Repeat versus Single Quadratus Lumborum Block to Reduce Opioids after Open Pancreatectomy (RESQU-BLOCK): A Randomized Clinical Trial

OBJECTIVE: The primary aim was to compare the proportion of opioid-free discharges between two postoperative analgesia bundles distinguished by receipt of a single-block versus a second, "rescue" block. Secondary outcomes included differences in discharge prescription oral morphine equivalents (OME) and patient-reported outcomes. SUMMARY BACKGROUND: After a preoperative quadratus lumborum (QL) block, our historical discharge opioid prescription for open pancreatectomy was 300mg OME, with only 5% patients discharged opioid-free. We hypothesized an opioid-reduction bundle with repeat block on postoperative day (POD)4 could increase opioid-free discharges while reducing symptom burden. METHODS: This was a single-institution, unblinded phase II randomized clinical trial, analyzed by intent-to-treat and post hoc Bayesian analyses. Patients undergoing open pancreatectomy were randomized 1:1 to receive a standardized analgesic bundle with or without the addition of the rescue-block on POD4. RESULTS: Among 106 patients randomized (44.3% female; median age 66.5 years; 84% pancreatoduodenectomy; median 5-day stay), 104 completed the trial (52 per arm). By intent-to-treat, 52% of second-block patients were discharged opioid-free versus 36.5% single-block. Median discharge OME was 0mg versus 25mg, respectively. Improved (lower) patient-reported pain and life interference scores were observed in the second-block arm at discharge and 1-month. CONCLUSIONS: Addition of a second, "rescue" block to an opioid reduction bundle did not significantly improve opioid-free discharges after open pancreatectomy and was not required to discharge >1/3 of patients opioid-free. Nevertheless, considering improvements in symptom inventory and the high threshold of opioid-free discharge, the concept of a rescue-block to purposefully wean patients to zero use is feasible.