ESP vs QL for Total Abdominal Hysterectomy

Summary

Participation Requirements

Description

The investigators will study 82 American Society of Anesthesiologists (ASA) physical status 1-3 subjects scheduled for open Total Abdominal Hysterectomy who will be identified by anesthesia providers during their Pre-Anesthesia Evaluation Clinic visit and/or Day Surgery Unit pre-anesthetic assessmen...

The investigators will study 82 American Society of Anesthesiologists (ASA) physical status 1-3 subjects scheduled for open Total Abdominal Hysterectomy who will be identified by anesthesia providers during their Pre-Anesthesia Evaluation Clinic visit and/or Day Surgery Unit pre-anesthetic assessment at Parkland Hospital. If the subjects agree to participate in the study, the researchers will determine eligibility. If the subject meets all inclusion/exclusion criteria, the subject will be asked to sign the Consent Form and HIPAA Authorization Form prior to any study procedures in a face-to-face meeting with the researchers. Protected patient information will include name, medical record number, date of birth, and contact information including telephone number. Height and weight will also be recorded. All patients will receive a standardized general anesthetic based on Enhanced Recovery After Surgery protocols. One of the investigators will randomly allocate patients using computer generated randomization schedule to one of the two groups. Study Groups: Group 1: Ultrasound-guided ESP block with liposomal bupivacaine Group 2: Ultrasound-guided QL block with liposomal bupivacaine. Anesthesiologists with previous experience in ultrasound-guided regional anesthesia procedures will perform the block based on randomization results. In both groups the patient will be placed in a sitting position, a SonoSite X-Porte linear ultrasound transducer will be used for real-time ultrasound guidance. Group 1: For the QL block, the transducer will be placed transversely over the lumbar spine at the level of the iliac crest. Then, the anesthesiologist will scan laterally to identify the ipsilateral L3 transverse process, psoas muscle, and quadratus lumborum muscle to identify the "Shamrock Sign" (7). Following aseptic preparation of the injection site and the ultrasound probe, a 22-gauge, 10mm block needle will be introduced parallel to the ultrasound guided beam (in-plane technique) until its tip reaches the plane between the quadratus lumborum muscle and psoas muscle. After negative aspiration, 20 ml of a mixture containing 10ml 0.25% bupivacaine and 10ml 1.3% liposomal bupivacaine will be injected in 5 ml increments to separate the fascial plane between the two muscles. The investigators will observe local anesthetic spread under real-time imaging. The block will then be performed in the same manner on the opposite site. Group 2: For the ESP block, the transducer will be placed parasagittally at the level of the tip of the scapula and the anesthesiologist will scan in a craniocaudal manner to identify the ipsilateral T10 transverse process and overlying erector spinae muscle. Following aseptic preparation of the injection site and the ultrasound probe, a 22-gauge, 10mm block needle will be introduced parallel to the ultrasound guided beam (in-plane technique) until its tip reaches the plane between the erector spinae muscle and transverse process. After negative aspiration, 20 ml of a mixture containing 10ml 0.25% bupivacaine and 10ml 1.3% liposomal bupivacaine will be injected in 5 ml increments to separate the fascial plane between the muscle and transverse process. The investigators will observe local anesthetic spread under real-time imaging. The block will then be performed in the same manner on the opposite site. A standard postoperative analgesic regimen in both groups will include acetaminophen 1000 mg, orally every 8 hours and meloxicam 15mg, orally every 24 hours. For breakthrough pain (or rescue), immediate-release oxycodone 5-10mg, orally every 4 hours as needed for pain will be provided. The efficacy of postoperative analgesia will be documented in all patients using the visual analog score (0=no pain, 10=worst pain). In addition, total morphine dose over the 72-hours study period will be documented. Postoperative nausea will be measured using a categorical scoring system (none=0, mild=1, moderate=2, severe=3) and episodes of vomiting will be documented. Rescue antiemetics will be given to any patient who complains of nausea or vomiting. All variables will be assessed at 4, 6, 12, 24, 48, and 72 hours postoperatively by an investigator blinded to group allocation. For each patient the following data will be recorded: Preoperatively: Age Gender Height Weight Baseline pain score Pre-operative block procedure, duration, amount of analgesia used Time to perform the blocks Intraoperatively: • Surgical time Postoperatively: Post-Anesthesia Care Unit time Post-operative pain scores at 4, 6, 12, 24, 48, 72 hours cumulative opioid consumption during the first 24-hours postoperatively Time to first ambulation Time to first oral intake Time to be ready for discharge home

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