Successful Use of Ultrasound Guided Quadratus Lumborum Block Without General Anesthesia for Open Appendectomy in a Patient with Heart Failure with Reduced Ejection Fraction- A Case Report and Literature Review

Figures & data

Figure 1 Anterior approach to a Quadratus Lumborum Block. Local anaesthesia is injected under ultrasound guidance and aseptic precautions to a space between the Psoas Major Muscle and Quadratus Lumborum Muscle (Abbreviations EOM: External Oblique Muscle; IOM: Internal Oblique Muscle; TAM: Transversus Abdominis Muscle; PM: Psoas Major Muscle; ES: Erector Spinae Muscle; QL: Quadratus Lumborum Muscle; LD: Latissimus Dorsi Muscle; TP: Vertebral Body Transverse Process). ©2023 Body Scientific International, LLC.

Figure 2 Clinical care pathway for our patient taking into consideration guidelines and recommendations for management of a cardiac patient presenting for non-cardiac surgery from the American Heart Association, American College of Cardiology, European Society of Cardiology and Canadian Cardiovascular Society. Additionally, we used input from a multidisciplinary team meeting with the surgical team and senior anaesthetists to make our decision. The black ticks highlight our steps in each phase of the patient’s care.

Notes: Data from these studies.^3–7

Abbreviations: HFrEF, Heart Failure with Reduced Ejection Fraction; RCRI, Revised Cardiac Risk Index; MACE, Major Adverse Cardiac Events; ACE Inhibitors, Angiotensin Converting Enzyme Inhibitors; MDT, Multidisciplinary Team; QLB, Quadratus Lumborum Block.

Figure 3 Pain type, intensity and distribution in Appendicitis patients. Acute appendicitis (top left) mainly produces well-localized sharp pain (red color overlay) in the left lower abdomen, with referred pain to the umbilicus (yellow color overlay), which is more poorly localized. Open appendectomy (top middle) produces sharp incisional pain in addition to pain associated with acute appendicitis (red overlay). Further pain occurs during blunt dissection of deeper muscles and tissues, and visceral pain occurs during peritoneal incision and appendix manipulation. Laparoscopic appendectomy (top right) produces sharp incisional pain at the sites of trocar insertion in addition to the pre-existing pain of acute appendicitis (red overlay). After carbon dioxide insufflation, diffuse stretching of the abdomen and peritoneum results in diffuse and poorly localized discomfort (green overlay). There is also referred pain in the shoulder due to irritation of the diaphragm (green overlay). ©2023 Body Scientific International, LLC.

Figure 4 Anesthetic coverage by a well performed Quadratus Lumborum block providing adequate coverage of the pain of open appendectomy (blue overlay). However, some amount of visceral pain is not completely blocked. ©2023 Body Scientific International, LLC.

Table 1 Summary of Case Reports of Quadratus Lumborum Block as Anesthetic Technique for Abdominal Surgeries

Case Type	Surgery	Comorbid Conditions	Quadratus Lumborum Approach	njectate	Additive Sedation/Analgesics	Postoperative Analgesia
Cassai et al^Citation18	Left inguinal incarcerated hernia repair	Dilated cardiomyopathy with EF 33%, CAD, pacemaker implantation for a third degree AV block, severe pulmonary HTN, severe mitral valve insufficiency and third stage CKD	Injectate given at the interfascial plane between the QL muscle and psoas muscle	30 mL of 0.5% ropivacaine	Conscious sedation with propofol 1mg/kg/hr and remifentanil 0/05 mcg/kg/min with additional local anesthetic infiltration with lidocaine 2% during manipulation of the hernia sac	Postoperative analgesia with paracetamol only and discharged on the fourth postoperative day
La Colla et al^Citation15	Right inguinal hernia open repair	Multiple system Atrophy, OSA, Autonomic dysfunction with severe orthostatic hypotension	Injectate given at the interfascial plane between the QL muscle and psoas muscle	20 mL of 0.5% ropivacaine	Fentanyl 50mcg i.v before block Sedation with low-dose propofol (10mcg/kg/min). Local infiltration with 6mL of 0.25% bupivacaine prior to incision	Postoperative analgesia with paracetamol and pregabalin 100 mg overnight
Balogh et al^Citation16	Open umbilical Hernia repair (case 1)	CM with EF of < 10%, CAD, end stage liver disease and CKD	Injectate given bilaterally into the lateral interfascial triangle behind QL muscle (QLB type 2)	20 mL of 0.5% ropivacaine	1 mg of i.v midazolam prior to block followed by 0.1 mcg/kg/min of remifentanil infusion	Multimodal modal analgesia (acetaminophen, gabapentin and tramadol)
Balogh et al^Citation16	Open repair of incarcerated ventral hernia (case 2)	CM with an EF< 10%, CAD, COPD, End stage renal disease, HTN, history of cocaine abuse	Injectate given bilaterally into the lateral interfascial triangle behind QL muscle (QLB type 2)	20 mL of 0.5% ropivacaine	Sedation with 0.1 mcg/kg/min infusion of remifentanil and 0.04 mcg/kg/hr of dexmedetomidine	Not reported
Mohan et al^Citation19	Open repair of left inguinal hernia repair	CAD with severe left ventricular dysfunction, DM-II, CLD	Injectate given between Quadratus lumborum and psoas muscles. Indwelling catheter inserted	25 mL of 0.5% ropivacaine	None	Ropivacaine (0.125%) 5mL/hr via indwelling catheter
Vieira et al^Citation17	Terminal colostomy for enterovesical fistula	CAD with a previous MI, chronic anemia, HTN, CKD, DM-II	Injectate deposited anterolateral to the QL muscle, lateral to the transversus abdominis muscle	20 mL of 1.33% of Mepivacaine	4 mg of dexamethasone i.v and fractionated boluses of fentanyl to a total of 75 mcg i.v given	No postoperative analgesia required

Abbreviations: CAD, coronary artery disease; EF, ejection fraction; AV, atrioventricular; HTN, hypertension; IV, intravenous; CKD, chronic kidney disease; QL, quadratus lumborum; OSA, obstructive sleep apnea; CM, cardiomyopathy; QLB, quadratus lumborum block; COPD, chronic obstructive pulmonary disease; DM-II, diabetes type 2; CLD, chronic liver disease; MI, myocardial infarction.

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