Bilateral continuous quadratus lumborum block for

E CLINICAL CARE
Bilateral Continuous Quadratus Lumborum Block for
Acute Postoperative Abdominal Pain as a Rescue
After Opioid-Induced Respiratory Depression
Mohamed Shaaban, MD,*† Wael Ali Sakr Esa, MD, PhD,*† Kamal Maheshwari, MD,*†‡
Hesham Elsharkawy, MD, MSc,*† and Loran Mounir Soliman, MD*†
We present a case of acute postoperative abdominal pain after proctosigmoidectomy and
colorectal anastomosis that was treated by bilateral continuous quadratus lumborum block. The
block was performed in the lateral position under ultrasound guidance with a 15-mL bolus of
0.5% bupivacaine injected anterior to the quadratus lumborum muscle followed by bilateral catheter placement. Each catheter received a continuous infusion of 0.1% bupivacaine at 8 mL/h
and an on-demand bolus 5 mL every 30 minutes. Sensory level was confirmed by insensitivity
to cold from T7 through T12. The block was devoid of hemodynamic side effects or motor weakness. This case demonstrates that bilateral continuous quadratus lumborum catheters can
provide extended postoperative pain control. (A&A Case Reports. 2015;5:107–11.)
P
ain is common after major abdominal surgeries.
Uncontrolled postoperative pain increases the incidence of postoperative complications.1,2 Multimodal
analgesia can improve pain control in the postoperative
period and reduces complications that may arise from using
a single mode of analgesia. For example, reliance on opioid
analgesia increases the incidence of adverse effects of opioids including pruritus, nausea, and vomiting, as well as
respiratory depression.3
The true incidence of respiratory depression varies in
different studies. Non-obstetric studies report an incidence
of respiratory depression with neuraxial opioids in 0.01%
to 7% of patients.4 The incidence of respiratory depression
after systemic opioid administered by IV patient-controlled
analgesia (PCA) was reported to be 1.2%, 1.26%, and 1.97%
in 3 different studies.5–7
Effective regional anesthesia techniques for abdominal
surgery include epidural analgesia, paravertebral block,
and transversus abdominis plane (TAP) block.8 Multiple
approaches have been used for TAP blocks including the
commonly used ultrasound-guided midaxillary approach.
TAP block provides analgesia mainly in T10-L2 dermatomes.9
TAP blocks are sometimes patchy with variable wound coverage.10 The use of an ultrasound-guided approach at the
level of the quadratus lumborum muscle is new and may
provide wider spread of local anesthetic (T5-L1) than TAP
blocks, and hence better analgesia.11 The patient gave verbal
permission for the authors to publish the report.
CASE DESCRIPTION
A 50-year-old man, weighing 95 kg, with a medical history of anxiety, prostate cancer, prostatectomy, and rectal
From the Departments of *General Anesthesia, †Pain Management, and
‡Outcomes Research, Cleveland Clinic, Cleveland, Ohio.
Accepted for publication March 10, 2015.
Funding: None.
The authors declare no conflicts of interest.
Address correspondence to Mohamed Shaaban, MD, Departments of General
Anesthesia and Pain Management, Cleveland Clinic, 9500 Euclid Ave., E-31,
Cleveland, OH 44195. Address e-mail to [email protected].
Copyright © 2015 International Anesthesia Research Society
DOI: 10.1213/XAA.0000000000000188
October 1, 2015 • Volume 5 • Number 7
cancer was admitted to the hospital for anterior proctosigmoidectomy and low colorectal anastomosis through a
midline longitudinal incision. Epidural analgesia was suggested; however, the surgical team preferred to use IV PCA
for postoperative pain to avoid possible hemodynamic
side effects of the epidural. After uneventful surgery, the
patient received IV hydromorphone in the postanesthesia
care unit for pain management. Hydromorphone PCA was
initiated and set at 0 mg basal, 0.3 mg bolus with a 6-minute
lockout interval, total 3 mg/h. After achieving an acceptable level of pain control, the patient was transferred to
the floor. Per institutional protocol, the patient received
2 L/min nasal oxygen. Nurse monitoring included respiratory rate and sedation score every 1 hour for the first 2
hours after initiation of hydromorphone PCA, then every
4 hours. In addition, he was monitored with continuous
pulse oximetry.
On the first postoperative day, the patient complained
of increased abdominal pain and required supplemental hydromorphone (total additional 1.2 mg in 3 divided
doses). Although still receiving nasal oxygen, the patient
developed respiratory failure requiring intervention by
the Acute Medical Emergency team. He was unresponsive, apneic, with oxygen saturation in the 50s. He had
strong palpable pulses and adequate arterial blood pressure. His airway was secured by nasal airway insertion
and bag-mask ventilation, which promptly increased his
oxygen saturation to the 90s. A 12-lead electrocardiogram
did not show any acute ST/T wave changes. Naloxone IV
was given in 2 doses of 0.4 mg each. The patient awoke and
followed commands. He was able to maintain adequate
respiratory effort and 99% oxygen saturation with a 100%
nonrebreathing mask.
With reversal of opioid analgesia, the patient complained of excruciating abdominal pain, which was
managed by IV acetaminophen and IV ketorolac. The IV
hydromorphone PCA was discontinued. The pain management team was consulted. The surgical team still preferred to avoid a thoracic epidural if possible. Therefore,
we considered bilateral continuous quadratus lumborum
blocks.
cases-anesthesia-analgesia.org
107
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After obtaining informed consent, the patient was
transferred to the induction room. He was connected to a
pulse oximeter and electrocardiograph. Noninvasive arterial blood pressure was measured every 3 minutes. The
patient was placed in a lateral position (Fig. 1). Using routine aseptic technique, a high-frequency (6–12 MHz) linear
ultrasound transducer probe in a sterile cover (Venue 40,
GE Healthcare, Waukesha, WI) was placed horizontally
between the coastal margin and the iliac crest. The 3 muscle layers of the abdominal wall were identified: external
oblique, internal oblique, and transversus abdominis muscles (Fig. 2). The fascia surrounding the transversus abdominis muscle was tracked posteriorly to its origin, where the
transversus abdominis muscle merges with the thoracolumbar fascia surrounding the quadratus lumborum muscle
(Fig. 3). A 17G 3-inch-long nonstimulating echogenic needle
(Plexus FlexBlock, ARROW, Reading, PA) was inserted inplane with the ultrasound probe and targeted toward the
fascia transversalis. Normal saline 3 mL was used to identify the splitting of the fascia. We injected 10 mL bupivacaine
0.5% in the same plane after negative aspiration. This was
seen spreading around the quadratus lumborum muscle
(Figs. 4 and 5). A 19G (1.1-mm diameter × 60 cm) echogenic styletted peripheral nerve catheter (Plexus FlexBlock,
ARROW) was advanced 5 cm beyond the tip of the needle
with minimal resistance, and another 5 mL bupivacaine
0.5% was injected to confirm the appropriate location of the
catheter tip within the quadratus lumborum fascial plane.
The procedure was repeated on the other side after placing the patient in the opposite lateral position. We injected
a total of 15 mL bupivacaine 0.5% on each side. Within 15
minutes, the patient reported pain as mild to none, with a
pain score ranging between 2 and 3 (on a numeric rating scale
0–10). After the initial bolus, the patient was unable to feel
cold in the upper, middle, and lower abdomen bilaterally.
Both catheters were connected to the patient-controlled infusion pumps with 0.1% ropivacaine at a basal rate of 8 mL/h
each and an on-demand bolus of 5 mL every 30 minutes.
Daily patient examination revealed sensory level T7-L1
bilaterally, while the infusion was running. The catheters
remained in place for 7 days. For the first 4 days, the patient
reported no pain. There were no significant changes in his
hemodynamics nor was there any weakness or difficulty
with ambulation. On postoperative day 5, the patient started
Figure 2. Layer of abdominal wall. EO = external oblique muscle;
IO = internal oblique muscle; TA = transversus abdominis muscle;
TAP = transversus abdominis plane.
Figure 1. Patient positioning. Induction room view.
108 cases-anesthesia-analgesia.org
Figure 3. TA muscle tracked posteriorly showing the fascia.
EO = ­external oblique muscle; FT = fascia transversalis; QL = ­quadratus
­lumborum; TA = transversus abdominis muscle.
A & A case reports
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an oral diet and began to take oral oxycodone tablets and
slowly transitioned to an oral regimen. The catheters were
removed on postoperative day 7, and he was discharged to
home. The length of stay was dictated by the surgical plans,
unrelated to pain management.
Figure 4. Local anesthetic spreading around the QL muscle.
FT = fascia transversalis; IO = internal oblique muscle; LA = local
anesthetic; QL = quadratus lumborum.
DISCUSSION
Untreated pain can lead to increased patient stress and dissatisfaction, in addition to other cardiopulmonary complications and slower recovery.1,2 There are many approaches
to pain control after abdominal and colorectal surgeries.
Epidural analgesia is associated with a shorter duration of
postoperative ileus, attenuation of stress response, fewer
pulmonary complications, and improved postoperative
pain control and recovery.12
Thoracic paravertebral block has been used as an alternative to an epidural providing analgesia for different indications. Blind and ultrasound-guided techniques have been
described with various success and complication rates. It
is still considered a neuraxial block with comparable side
effects to an epidural.13
TAP block is a simple alternative after abdominal surgery, with the advantage of lacking the sympathetic effects
of neuraxial anesthesia. In one study, TAP blocks were
shown to provide better analgesia and reduce opioid
requirements when compared with a control group receiving morphine PCA, nonsteroidal antiinflammatory drugs,
and acetaminophen.14
The extent of analgesia provided by the TAP block
depends on the site of injection and pattern of spread within
the plane. Currently, there are a number of ultrasoundguided approaches in use, including an anterior oblique
subcostal approach, a midaxillary approach, and a more
recently proposed posterior approach.9–11 Studies have not
yet definitely identified the appropriate local anesthetic
Figure 5. Cross-sectional view showing the tip of the needle in relation to the back muscles.
October 1, 2015 • Volume 5 • Number 7
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109
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Table 1. Truncal Blocks for Abdominal Surgery16
Dermatomes
covered
T6-T9
Classical TAP
Abdominal surgery below umbilicus
e.g., Large bowel resections,
open/laparoscopic
appendectomy, cesarean
delivery, renal transplant
surgery, abdominoplasty
T10-L2
Lower extremity
weakness
Level performed
or site of
needle entry
No
Had been reported
Possible
Just below the
coastal margin
midclavicular line
Anterior axillary line below the
coastal margin and above the
iliac crest
Plane of
injection
Plane between the
RA muscle and the
TA muscle
TA plane between the internal
oblique and the TA near the
midaxillary line
Complications
Potential injury to
pleura liver and
spleen
No hypotension nor
urinary retention
Muscle hematoma
Bowel injury
No hypotension nor urinary
retention
Lateral abdomen near the
posterior axillary line, below
the coastal margin and
above the iliac crest
Potential space medial to the
abdominal wall muscles
and lateral to QL muscle.
Optimal site is still
investigational
Muscle hematoma, kidney
injury
No hypotension nor urinary
retention
Clinical
indications
Subcostal TAP
Abdominal surgery
above umbilicus
e.g., Cholecystectomy
QL
Abdominal surgery either
above or below the
umbilicus
e.g., Cesarean delivery
and lower abdominal
operations, abdominoplasty
T6-L1
Paravertebral
Thoracic and abdominal
surgery
e.g., Breast surgery,
thoracotomy, partial
nephrectomy, inguinal
hernia repair
4–5 thoracic/lumbar
segments depending on
the injection site and
volume injected
Possible if lumbar
About 3 cm lateral to the
spinous process of the
vertebra at the intended
vertebral level
Potential space bound
posteriorly by
costotransverse ligament
and pleura anteriorly
Potential injury to lungs and
major vessels. Neuraxial,
and intrathecal spread can
cause hypotension
QL = quadratus lumborum; RA = rectus abdominis; TA = transversus abdominis muscle; TAP = transversus abdominis plane.
dose, regional technique, and timing (preincisional or
postincisional) that would ensure optimal analgesia after
TAP blocks.15 Table 1 summarizes some of the clinical
aspects of these blocks.16
The limited duration of a single injection is a major concern when using abdominal wall blocks for major abdominal surgeries. Another limitation is that midline incisions
require bilateral blocks. Continuous quadratus lumborum
block has been rarely reported. There is one case of continuous quadratus lumborum block in a 5-year-old child scheduled for colostomy takedown under general anesthesia,
with a reported excellent outcome.17
In conclusion, this case report demonstrates successful
placement of bilateral quadratus lumborum catheters producing excellent pain control with minimal opioid use in an
adult patient. This is a deep block, and, thus, there is a risk
of deep bleeding and retroperitoneal spread of hematoma in
anticoagulated patients, similar to lumbar plexus (psoas compartment) block. The risk versus benefits should be carefully
considered.18 A prospective study comparing the efficacy and
side effects of quadratus lumborum block with the traditional
TAP block and epidural analgesia would help assess the utility of quadratus lumborum block for abdominal surgery. E
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