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Pushing the Limits: The Use of Quadratus Lumborum Blocks in Super Obesity
Abstract Number: S2D-2
Abstract Type: Case Report/Case Series
Super obesity presents postoperative analgesic challenges in the parturient. Patients are at an increased risk of pulmonary complications with higher rates of undiagnosed obstructive sleep apnea and difficult ventilation. While intrathecal morphine remains the gold standard in managing post c-section pain,1 quadratus lumborum blocks have been suggested as a possible alternative to reduce opioid consumption2 and their related complications. Extremes of body habitus have been cited as potential obstacles to the performance of abdominal wall blocks.3 With proper guidance, however, these techniques can be used even by novices to provide satisfactory analgesia.
A 33 YO G2P1 at 39+0 with PMH mild intermittent asthma and BMI of 73.22 presented for planned C-section due to prior C-section. Patient received combined spinal-epidural with 13.5mg bupivacaine and 15mcg fentanyl in the intrathecal space. She received a further 2 boluses of epidural ropivacaine 0.5%, 5mL each. The patient tolerated the procedure well and the epidural catheter was removed at the end of the procedure. In PACU, the anesthesia team performed bilateral QL Blocks with a 22G 100 mm Stimplex needle using 40ml 0.25% ropivacaine per side. Patient was given a multimodal pain regimen using gabapentin 600mg 1 dose, acetaminophen 650mg PO q6hrs RTC and ibuprofen 600mg PO q6hrs RTC. While oxycodone 10mg was prescribed q6hours PRN for breakthrough pain, the patient did not require any opioids in the subsequent 24 hours and was satisfied with her pain control.
The use of quadratus lumborum blocks for pain after c-section has been described since 20152 yet their adoption remains variable in clinical practice. QL blocks have been used at our institution as a component of a multi-modal pain regimen for almost one year and to date, we have not had any major compilations in over 90 patients. The use of this technique may allow us to safely discontinue routine use of intrathecal opioids, eliminating their associated side effects, while maintaining effective analgesia and high patient satisfaction.
1 Palmer, Craig M., et al. “Dose-Response Relationship of Intrathecal Morphine for Postcesarean Analgesia.” Anesthesiology, vol. 90, no. 2, 1999, pp. 437–444., doi:10.1097/00000542-199902000-00018.
2 Blanco, Rafael, et al. “Quadratus lumborum block for postoperative pain after caesarean section.” European Journal of Anaesthesiology, vol. 32, no. 11, 2015, pp. 812–818., doi:10.1097/eja.0000000000000299.
3 Keller, Deborah S., et al. “Transversus abdominis plane blocks: pilot of feasibility and the learning curve.” Journal of Surgical Research, vol. 204, no. 1, 2016, pp. 101–108., doi:10.1016/j.jss.2016.04.012.