|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 91-92
Quadratus lumborum block for postoperative analgesia – A feasible option in pediatric patients with congenital anomalies
Deepak Dwivedi1, Kapil Kulkarni2, Shankar Raman2, Shalendra Singh3
1 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India
2 Department of Paediatric Surgery, Command Hospital (Southern Command), Pune, Maharashtra, India
3 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Web Publication||27-Apr-2021|
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dwivedi D, Kulkarni K, Raman S, Singh S. Quadratus lumborum block for postoperative analgesia – A feasible option in pediatric patients with congenital anomalies. Indian J Pain 2021;35:91-2
|How to cite this URL:|
Dwivedi D, Kulkarni K, Raman S, Singh S. Quadratus lumborum block for postoperative analgesia – A feasible option in pediatric patients with congenital anomalies. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:91-2. Available from: https://www.indianjpain.org/text.asp?2021/35/1/91/314701
Postoperative pain in children if dealt inadequately has been a significant cause of morbidity. Assessment and management of pain in a pediatric population has always been a challenge as they are unable to express pain to the noxious stimulus and there is always a fear of opioid-related side effects. Regional anesthesia has become the mainstay of the perioperative pediatric pain management strategy. The inclusion of regional blocks in multimodal analgesia model has shown a marked improvement in providing an effective postoperative analgesia and a decrease in the stress response in pediatric patients with fewer complications.
We present an effective utilization of ultrasound (USG)-guided quadratus lumborum block (QLB) in a child with rare combination of the defects a case of omphalocele, exstrophy of the cloaca, imperforate anus, and spinal defects (OEIS) complex where a neuraxial technique was contraindicated.
A 3-year-old female child weighing 14 kg with a known OEIS complex was posted for a single-stage reconstruction of the bladder with anoplasty and ileostomy. Magnetic resonance imaging of the lumbosacral spine and pelvis revealed Arnold–Chiari malformation type 1, a low-lying tethered cord, holocord syrinx, spina bifida, and segmental anomalies of sacral spine. Standard general anesthesia with controlled ventilation was done, and for achieving prolonged postoperative analgesia, a bilateral posterior QLB was administered before the extubation.
QLB was first described by Blanco et al. It consists of three approaches: lateral (QL1) where the needle is targeted at the lateral end of the QL muscle penetrating the transversus abdominis aponeurosis. In posterior (QL2), the transducer is moved more posteriorly from the QL1 position and the needle is inserted in the middle layer of the thoracolumbar fascia posterior to QL belly in the lumbar interfascial triangle proximal to the paraspinal retinacular sheath (PRS). In anterior (transmuscular) approach, the needle targets the fascial plane between the QL muscle belly and the psoas major muscle.
In our patient, USG-guided posterior (QL2) block was performed after positioning a roll under the back of the patient in the midline for the ease of opening up the space laterally and improving the access posteriorly at the level of posterior axillary line in a supine patient with a slight lateral tilt. Linear array probe (7–13 MHz, Sonosite, M-TURBO, FUJIFILM, India) was placed in an axial plane corresponding to the midaxillary line above the iliac crest and then was moved slight posteriorly until QL belly was visible in continuation with transversus abdominis aponeurosis [Figure 1]. The 50 mm, 22G Stimuplex needle (B Braun, India) was inserted with inline approach, from posterior to anterior direction, followed by injection of 7 ml of 0.2% ropivacaine on each side between the posterior border of QL muscle and PRS. The level of sensory block achieved was up to T9 in our case and pain was assessed by the Face, Leg, Activity, Cry, and Consolability score. The postoperative pain scores at 2 h, 6 h, and 12 h were zero indicating toward a comfortable child with adequate analgesia. Paracetamol 15 mg/kg was administered 8 hourly which helped in pain relief due to anoplasty.
|Figure 1: Ultrasound-guided image showing the injection site of local anesthetic during the posterior quadratus lumborum block (QL2). EO: External oblique, IO: Internal oblique, TA: Transversus abdominis|
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In a study by Öksüz et al., QL block provided prolonged duration of analgesia for the first 24 h when was compared to transversus abdominis plane block in pediatric patients undergoing lower abdominal surgeries. Makoto Sato concluded that QLB reduces the postoperative opioid consumption compared with the caudal block in pediatric patients undergoing vesicoureteral reflux surgery. The probable reason could be the spread of the local anesthetic solution to the thoracic paravertebral area.
Hence, QLB could be a feasible option for providing effective perioperative analgesia for children undergoing abdominal surgeries where the neuraxial techniques (caudal or epidural) are otherwise contraindicated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published, and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus lumborum block, anatomical concepts, mechanism and techniques. Anesthesiology 2019;130:322-25.
Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, et al
. Quadratus lumborum block versus Transversus Abdominis plane block in children undergoing lower abdominal surgery. Reg Anaes Pain Med 2017; 42; 674-9.
Sato M. Ultrasound-guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex. Pediatr Anesth 2019;29:738-43.