Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block: A comparative cadaveric study.

BACKGROUND: The dermatomal level of analgesia achieved with quadratus lumborum blocks varies according to the location of injection. The most commonly used approaches are either at the postero-lateral aspect or anterior to the quadratus lumborum muscle. OBJECTIVE: To determine whether the site of injection of contrast dye around the quadratus lumborum muscle of cadavers affects the extent and mechanism of dye spread. DESIGN: Observational human cadaver study. SETTING: Cleveland Clinic cadaveric laboratory. PARTICIPANTS: Six fresh human cadavers. INTERVENTIONS: The cadavers received either a posterior quadratus lumborum block or an anterior subcostal quadratus lumborum block on each side. MAIN OUTCOME MEASURES: Cadavers were dissected to determine the extent of dye spread. RESULTS: The posterior quadratus lumborum block approach revealed consistently deep staining of the iliohypogastric, ilioinguinal, subcostal nerve, T11 to 12 and L1 nerve roots. In addition, staining of the middle thoracolumbar fascia was seen in all specimens but only variable staining of T10 nerve roots. The anterior subcostal quadratus lumborum block approach in all specimens demonstrated predictable deep staining of the iliohypogastric and ilioinguinal nerves, subcostal nerves, T11 to 12 and L1 nerve roots, and in addition traversing the arcuate ligaments to involve T9 to 12 nerve roots with variable staining of higher thoracic nerve roots. CONCLUSIONS: Our cadaveric study demonstrates that injection of dye on the posterior aspect of quadratus lumborum muscle led to injectate spread through the lateral and posterior abdominal wall but with limited cranial spread, whereas the anterior approach produced broader coverage of the lower to mid-thoracic region. Clinical translation of these findings to determine the practical significance is warranted.

Bilateral continuous posterior quadratus lumborum block for analgesia after open abdominal surgery: A prospective case series.

The quadratus lumborum (QL) block provides analgesia to the abdominal wall while sparing the side effects of neuraxial blocks. We describe a case series of eight patients treated with a continuous infusion of local anesthetic via bilateral posterior QL catheters infusion block for analgesia after abdominal surgeries. We found that the median duration of the procedure was 26 min and the median opioid consumption over the first postoperative 72 h was 110 mg of morphine equivalents. The bilateral continuous posterior QL block is a feasible analgesic intervention and can be considered as a component of multimodal analgesic pathways.

Thoracic epidural catheter in the management of a child with an anterior mediastinal mass: a case report and literature review.

We describe a case of an anterior mediastinal mass compressing the right main bronchus that required a biopsy through a thoracotomy incision. The anesthetic management of these patients is associated with several risks and challenges, including potential airway compression and cardiovascular collapse. Inhalation induction and maintenance of spontaneous respiration is recommended to preserve normal transpulmonary pressure gradient and improve flow through conducting airways. We placed a thoracic epidural catheter under general anesthesia as the main analgesic technique in order to maintain spontaneous breathing. The use of regional anesthesia, especially continuous epidurals in pediatric cardiothoracic anesthesia have many theoretical advantages including attenuation of the neuroendocrine response, facilitation of rapid extubation and improved ventilatory mechanics secondary to decreased narcotic requirements. The absolute risk of nerve injury and epidural hematoma for this procedure is unknown and hard to define in this patient population. We reviewed multiple studies and case reports addressing its safety and reported side effects. Finally, we emphasize that a thoracic epidural anesthesia is a reasonable choice that can be applied carefully in special situations even for children under general anesthesia.