The analgesic effect of transmuscular quadratus lumborum block versus erector spinae plane block for women undergoing elective Caesarean section: A randomized controlled trial.

Background: We aimed to compare the analgesic effect and quality of recovery of transmuscular quadratus lumborum block (QLB) and erector spinae plane block (ESPB) in the presence of multimodal analgesia following Caesarean section. Methods: This randomised controlled trial included full-term pregnant women who underwent elective Caesarean section under spinal anaesthesia without intrathecal morphine. The included women were randomised to receive either bilateral QLB (n = 51) or bilateral thoracic ESPB (n = 51), in addition to the control group (n = 51) who did not receive any block. All participants received regular paracetamol (1 g/6h) and diclofenac (50 mg/8 h). Intravenous morphine was used as a rescue analgesic. The primary outcome was time to first morphine requirement. Secondary outcomes included total postoperative morphine consumption and total Obstetric Quality of Recovery-11 (ObsQoR-11) score. Results: We analysed 51, 50 and 48 patients in the QLB, ESPB and control groups, respectively. The time to first morphine requirement in both QLB and ESPB groups was longer than that in the control group (median [quartiles] time: 6 [6,12] h, 6 [6,6] h and 4 [3,4] h, respectively; p-value <0.001), without significant differences between the two former groups. The total morphine consumption in both QLB and ESPB groups was lower than that in the control group (median [quartiles]:0 [0,5] mg, 0 [0,5] mg and 25 [25,30] mg, respectively; p-value <0.001), without significant differences between the two former groups. The QLB and ESPB groups had comparable ObsQoR-11 score, and both groups' scores were higher than the control group. Conclusion: In patients undergoing elective Caesarean section under spinal anaesthesia without intrathecal morphine, both QLB and ESPB provided superior analgesia and quality of recovery compared to the standard care, without significant difference between the two blocks.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study.

BACKGROUND: It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry. METHODS: A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds). RESULTS: Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described. CONCLUSIONS: The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

Ultrasound-guided quadratus lumborum block for postoperative pain control in patients undergoing unilateral inguinal hernia repair, a comparative study between two approaches.

BACKGROUND: Early postoperative ambulation and reduction of hospital stay necessitate efficient postoperative analgesia. Quadrates Lumborum Block (QLB) has been described to provide adequate postoperative analgesia after abdominal surgery. This randomized comparative trial was designed to compare the duration of analgesia provided by two different QLB approaches; the posterior QLB (QLB-2) and transmuscular QLB (QLB-3) in patients undergoing surgical repair of unilateral inguinal hernia. METHODS: Forty patients, aged from 18 to 50 years, ASA physical status I or II, scheduled for unilateral inguinal hernia repair were enrolled. At the end of the surgical procedure and before recovery from general anesthesia, Patients were randomly assigned into two groups to receive either posterior QLB (Group QLB-2) or transmuscular QLB (Group QLB-3) using 20 ml 0.25% bupivacaine. Duration of analgesia, postoperative VAS and postoperative opioid consumption were recorded. RESULTS: Duration of block was significantly longer in QLB-3 group when compared to QLB-2 group (20.1 + 6.2 h versus 12.0 + 4.8 respectively) with P value of < 0.001. A statistically significant lower VAS score was recorded in QLB-3 group immediately and 12 h postoperative. QLB-3 group showed a statistically significant delayed time of first analgesic request and less postoperative morphine consumption with P value of < 0.001 and 0.001 respectively. CONCLUSIONS: Ultrasound guided postsurgical transmuscular approach of QLB (QLB-3) using 20 ml 0.25% bupivacaine produces more postoperative analgesic effect and less postoperative opioid consumption when compared to posterior QLB approach (QLB-2) in patients underwent unilateral inguinal hernia repair under general anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03526731 - on 16 May 2018.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. METHODS: We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). FINDINGS: We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. INTERPRETATION: Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. FUNDING: Medical Research Council of South Africa.

Evaluation of Noninvasive Hemoglobin Monitoring in Trauma Patients with Low Hemoglobin Levels.

OBJECTIVE: Bleeding is a leading cause of death among trauma patients. Delayed assessment of blood hemoglobin level might result in either unnecessary blood transfusion in nonindicated patients or delayed blood transfusion in critically bleeding patients. In this study, we evaluate the precision of noninvasive hemoglobin monitoring in trauma patients with low hemoglobin levels. METHODS: We included trauma patients with low hemoglobin levels (less than 8 g/dL) scheduled for surgical intervention. Blood samples were obtained on admission and after each blood unit with concomitant measurement of serum hemoglobin using radical-7 Masimo device. The change in blood hemoglobin after every transfused blood unit was also assessed by both methods (change in noninvasive Masimo hemoglobin [Delta-Sp-Hb] and change in laboratory hemoglobin [Delta-Lab-Hb]). The precision of Masimo hemoglobin level (Sp-Hb) compared with Laboratory hemoglobin level (Lab-Hb) was determined using both Bland-Altman and Pearson correlation analyses. RESULTS: One hundred eighty-four time-matched samples were available for final analysis. Bland-Altman analysis showed excellent accuracy of Sp-Hb compared with Lab-Hb with mean bias of 0.12 g/dL and limits of agreement between -0.56 g/dL and 0.79 g/dL. Excellent correlation was reported between both measures with Pearson correlation coefficient of 0.872. Excellent agreement was also reported between both Delta-Sp-Hb and Delta-Lab-Hb with mean bias of -0.05 and limits of agreement from -0.62 to 0.51 CONCLUSIONS:: Sp-Hb showed accurate precision in both absolute values and trend values compared with Lab-Hb measurement in trauma patients with low hemoglobin levels.