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Ultrasound-guided Quadratus Lumborum Blocks for analgesia in morbidly obese patients undergoing cesarean delivery: A case series
Abstract Number: S1C-1
Abstract Type: Case Report/Case Series
Managing obese patients with obstructive sleep apnea(OSA) is challenging as they are sensitive to the respiratory effects of opioids. Performing regional anesthetics on obese patients could reduce postoperative opioid needs for those prone to pulmonary complications.1
The quadratus lumborum block(QLB) is a regional analgesic technique that can effective and long lasting postoperative analgesia for abdominal surgeries.2 We performed bilateral QLB in three morbidly obese women with OSA undergoing cesarean delivery under neuraxial anesthesia to provide optimal postoperative analgesia with minimal adverse effects.
26 yo G3P1 at 35+6 weeks with OSA and morbid obesity(BMI 48.5) presented for emergency C/S due to fetal tachycardia. Intrathecal block was performed with 12mg of 0.75% hyperbaric bupivacaine and 20mcg fentanyl via 27G Pecan needle. In PACU b/l QLB was performed with Ropivacaine 0.25%, 30ml per side through a 22G 100mm Stimplex needle between QL muscle and the aponeurosis of oblique muscles (QL I approach) under ultrasound guidance.Pre-block pain 6/10 was reduced to 2/10. Patient received acetaminophen 650mg and ibuprofen 600mg q6h, with one dose of 600 mg oral gabapentin. Oral oxycodone 5mg was prescribed as needed. Patient was satisfied with pain relief and did not require any opioids in the first 24h.
32 yo G3P2 at 35+5 weeks with asthma and morbid obesity(BMI 48.3) with preeclampsia presented for repeat C/S.Neuraxial block was performed with 13.5mg of 0.75% bupivacaine and 20mcg fentanyl.QLB was performed with Ropivacaine 0.25% 30ml per side.Pain was reduced from 7/10 to 2/10 post-block.Patient received multimodal analgesia as per Case 1 and required no opioids in the first 24h.
37 yo G5P2 at 37 weeks with OSA and morbid obesity(BMI 46.5), presented for repeat C/S.Neuraxial block was performed with 13.5mg 0.75% bupivacaine and fentanyl 20mcg.QLB was performed with Ropivacaine 0.25% 30mL per side.Pain was reduced from 7/10 to 1/10 post-block.Patient received multimodal analgesia and no opioids the first 24 h.
Obesity increases the risk of postoperative pulmonary complications. Intrathecal morphine should be used with caution in obese patients with OSA due to the risk of respiratory depression. The use of regional anesthetics for obese patients allows minimal postoperative pulmonary complications and reduced postoperative opioid requirements.1 QLB was described as a variation of the TAP block by Blanco, who found decreased opioid consumption in the first 12h after QLB.2 We found this technique to be easy to apply. Patients did not require any opioids in first 24h after C/S, avoiding side effects of opioids. When appropriate, QLB should be a part of multimodal analgesia of obese patients.
1.Ingrande J,Brodsky JB,Lemmens HJ.Regional Anesthesia and Obesity.Curr Opin Anaest.2009;22:683-6
2.BlancoA, AnsariT,Girgis E.QLB for postoperative pain after C/S.Eur J Anaest.2015;32:812-8