RevBrasAnestesiol.2019;69(2):208---210
REVISTA
BRASILEIRA DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL INFORMATION
Continuous quadratus lumborum type 3 block provides effective postoperative analgesia for hip surgery:
case report
Ahmet Murat Yayik
a,∗, Sevim Cesur
a, Figen Ozturk
a, Ali Ahiskalioglu
b, Erkan Cem Celik
aaRegionalTrainingandResearchHospital,DepartmentofAnesthesiologyandReanimation,Erzurum,Turkey
bAtaturkUniversitySchoolofMedicine,DepartmentofAnesthesiologyandReanimation,Erzurum,Turkey
Received25April2018;accepted15June2018 Availableonline17July2018
KEYWORDS Quadratuslumborum block;
Hipsurgery;
Postoperative analgesia
Abstract
Introduction:Hipsurgeryisamajorsurgerythatcausesseverepostoperativepain.Although painduringrestisusuallyconsiderablyreducedmobilizationisimportantintermsofthrom- boemboliccomplications.Thequadratuslumborumblockisaregionalanalgesictechniquethat blocks T6-L3nervebranches.Thisblock mayprovideadequate analgesiaandreduceopioid consumptionafterhipsurgery.
Casereport: Weperformedcontinuousquadratuslumborumtype3blockintwopatientswho underwent hip arthroplasty. Postoperative 24-h pain scores, local anesthetic consumptions onpatient-controlledanalgesiaandadditionalanalgesicrequirementwererecorded.In two patients,postoperativepainscoreswerelessthan6duringrestandphysiotherapy.Patientwas mobilized intheearlypostoperativeperiod withoutadditional opioidanalgesicrequirement andwithoutmuscleweakness.
Discussion: Continuousquadratuslumborumblockmaybeusedtorelievepostoperativeacute paininhipsurgerybecauseitprovidesone-sidedanesthesiawithoutmuscleweakness.
©2018SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).
PALAVRAS-CHAVE Bloqueiodoquadrado lombar;
Cirurgiadequadril;
Analgesia pós-operatória
Obloqueiocontínuodoquadradolombartipo3forneceanalgesiapós-operatória efetivaparacirurgiadoquadril:relatodecaso
Resumo
Introduc¸ão:A cirurgia de quadrilé umacirurgia de grandeporte quecausadorintensa no pós-operatório. Embora a dor durante o repouso seja consideravelmente reduzida, a
∗Correspondingauthor.
E-mail:myayik@hotmail.com(A.M.Yayik).
https://doi.org/10.1016/j.bjane.2018.07.002
0104-0014/©2018SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Continuousquadratuslumborumblockforhipsurgery 209 mobilizac¸ão é importante em termos de complicac¸ões tromboembólicas. O bloqueio do quadradolombaréumatécnicaanalgésicaregionalquebloqueiaosramosnervososdeT6-L3.
Essebloqueiopodeforneceranalgesiaadequadaereduziroconsumodeopioidesapóscirurgias dequadril.
Relatodecaso: Realizamosobloqueiocontínuodoquadradolombartipo3emdoispacientes submetidos àartroplastia de quadril.Durante as24 hsde pós-operatório foramregistrados osescoresdedor,oconsumodeanestésicoslocais emanalgesiacontroladapelopacientee anecessidadedeanalgésicosadicionais.Emdoispacientes,osescoresdedorpós-operatória foram<6duranteorepousoefisioterapia.Opacientefoimobilizadonoperíodopós-operatório imediato,semprecisardeanalgésicoopioideadicionalesemfraquezamuscular.
Discussão: Obloqueiocontínuodoquadradolombarpodeserusadoparaaliviaradoraguda no pós-operatório de cirurgia de quadril porquefornece anestesia unilateral semfraqueza muscular.
©2018SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by- nc-nd/4.0/).
Introduction
Hiparthroplastyhasbecomeacommonorthopedicsurgery withtheagingofsociety.Itisamajorsurgerywithextensive and severe tissue dissection in muscle, bone, and vascu- larstructures.Thereforethisleadstoseverepostoperative pain.1Painduringrestisusuallyconsiderablyreduced,how- evermobilizationisimportantintermsofthromboembolic complications. Patient-controlled analgesia with opioids, variousregionalanesthesiamethods,suchasepiduraland spinal analgesia, peripheral nerve blocks and local anes- theticinfiltrationhavebeenappliedtocontrolhipsurgery pain.2
Quadratus lumborumblock (QLB), defined asa variant ofTAPblock,iswidelyusedforpostoperativeanalgesiain abdominalsurgery.3Thistechniqueinvolvestheprocessof injectingalocalanestheticintothefascialplanebetween thequadratuslumborumandpsoasmuscles.Thequadratus lumborummuscleoriginatesfromtheiliaccrestandinserts onthe12thribandthe transverseprocessesof vertebrae L1---L5.Thelocalanestheticsspreadalongthemusclesand provideT6-L3sensoryblock.Thereforethishasbeenused inpelvicandhipsurgeriesasreportedbysomecases.4
Figure1 (A)Ultrasoundimageofquadratuslumborumblock.(B)Quadratuslumborumblockcatheterposition.
Case report
We present twocases of hip arthroplasty performing the continuousQLBinthisreport.Awritten consentformwas obtainedfromthepatients.
Case1
A67-year-oldmalepatientwastakentotheoperatingroom for hip arthroplasty.Standard monitoring was performed.
Onemgmidazolamand50mcgfentanylwereadministered forsedationandthenthepatientwasplacedinthelateral positionwiththefracturedsideonthetop.Spinalanesthesia wasperformed with7.5mgisobaric bupivacainefor surgi- calanesthesia.Aftersurgery,thepatientwasinthelateral decubitusposition----theareatobetreatedandtheconvex USGprobewassterilized.Theprobewasplacedintheaxial planeonthepatient’siliaccrest(Fig.1A).Transversepro- cessofvertebraL4,quadratuslumborum,psoas,anderector spinaemuscles was visualized. The intervention wasper- formedbyusinganin-planetechniquewithan18G100mm Tuohyneedle.Thequadratuslumborummusclewaspassed astransmuscular. Entering among the fascia of the psoas
210 A.M.Yayiketal.
andthequadratuslumborummuscles,theblockwasapplied with20mLof0.25%bupivacaine.Andthen20Gcatheterwas placed4cminsidethespacecreatedbythelocalanesthetic injectate(Fig.1B).Thecatheterinfusionwasconnectedtoa PCAdevicethatadministeredbupivacaine0.1%at5mL.h−1 witha5mLbolusand20minlockout.Thirtyminutesbefore theendoftheoperation400mgIVibuprofenweregivenand thiswasrepeatedtwiceaday.Postoperative24-hrestVAS scoreswere0,andVASscoreswerebetween2and4during physiotherapy.The patientwasmobilizedinthe8thhour;
24htotalbupivacaineconsumptionwas140mganddidnot requireanyadditionalopioidanalgesic.
Case2
A75-year-oldfemalepatientwithintracranialmeningioma history wasscheduled for a hip arthroplasty. The patient wastakentotheoperatingroom,standardmonitoringwas performed.Inductionofgeneralanesthesiawasperformed with propofol, fentanyl, and rocuronium, intraoperative analgesia was achieved with remifentanil. After surgery, continuousQLBwasappliedusingthesametechniqueand samevolumeasdescribed inthe firstcaseand connected toaPCAdevice(bupivacaine0.1%at5mL.h−1witha5mL bolus and 20min lockout). Postoperative 24h VAS scores werebetween0and2atrest,andbetween0and4during physiotherapy.Patient without additionalopioid analgesic requirementandwithoutmuscleweaknesswasmobilizedin thesixthhour.Totalof24hofbupivacaineconsumptionwas 170mgand10timesPCAboluswasused.
Discussion
Hipfractures areusuallyseen inthe older age andthese patientsusuallyhavecomorbiditiessuchasdiabetes,hyper- tension,andcardiacinstability.Managementofanesthesia and postoperative analgesia should be planned consider- ingthese comorbidities.Neuraxial blocksare widely used for postoperative analgesiain hipsurgery. In the studies, theopioidsandthelocalanestheticswereusedforepidu- ralanalgesiaandtheefficacywasshown.Thesideeffects, as well as the efficacy of the epidural block, should be considered. It can cause serious complications in elderly patients.Sympatheticblock-relatedcardiaccomplications, respiratory depression, pulmonary hypertension, pruritus, andurinaryretentionaresomeofthese.
Peripheralnerveblocksareanotheroptionforpainman- agementin hiparthroplasty.Femoralblock, sciaticblock, andlumbarplexusblockhavebeenprovedtobeveryeffec-
tiveatcontrollingpainandreducingnarcoticrequirements.
Peripheralnerveblockshavethefewerriskofcomplications such as hypotension, urinary retention, and respiratory depressionwhencomparedtoepiduralblock.Thedisadvan- tagesof nerveblocksarepossibilitiesofinjury associated muscleweaknessonthepostoperativeperiod.Therewere afewreports ofincidenceofquadricepsmuscleweakness after QLB and the sustained mechanism of muscle weak- ness of QLB is spread of local anesthetics to epidural or paravertebralspaceoflumbarregionbutthishypothesisis unclear.5Volumeandconcentrationoflocalanestheticmay beanimportantfactorforlower-extremitymuscleweakness afterQLB.MoreovercadavericandMRIstudiesareneeded tovalidatetheblock’spotentialanatomicspread.
Postoperativemobilizationofthepatientinhipsurgery is very important in terms of preventing morbidity and mortality, therefore effective and continuous analgesia is essential. Inthese casesreport,continuous QLBhasbeen provided for superior analgesia in hip arthroplasty. There wasnomuscle weaknessdue toQLBin patients andthey weremobilizedearlypostoperativeperiod.
Continuous QLBcanbeused inplaceof other regional anesthetic techniques torelievepostoperative acutepain inhipsurgerybecauseofitbeinglessinvasive,causesless muscleweakness,andprovidesone-sidedanesthesia.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
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