DOI: https://doi.org/10.21203/rs.3.rs-19158/v1
Background
Recently, several case reports and limited randomized studies have shown that the quadratus lumborum block (QLB) is effective in providing pain relief after intra-abdominal and retroperitoneal operations. Robot-assisted partial nephrectomy (RAPN) has also been proposed as a promising operative treatment for renal carcinoma because it enables early recovery and ambulation. Therefore, we aimed to evaluate the analgesic and opioid-sparing effects of a single-injection QLB, which may paly an important role on early recovery program in RAPN.
Methods
Fifty-six patients undergoing elective RAPN under general anesthesia were randomised to two equally sized groups. Patients were randomly allocated to receive unilateral QLB (n=28) with 0.375% bupivacaine 0.5 mL/kg (QLB group) or a conventional scheme (n=28) group (Control group). The QLB technique was performed as first described by Blanco, termed QLB2. The primary outcome was the visual analogue scale (VAS) scores with movement at 6 hours postoperatively. The secondary endpoints were the morphine consumption at different time-period after surgery, morphine-related side effects and assessment of postoperative rehabilitation.
Results
Both VAS pain score and cumulative opioid consumption were significantly lower in the QLB group at 6 hours after surgery as compared with the control group (all P<0.05). There was significant difference in pain scores at any other time-point except at 4 hours on movement and 48 hours at rest. However, no significant difference was observed in 12-48 hours cumulative opioid consumption, and in the duration of PACU and hospital stay between the two groups. The patient recovery scores was significantly higher in the QLB group.
Conclusions
Single-injection pre-emptive QLB applied to RAPN was effective and provided satisfactory analgesia and opioids-sparing in combination with a typical patient-controlled analgesia. In addition, it may provide an effective technique for early recovery in perioperative period.
The quadratus lumborum block (QLB) was first described by Blanco in 2007, which later can be subdivided into three basic approaches, known as QLB1, 2, 3 and a modified approach, called intramuscular QLB, based on needle tip position and the spread of local anesthetic (LA)[1]. Recently, an increasing case reports and randomized trials have show that QLB may be effective in postoperative pain relief and opioids-sparing effect after various surgery operations [2–10].
Although analgesic effect is theoretically thought to be comparable among these four types of QLB, in fact that each approach resulted in different range of sensory blockade, due to the spread of LA vary for each method. QLB2 has been reported to be effective for both somatic and visceral pain due to the spread of LA tend to the paravertebral space, and is believed to achieve sensory blockade of ipsilateral abdominal wall (lateral and lower)[11, 12]. Furthermore, QLB2 technique, also termed the posterior approach, aims to inject LA into a fascial plane that is between the quadratus lumborum and the latissimus dorsi muscles. The superficial point of LA injection permits to be safer and user-friendly with real-time ultrasound guidance. Thus it is of paramount importance to analyze its clinical efficacy under different clinical procedures.
The past decade has seen the rise of robot-assisted partial nephrectomy (RAPN) for treatment of renal carcinoma, that has the advantage of shorten warm ischemia time and providing better solution for difficult-to-access renal tumors [13–16]. It acts as a minimally invasive technique and now is an an important part of early recovery program. Several case reports have shown that QLB was effective in providing pain relief after unilateral abdominals surgeries (e.g. pyeloplasty, radical nephrectomy [17, 18]). However, a literature search throughout the whole study had not yet found any randomised controlled trials that evaluated the effect of QLB after RAPN. In this randomised, controlled, double-blinded study, we investigated our hypothesis using QLB2 technique in combination with a typical postoperative analgesic scheme to evaluate the clinical efficacy on perioperative analgesia in RAPN.
Ethical approval for this study was provided by the Research Ethics Committee of Sun Yat-sen University Cancer Center (Chairperson Prof. Wangqing Peng) on 5th June 2018. The study was registered at a clinical trials registry (, registered number: ChiCTR1800016790), and was conducted at the Sun Yat-sen University Cancer Center from June 2018 to November 2018. This study was designed and conducted on the basis of the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Patients of American Society of Anesthesiologists (ASA) physical status Ⅰ to Ⅲ, aged 18 to 75 years old, were scheduled for elective robot-assisted partial nephrectomy received general anesthesia were enrolled into the study (Fig. 1). Exclusion criteria included: patient's refusal, mental illness, history of alcohol or analgesics dependence, coagulopathy, severe hepatic dysfunction, chronic pain, infection at the needle insertion site, allergy to local anesthetics, and body mass index (BMI) more than 30 kg/m2 or less than 15 kg/m2. Written informed consent was obtained from all patients for this trial. These patients were allocated randomly by computer-generated randomization schedule into one of the two groups (QLB group and control group). The QLB group received a unilateral QLB after anesthesia induction, and no nerve block was performed the in the control group.
A sealed opaque envelope contained a card with the computer-generated allocation number (1 = QLB group, 2 = control group) was opened by an anesthesia assistant who was not involved in the study. Ultrasound-guided QLB was carried out by attending anesthesiologists who had extensive experience with this technique (over 60 attempts). Another anesthesiologists who were blinded to the patient group assignment were responsible for anesthesia management and pain management in postoperative care based on the specified scheme of anesthesia and analgesia. The research assistants who were engaged in the study performed the 48-hours postoperative follow-up and recorded the clinical variables.
All patients were seen on two days before surgery and were instructed on the use of a 11 points visual analogue scale (VAS): 0 = no pain, 10 = worst imaginable pain, for assessment of postoperation pain and how to use a patient controlled analgesia (PCA) device. Prophylactic analgesia was performed at the night before the surgery for all patients with celecoxib 200 mg except for contraindications.
Upon arrival in the preparation room, peripheral venous access (20-gauge) was established and standard ASA monitors were applied. Additionally, each patient received routinely continuous monitoring of bispectral index (BIS) and train-of-four stimulation. General anesthesia was induced with target-controlled infusion (TCI) of propofol 3–6 µg/ml and intravenous sufentanil 0.3 µg/kg and tracheal intubation was facilitated with rocuronium 0.9 mg/kg. A total intravenous anaesthesia with TCI propofol and remifentanil was used for maintenance of anaesthesia in accordance with BIS 40–60. Neuromuscular blockade was ensured thoughout surgical procedure using rocuronium according to TOF(train-of-four)index for adequate muscle relaxation. After intubation, the lungs were ventilated at 8 mL/kg tidal volume with 0–5 mmHg positive end-expiratory pressure. The frequency was set to keep the end-tidal carbon dioxide within the range of 35 to 45 mmHg. An infusion of phenylephrine between 0.1–0.4 µg/kg/min will be initiated in order to maintain blood pressure values within 20% of the baseline value, and bradycardia (heart rate < 50 beats/min) was treated with atropine 0.5 mg. Dexamethasone 8 mg combined with tropisetron 5 mg were used to treat nausea and vomiting. A single bolus of sufentanil 0.1 µg/kg and flurbiprofen 50 mg were administered at the start of skin closure. All patients were extubated prior to transport to the post-anesthesia care unit (PACU).
At the PACU, A dose of intravenous morphine 2 mg was defined for rescue analgesia if VAS pain score was > 3, every 15 minutes until the pain VAS was ≤ 3. Patients were transfered to ward when they achieved a modified Aldrete score ≥ 9 and VAS scores ≤ 3. All the patients were routinely received a morphine PCA pump with no background infusion. The PCA pump was programmed to deliver 1-mL bolus doses of morphine (1 mg/mL) on demand with a minimum lock-out interval of 6 minutes, and a total morphine dose not to exceed 15 mg during any 4 h interval. All patients received regular flurbiprofen 50 mg at 8-hourly intervals and a dose of intravenous tramadol 50 mg was defined for breakthrough pain if VAS was ≥ 6, every 1 hour until the VAS was ≤ 3 at the surgical ward. Antiemetic treatment with intravenous tropisetron was available as needed.
All blocks were performed with the patient in the lateral decubitus position after induction of general anesthesia. After local sterilization with povidone iodine, a high-frequency (6–13 MHz) linear array ultrasound probe (Sonosite M-turbo, SonoSite, Inc., Bothell, WA) covered with a sterile sheath was placed above the iliac crest, and moved cranially until the three abdominal wall muscles were clearly identified. Then, it slided medially until latissimus dorsi and quadratus lumborum muscle was confirmed within identical short-axis view. A 22-gauge, short-beveled stimulating needle (B. Braun Melsungen AG, Melsungen, Germany) was used for the single-injection block. The needle tip was inserted in-plane with the ultrasound beam and targeted the posterior of quadratus lumborum muscle. Accurate needle tip position was initially readjusted by injecting 1–2 mL of normal saline with hydrodissection image, 0.5 mL/kg of 0.375% bupivacaine was injected into the lumbar interfascial triangle behind the quadratus lumborum muscle under real-time ultrasound guidance.
Demographic, anaesthesia- and operation-related parameters were recorded, including sex, age, height, weight, BMI, performance time, surgical duration, and intraoperative propofol and remifentanil consumption. The primary outcome measure of this study was the VAS scores with movement (cough or turn around the body) at 6 hours postoperatively. After surgery, patients were evaluated at 4, 6, 12, 24, and 48 hours postoperatively. The measured variables were as follows: VAS scores during rest and with movement at the predetermined intervals; morphine titration consumption in PACU, and cumulative morphine PCA consumption; length of PACU stay; morphine-related side effects included nausea and vomiting, sedation (Ramsay scale > 2), dizziness, hyoxemia (pulse oxygen saturation < 95%), pruritus; hospital stay duration and quality of recovery (measured using a 15-item quality of recovery score, QoR-15) were also documented.
The sample size was calculated based on data from our pilot study (n = 10). we observed that the VAS scores (at movement) at 6 hours postoperatively was 4 (± 2.0). We considered that a 50% reduction in the VAS scores to be statistically significant, and therefore 23 patients per group were required to establish variance test with α = 0.05 and β = 0.1. A total of 56 patients were finally calculated to account for the anticipated 20% dropout rate.
SPSS software of Windows 19.0 (SPSS, Chicago, IL, USA) was used for statistical analysis. For continuous variables, normality of the data was assessed using the Kolmogorov-Smirnov test. Continuous variables were summarized as mean ± standard deviation, median and interquartile range, and analyzed using the Student’s t test or a Mann-Whitney U test, as appropriate. For categorical variables, research data of the 2 study groups summarized as a frequency, n (%), and the Pearson c2 test, or Fisher exact test was performed, as appropriate. A P < 0.05 was considered statistically significant for all results.
The flow chart of this study is presented in Fig. 1. Sixty-five patients scheduled for RAPN were screened for eligibility, and 9 patients were excluded due to not meeting inclusion criteria or decline to participate. A total of 56 patients were randomized into two equally sized groups (n = 28, for each group) and included in final analysis. The results showed significant reduction for remifentanil consumption (1129.3 ± 310.22 µg vs 1778.43 ± 668.74 µg, P < 0.001) in the QLB group than in the control group. The two groups were similar regarding other demographic, anaesthesia- and surgery-related characteristics (Table 1).
| Control group (n = 28) | QLB group (n = 28) | P value | |
|---|---|---|---|
| Age(years) | 48.25 ± 11.30 | 47.07 ± 12.05 | 0.707 |
| Sex (male/female) | 0.284 | ||
| Male | 13 (46.43) | 17 (60.71) | |
| Female | 15 (53.57) | 11 (39.29) | |
| BMI (kg/m2) BMI | 23.61 ± 2.51 | 23.27 ± 3.14 | 0.661 |
| ASA (Ⅰ/Ⅱ/Ⅲ) | 0.540 | ||
| Ⅰ | 9 (32.14) | 11 (39.29) | |
| Ⅱ | 15 (53.57) | 14 (50.00) | |
| Ⅲ | 4 (14.29) | 3 (10.71) | |
| Surgical site (left/right) | 0.593 | ||
| Left | 13 (46.43) | 15 (53.57) | |
| Right | 15 (53.57) | 13 (46.43) | |
| Surgical duration (min) | 187.68 ± 49.08 | 187.75 ± 53.57 | 0.996 |
| Propofol consumption (mg) | 1412.68 ± 449.30 | 1366.25 ± 464.85 | 0.705 |
| Remifentanil consumption (µg) | 1778.43 ± 668.74 | 1129.39 ± 310.22 | < 0.001 |
| Length of PACU stay (min) | 50.61 ± 16.26 | 47.75 ± 17.23 | 0.526 |
| Hospital stay (days) | 6.32 ± 2.06 | 5.82 ± 1.87 | 0.345 |
| Data are presented as mean ± standard deviation or number (%). | |||
| *Significant (P < 0.05) difference between groups. | |||
| ASA: American Society of Anesthesiologists physical status; BMI: Body Mass Index; PACU: Post-anesthesia Care Unit | |||
All VAS assessments (pain scores at rest, and during movement) at all predetermined intervals are shown in Table 2. Pain scores during movement at 6 hours postoperatively (primary outcome) were statistically significant lower in the QLB group than in the control group (3.4 ± 1.1 vs 4.4 ± 1.1, P < 0.001). Meanwhile, VAS scores during movement at other times except 4 hours were statistically lower in the QLB group (all P < 0.05). VAS scores at rest for most of the predetermined intervals, included at PACU, 4 hours, 12 hours and 24 hours but not at 48 hours were statistically significant lower in the QLB group than in the control group (all P < 0.05). In addition, during the first 6 hours after surgery (morphine titration and PCA use), patients in the QLB group used significantly less morphine than in the control group (all P < 0.05) but not at 12 hours, 24 hours and 48 hours (Table 3).
| Measurement time | Control group (n = 28) | QLB group (n = 28) | P value |
|---|---|---|---|
| Rest | |||
| 4 h | 1.93 ± 0.86 | 1.43 ± 1.03 | 0.022 |
| 6 h | 3.04 ± 0.88 | 1.82 ± 0.77 | < 0.001 |
| 12 h | 2.64 ± 1.06 | 1.50 ± 0.69 | 0.001 |
| 24 h | 2.04 ± 0.74 | 1.32 ± 0.82 | 0.008 |
| 48 h | 1.46 ± 0.64 | 0.96 ± 0.69 | 0.076 |
| Movement | |||
| 4 h | 2.61 ± 0.88 | 2.07 ± 0.72 | 0.075 |
| 6 h | 4.4 ± 1.1 | 3.4 ± 1.1 | < 0.001 |
| 12 h | 3.46 ± 1.10 | 2.32 ± 0.67 | 0.001 |
| 24 h | 3.29 ± 0.85 | 2.57 ± 0.88 | 0.002 |
| 48 h | 2.61 ± 0.63 | 2.25 ± 0.65 | 0.013 |
| Data are presented as mean ± standard deviation. | |||
| *Significant (P < 0.05) difference between groups. | |||
| Measurement time | Control group (n = 28) | QLB group (n = 28) | P value |
|---|---|---|---|
| Morphine titration consumption (mg) | 2.00 (1.00, 4.00) | 2.00 (0.00, 2.00) | 0.037 |
| Morphine PCA use (mg) | |||
| Titration-4 h | 1.00 (0.50, 2.00) | 0.00 (0.00, 1.00) | 0.002 |
| 6 h | 3.00 (2.50, 4.00) | 2.00 (1.00, 2.50) | < 0.001 |
| 12 h | 8.00 (6.00, 10.50) | 7.00 (6.00, 8.00) | 0.089 |
| 24 h | 13.00 (10.50, 16.00) | 13.00 (11.50, 14.00) | 0.718 |
| 48 h | 17.00 (14.00, 19.00) | 16.50 (15.00, 19.50) | 0.617 |
| Data are presented as median (IQR). IQR: Inter Quartile Range. | |||
| PCA:Patient Controlled Analgesia. | |||
| *Significant (P < 0.05) difference between groups. | |||
There were significant difference in terms of nausea and vomiting (all P < 0.05), and the proportion of subjects calculated in other morphine-related side effects were similar between the groups (all P > 0.05) (Table 4). However, the mean (SD) QoR-15 quality of recovery score was 75.4 (4.6) and 83.5 (4.5) for patients receiving QLB or no block, respectively (P < 0.001) (Table 5). There were significant difference in the five sub-items of QoR-15, those were “Have had a good sleep”, “Able to look after personal hygiene, urination and defecation unaided”, “Moderate pain”, “Severe pain”, and “Nausea or vomiting”, respectively (all P < 0.05).
| Control group (n = 28) | QLB group (n = 28) | P value | |
|---|---|---|---|
| Hyoxemia n(%) | 2 (7.1%) | 0 | 0.245 |
| Sedation n(%) | 9 (32.1%) | 4 (14.3%) | 0.114 |
| Dizziness n(%) | 10 (35.7%) | 6 (21.4%) | 0.237 |
| Nausea n(%) | 12 (42.9%) | 5 (17.9%) | 0.042 |
| Vomiting n(%) | 8 (28.6%) | 2 (7.1%) | 0.036 |
| Pruritus n(%) | 6 (21.4%) | 4 (14.3%) | 0.485 |
| Data are presented as number (%). | |||
| *Significant (P < 0.05) difference between groups. | |||
| Control group (n = 28) | QLB group (n = 28) | P value | |
|---|---|---|---|
| Able to breathe easily | 6.0 (1.4) | 6.3 (1.3) | 0.559 |
| Able to enjoy food | 5.4 (1.6) | 5.5 (1.3) | 0.788 |
| Feeling energized | 5.2 (1.4) | 5.2 (1.5) | 1.000 |
| Have had a good sleep | 3.4 (1.1) | 5.1 (1.5) | < 0.001 |
| Able to look after personal hygiene, urination and defecation unaided | 2.2 (1.0) | 3.0 (0.8) | 0.002 |
| Able to communicate with family and friends | 7.0 (1.5) | 7.0 (1.3) | 1.000 |
| Getting support from hospital, doctors and nurses | 6.5 (1.0) | 6.9 (1.1) | 0.190 |
| Able to return to work or usual home activities | 1.4 (1.0) | 1.7 (0.9) | 0.275 |
| Feeling comfortable and in control | 7.1 (1.0) | 7.0 (1.0) | 0.697 |
| Having a feeling of general well-being | 6.9 (0.9) | 7.0 (1.4) | 0.815 |
| Moderate pain | 3.3 (1.3) | 4.8 (1.0) | < 0.001 |
| Severe pain | 5.0 (1.0) | 6.4 (1.2) | < 0.001 |
| Nausea or vomiting | 3.5 (1.8) | 5.1 (1.9) | 0.003 |
| Feeling worried or anxious | 6.0 (1.7) | 6.2 (1.6) | 0.744 |
| Feeling sad or depressed | 6.2 (1.3) | 6.5 (1.4) | 0.438 |
| Total score | 75.4 (4.6) | 83.5 (4.5) | < 0.001 |
| Data are presented as mean ± standard deviation. | |||
| QoR-15: 15-item Quality of Recovery Score | |||
| *Significant (P < 0.05) difference between groups. | |||
This current study was designed to evaluate the analgesic efficacy of preoperatively ultrasound-guided single-injection QLB in patients undergoing RAPN under general anesthesia for perioperative analgesia. The main findings of this study are that the QLB provided superior analgesia at early postoperative stage resulting in lower pain scores and less opioid consumption and adverse reactions. We found that the preventive implement of QLB did reduce pain scores at rest during any time-point up to 24 hours. VAS scores at movement were significantly lower in the QLB group at all observed intervals except at 4 hours postoperatively. Similarly, the consumption of intraoperative remifentanil or postoperative morphine during the first 6 hours but not thereafter was significantly lower in the QLB group than in the control group. Hence, the QLB seem to be a useful analgesic method with a typical patient-controlled analgesia for RAPN.
Ultrasound-guided QLB technique was first described by Blanco [11, 12], and the benefits of QLB for postoperative pain relief and opioids-sparing effect have been reported by several randomized controlled trials and case reports[2, 5, 6, 8–10, 19–30]. All approaches have been proved the synergistic efficacy for multimode analgesia, especially for QLB2 or QLB3 after laparoscopic surgery, cesarean section and total hip arthroplasty. This is the first randomized, double-blinded controlled trial study that has compared the the preventive implement of QLB2 block to a standard perioperative analgesic regimen when applied in RAPN. For most studies, the QLB2 (posterior approach) was chosen as its targeted injection was more superficial and be focused much more tightly and can be easily positioned. Our findings echo most of previous trials. Irwin et al. [10]investigated the posterior approach for postoperative pain relief after caesarean section, and showed a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h postoperatively. However, opioid consumption was similar in both groups during the first 24 hours after surgery. Kukreja et al. [29]have also demonstrated the benefits of opioid-sparing analgesic effect of the anterior quadratus lumborum block in total hip arthroplasty. The true mechanism of action of the QLB is not completely known. One of the important diffusion mechanisms of either anterior or posterior approaches is that local anesthetic spread to the paravertebral space region to achieve effective analgesia in the desired dermatomes. However, the postulation of local anaesthetic consistently tracking into the anterolateral penetration of quadratus lumborum and anterior thoracolumbar fascia has been called into question [31, 32]. It remains to be seen whether a different approach, such as the intramuscular or lateral, would provide superior or longer lasting analgesia.
The multi-modal analgesia consists of preoperative prophylactic analgesia, combined different analgesic medication, local infiltration anesthesia, and patient-controlled intravenous analgesia has become a routine standard for the postoperative pain management in our surgical center. We did not directly compare the use of QLB with sham block group (same volume of saline) or other approaches or epidural analgesia. We felt that the aforementioned analgetic scheme has remarkable efficacy in pain relief, especially for patients who are involved in the enhanced recovery programs. Therefore, this study focused on whether the QLB may enable an increased analgesic effect and the role it plays in the combination of a typical multi-modal analgesia[33, 34]. A recent study by Aditianingsih et al. [2]compared the anterior approach with epidural analgesia in patients underwent laparoscopic donor nephrectomy. They demonstrated that the morphine consumption and pain scores at 24 hours after surgery were comparable. A propensity score matching analysis has reported that postoperative pain was not significantly different between the different operation mode (robot-assisted partial nephrectomy vs laparoscopic partial nephrectomy)[35]. A third arm in our study may have been beneficial in discerning whether the QLB has assistant effects when compared to“no block” pattern.
Postoperative pain management has always been a core value to enhanced recovery after surgery. We took this opportunity to use the 15-item quality of recovery score (QoR-15) developed by Stark et al. [36]as a secondary outcome measure. As the pain scores were the highest within 24 hours after surgery in accordance with previous studies, severe pain is associated with a series of adverse reactions after surgery and anesthesia. The QoR-15 providing a quantitative measure of comfort, emotional wellbeing, and physical functioning has the ability to assess functional recovery rather than pain, which may become more relevant supplementary information. In this study, there were significant statistical differences in terms of five sub-items (Have had a good sleep, Able to look after personal hygiene, urination and defecation unaided, Moderate pain, Severe pain and Nausea or vomiting) and total scores between the groups at 24 hours after surgery. Therefore, it seems like that single-injection QLB is not merely used to relieve acute pain. Besides, it serves as a supportive role for improving the overall health status at the early stages after surgery.
There are some of limitations to our study. Firstly, VAS scores with movement at 6 hours postoperatively was chosen as the primary outcome measure. VAS scores in a pilot study and this study were tested to conform to a normal distribution. Then we chosen a Student’s t test for pain scores at all the predetermined intervals. Secondly, we did not check sensory dermatomal levels, assess visceral pain, record lower extremity weakness and accurately calculate the duration of the QLB to explain the characteristic of sensory blockade. The main purposes of this study were to compare pain scores and opioid consumption between two groups. Thirdly, some studies have proposed the problem of “rebound pain” phenomenon after single-shot peripheral nerve block, which defined as very severe pain when peripheral nerve block wears off. It is not so rare problem in clinical practice and could reach 40% of patients undergoing orthopedic procedures [37], but pathophysiological mechanisms remain unknown. The QoR-15 collected all the related data at 24 hours postsurgery, such as Have had a good sleep and Severe pain, which might provide a bit of tracing data in regard to rebound pain. However, we have not observed that severe pain interferes with sleep and complain of severe discomfort when QLB wore off. In the future, randomized controlled trials may be needed to include all the aforementioned indicators, which might have impacted pain management program and patient satisfaction.
In conclusion, the posterior QLB enabled adequate postoperative analgesia for patients undergoing RAPN, which could reduce pain scores and had opioid-sparing effects postoperatively. The preoperative implementation of single-shot QLB is an important component of multi-modal analgesia and may helpful to enhanced functional recovery. Further studies are warranted to determine the best approach and the optimal dose and volume of LA or adjuncts required for more effective and lasting QLB for patients received RAPN.
Quadratus Lumborum Block
Local anesthetic
Robot-assisted partial nephrectomy
American Society of Anesthesiologist
Body Mass Index
Visual analogue scale
Patient controlled analgesia
bispectral index
target-controlled infusion
Train-of-four
Post-anesthesia care unit
15-item quality of recovery score
Inter Quartile Range.
Availability of data and materials
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Acknowledgements
This research was supported by Department of Anesthesiology, Sun Yat-sen University Cancer Center. The authors thank Professor Fangjian,Zhou,and Professor Hui，Han for performing the operation and assisting in manuscript preparation.
Funding
This research was supported by Department of Anesthesiology, Sun Yat-sen University Cancer Center.
Author information
Affiliation
Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, P. R. China
Jielan Lai, Yanling Liu, Ruifeng Xue,Yang Huang, Yongchun Li, Renchun Lai
The Second School of Clinical Medicine, Southern Medical University, Guangzhou,China
Quehua Luo
Department of Anesthesiology, Guangdong Second Provincial General Hospital, Guangzhou, China.
Quehua Luo
Contributions
JL;Contribution:cnotributed to data acquisition and analysis, and drafted manuscripts . QL;Contribution:contributed to interpretation of data and helped to revise the manuscripts. YL;Contribution:contributed to data acquisition and helped evaluate the patients’ responses and was blinded to the patient group assignment. RX;Contribution:contributed to performing the operation and was blinded to the patient group assignment. YH;Contribution:contributed to performing the operation and was blinded to the patient group assignment, and statistical analysis. YL;Contribution:contributed to data acquisition and revised the manuscripts. RL;Contribution:contributed to the design of the research and agreed to be accountable for all aspects of the work.All authors read and approved the final manuscript version.
Corresponding authors
Correspondence to Renchun Lai or Yanling Liu.
Ethics declarations
Ethics approval and consent to participate
Ethical approval for this study was provided by the Research Ethics Committee of Sun Yat-sen University Cancer Center (Chairperson Prof. Wangqing Peng) on 5th June 2018. Written informed consent was obtained from all patients participating in the trial.The study was registered at a clinical trials registry (http://www.chictr.org.cn, registered number: ChiCTR1800016790), and was conducted at the Sun Yat-sen University Cancer Center from June 2018 to November 2018. Our methodology followed the international guidelines for observational studies.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.