Quadratus Lumborum Block for Incarcerated Hernia Repair in a Multi-Morbid Elderly Patient: A Letter to Editor
Alessandro De Cassai*, Tommaso Tonetti and Carlo Ori
Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Italy
Submission: March 28, 2018; Published: May 24, 2018
*Corresponding author: Alessandro De Cassai, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121 Padova, Italy.
How to cite this article: Alessandro De Cassai, Tommaso Tonetti, Carlo Ori. Quadratus Lumborum Block for Incarcerated Hernia Repair in a Multi-Morbid
Elderly Patient: A Letter to Editor. J Anest & Inten Care Med. 2018; 6(5): 555696. DOI: 10.19080/JAICM.2018.06.555696
We report here the case of a 91 years old male patient who presented to our emergency department for lower abdominal pain persisting for two days. Physical examination deposed for left inguinal incarcerated hernia and the surgeon indicated urgent surgical repair. The patient had a history of post-infarctual dilated cardiomyopathy with hypokinesia of the inferior and the lateral left ventricular wall with reduction of ejection fraction (33%), triple PCI (seventeen years ago), pace-maker implantation for a third degree atrioventricular block, severe pulmonary hypertension
(echocardiography-derived systolic pulmonary artery pressure of 70 mmHg), severe mitral valve insufficiency and third stage chronic kidney disease (CKD).
He was hemodynamically stable and the routine blood exams showed only an elevation of urea and creatinine consistent with the patient’s CKD; all other laboratory values, including blood cell count and coagulation profile, were normal. An anesthesiological written informed consent was then acquired
On admission to the operatory room, the patient was
monitored, and his vitals were: heart rate 70 bpm, radial artery
blood pressure 150/80 mmHg and SpO2 97%. An intravenous line
was started. The patient was then placed in left lateral recumbent
position. After aseptic preparation, a transmuscular quadratus
lumborum blockade (QLTM) was performed . An ultrasound
low frequency curvilinear probe was placed on patient’s flank
between the costal margin and the iliac crest to identify the tip of
the transverse process (Figure 1). A 22-Gauge, 100mm long nerve
block needle (Sonoplex, Pajunk, Germany) was then advanced
with an ‘in-plane’ approach until the border of the quadratus
lumborum muscle was reached; 30 ml of 0.5% ropivacaine were
then injected under ultrasound vision. Expansion of intermuscular
plane due to local anaesthetic spread was observed.
The patient was then positioned back on supine position and
a conscious sedation with propofol 1mg/kg/h and remifentanil
0.05mcg/kg/min was started. Thirty minutes after the nerve block
the surgery started. Heart rate, blood pressure, and SpO2 were
recorded perioperatively, and the vitals kept stable. The patient
remained comfortable and spontaneously breathing throughout
the surgery, which lasted for about 60 minutes. Additional local
anesthetic infiltration with lidocaine 2% was required only during
manipulation of the hernia sac, which contained an incarcerated
but vital ileal segment, that didn’t required resection. The
postoperative course was uneventful, and the patient required
only paracetamol administration for pain control. He was then
discharged from the hospital on the fourth postoperative day.
Anaesthesia in very old and multi-morbid patients can be very
challenging, even for minor surgery. Compared to younger patients,
the elderly ones suffer from metabolic impairment, impaired
wound-healing ability, higher sensibility to fluid overload and
predisposition to complications and prolonged hospitalization
. Both general and regional anesthesia is associated with side
effects in geriatric patients [3-5]. Mini-invasive surgery, lowimpact
anesthesiological techniques and short hospital stays
should be considered to decrease such complications.
In our opinion, QLTM emblematizes the best approach for
inguinal hernioplasty in multi-morbid elderly patient, preserving
both circulation and spontaneous breathing.