Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy
66-year-old gentleman, ASA 3 was scheduled for laparotomy for duodenal tumour excision. His other medical conditions were type 2 diabetes mellitus, cardiomyopathy, chronic smoker, and obstructive sleep apnoea on Continuous Positive Airway Pressure (CPAP) machine. Postoperative analgesia options were discussed with the patient. He was not keen on epidural, but happy to consider other options. He was offered patient controlled analgesia (PCA) fentanyl, QL block, and multimodal analgesia. We had explained the QL block as a novel technique. He preferred to undergo the block while sleeping. After taking informed consent, anesthesia was induced with propofol (Fresofol® fresenius, Sydney, New South Wales, Australia), fentanyl (fentanyl citrate DBL Hospira, Melbourne, Australia), and rocuronium (Esmeron, MSD, Sydney, New South Wales, Australia) for Neuro muscular (NM) paralysis. Maintenance of anesthesia was with 50:50 O2 and air with sevoflurane. The abdomen was opened via right-side large subcostal incision. The procedure lasted 2.5 h and was uneventful. At the end of the procedure, he was positioned in left lateral to obtain appropriate view of QL and TAP extensions of lateral abdominal muscles. Aseptic precautions were taken by wearing sterile gown and sterile drapes. Ultrasound Macro Maxx™ (SonositeInc, Bothell, Washington, USA) was used with linear probe (HFL38_10-5 MHz) covered with sterile plastic sheath SiteRite (Bard Access Systems Inc., Salt lake city, Utah, USA) placed in the anterior axillary line to visualize the typical triple abdominal layers. Then, the probe was placed in the midaxillary line and at this juncture the layers of abdominal layers started to taper. When the probe was placed in the posterior axillary line as per the posterior approach, sonoanatomy showed first the transversus abdominis disappearing then the internal oblique and external oblique forming aponeurosis and appearance of QL noticed []. shows typical muscles layers and the fascia. At the junction of the tapered ends of abdominal muscles and QL, a 21 g 100 mm SonoPlexStimu cannula needle (Pajunk Medizintechnologie Geisingen, Germany0) was inserted in plane [] and confirmed its position by injecting saline. Under ultrasound (US) guidance, saline separating the fascia similar to what is seen in the TAP plane was observed. Then in that space 25 mL of 0.5% ropivacaine (Naropin-AstraZeneca, Sydney, North South Wales, Australia) was injected []. Pain scores using the numerator rating scale (NRS) from 0 to 10 were recorded hourly in recovery room and then in the high dependency ward and fentanyl use was monitored for 24 h. He received a fentanyl PCA with bolus dose of 20 mcg with lock out interval of 5 min and multimodal analgesia comprising paracetamol1g every 6 h and parecoxib (Dynastat, Pfizer Pty Ltd, North South Wales Australia) 40 mg daily.\nPostoperatively in recovery, he did not require any further analgesia. Pain scores were 0/10 and the ipsilateral sensory block was T8-L1. The first analgesic request was about 3 h postoperative. After 15 h, he started experiencing pain requiring more fentanyl PCA amounting to 720 mcg for the remaining day. The average pain scores on day one were 4/10 at rest and 6/10 on coughing and comfortable. The 2nd day, the pain scores were 7/10 and 9/10 requiring 1000 mcg of fentanyl.