kesavan Sadacharam
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  4. Robert S. Lang
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  7. Loren Berman
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Contributions

L.B., K.S., and R.L. contributed to the conception and design of the research project. K.S., D.P., K.F., and B.B. contributed through data acquisition. S.J.M. and D.P. contributed through data analysis. All authors contributed to the interpretation of the data and its analysis. D.P. and S.J.M. contributed to the drafting of the manuscript and development of all figures. All authors critically revised the manuscript, agreed to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Corresponding author

Correspondence to Devon Pace.

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The authors declare there are no competing interests associated with this study.

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Pace, D., Mack, S.J., Sadacharam, K. et al. Implementation of a quadratus lumborum regional block protocol with assessment of effectiveness for patients with appendicitis: a quality improvement project. Pediatr Surg Int 39, 267 (2023). https://doi.org/10.1007/s00383-023-05522-x

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  • DOI: https://doi.org/10.1007/s00383-023-05522-x

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