Local and Regional Anesthesia (Oct 2023)
Quadratus Lumborum Block as a Cornerstone for Neonatal Intestinal Surgery Enhanced Recovery (ERAS): A Case Series
Abstract
Cassandra Hoffmann,1 Angela Snow,2 Celine Chedid,3 Carol Abi Shadid,3 Eiichi A Miyasaka4 1Pediatric Anesthesiology, Akron Children’s Hospital, Akron, OH, USA; 2Pediatric Anesthesiology, Nemours Children’s Hospital, Wilmington, DE, USA; 3Pediatric Anesthesiology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USA; 4Pediatric Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USACorrespondence: Eiichi A Miyasaka, Pediatric Surgery, University Hospitals Rainbow Babies and Children’s Hospital, 11100 Euclid Ave, MAC 1000, Cleveland, OH, 44106, USA, Tel +1 216-844-3015, Fax +1 216-844-8647, Email [email protected]: Neonates present unique challenges for pediatric surgical teams. To optimize outcomes, it is imperative to standardize perioperative care by using early extubation and multimodal analgesic techniques. The quadratus lumborum (QL) block provides longer duration and superior pain relief than other single-injection abdominal fascial plane techniques. The purpose of this case series was to report our initial experience with QL blocks in neonatal patients treated with intestinal ERAS.Patients and Methods: Ten neonates requiring intestinal surgery at a single tertiary care center who received QL blocks between December 2019 and April 2022 for enhanced recovery were studied. Bilateral QL blocks were performed with 0.5 mL/kg of 0.25% ropivacaine per side with an adjuvant of 1 mcg/kg of dexmedetomidine.Results: Gestational age at birth ranged from 32.2 to 41 weeks. The median age, weight, and American Society of Anesthesiologists (ASA) score at the time of surgery was 5 days [range 7.5 hours, 60 days], 2.84 kg [range 1.5, 4.5], and 3, respectively. Bilateral QL blocks were performed without complications in all patients. Two patients were outside the neonatal range from birth to surgery, but were under 42 weeks gestational age when corrected for prematurity. All patients were extubated with well-controlled pain, and no patient required reintubation within the first 24 hours. Postoperatively, median cumulative morphine equivalents were 0.16 mg/kg [range 0, 0.79] and six patients received scheduled acetaminophen. Morphine (0.1 mg/kg) was administered to patients with a modified neonatal infant pain scale (NIPS) score greater than or equal to 4, and pain was reassessed 1 hour after administration (Appendix).Conclusion: When developing intestinal ERAS protocols, Bilateral QL blocks may be considered for postoperative analgesia in the neonatal population. Further prospective studies are required to validate this approach in neonates.Keywords: neonatal pain, neonatal regional anesthesia, early neonatal extubation, neonatal intestinal surgery, neonatal enhanced recovery
