PR2-164
Quadratus Lumborum Blocks for Post-operative Analgesia for In-utero Myelomeningocele Repair
Mohammad S, Donepudi R, Austin M, Quintana O, Sridhar S, Seshachellam V, Senior L, Jain R
University of Texas Houston Medical Center, Rosenberg, TX, USA
The success of intrauterine myelomeningocele (MMC) repair relies on a well-coordinated multidisciplinary team from the time of diagnosis to birth. The perioperative anesthetic management is unique as it requires provision of very delicate care to a fetus in a stressful condition and provision of adequate maternal anesthesia for uterine relaxation and hemodynamic stability during and after the surgery. Our institution has provided care for over 54 MMC patients.
The fetal repair of MMC is through a hysterotomy; the intraoperative pain is managed by intravenous analgesics while anesthesia is primarily maintained by inhalational agents. The patient also receives a large dose of magnesium sulfate for tocolysis. Preoperative placement of a thoracic epidural catheter allows for adequate post-surgical analgesia with minimal use of opioids; analgesia is maintained with patient-controlled epidural analgesia (PCEA) with an infusion of local anesthetic with narcotic (0.1% ropivacaine with 2 mcg/ml fentanyl) and rescue doses of morphine and intravenous acetaminophen.
The epidural catheter has historically been discontinued on post-operative day (POD) 2 while transitioning to oral pain medications; however, we have noted that the transition from epidural to oral pain medications was challenging for some patients. Typical problems encountered were inadequate analgesia, nausea, and ileus, all of which created delays in return to function. We then introduced the bilateral quadratus lumborum (QL) block with 20 ml of 0.25% bupivacaine and 3 mg of dexamethasone to each side of the abdomen to bridge this gap in pain control. After this change in protocol, we have had three patients receiving the QL block and noted that the oral pain medication requirement has substantially decreased, and patient satisfaction has improved.
From our preliminary data, this intervention has reduced our hydrocodone/oxycodone consumption by 13% on POD 2 and by 90% POD 3. We have also noted excellent pain control with a reduction of pain scores by 44% on POD 2 and 45% on POD 3. Our study still requires more data in order to draw conclusions given our small pool of patients. Further investigation is needed to identify an optimal pain management regimen and potentially allow better and faster maternal recovery from this major operation, especially given the recent focus on development of enhanced recovery pathways for various types of surgery.
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