|LETTERS TO EDITOR
|Year : 2017 | Volume
| Issue : 2 | Page : 261-262
Continuous bilateral quadratus lumborum block after abdominal surgery
Manuel Ángel Gómez-Ríos, David Gómez-Ríos
Department of Anaesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
|Date of Web Publication||7-Jul-2017|
Manuel Ángel Gómez-Ríos
Departmento de Anestesiología, Complejo Hospitalario Universitario de A Coruna, Xubias de Arriba, 84, 15006 A Coruña
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gómez-Ríos M&, Gómez-Ríos D. Continuous bilateral quadratus lumborum block after abdominal surgery. J Anaesthesiol Clin Pharmacol 2017;33:261-2
|How to cite this URL:|
Gómez-Ríos M&, Gómez-Ríos D. Continuous bilateral quadratus lumborum block after abdominal surgery. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2019 May 27];33:261-2. Available from: http://www.joacp.org/text.asp?2017/33/2/261/168163
I read with great interest the letter of Rao Kadam et al. concerning the use of continuous local anesthetic infusion via catheters placed bilaterally in the junction of transversus abdominis plane (TAP) and quadratus lumborum muscle for postoperative analgesia after open right hemi colectomy. I congratulate him on the presentation of the case. However, we have previously described this technique with excellent results in six cases including its pharmacokinetic profile. I would like to add some comments that could contribute to improve the technique.
We use bilateral TAP catheters inserted by ultrasound imaging using a Contiplex ® C needle (B. Braun, Melsungen, Germany). When the incision is predominantly subumbilical, a posterior TAP block in the triangle of Petit is performed. For surgical incisions that are supraumbilical or full abdominal length, a postero-subcostal approach is performed. After location of the neurofascial TAP, 0.25% levobupivacaine 5 ml is injected. After withdrawing the needle, bilateral continuous infusion of 0.125% levobupivacaine at 2 ml/h from elastomeric pumps (INFUSOR SV2, Baxter, France) is started and continued for 50 h. Before removal of the catheters, 0.25% levobupivacaine 10 ml is administered.
Our technique has several advantageous features. First, it involves placement of Contiplex ® C catheters, a novel system in which the catheter-over-the-needle design helps to simply and effectively overcome some challenges of insertion. Previously, all studies and case reports used epidural catheters inserted through a Tuohy needle as the author. Secondly, the technique decreases systemic exposure to the local anesthetic, by minimizing the volume required for an effective block. It is much lower than infusion employed by the author. Higher volumes of the local anesthetic have traditionally been used to ensure block across multiple dermatomes, but it is possible that this approach is only necessary for a single shot block. Previous catheter studies have used large volumes (and doses) of local anesthetic without evaluating smaller volumes. Moeschler et al. in a cadaveric study, determined that anterior-posterior and transverse spread of contrast did not correlate with an increasing volume of injected contrast, which differed from the relationship to cranial-caudal spread. The volume that we use is much lower than previously described. One possible explanation is that insertion of the catheter in an optimal position and the volume accumulation during the infusion compensated for a low initial volume. The instillation of large volumes into the TAP bilaterally can lead to significant intravascular concentrations of local anesthetic, even exceeding the threshold of toxicity. Careful risk-benefit assessment should be performed before continuous TAP blocks, especially in elderly patients, renal or hepatic dysfunction. The main objective of a continuous technique should be given the lowest total dose of local anesthetic effective to prevent undesirable effects due to toxicity because otherwise we consider that it does not provide additional benefit with respect to a technique based on bolus administration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rao Kadam V. Ultrasound guided quadratus lumborum block or posterior transversus abdominis plane block catheter infusion as a postoperative analgesic technique for abdominal surgery. J Anaesthesiol Clin Pharmacol 2015;31:130-1.
Gómez-Ríos MÁ , Paech MJ. Postoperative analgesia with transversus abdominis plane catheter infusions of levobupivacaine after major gynecological and obstetrical surgery. AQA case series. Rev Esp Anestesiol Reanim 2015;62:165-9.
Moeschler SM, Murthy NS, Hoelzer BC, Gazelka HM, Rho RH, Pingree MJ. Ultrasound-guided transversus abdominis plane injection with computed tomography correlation: A cadaveric study. J Pain Res 2013;6:493-6.
Gómez-Ríos MA. Continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesth Intensive Care 2014;42:265-6.
Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al.
Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66:465-71.