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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 36  |  Issue : 1  |  Page : 115-116

Quadratus lumborum block provides significant pain relief after abdominal transplant


University of Alabama Birmingham Medical Center, Division of Multispecialty Anesthesia, Department of Anesthesiology and Perioperative Medicine, JT 923, 619 19th Street South, Birmingham, AL 35249-6810, United States of America

Date of Submission21-Aug-2018
Date of Acceptance05-Sep-2019
Date of Web Publication18-Feb-2020

Correspondence Address:
Dr. Christopher Adam Godlewski
University of Alabama Birmingham Medical Center, Division of Multispecialty Anesthesia, Department of Anesthesiology and Perioperative Medicine, JT 923, 619 19th Street South, Birmingham, AL 35249-6810
United States of America
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_266_19

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  Abstract 


Abdominal organ transplantation - and more specifically small bowel transplant - can be quite painful, generally requiring significant opioid administration with the attendant negative ramifications. We present contrasting experiences with a gentleman who underwent transplantation for Crohn's disease and his retransplantation with the addition of post-operative anterior Quadratus Lumborum (QL) block. After the index procedure, he had significant pain and discomfort. The addition of the QL block lead to substantial improvement in both subjective and objective endpoints. While each case is different, a QL block can be a useful adjunct to achieve pain control, decrease opioid requirements, and potentially facilitate early extubation.

Keywords: Organ transplantation, postoperative analgesia, regional anesthesia


How to cite this article:
Godlewski CA. Quadratus lumborum block provides significant pain relief after abdominal transplant. J Anaesthesiol Clin Pharmacol 2020;36:115-6

How to cite this URL:
Godlewski CA. Quadratus lumborum block provides significant pain relief after abdominal transplant. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 May 27];36:115-6. Available from: http://www.joacp.org/text.asp?2020/36/1/115/278455



Patients undergoing intestinal transplant have a high potential for pain, as repeated intraabdominal procedures can result in central sensitization, “wind-up”, and chronic pain. Using a multimodal approach to acute pain that includes nerve blocks, the opioid burden and associated risks can be mitigated, possibly facilitating earlier extubation, ambulation, and increased patient comfort.

A 56-year-old Caucasian male with Crohn's disease had short bowel syndrome (SBS), requiring intestinal transplantation following multiple bowel resections. He had severe pain after being extubated 3 h postoperatively (post-op), and a patient-controlled fentanyl infusion was instituted. Pain scores ranged from zero to eight in the first 48 h. The patient complained of significant abdominal and incisional pain while appearing diaphoretic and in distress. Due to graft failure, he necessitated explantation with creation of tube duodenostomy.

A year later, the patient presented for retransplantation. One of his primary concerns was the significant pain he experienced with the first procedure. After completing the surgery, we performed bilateral ultrasound (UG)-guided anterior QL blocks [Figure 1] using 20 mL of 0.25% bupivacaine with 2 mg of dexamethasone per side.
Figure 1: Real-time ultrasound view of QL muscle and injection targets for QL block. QL = Quadratus Lumborum

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Less than 3 h post-op, he was extubated. He was quite comfortable, requiring only a one-time dose of fentanyl 50 μg. A patient-controlled fentanyl infusion was provided as the quadratus lumborum (QL) block began to regress.

Subjectively, his retransplantation was a stark contrast to his index procedure. The first post-op day, he was able to sleep comfortably and appeared in no distress, smiling frequently. He felt the block made a tremendous difference in his level of pain and comfort. Maximum pain score was a 3/10, 8 h after the block was performed. The block began to recede 6 h after being performed. Otherwise, pain scores ranged from 0–2/10 in the first 48 h after surgery, and he required no breakthrough medications.

The QL block is a fascial plane block that has drawn attention for excellent analgesia, variety of applications, and ease of performance with a good safety profile. Its potency may stem partly from the paravertebral spread of local anesthetic,[1],[2] which is applicable to all manners of abdominal surgeries.[3],[4],[5],[6]

Many transplant recipients are not candidates for early extubation because of comorbidities or physiologic perturbations from surgery. However, with modern surgical and anesthetic techniques, the addition of a QL block may serve as a tool in a multimodal “analgesic bridge” for patients undergoing early extubation.

Though our results are promising, we acknowledge there are unanswered questions and the possibility of confounding variables. The patient admitted to having substantial pain immediately post-op after initial transplantation, but this may be attributable to graft failure. The patient also received more opioid for the second surgery (420 mcg vs. 310 mcg sufentanil), but we do not feel that this is solely responsible for the substantial decrease in pain.

In our practice, it is customary to perform nerve blocks prior to surgery to provide pre-emptive analgesia, mitigate intraoperative opioid requirements, and prevent central sensitization and “wind-up” pain. However, this was the first adult intestine transplant performed at our institution and we did not want to risk potential surgical or hemodynamic complications as a result of our block. Better results may have occurred using a higher volume of local anesthetic; however, this needs validation in a larger sample of patients. Though it is our opinion that the QL should prove to be beneficial for other abdominal organ transplantations, we advise caution on the extrapolation of our results in the use of these procedures as there are no randomized, prospective studies demonstrating the efficacy and safety of this block in these scenarios.

Abbreviations

QL = Quadratus lumborum

GERD = Gastroesophageal reflux disease

SICU = Surgical intensive care unit

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dam M, Moriggl B, Hansen CK, Hoermann R, Bendtsen TF, Børglum J. The pathway of injectate spread with the transmuscular quadratus lumborum block: A cadaver study. Anesth Analg 2017;125:303-12.  Back to cited text no. 1
    
2.
Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani N, Nixon AM, Chin KJ. A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Anaes 2017;72:73-9.  Back to cited text no. 2
    
3.
Børglum J, Gögenür I, Bendtsen TF. Abdominal wall blocks in adults. Curr Opin Anaesthesiol 2016;29:638-43.  Back to cited text no. 3
    
4.
Graça R, Miguelez P, Cardoso JM, Sá M, Brandão J, Pinheiro C, et al. Continuous quadratus lumborum type II block in partial nephrectomy. Rev Bras Anestesiol 2018. doi: 10.1016/j.bjan. 2018.03.001.  Back to cited text no. 4
    
5.
Putzu M, Gambaretti E, Rizzo F, Latronico N. Postoperative analgesia for laparotomic surgery provided by bilateral single-shot Quadratus Lumborum block. Minerva Anestesiol 2018. doi: 10.23736/S0375-9393.18.12777-5.  Back to cited text no. 5
    
6.
Ueshima H, Otake H. Clinical experiences of unilateral anterior sub-costal quadratus lumborum block for a nephrectomy. J Clin Anesth 2018;44:120.  Back to cited text no. 6
    


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