GA4-84
Quadratus Lumborum and Rectus Sheath Blocks in an Infant with Severe pulmonary Hypertension Undergoing Laparoscopic Cholecystectomy; A Case Report.
Falciola V, Boretsky K
Boston Children's Hospital, Boston, MA, USA
Introduction
Perioperative pain management and blunting of stress responses is challenging in infants with severe pulmonary hypertension (PH) especially those with pre-existing opiate tolerance. Unmanaged painful stimuli can precipitate pulmonary hypertensive crisis with severe hemodynamic consequences. Regional anesthesia, as part of multimodal analgesia, may be uniquely advantageous in managing acute pain in this population. While neuraxial approaches are excellent at blocking the stress response during abdominal surgery and are commonly used in small infants, absolute and relative contraindications may preclude their use. We present the case report of an infant with severe PH presenting for laparoscopic surgery for which bilateral rectus sheath (RS) and quadratus lumborum (QL) blocks were placed for perioperative blunting of stress reponses to surgical stimuli.
Case
A 5 month old 5.3 kg male with severe PH due to congenital diaphragmatic hernia presented for laparoscopic cholecystectomy. He had acute cholecystitis with ongoing bacteremia. He was mechanically ventilated with frequent breakthrough agitation and hemodynamic deterioration characteristic of pulmonary hypertensive crisis, requiring escalation of sedation. Baseline sedation was robust, consisting of continuous infusions of morphine, midazolam, dexmedetomidine, scheduled methadone and as needed boluses of ketamine, midazolam and morphine.
Baseline infusions were continued in the operating room. Prior to incision and under ultrasound guidance, the RS blocks were performed by injecting 0.75ml/side of ropivacaine 0.2%. The QL blocks were performed by injecting 2.0ml/side of ropivacaine 0.2% under ultrasound visualization.
Over the course of the surgery and in the following 24 hours in ICU, the infant remained hemodynamically stable with no oxygen desaturations and no changes to baseline sedation.
Discussion.
This infant typifies many of the issues in opiate tolerant patients with PH. Intraoperative painful stimuli can precipitate pulmonary hypertensive crisis. Epidural are considered the gold standard for analgesia following abdominal surgery in small infants but the ongoing bacteremia in this infant was considered a relative contraindication to neuraxial techniques. The opioid sparing effects of paravertebral nerve blocks in mechanically ventilated infants has been described but these blocks were also contraindicated due to the relative risk of pneumothorax. Single injection QL plus RS block were chosen for their long duration and low risk profile.
While the exact role the RS and QL blocks played in this patient is unclear, the lack of hemodynamic reactivity and consistent arterial oxygenation and lack of need for escalating sedation is encouraging. In this population of patients, all potential means to prevent hypertensive crisis including abdominal wall blocks should be considered.
References:
Twite M et all. The anesthetic management of children with pulmonary Hypertension in the cardiac catheterization Laboratory. Anesthesiology Clinics 2014
Bairdain, S. et all. Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia. Pediatric Anesthesia 2015
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