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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 34  |  Issue : 3  |  Page : 209-211

Ultrasound-guided continuous transmuscular quadratus lumborum block as a sole anesthetic technique for inguinal hernia repair in a high-risk patient


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission14-Feb-2020
Date of Decision19-Jun-2020
Date of Acceptance26-Jun-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Prof. Virender Kumar Mohan
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi - 110 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_17_20

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  Abstract 


Quadratus lumborum (QL) block has been described as a postoperative analgesic technique by Blanco following superficial abdominal surgeries but has not been used as a sole anesthetic technique. This ipsilateral block with an indwelling catheter inserted for continuous QL block provided the pain-free course. It decreased opioid use both during intra and postoperative periods with a sensory block of T8–L1, thus avoiding complications related to general and neuraxial anesthesia in patients with low cardiac reserve. We report a high-risk case undergoing inguinal mesh hernioplasty under continuous QL block.

Keywords: Local anesthesia, quadratus lumborum block, ultrasound-guided regional anesthesia


How to cite this article:
Mohan VK, Jain S. Ultrasound-guided continuous transmuscular quadratus lumborum block as a sole anesthetic technique for inguinal hernia repair in a high-risk patient. Indian J Pain 2020;34:209-11

How to cite this URL:
Mohan VK, Jain S. Ultrasound-guided continuous transmuscular quadratus lumborum block as a sole anesthetic technique for inguinal hernia repair in a high-risk patient. Indian J Pain [serial online] 2020 [cited 2021 Apr 12];34:209-11. Available from: https://www.indianjpain.org/text.asp?2020/34/3/209/305143




  Introduction Top


Blanco described the quadratus lumborum (QL) block as a postoperative analgesic technique for abdominal surgeries.[1] The ipsilateral block had low pain score and decreased opioid use both during intra and postoperative periods, with sensory block up to T8–L.[2] The QL block has not been used as a sole anesthetic technique for superficial abdominal surgery such as unilateral hernia repair. We successfully managed inguinal hernia repair under the ultrasound-guided (USG) continuous transmuscular QL block, thus avoiding complications related to general and neuraxial anesthesia in patients with poor cardiac reserve.


  Case Report Top


A 60-year-old, 50 kg, male patient, ASA III presented with the left inguinal hernia was scheduled for hernia repair. His medical status was coronary artery disease (triple-vessel disease) with severe left ventricular dysfunction, diabetes mellitus type-2 on insulin therapy, and chronic liver disease. The anesthetic management options and the associated risks were discussed with the patient. As the patient refused for the neuraxial blockade, an alternate choice of the regional anesthetic block was explained, and informed consent was taken from him. The patient was monitored as per the standard monitoring protocol. Invasive continuous arterial pressure monitoring was employed due to high-risk status. Supplemental oxygen was provided by nasal cannula during the intraoperative period.

We performed a transmuscular QL block, as described by Børglum et al.[3] After positioning the patient in a left lateral position, scanning was started by placing the curvilinear transducer (2–5 MHz) just above the iliac crest in the mid-axillary line in the transverse orientation, and the transducer was moved dorsally to identify the QL muscle with its attachment to the lateral edge of the transverse process of L4 vertebrae. An US image resembling a shamrock with three leaves, formed by acoustic shadow of the transverse process of L4 vertebrae and QL at the apex of the transverse process, psoas major (PM) muscle anteriorly, and erector spinae muscle posteriorly (Shamrock sign) [Figure 1] and [Figure 2]. An echogenic needle was inserted from the lateral edge of the transducer, and the tip of the needle was advanced through the subcutaneous tissue and QL muscle until the tip lies between the QL and PM. After confirming the tip position by hydrodissection, 25 ml of 0.5% ropivacaine was injected, and an indwelling plexus catheter was inserted and secured with the sterile dressing. Adjuvants with local anesthetic (LA) were not used because of the associated risk of respiratory problems, and we planned for continuous infusion of LA during the intra and postoperative period. The level of the blockade was checked with the pinprick method at a regular interval, and at 30 min, the sensory blockade was from T8 to L1 level. Intraoperative sedation was not used because of the risk of adverse cardiovascular events. Vital was stable during the intraoperative course. Intraoperative pain scores numeric rating scale (NRS) were zero. The surgery lasted for 2 h and was uneventful. During the postoperative period, ropivacaine (0.125%) 5 ml/h was started. The patient did not require any rescue analgesia for the next 48 h. During the postoperative period, his vitals were stable and did not have any respiratory depression, nausea, and vomiting.
Figure 1: Ultrasound image showing Shamrock sign. QLM: Quadratus lumborum muscle, PMM: Psoas major muscle, ESM: Erector spinae muscle

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Figure 2: Ultrasound image showing the echogenic needle and hydrodissection between QLM and PMM. QLM: Quadratus lumborum muscle, PMM: Psoas major muscle

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  Discussion Top


The anesthesia techniques used for superficial surgeries such as inguinal hernia repair are general anesthesia and spinal anesthesia. General anesthesia, however, is associated with higher morbidity as compared to regional anesthesia.[4] The neuraxial block is associated with sympatholytic action, leading to cardiovascular collapse in poor cardiac reserve patients.

Peripheral nerves derived from lumbar plexus are widely distributed in the inguinal region and hence explains why local anesthetics block may be sufficient for surgical pain during superficial inguinal surgeries. We opt for the QL block over transversus abdominis plane and iliohypogastric–ilioinguinal and ilioinguinal block as it blocks all the nerves that supply the operative area in a single injection and avoids the deposition of LA solution in the surgical area.USG QL block is effective in providing better postoperative analgesia.[5] The QL block has been shown to provide analgesia from T10 to L1.[6]

The mechanism of the QL block is still not completely known. According to one hypothesis, local anesthetics spread from QL muscle to neighboring paravertebral space and act at several nerve roots.[7]

The QL block has been reported for postoperative analgesia of various abdominal procedures, including cesarean section, laparoscopy, colostomy, and pyeloplasty.[8],[9],[10]

Recently, the USG QL block was reported for providing postoperative analgesia for abdominal surgery.[5] The single-shot ipsilateral QL block has been reported to provide effective analgesia for 24 h.[5] Recently, a case of continuous postoperative analgesia has been reported via continuous QL block for pediatric surgery.[4] Recently, QL block has been successfully used as a sole, homeostatic-preserving anesthetic for a patient with multiple system atrophy for hernia repair. Authors find that it provides excellent and complete surgical anesthesia and does not require any other supplementation, which may cause hemodynamic adverse effects and mental state changes.[11] We choose a transmuscular approach for QL block to deposit the drug between QL and PM because of its advantage of spreading cranially and toward the thoracic paravertebral space (TPVS) with an even lesser volume of injectate and providing extensive thoracolumbar anesthesia.[3] We choose to inject 25 ml of LA as studies have shown that 0.3–0.6 ml/kg spread from T4 to L1 level.[10] In our case, transmuscular QL block appears to be a good alternative technique to provide surgical anesthesia for hernia repair.

In conclusion, USG QL block, commonly used as an analgesic technique, can also be used as a sole anesthetic technique, especially in high-risk cases, such as patients with low cardiac reserve. It provides excellent surgical anesthesia for hernia repair with good intra and postoperative analgesia. Peripheral blocks are safe, effective, and reported to have minimal risk of complications as compared to neuraxial blocks and general anesthesia, especially in high-risk patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blanco R. TAP block under ultrasound guidance: The description of a 'non-pops-technique.' Reg Anaesth Pain Med 2007;32:130.  Back to cited text no. 1
    
2.
Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011;66:1023-30.  Back to cited text no. 2
    
3.
Børglum J, Morriggl B, Jensen K, Linnquist PA. Ultrasound-guided transmuscular quadratus lumborum blockade. Br J Anaesth 2013;111:eLetters Supplement, 22. Available from: http:/bja.oxfordjournals.org/forum/topic/brjana_el%3b1. [Last assessed on 2015 July 12].  Back to cited text no. 3
    
4.
Singh N, Sidawy AN, Dezee K, Neville RF, Weiswasser J, Arora S, et al. The effects of the type of anesthesia on outcomes of lower extremity infrainguinal bypass. J Vasc Surg 2006;44:964-8.  Back to cited text no. 4
    
5.
Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane block posterior approach or quadratus lumborum block type I with femoral block for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol Reanim 2016;63:141-8.  Back to cited text no. 6
    
7.
Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol 2015;32:812-8.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
9.
Shaaban M, Esa WA, Maheshwari K, Elsharkawy H, Soliman LM. Bilateral continuous quadratus lumborum block for acute postoperative abdominal pain as a rescue after opioid-induced respiratory depression. A A Case Rep 2015;5:107-11.  Back to cited text no. 9
    
10.
Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: A cadaveric study. Anaesthesia 2009;64:745-50.  Back to cited text no. 10
    
11.
La Colla L, La Colla MD, Schroeder R, Schroeder RM. Quadratus lumborum block as sole, homeostatic-preserving anesthetic for a patient with multiple system atrophy undergoing open inguinal hernia repair: A case report. Case Rep Anesthesiol 2018;2018:7161860.  Back to cited text no. 11
    


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