Journal of Clinical Anesthesia (2015) xx, xxx–xxx
Letter to the Editor Quadratus lumborum block: an effective method of perioperative analgesia in children undergoing pyeloplasty Informed written consent was obtained from the parents of all children. Quadratus lumborum (QL) block is a new addition into the league of truncal nerve block techniques that has been found to provide analgesia for abdominal surgeries in both adults and children. We used posterior transmuscular approach of QL block for pyeloplasty in children. Quadratus lumborum block was used in 5 children aged between 3 and 5 years, weighing 12 to 18 kg, undergoing pyeloplasty under general anesthesia as part of multimodal analgesic technique. After induction of general anesthesia and endotracheal intubation, block was given in lateral position with side to be blocked kept up. A linear ultrasonographic (US) probe (Sonosite M-Turbo; Sonosite Inc, Bothell, WA) was kept just above the iliac crest; and initially, tapering end of 3 anterior abdominal wall muscles and anterior end of QL muscle were identified. Then we moved the US probe dorsally to identify the posterior end of QL, psoas major (PM) muscle, and attachment of QL with transverse process of fourth lumbar vertebra. A 23G needle was inserted in-plane from the anterior to posterior direction under US guidance through the QL muscle as described by Börglum et al [1]. We used 0.5 mL/kg of 0.2% ropivacaine and deposited local anesthetic (LA) between QL and PM after penetrating ventral fascia QL muscle (Fig. 1). We used only 2 μg/kg fentanyl at time of induction, and no more opioid was required during surgery. At the end of surgery, intravenous paracetamol was given at a dose of 15 mg/kg. In the postoperative period, pain was assessed by Wong-Baker Faces scale; and intravenous morphine at a dose of 50 μg/kg was prescribed when pain score was N 2 in the Wong-Baker Faces scale. Median time to administer morphine was 5 hours, and longest duration obtained was 8 hours in 1 child. Various approaches of this nerve block have been described in literature. Visoiu and Yakovleva [2] injected 10 mL LA between the anterior border of QL muscle and its fascia in a 5-year-old child for colostomy. Kadam [3] had similarly used anterior technique for QL block in an adult patient for laparotomy. In the anterior approach to QL block, probably LA spreads anteriorly towards transversus abdo0952-8180/© 2015 Elsevier Inc. All rights reserved.
minis plane (TAP) as well as posteriorly towards paravertebral plane similar to posterior TAP block. Carney et al [4] found that posterior TAP block leads to prolonged contrast pooling in fascia transversalis, QL muscle, and PM muscle. However, from the anatomic point of view, posterior transmuscular deposition of LA along the posterior border of QL would produce more consistent paravertebral spread of LA. Börglum et al [1] also reported similar findings with this approach and did not find anterior spread of LA with transmuscular approach. In the present series, pyeloplasty was performed by lumbotomy [5] approach with transverse incision in the lumbar paravertebral area at midscapular line. Therefore, we wanted a more posterior paravertebral spread of LA and chose the transmuscular approach. The most important advantage of transmuscular QL block over TAP block is a consistent posterior spread of local anesthetic up to the paravertebral space. Visoiu and Yakovleva [2] in their case had advanced the catheter 7 cm into the QL fascial plane and ensured posterior spread of drug by using color Doppler. In the current series, we observed that transmuscular QL block with 0.5 mL/kg of 0.2% ropivacaine provides very good postoperative analgesia in children undergoing lumbotomy and pyeloplasty surgery. However, this was a series of 5 patients only. Further studies with larger number of patients are required to test the efficacy of QL block in comparison to TAP block. Moreover, the volume of drug to be used in adults and children is not yet known. Carney et al used 0.3 to 0.6 mL/kg of drug in their anatomic study in adults. Hence, we arbitrarily used 0.5-mL/kg volume of LA. We believe that further randomized trials are required to delineate clinical efficacy and safety of QL block in unilateral abdominals surgeries. Dalim K. Baidya (Assistant Professor) Souvik Maitra (Senior Resident)* Mahesh K. Arora (Professor and Head) Anil Agarwal (Assistant Professor) Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India *Corresponding author at: Department of Anaesthesiology All India Institute of Medical Sciences, Ansari Nagar New Delhi 110029, India. Tel.: +91 9968859756 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.05.006
2
Letter to the Editor
Fig. 1
US image showing QL muscle and its relation of PM muscle.
References [1] Börglum J, Moriggl B, Lonnqvist PA, Christensen AF, Sauter A, Bendtsen AF. Ultrasound-guided transmuscular quadratus lumborum blockade. Br J Anaesth 2013 [http://bja.oxfordjournals.org/forum/topic/ brjana_el%3B9919, Accessed on 24th November, 2014]. [2] Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block—an alternative to transversus abdominis plane block. Paediatr Anaesth 2013;23:959-61.
[3] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2. [4] 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. [5] Verma A, Bajpai M, Baidya DK. Lumbotomy approach for upper urinary tract surgeries in adolescents: feasibility and challenges. J Pediatr Urol 2014;10:1122-5.
Letter to the Editor Quadratus lumborum block: an effective method of perioperative analgesia in children undergoing pyeloplasty Informed written consent was obtained from the parents of all children. Quadratus lumborum (QL) block is a new addition into the league of truncal nerve block techniques that has been found to provide analgesia for abdominal surgeries in both adults and children. We used posterior transmuscular approach of QL block for pyeloplasty in children. Quadratus lumborum block was used in 5 children aged between 3 and 5 years, weighing 12 to 18 kg, undergoing pyeloplasty under general anesthesia as part of multimodal analgesic technique. After induction of general anesthesia and endotracheal intubation, block was given in lateral position with side to be blocked kept up. A linear ultrasonographic (US) probe (Sonosite M-Turbo; Sonosite Inc, Bothell, WA) was kept just above the iliac crest; and initially, tapering end of 3 anterior abdominal wall muscles and anterior end of QL muscle were identified. Then we moved the US probe dorsally to identify the posterior end of QL, psoas major (PM) muscle, and attachment of QL with transverse process of fourth lumbar vertebra. A 23G needle was inserted in-plane from the anterior to posterior direction under US guidance through the QL muscle as described by Börglum et al [1]. We used 0.5 mL/kg of 0.2% ropivacaine and deposited local anesthetic (LA) between QL and PM after penetrating ventral fascia QL muscle (Fig. 1). We used only 2 μg/kg fentanyl at time of induction, and no more opioid was required during surgery. At the end of surgery, intravenous paracetamol was given at a dose of 15 mg/kg. In the postoperative period, pain was assessed by Wong-Baker Faces scale; and intravenous morphine at a dose of 50 μg/kg was prescribed when pain score was N 2 in the Wong-Baker Faces scale. Median time to administer morphine was 5 hours, and longest duration obtained was 8 hours in 1 child. Various approaches of this nerve block have been described in literature. Visoiu and Yakovleva [2] injected 10 mL LA between the anterior border of QL muscle and its fascia in a 5-year-old child for colostomy. Kadam [3] had similarly used anterior technique for QL block in an adult patient for laparotomy. In the anterior approach to QL block, probably LA spreads anteriorly towards transversus abdo0952-8180/© 2015 Elsevier Inc. All rights reserved.
minis plane (TAP) as well as posteriorly towards paravertebral plane similar to posterior TAP block. Carney et al [4] found that posterior TAP block leads to prolonged contrast pooling in fascia transversalis, QL muscle, and PM muscle. However, from the anatomic point of view, posterior transmuscular deposition of LA along the posterior border of QL would produce more consistent paravertebral spread of LA. Börglum et al [1] also reported similar findings with this approach and did not find anterior spread of LA with transmuscular approach. In the present series, pyeloplasty was performed by lumbotomy [5] approach with transverse incision in the lumbar paravertebral area at midscapular line. Therefore, we wanted a more posterior paravertebral spread of LA and chose the transmuscular approach. The most important advantage of transmuscular QL block over TAP block is a consistent posterior spread of local anesthetic up to the paravertebral space. Visoiu and Yakovleva [2] in their case had advanced the catheter 7 cm into the QL fascial plane and ensured posterior spread of drug by using color Doppler. In the current series, we observed that transmuscular QL block with 0.5 mL/kg of 0.2% ropivacaine provides very good postoperative analgesia in children undergoing lumbotomy and pyeloplasty surgery. However, this was a series of 5 patients only. Further studies with larger number of patients are required to test the efficacy of QL block in comparison to TAP block. Moreover, the volume of drug to be used in adults and children is not yet known. Carney et al used 0.3 to 0.6 mL/kg of drug in their anatomic study in adults. Hence, we arbitrarily used 0.5-mL/kg volume of LA. We believe that further randomized trials are required to delineate clinical efficacy and safety of QL block in unilateral abdominals surgeries. Dalim K. Baidya (Assistant Professor) Souvik Maitra (Senior Resident)* Mahesh K. Arora (Professor and Head) Anil Agarwal (Assistant Professor) Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India *Corresponding author at: Department of Anaesthesiology All India Institute of Medical Sciences, Ansari Nagar New Delhi 110029, India. Tel.: +91 9968859756 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.05.006
2
Letter to the Editor
Fig. 1
US image showing QL muscle and its relation of PM muscle.
References [1] Börglum J, Moriggl B, Lonnqvist PA, Christensen AF, Sauter A, Bendtsen AF. Ultrasound-guided transmuscular quadratus lumborum blockade. Br J Anaesth 2013 [http://bja.oxfordjournals.org/forum/topic/ brjana_el%3B9919, Accessed on 24th November, 2014]. [2] Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block—an alternative to transversus abdominis plane block. Paediatr Anaesth 2013;23:959-61.
[3] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2. [4] 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. [5] Verma A, Bajpai M, Baidya DK. Lumbotomy approach for upper urinary tract surgeries in adolescents: feasibility and challenges. J Pediatr Urol 2014;10:1122-5.
