Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Original Investigation

Minimum effective concentration of ropivacaine for ultrasound-guided transmuscular quadratus lumborum block in total hip arthroplasty: a randomized clinical trial

Concentração mínima efetiva de ropivacaína para bloqueio transmuscular do quadrado lombar guiado por ultrassom em artroplastia total de quadril: ensaio clínico randomizado

Jian Hu, Xingcheng Li, Qiuru Wang, Jing Yang

Downloads: 1
Views: 432



This trial aimed to identify the Minimum Effective Concentration (MEC90, defined as the concentration which can provide successful block in 90% of patients) of 30 mL ropivacaine for single-shot ultrasound-guided transmuscular Quadratus Lumborum Block (QLB) in patients undergoing Total Hip Arthroplasty (THA).


A double-blind, randomized dose-finding study using the biased coin design up-and-down sequential method, where the concentration of local anesthetic administered to each patient depended on the response from the previous one. Block success was defined as a Numeric Rating Scale (NRS) score during motion ≤ 3 at 6 hours after arrival in the ward. If the block was successful, the next subject received either a 0.025% smaller dose (probability of 0.11) or the same dose (probability of 0.89); otherwise, the next subject received a 0.025% higher ropivacaine concentration. MEC90, MEC95 and MEC99 were estimated by isotonic regression, and the corresponding 95% Confidence Intervals (95% CIs) were calculated by the bootstrapping method.


Based on the analysis of 52 patients, MEC90, MEC95, and MEC99 of ropivacaine for QLB were estimated to be 0.352% (95% CI 0.334–0.372%), 0.363% (95% CI 0.351–0.383%), and 0.373% (95% CI 0.363–0.386%). The concentration of ropivacaine at 0.352% in a volume of 30 ml can provide a successful block in 90% of patients.


For ultrasound-guided transmuscular QLB in patients undergoing THA, 0.352% ropivacaine in a volume of 30 ml can provide a successful block in 90% of patients. Further dose-finding studies and large sample size are required to verify the concentration.


Analgesia Ropivacaine Nerve block Drug dose-response relationship Total hip arthroplasty



Este estudo teve como objetivo identificar a concentração mínima eficaz (MEC90, definida como a concentração que pode fornecer bloqueio bem-sucedido em 90% dos pacientes) de 30 mL de ropivacaína para bloqueio transmuscular do quadrado lombar (BQL) guiado por ultrassom de dose única em pacientes submetidos a cirurgia de artroplastia total de quadril (ATQ).


Estudo duplo-cego, randomizado de determinação de dose usando o método sequencial up-and-down de desenho de moeda tendenciosa, onde a concentração de anestésico local administrado a cada paciente dependia da resposta do anterior. O sucesso do bloqueio foi definido como uma pontuação na Escala de Avaliação Numérica (NRS) durante o movimento ≤ 3, 6 horas após a chegada à enfermaria. Se o bloqueio fosse bem-sucedido, o próximo sujeito recebia uma dose 0,025% menor (probabilidade de 0,11) ou a mesma dose (probabilidade de 0,89); caso contrário, o próximo sujeito recebeu uma concentração de ropivacaína 0,025% maior. MEC90, MEC95 e MEC99 foram estimados por regressão isotônica, e os correspondentes intervalos de confiança de 95% (IC95%) foram calculados pelo método de bootstrapping.


Com base na análise de 52 pacientes, MEC90, MEC95 e MEC99 de ropivacaína para BQL foram estimados em 0,352% (IC 95% 0,334–0,372%), 0,363% (IC 95% 0,351–0,383%) e 0,373% ( IC 95% 0,363–0,386%). A concentração de ropivacaína a 0,352% em um volume de 30 ml pode proporcionar bloqueio bem-sucedido em 90% dos pacientes.


Para BQL transmuscular guiado por ultrassom em pacientes submetidos à ATQ, a ropivacaína a 0,352% em um volume de 30 ml pode proporcionar um bloqueio bem-sucedido em 90% dos pacientes. Mais estudos de determinação de dose e um grande tamanho de amostra são necessários para verificar a concentração.


Analgesia; Ropivacaína; Bloqueio nervoso; Relação dose-resposta do medicamento; Artroplastia total do quadril


1. Wylde V, Rooker J, Halliday L, et al. Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep. Orthop Traumatol Surg Res. 2011;97: 139−44.

2. Wylde V, Hewlett S, Learmonth ID, et al. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011;152:566−72.

3. Classen T, Zaps D, Landgraeber S, et al. Assessment and management of chronic pain in patients with stable total hip arthroplasty. Int Orthop. 2013;37:1−7.

4. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105−20.

5. Harirforoosh S, Asghar W, Jamali F. Adverse effects of nonsteroidal antiinflammatory drugs: an update of gastrointestinal, cardiovascular and renal complications. J Pharm Pharm Sci. 2013;16:821−47.

6. Patel N, Solovyova O, Matthews G, et al. Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-day bilateral total knee arthroplasty. J Arthroplasty. 2015;30:330−4.

7. Maddali P, Moisi M, Page J, et al. Anatomical complications of epidural anesthesia: a comprehensive review. Clin Anat. 2017;30:342−6.

8. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth. 2005;94:7−17.

9. Yang HM, Park SJ, Yoon KB, et al. Cadaveric evaluation of different approaches for quadratus lumborum blocks. Pain Res Manag. 2018;2018:2368930.

10. Ueshima H, Otake H, Lin JA. Ultrasound-guided quadratus lumborum block: an updated review of anatomy and techniques. Biomed Res Int. 2017;2017:1−7.

11. Steingrímsdottir GE, Hansen CK, Børglum J. Ultrasound-guided  transmuscular quadratus lumborum catheters for elective caesarean section: a protocol for a single-centre, double-blind randomised trial. Acta Anaesthesiol Scand. 2020;64:1218−23.

12. Yoshida K, Tanaka S, Watanabe K, et al. The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after cesarean section with vertical incision: a randomized, double-blinded placebo-controlled study. J Anesth. 2020;34:849−56.

13. Hu J, Wang Q, Zeng Y, et al. The impact of ultrasound-guided transmuscular quadratus lumborum block combined with local infiltration analgesia for arthroplasty on postoperative pain relief. J Clin Anesth. 2021;73:110372.

14. Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med. 2016;41: 146−50.

15. Adhikary SD, Short AJ, El-Boghdadly K, et al. Transmuscular quadratus lumborum versus lumbar plexus block for total hip 6 arthroplasty: a retrospective propensity score matched cohort

16. Dam M, Hansen CK, Poulsen TD, et al. Transmuscular quadratus lumborum block for percutaneous nephrolithotomy reduces opioid consumption and speeds ambulation and discharge from hospital: a single centre randomised controlled trial. Br J Anaesth. 2019;123:e350−8.

17. Polania Gutierrez JJ, Ben-David B, Rest C, et al. Quadratus lumborum block type 3 versus lumbar plexus block in hip replacement surgery: a randomized, prospective, non-inferiority study. Reg Anesth Pain Med. 2021;46:111−7.

18. Neuburger M, Buttner J. Komplikationen bei peripherer Region- € alanasthesie [Complications of peripheral regional anesthesia]. € Anaesthesist. 2011;60:1014−26.

19. Saranteas T, Finlayson RJ, Tran DQ. Dose-finding methodology for peripheral nerve blocks. Reg Anesth Pain Med. 2014;39: 550−5.

20. C, Steiger E. Review of preoperative carbohydrate loading. Nutr Clin Pract. 2015;30:660−4.

21. Wang Q, Hu J, Zhang W, et al. Comparison between ultrasoundguided suprainguinal fascia iliaca block and anterior quadratus lumborum block for total hip arthroplasty: a prospective, double-blind, randomized controlled trial. J Arthroplasty. 2022;37:763−9.

22. Fang G, Wan L, Mei W, et al. The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided supraclavicular brachial plexus block. Anaesthesia. 2016;71:700−5.

23. Tran DQ, Dugani S, Correa JA, et al. Minimum effective volume of lidocaine for ultrasound-guided supraclavicular block. Reg Anesth Pain Med. 2011;36:466−9.

24. Stylianou M, Proschan M, Flournoy N. Estimating the probability of toxicity at the target dose following an up-and-down design. Stat Med. 2003;22:535−43.

25. Saranteas T, Finlayson RJ, Tran de QH. Dose-finding methodology for peripheral nerve blocks. Reg Anesth Pain Med. 2014;39:550−5.

26. Nader A, Kendall MC, De Oliveira Jr GS, et al. A dose-ranging study of 0.5% bupivacaine or ropivacaine on the success and duration of the ultrasound-guided, nerve-stimulator-assisted sciatic nerve block: a double-blind, randomized clinical trial. Reg Anesth Pain Med. 2013;38:492−502.

27. Olapour A, Akhondzadeh R, Rashidi M, et al. Comparing the effect of bupivacaine and ropivacaine in cesarean delivery with spinal anesthesia. Anesth Pain Med. 2020;10:e94155.

28. Sauter AR, Ullensvang K, Niemi G, et al. The Shamrock lumbar plexus block: a dose-finding study. Eur J Anaesthesiol. 2015;32:764−70.

29. Gupta PK, Hopkins PM. Effect of concentration of local anaesthetic solution on the ED50 of bupivacaine for supraclavicular brachial plexus block. Br J Anaesth. 2013;111:293−6.

30. Pace NL, Stylianou MP. Advances in and limitations of up-anddown methodology: a precis of clinical use, study design, and dose estimation in anesthesia research. Anesthesiology. 2007;107:144−52.

31. Rey Moura EC, de Oliveira CMB, da Cunha Leal P, et al. Minimum effective analgesic concentration of ropivacaine in saphenous block guided by ultrasound for knee arthroscopic meniscectomy: randomized, double-blind study. J Pain Res. 2021;14: 53−9.

32. Kumar A, Sadeghi N, Wahal C, et al. Quadratus lumborum spares paravertebral space in fresh cadaver injection. Anesth Analg. 2017;125:708−9.

33. Kukreja P, MacBeth L, Sturdivant A, et al. Anterior quadratus lumborum block analgesia for total hip arthroplasty: a randomized, controlled study [published online ahead of print, 2019 Oct 25]. Reg Anesth Pain Med. 2019. rapm-2019-100804.

34. Almeida CR, Cunha F, Pinto M, Goncalves J, Cunha P, Antunes P. ¸ A lumbar anterior lateral transverse-process (LALaT) block for a patient with multiple traumatic injuries. J Clin Anesth. 2021;71:110252.

35. Almeida CR, Vieira L. Combination of a deep fascia iliaca block with ultra-low dose spinal anesthesia for hip fracture surgery. Can J Anaesth. 2022;69:402−4.

36. Almeida CR. The novel proximal para-iliopsoas (PPIP) block for hip surgery: a technical report. Indian J Anaesth. 2022;66: 885−6.

Submitted date:

Accepted date:

6516ec4ea9539510014e3fb3 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections