P040: CASE REPORT: BILATERAL QUADRATUS LUMBORUM CATHETERS IN A PATIENT WITH BIFID SPINE AND ABDOMINAL ORGAN DUPLICATION UNDERGOING MAJOR ABDOMINAL SURGERY
Katrin Post-Martens, MD, MHS, Robert B Bryskin, MD; Nemours Jacksonville Specialty Clinics
INTRO/BACKGROUND: Quadratus Lumborum (QL) nerve block injections are gaining favor as alternatives to Transverse Abdominis plane (TAP) blockade for abdominal procedures. Advantages include visceral pain control by neuraxial spread, wider dermatome spread, reduction in peak systemic levels of local anesthetic, and increased duration of pain control.
We present a case of bilateral QL catheter placement in a 17yo girl with chronic pain and history of severe post-surgical pain. PMHx includes cloacal extrophy, abdominal organ and neuraxial skeletal duplication below T10, imperforate anus and bifid lumbar vertebral- and spinal columns with spina bifida and tethered cord. She had numerous abdominal surgeries to remove duplicated organs, for ostomy creation, and appendicovesicostomy. Her baseline pain was 7/10, attributed to chronic abdominal and lower extremity neuropathic pain. Home medicines for pain include Hydrocodone, Pregabalin, Valium and Effexor. She presented for exploratory laparotomy with excision of hindgut and enterocutaneous fistula, resection of extravaginal material, drainage of hydrocolpos, complex vaginoplasty, and ventral hernia repair.
The patient had distorted abdominal muscle and -fascia secondary to previous surgeries and underlying disorders. Surgical incision spanned ~30cm from her appendicovesicostomy (~T9) to her perinium.
METHODS: The patient was placed under general endotracheal anesthesia and positioned in the R/L lateral decubitus position for US-guided catheter placements. Sterile technique was observed. A 10cm 17G Touey needle was inserted under direct visualization to a needle endpoint of 6.3cm using an in-line technique and infusion catheters were threaded to 13cm (R) and 14cm (L). After negative aspiration, 30ml of 0.375% bupivacaine with 1:20K epinephrine was injected in divided doses, observing fascial spread.
Intraoperatively, catheter infusion was started using ropivacaine 0.2% at 6ml/hr/catheter. Postoperatively, the infusion was continued at 4ml/hr/catheter until POD7. Hydromorphone PCA with 0.3mg/hr continuous and 0.2mg q15min demand dosing was initiated in addition to scheduled Tylenol, Valium and Oxybutynin. The patient was weaned from the PCA on POD6.
RESULTS: VAS scores were 0 for POD0. Exam revealed numbness to touch and cold in dermatomes T8- L1. Average VAS was 7.3 (approximating patients baseline) for POD1, 8.1 for POD2, 7.5 for POD3 and POD4, 6.1 for POD5, 5.4 for POD6 and 5.2 for POD7. The most bothersome pain was spasmodic which responded to antispasmodics, and discomfort related to the NGT. Overall, the patient and patient’s family were satisfied with the level of pain control.
DISCUSSION: QL catheters are a good choice for abdominal surgeries when TAP catheters or neuraxial techniques are not viable. They may be favorable over TAP catheters when anticipating large abdominal incisions and/or a large component of visceral- in addition to somatic pain.
In our case, we were unable to offer neuraxial techniques because of the patient’s unique anatomy. TAP catheters were not an option because of distorted abdominal wall anatomy and surgical field requirements. Despite abdominal and lumbar spine abnormalities we were able to identify bilateral QL muscles and to place catheters in this location. This resulted in good pain control.