PR2-165
Ultrasound Guided Quadratus Lumborum Block for an Opioid-Free CDH Repair
1Liu Y, 2Barlow M, 2Lipskar A, 2Barnett N, 2Hagen J, 2Kars M
1Zucker School of Medicine at HOFSTRA/Northwell, New Hyde Park, NY, United states; 2LIJ Cohen Children's Hospital, New Hyde Park, NY, United states
Congenital diaphragmatic hernia (CDH) is a defect allowing viscera to herniate into the chest that occurs in 1-4 out of 10,000 births that can be lethal in up to 30% of patients. Treatment involves intubation, followed by surgical correction. These patients present a particular set of challenges in the perioperative and intraoperative settings.
Regional techniques have become increasingly important in pediatric anesthesia, given the current climate of the opioid epidemic and question of long-term outcomes from inhalational anesthetics. The quadratus lumborum (QL) block is a versatile block typically used for a variety of abdominal surgeries. We would like to report a new application for the QL block for CDH repair that has not been previously reported in the literature.
We present a case of a 3 day old, 1.85 kg, ex-36 weeks female who underwent repair of a left sided congenital diaphragmatic hernia under general anesthesia with an endotracheal tube and unilateral quadratus lumborum block.
The patient’s mother was 35 years old with an obstetrical history of two previous miscarriages. CDH was diagnosed late in the course of pregnancy which was otherwise uncomplicated.
After delivery, the patient was intubated at by the pediatric NICU team and maintained on high frequency oscillatory ventilation. An echocardiogram was performed and was unremarkable.
On the third day of life, surgical repair for left sided CDH was performed. The patient was brought to the OR and standard ASA monitors were applied. Induction proceeded with the in-situ ETT and a radial arterial line was placed. The abdomen was prepped with chlorhexidine gluconate solution and a left quadratus lumborum block was placed under ultrasound guidance prior to surgical incision. A 25G PrecisionGlide needle was used for injection of 0.9 mL of 0.50% bupivacaine. There were no complications.
The surgical procedure then proceeded with a left subcostal incision. A typical Bochdaleck hernia defect was identified. The viscera was reduced and the defect was closed primarily. The patient was maintained on a dopamine infusion for the duration of the case and fluids consisted of NaCl 0.9% 50 mL/kg and 5% Albumin 10 mL/kg. No opioids were given throughout the case and IV acetaminophen was given towards the conclusion of the surgery. The patient was extubated without event to nasal CPAP and transported to NICU.
In the NICU, the patient was weaned successfully off of nasal CPAP to room air. Her post-operative course was uneventful and she was discharged to home on the 9th postoperative day.
Following CDH repair, mortality has been shown to correlate with a patient’s respiratory status in the first 24 hours immediately after the surgery. Here we present a regional anesthesia based method for providing analgesia during CDH repair that decreases the likelihood of needing opioids and resulted in early extubation in the operating room. We believe that this method of multimodal analgesia is a safe and effective option for CDH repair.
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