不同层面腰方肌阻滞对剖宫产产妇术后镇痛的影响

目的 探讨超声引导下前层胸腰筋膜下和前层胸腰筋膜外实施腰方肌阻滞（QLB）对剖宫产术后镇痛的影响。
方法 选择择期腰-硬联合麻醉下行剖宫产手术的产妇113例,年龄23～39岁,体重50～90 kg,ASA Ⅰ或Ⅱ级,孕期>37周。采用随机数字表法将产妇分为两组：前层胸腰筋膜下阻滞组（S组,n=57）和前层胸腰筋膜外阻滞组（E组,n=56）。所有产妇腰-硬联合麻醉用药相同,术毕连接患者自控静脉镇痛（PCIA）泵,S组术毕行超声引导下前层胸腰筋膜下阻滞,E组行超声引导下前层胸腰筋膜外阻滞。记录首次按压PCIA时间,术后24 h内PCIA有效按压次数以及布托啡诺用量。记录QLB实施后6、9、12、24、48 h静息和活动时VAS疼痛评分、BCS舒适度评分以及阻滞平面存在情况。记录头晕、恶心呕吐、肌力减退等不良反应发生情况。
结果 两组首次按压PCIA时间差异无统计学意义。S组术后24 h内PCIA有效按压次数、布托啡诺用量明显少于E组（P＜0.05）。QLB阻滞实施后不同时点静息和活动时VAS疼痛评分、BCS舒适度评分差异均无统计学意义。S组QLB实施后24 h阻滞平面存在的产妇比例明显高于E组（P＜0.05）。S组头晕发生率明显低于E组（P＜0.05）。
结论 超声引导下前层胸腰筋膜下实施腰方肌阻滞应用于剖宫产术后镇痛效果好,不良反应少,是剖宫产术后镇痛更适宜的阻滞层面。     

超声引导下腰方肌阻滞与髂筋膜间隙阻滞在老年髋关节术后镇痛的比较

目的比较腰方肌阻滞(quadratus lumborum block,QLB)和髂筋膜间隙阻滞(fasciailiaca compartment block,FICB)在老年髋关节置换术的镇痛效果。方法选择择期拟行腰麻下全髋关节置换术的老年患者55例,男22例,女33例,年龄65～85岁,ASAⅠ或Ⅱ级,随机分为QLB组(n=28)和FICB组(n=27)。术后分别于超声引导下行QLB和FICB,予0.375%罗哌卡因30ml。所有患者术后行舒芬太尼静脉自控镇痛。记录术后6、12、24、48h镇痛泵按压次数及舒芬太尼用量;记录静息及运动时VAS疼痛评分;记录术后恶心呕吐、眩晕等不良反应情况。结果术后12、24、48h QLB组镇痛泵按压次数及舒芬太尼用量明显少于FICB组(P0.05);术后12、24、48hQLB组运动时VAS评分明显低于FICB组(P0.05),两组不同时点静息时VAS评分差异无统计学意义;QLB组恶心呕吐发生率明显低于FICB组[2(7.1%)vs 9(33.3%),P0.05]。结论腰方肌阻滞较髂筋膜间隙阻滞更能明显减轻髋关节置换术后活动痛,减少阿片类药物的使用及不良反应发生率。     

后路腰方肌阻滞对二次剖宫产术后子宫复旧痛的影响

目的 观察后路腰方肌阻滞（QLB）对二次剖宫产产妇术后子宫复旧痛及术后早期恢复的影响。
方法 选择2020年6—12月因瘢痕子宫行二次剖宫产产妇73例，年龄22～40岁，体重50～90 kg，ASA Ⅰ或Ⅱ级，单胎足月妊娠，采用随机数字表法将产妇分为两组：观察组（n=36）和对照组（n=37）。观察组术毕在超声引导下行双侧后路QLB，对照组模仿观察组超声下寻找腰方肌但不给药。术后24 h和48 h随访并记录产妇子宫复旧痛评分（VAS疼痛评分）和镇痛泵按压次数，并完成术后恢复量表（QoR-40）问卷，以及记录术后初次母乳喂养时间、首次下床活动时间和首次进食时间，以及麻醉相关并发症发生情况。
结果 与对照组比较，观察组术后24 h内及24～48 h最严重及最轻微子宫复旧痛评分明显降低，观察组术后镇痛泵总按压次数及有效按压次数明显减少，术后恢复量表问卷得分明显升高，术后初次母乳喂养时间明显缩短（P<0.05）。两组首次下床活动时间和首次进食时间及麻醉相关并发症发生率差异无统计学意义。
结论 后路腰方肌阻滞可降低二次剖宫产产妇术后48 h内子宫复旧痛程度，缩短初次母乳喂养时间，减少术后阿片药物用量并促进产妇术后早期恢复。     

腰方肌阻滞与腹横肌平面阻滞用于老年患者腹腔镜结肠癌根治术后镇痛的效果对比

目的：比较腰方肌阻滞（QLB）与腹横肌平面阻滞（TAPB）用于老年患者腹腔镜结肠癌根治术后镇痛的效果。方法：将2020年8月至2021年12月于我院行腹腔镜结肠癌根治术治疗的82例老年患者随机分为2组,术后分别采用QLB和TAPB法进行术后镇痛。比较2组患者术后2h、8h、12h、24h疼痛程度及深呼吸或咳嗽时的舒适度。疼痛程度采用疼痛数字评估量表（NRS）评价,舒适度采用Bruggrmann舒适量表（BCS）评价。结果：QLB组患者术后2h、8h、12h、24hNRS评分均明显低于TAPB组（P <0.05）,而且各观察点BCS评分均明显高于TAPB组（P <0.05）。结论：QLB用于老年患者腹腔镜结肠癌根治术后镇痛效果优于TAPB。     

超声引导下神经阻滞技术用于患儿腹部手术后镇痛的进展

区域神经阻滞是多模式镇痛的基础方案。与静脉镇痛比较,区域神经阻滞具有更强的针对性和有效性,神经阻滞麻醉镇痛可有效减少阿片类药物使用带来的不良反应。联合应用超声引导技术,能够提高神经阻滞的安全性和精确性。患儿腹部神经阻滞解剖结构以及局麻药物扩散途径、临床应用以及并发症的报道较少,药物浓度与剂量缺乏统一标准,需要进一步的临床研究。本文分别从患儿腰方肌阻滞（QLB）、腹横肌平面阻滞（TAPB）、腹直肌鞘阻滞（RSB）、竖脊肌平面阻滞（ESPB）和椎旁阻滞（PVB）的局麻药物扩散途径、浓度剂量、临床应用及相关并发症等方面进行综述,以期为患儿术后镇痛提供参考。     

腰方肌阻滞在髋关节术后镇痛中的应用

髋关节手术创伤大,患者术后往往伴随中重度疼痛。安全且有效的术后镇痛可以有效促进患者的康复活动,有利于髋关节手术后患者早期功能恢复。常规使用的静脉自控镇痛虽然镇痛效果确切,但可能引起恶心呕吐、过度镇静、肠麻痹,甚至呼吸抑制等不良反应。腰方肌阻滞（QLB）作为一种替代腹横肌平面阻滞（TAPB）的技术。近年来逐渐应用于髋关节手术。本文通过对QLB的解剖基础、作用特点及其在髋关节手术中的应用作一综述,为QLB在髋关节术后镇痛中的应用提供参考。     

腰方肌阻滞临床应用的研究进展

腰方肌阻滞是一种将局麻药物注射至腰方肌周围的躯干神经阻滞技术。近年来,腰方肌阻滞的临床应用已成为研究热点,是广受欢迎的镇痛方式。腰方肌阻滞逐渐被应用于剖宫产手术、胃肠道手术、泌尿手术、下肢手术等围术期多模式镇痛,并且在慢性疼痛治疗中也有报道。全文就腰方肌阻滞的应用解剖、穿刺入路、临床应用及可能的作用机制进行综述,为其临床应用提供参考。     

弓状韧带上腰方肌阻滞的解剖基础和临床应用

弓状韧带上腰方肌阻滞(QLB)技术是在超声引导下直接将药物注射于外侧弓状韧带上的腰方肌前侧, 药物更容易进入低位胸椎旁间隙, 避免了传统QLB的许多弊端, 为腹部手术的术中和术后镇痛提供了一种更优的选择, 在临床麻醉中具有广阔的应用前景。本文对超声引导弓状韧带上QLB的解剖基础和临床应用进行综述。     

腰方肌阻滞的临床应用进展

正腰方肌阻滞(quadratus lumborum block,QLB)是近年来一种新型的躯干神经阻滞技术,最早由Blanco~([1])于2007年提出,适用于腹部、髋部及下肢手术的围术期镇痛。研究表明,与腹横肌平面阻滞(transversus abdominis plane block,TAPB)比较,QLB能同时阻断体表躯体痛与内脏痛,镇痛效果更好、持续时间更长[2-3],在临床上具有广阔的     

超声引导下经弓状韧带上或前路腰方肌阻滞在腹腔镜全子宫切除术中的比较

目的 探讨超声引导下经弓状韧带上入路或前路腰方肌阻滞（QLB）在腹腔镜全子宫切除术中的镇痛效果。
方法 择期行腹腔镜全子宫切除术的患者38例,年龄18～64岁,BMI 16～29 kg/m²,ASA Ⅰ或Ⅱ级。随机分为经前路QLB组（C组）和经弓状韧带上QLB组（E组）,每组19例。麻醉诱导前在超声引导下C组行双侧前路QLB,E组行弓状韧带上QLB,每侧给予0.3%罗哌卡因20 ml。记录术后住院时间、阻滞操作时间、阻滞后起效时间,测定阻滞后5、10、20、30 min的阻滞平面和术中瑞芬太尼和麻黄碱用量。记录术后2、6、12、24、48 h的VAS疼痛评分和补救镇痛,局麻药中毒、血肿、严重低血压、内脏损伤、肌力下降等神经阻滞并发症和恶心呕吐等不良反应。
结果 两组术后住院时间、阻滞操作时间差异无统计学意义。E组阻滞起效时间明显短于C组（P<0.05）。阻滞后5、10、20、30 min E组阻滞平面节段数量明显多于C组（P<0.05）。术后2、6、12 h E组静息和活动时VAS疼痛评分明显低于C组（P＜0.05）。两组均无补救镇痛,术中瑞芬太尼、麻黄碱用量,局麻药中毒、血肿、严重低血压、内脏损伤、肌力下降等神经阻滞并发症和恶心呕吐等不良反应差异无统计学意义。
结论 在腹腔镜全子宫切除术中经弓状韧带上腰方肌阻滞较传统前路腰方肌阻滞起效更快,阻滞平面更广,术后12 h镇痛效果更好。     

舒芬太尼或羟考酮自控静脉镇痛联合腰方肌阻滞用于剖宫产术后镇痛的效果

目的评价超声引导下腰方肌阻滞(quadratus lumborum block,QLB)联合舒芬太尼或羟考酮PCIA用于剖宫产术后镇痛的效果。方法择期在腰-硬联合阻滞下行剖宫产术的产妇120例,年龄22~38岁,体重50~80 kg,ASAⅠ或Ⅱ级,采用随机数字表法分为四组,每组30例:舒芬太尼组(S组)、羟考酮组(Q组)、QLB联合舒芬太尼组(BS组)和QLB联合羟考酮组(BQ组)。BS组和BQ组术毕行超声引导下双侧QLB,每侧注射0.25%罗哌卡因20 ml。四组术后均行PCIA,S组和BS组镇痛泵药物为舒芬太尼100μg加生理盐水至100 ml,Q组和BQ组镇痛泵药物为羟考酮50 mg加生理盐水至100 ml。设置镇痛泵背景输注速率2 ml/h,单次剂量2 ml,锁定时间10 min。记录术后24 h内PCIA给药总量、有效按压次数、补救镇痛情况和镇痛满意度评分。记录镇痛期间恶心呕吐、呼吸抑制、皮肤瘙痒等不良反应的发生情况。结果与S组比较,Q组、BS组和BQ组PCIA给药总量、有效按压次数明显减少,镇痛满意度评分明显升高(P<0.05),Q组术后恶心呕吐发生率明显降低(P<0.05),BS组和BQ组补救镇痛率明显降低(P<0.05)。与Q组比较,BS组和BQ组PCIA给药总量、有效按压次数明显减少,补救镇痛率明显降低,镇痛满意度评分明显升高(P<0.05)。与BS组比较,BQ组PCIA给药总量、有效按压次数明显减少,镇痛满意度评分明显升高,术后恶心呕吐发生率明显降低(P<0.05)。结论超声引导下QLB可增强剖宫产术后镇痛效果,减少术后镇痛药物用量,提高产妇满意度,联合羟考酮PCIA可更有效抑制术后宫缩痛,并降低术后恶心呕吐的发生率。     

Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial

Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. This was a prospective, double-blind, placebo-controlled trial. Participants were randomly allocated to receive bilateral quadratus lumborum block (40 ml levobupivacaine 0.25%) or sham block (control) after undergoing elective caesarean section under spinal anaesthesia. The primary outcome was 24-h morphine consumption measured by patient-controlled analgesia. Secondary outcomes included pain scores and quality of recovery. Data from 86 women were analysed. Median (IQR [range]) 24-h morphine consumption was similar in patients receiving quadratus lumborum block and sham block (12 (8–29 [0–68]) mg vs. 14 (5–25 [0–90]) mg, respectively; p = 0.986). There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0–14 [0–98]) mm vs. 14 (3–23 [0–64]) mm (p = 0.019); and on movement: 23 (10–51 [0–99]) mm vs. 44 (27–61 [2–94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.     

Single injection Quadratus Lumborum block for postoperative analgesia in adult surgical population: A systematic review and meta-analysis

Study objectiveThe Quadratus lumborum (QL) block was first reported as a postoperative analgesic technique for abdominoplasty, and since has been used for a variety of surgeries. In this systematic review and meta-analysis, we summarize the current literature on the postoperative analgesic effect of QL block.DesignWe systematically searched PubMed, CENTRAL, CINAHL, EMBASE, Clinical Trials Registry (U.S. National Library of Medicine), Web of Science and Google Scholar for randomized control trials. The primary outcome was the comparison of 24-hour opioid requirements between the QL block and systemic analgesia cohorts; secondary outcomes included time to rescue analgesia, postoperative nausea and vomiting, block related complications and comparison between QLB and other regional anesthesia techniques.Main resultsWe identified 22 studies for inclusion: 16 studies compared QL block to GA with systemic analgesia, four studies compared the QL block with the TAP block, and the rest on other comparisons (such as femoral block and continuous wound infiltration). QL block significantly reduced the opioid requirement in cesarean deliveries and renal surgeries, there were insufficient studies for the other surgery types. Several studies reported that QLB was associated with significantly reduced pain for up to 24 h postoperatively, but quantitative analysis is not possible due to high heterogeneity. The most common block related complication was local anesthetic toxicity.ConclusionsQL block significantly reduces opioid requirement in cesarean delivery and in renal surgery. The evidence for other surgery types are limited. QL block may have analgesic effect for up to 24 h postoperatively, but the evidence is again limited. There is currently limited evidence comparing QL block to other analgesic techniques, further studies are needed in this area.     

Local anaesthetic techniques for post-caesarean delivery analgesia

In this narrative review we summarise pertinent data from published studies investigating the use of local anaesthetic techniques as adjuncts for managing post-caesarean delivery pain.Based on currently available evidence, ultrasound-guided transversus abdominis plane (TAP), quadratus lumborum (QL) and ilio-inguinal and iliohypogastric (ILIH) blocks are preferable to landmark techniques. When intrathecal morphine is used for caesarean delivery analgesia, TAP blocks do not confer any additional benefit. In the absence of intrathecal morphine, TAP blocks have been shown to reduce pain scores and opioid consumption in the first 24 h postoperatively. In the absence of intrathecal morphine, single-dose local anaesthetic wound infiltration also results in a moderate reduction in opioid consumption postoperatively. If a wound catheter is to be incorporated into a multimodal analgesic regimen, a position below the fascia and a continuous infusion of low-concentration local anaesthetic solutions should be considered. Intraperitoneal local anaesthetic instillation may be of benefit in patients who undergo peritoneal closure but larger studies are still needed. Quadratus lumborum and ILIH blocks show promising results but the data are limited, so recommendations for routine use cannot be made.In summary, evidence supports the use of local anaesthetic techniques for post-caesarean delivery pain but additional research is required to determine the optimum dosing regimens, and the potential role of liposomal local anaesthetics. Further studies are required to compare techniques and determine their role in conjunction with low-dose long-acting neuraxial opioids.     

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis*

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4–6 h, 8–12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.     

O bloqueio contínuo do quadrado lombar tipo 3 fornece analgesia pós‐operatória efetiva para cirurgia do quadril: relato de caso

Introduction

Hip surgery is a major surgery that causes severe postoperative pain. Although pain during rest is usually considerably reduced mobilization is important in terms of thromboembolic complications. The quadratus lumborum block is a regional analgesic technique that blocks T6‐L3 nerve branches. This block may provide adequate analgesia and reduce opioid consumption after hip surgery.

Editorial Commentary: Quadratus Lumborum Analgesia for Hip Arthroscopy: The New Kid on the (Nerve) Block

Quadratus lumborum (QL) nerve block is a new technique aimed to improve perioperative analgesia for patients undergoing hip arthroscopy. The QL block targets nerve roots from the lumbar plexus supplying the hip and is an alternative to the fascia iliaca compartment block, which has been shown to have variable effects on pain control while increasing motor weakness and postoperative fall risk. Although a recent Level I study showed decreased opioid consumption without increased motor weakness after QL block compared to sham block, another Level I study reported contrasting results with QL block demonstrating no improvement in pain control or opioid consumption compared to a multimodal pain regime after hip arthroscopy. These differing conclusions from high-level studies indicate further research is needed for QL block and that investigation of other potential nerve block options for hip arthroscopy patients, such as the PENG block, is warranted.     

腰方肌阻滞应用于剖宫产手术术后镇痛效果的系统评价

目的 系统评价腰方肌阻滞应用于剖宫产手术术后镇痛的有效性和安全性.方法计算机检索PubMed、The Cochrane Library、Embase、中国生物医学数据库(CBM)、万方数据库、中国知网和维普网数据库,收集从建库到2020年4月所有关于腰方肌阻滞用于剖宫产手术术后镇痛效果的随机对照试验.由两位评价员独立筛...