Rapid Summary - January 2025
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January 2025
Ultrasound-guided quadratus lumborum block in children
- There is no difference in number of complications between central neuraxial and peripheral nerve blocks, however the potential complications of central blocks are clearly worse - think paralysis and LAST
- Quadratus lumborum blocks seem to provide similar pain relief to neuraxial techniques, without the heady risk profile
- Basically you inject local anaesthetic next to quadratus lumborum
Some anatomy
- QL sits in the posterior abdominal wall
- It is dorsolateral to psoas major
- It originates from the iliac crest and iliolumbar ligament
- It inserts into the 12th rib and transverse processes of L1 to L5
The block
- Two main approaches - lateral and anterior
The effects
- Somatic analgesia of the abdomen and lower limb
- Some sensory blockade between T6 and L4
- Some visceral analgesia via transversalis and endothoracic fascia to the paravertebral space
The evidence
- As with everything in paeds, there isn't much evidence but the studies that exist suggest it does work pretty well
Indications
Lateral can be used for day case stuff:
- Inguinal hernia repair
- Orchidopexy
- Hydrocoele
- Laparoscopic surgery
- Iliac crest bone graft
Anterior is mainly for inpatient orthopaedic procedures, because there's often temporary leg weakness afterwards:
- Hip reconstruction
- Lateral hip surgery
- Removal of metalwork
- Femoral/Pelvic osteotomy
Helpful tips
- Optimise position - lateral QL block can be done in supine position with hip bolster if needed, while anterior should be done with patient in lateral decubitus
- Use linear probe for kids <20kg, curvilinear otherwise
- Low concentration, high volume block - e.g. 0.5ml/kg 0.25% levobupivacaine
- Start scanning over the anterior abdomen with moderate pressure to smooth out the muscle layers underneath
- Use an anterior to posterior in plane approach for lateral blocks
- Use a posterior to anterior approach for anterior blocks
- Angling the probe cranially will help spot the kidneys and liver
- Doppler can be used to find any lumbar arteries running down the back of psoas and QL
Complications
- Failure
- Infection
- Bleeding or haematoma
- Kidney damage
- Bowel perforation
- Leg weakness due to lumbar plexus and femoral nerve block
Here's a great video, shared with permission.