Short Communication J Clin Med Res.

2022;14(10):425-431

Preliminary Experience With Quadratus Lumborum

Catheters for Postoperative Pain Management in
Pediatric-Aged Patients With Contraindications
to Epidural Anesthesia
Rachel Pooleya, Giorgio Venezianob, c, Candice Burrierb, c,
Nguyen K. Tramb, c, Joseph D. Tobiasb, c, d

Abstract caine and four patients received 0.2% ropivacaine of an initial bolus.
The local anesthetic used for continuous infusion was 0.2% ropiva-
Background: Although neuraxial techniques such as caudal and epi- caine in five patients, 0.1% ropivacaine in two patients, and 1.5%
dural anesthesia were initially the predominant regional anesthetic chloroprocaine in one patient, with a median infusion rate of 0.11
technique used to provide postoperative analgesia in children, there mL/kg/h. QL catheter infusions were supplemented with intravenous
has been a transition to the use of peripheral nerve blockade such as opioids delivered by patient-controlled or nurse-controlled analgesia.
the quadratus lumborum block (QLB). We present preliminary expe- The median opioid requirements in oral morphine milligram equiva-
rience with QL catheters for continuous postoperative analgesia in a lents (MME) were 1.2, 1.0, 1.1, 0.5, and 0.6 MME/kg on postopera-
tive days 1 - 5. Daily median pain scores were ≤ 2 during the 5-day
cohort of pediatric patients following colorectal surgery.
postoperative course. All catheters functioned successfully and were
Methods: After institutional review board (IRB) approval, we ret- in place for a median of 79.3 h. Other than early inadvertent removal
rospectively reviewed the records of patients who underwent major of two catheters, no adverse effects were noted.
colorectal surgery and received QL catheters for postoperative anal-
Conclusions: Although our preliminary data suggest the efficacy of
gesia. The postoperative pain control data consisted of QL catheter
QL catheters in providing prolonged postoperative analgesia for up
characteristics, anesthetic agents, adjuncts, pain scores, and opioid
to 3 - 5 days following colorectal procedures, attention needs to be
consumption during the postoperative period.
directed at measures to ensure that the catheter is secured to avoid
inadvertent removal.
Results: The study cohort included eight pediatric patients, ranging
in age from 1 to 19 years (median age 11.8 years). The QL catheters
Keywords: Quadratus lumborum block; Pediatric; Children; Postop-
were placed in the operating room after the induction of anesthesia. erative analgesia; Local anesthetic
Comorbid conditions in the cohort that were contraindications to neu-
raxial anesthesia included spinal/vertebral malformations, presence
of a ventriculoperitoneal (VP) shunt, anal atresia, tracheo-esophageal
fistula (VACTERL) association, and coagulation disturbances. All pa-
tients underwent complex colorectal or genito-urologic procedures. Introduction
Bilateral QL catheters were placed in six patients, and unilateral cath-
eters were placed in two patients. Four patients received 0.5% ropiva- The assessment and management of postoperative pain in
the pediatric population remains challenging and despite on-
going refinements of techniques, the control of post-surgical
Manuscript submitted August 17, 2022, accepted September 23, 2022
Published online October 28, 2022
pain may be suboptimal [1, 2]. To address these issues, there
has been an increased use of regional anesthetic techniques to
aHeritage College of Osteopathic Medicine, Dublin Campus, Dublin, Ohio and improve postoperative analgesia while limiting the adverse
Ohio University, Athens, OH, USA effects of systemic opioids [3, 4]. Although neuraxial tech-
bDepartment of Anesthesiology & Pain Medicine, Nationwide Children’s Hos-
niques (caudal and epidural anesthesia) were the predominant
pital, Columbus, OH, USA regional anesthetic technique initially used in children, there
cDepartment of Anesthesiology & Pain Medicine, The Ohio State University
has been a transition to peripheral nerve blockade as a means
College of Medicine, Columbus, OH, USA
dCorresponding Author: Joseph D. Tobias, Department of Anesthesiology & of prolonged postoperative analgesia [5]. Advantages of pe-
Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA. ripheral nerve blockade include selective blockade with uni-
Email: [email protected] lateral analgesia, avoidance of sympathetic blockade, selective
sensory blockade and preservation of motor function, a lower
doi: https://doi.org/10.14740/jocmr4813 incidence of urinary retention, and the use of lower volumes of

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This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits 425
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited
QL Catheters for Postoperative Pain Management J Clin Med Res. 2022;14(10):425-431

the local anesthetic agent thereby resulting in a limited poten- time period were identified. The electronic medical record was
tial for local anesthetic systemic toxicity (LAST) [5, 6]. Addi- reviewed for patient demographic data including the surgical
tionally, there may be anatomical or patient-related comorbid procedure (type and duration), and specifics regarding the QL
conditions which preclude the use of neuraxial techniques. block including the technique of placement. Demographic in-
First described in the adult population, the quadratus lum- formation obtained included age, weight, gender, and coexist-
borum block (QLB) is a variation of a transversus abdominis ing medical conditions, such as the presence of spinal cord or
plane (TAP) block used to provide postoperative analgesia fol- vertebral abnormalities (spinal dysraphism) and coagulation
lowing abdominal surgery. Like the TAP block, the QLB is disturbances. The postoperative pain control data consisted of
an inter-fascial block requiring deposition of the local anes- QL catheter characteristics (local anesthetic used and the in-
thetic agent between the fascial layers. The primary ultrasound fusion rate), analgesic adjuncts administered postoperatively,
landmark for accurate performance is the quadratus lumborum and opioid consumption. Also documented were postoperative
muscle (QLM) while the key to analgesia is the thoracolumbar pain scores, hospital length of stay, time to first ambulation,
fascia (TLF). While it remains open for debate, the mechanism intensive care unit (ICU) stay, time to first bowel movement,
of the analgesia provided by the QLB is postulated to result and time to first oral intake. Adverse effects and complications
from the spread of the local anesthetic agent along the TLF and related to the QL catheter, and the local anesthetic infusion
the endothoracic fascia into the paravertebral space, over the were also noted.
anterior primary rami of the various spinal nerves in the thora-
columbar region, thereby providing cutaneous analgesia to the
dermatomes of the anterior abdominal wall [7-11]. The degree Technique for catheter placement
of dermatomal coverage, which may extend from T5 to L1,
depends on the volume injected and hence the spread within Intraoperative placement of the QL catheters, postoperative
the paravertebral space. Additional visceral analgesia may be use of the QL catheters and, analgesic decisions were directed
provided by epidural spread of the local anesthetic agent or by the attending pediatric anesthesiologist on the Acute Pain
splanchnic sympathetic blockade. As QLBs can provide so- Service. This included the use of local anesthetic bolus doses
matic as well as visceral analgesia of both the abdominal wall and rate changes of the ropivacaine infusion. All catheters were
and the lower aspects of the thoracic wall, it may be a useful placed after the induction of general anesthesia and endotra-
analgesic modality for selected abdominal surgical procedures cheal intubation. The patient was positioned in the lateral de-
involving the lower thoracic and lumbar dermatomes [12-20]. cubitus with the surgical side facing up. Prior to catheter place-
To date, the majority of experience with QLBs in both the ment, the skin was prepped with chlorhexidine and draped in
adult and pediatric population have included single injection sterile fashion. An 18-gauge Tuohy needle was advanced with
techniques. As with other forms of peripheral nerve or inter- in-plane ultrasound guidance to the inter-fascial plane between
fascial blockade, the duration of analgesia may be extended the quadratus lumborum and iliopsoas muscles (anterior tech-
by catheter placement and continuous infusion of a local an- nique) or to the lateral aspect of the quadratus lumborum mus-
esthetic agent rather than a single shot technique [21, 22]. cle adjacent to the aponeurosis of the transversus abdominis
So far, there are a limited number of reports of the use of QL muscle (lateral technique). Using weight-based local anesthet-
catheters to provide analgesia following abdominal surgery ic dosing, ropivacaine (0.2% or 0.5%) was deposited in the
in pediatric-aged patients. We present preliminary experience fascial plane and a 20-gauge catheter was threaded 4 - 6 cm be-
with the largest reported cohort of pediatric patients in whom yond the needle tip prior to removing the needle. The catheter
QL catheters were used for continuous postoperative analgesia was secured with 2-octyl cyanoacrylate (Dermabond®) and an
following colorectal surgery. occlusive dressing was placed over the insertion site. For bilat-
eral catheters, the patient was repositioned, and the procedure
was repeated on the contralateral site.
Materials and Methods
Postoperative catheter care
This study was approved by the Institutional Review Board
of Nationwide Children’s Hospital (MOD00012593) and con-
ducted in accordance with the regulations of the Declaration Postoperatively, the QL catheters were continuously infused
of Helsinki for research involving human subjects. As a ret- with ropivacaine (0.1% or 0.2%) or chloroprocaine 1.5%.
rospective cohort study, patients were deemed as exposed to When ropivacaine was used, the infusion rate and concentra-
no more than minimal risk and the need for individual written tion were adjusted so as not to exceed departmental-based
informed consent was waived. To maintain patient confidenti- guidelines of 0.4 mg/kg/h. Selection of the ropivacaine con-
ality, only deidentified data were used for the purpose of this centration was based on the patient’s weight, the intended
study. Data collected during this study were stored in a secure infusion rate, and adherence to institutional local anesthetic
location and only the collaborators directly involved in this dosing guidelines. Postoperative analgesia was supplemented
study have access. All electronic files were stored on a secure, by bolus doses of intravenous opioids (morphine or hydromor-
password-protected network. phone) administered by patient-controlled or nurse-controlled
Patients who received a unilateral QL catheter or bilat- analgesia. Once patients were tolerating oral intake, analgesia
eral QL catheters for postoperative analgesia during 36-month supplementation was changed to oral opioids (oxycodone).

426 Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org
Pooley et al J Clin Med Res. 2022;14(10):425-431

Catheters were removed at the bedside when no longer indi-

Data are listed as the number, mean ± SD or median (IQR). ICU: intensive care unit; BMI: body mass index; QL: quadratus lumborum; SD: standard deviation; IQR: interquartile range.
Unilateral
Patient 8
cated or when catheter concerns (nonocclusive dressing barrier
breach, inadvertent catheter disconnect) were noted.

143.6

0.5%
Male

20.5
42.2

0.14
11.9

Yes
No

No
-
Data presentation and statistical analysis

Patient 7

Bilateral
Female

0.2%
19.8
14.8
37.2

0.12
137

Yes
No

No
The following postoperative outcomes were analyzed during

-
the postoperative period: pain scores, use of adjunctive analge-

Unilateral
Patient 6
sic agents, opioid consumption, and QLB-related complications.

Female
Pain was evaluated in our study population by a visual analog

0.2%
16.1

0.37
Yes
Yes
1.1
8.1
pain score (VAS) using a 0 - 10 scale. If the VAS scale could not

No
71

-
be used based on the patient's age or cognitive state, an observa-

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

tional scale (Wong-Baker pain scale or Faces, Legs, Agitation,

Bilateral
Female
Cry, and Consolability or FLACC scale), was used. All three

0.2%
16.4
92.4

0.21
Yes
Yes
2.8
scales are validated assessment tools for pain that use a 10-point

No
14

-
grading system, with zero being most comfortable or no pain.

Bilateral
Pain scores were collected at 6-h intervals for all patients. Mean

Female

141.4
individual pain scores for each 24-h postoperative period were

0.5%
15.1

0.06
11.6

Yes

Yes
No
17
34
tabulated and the median and interquartile range were calculated.
Opioid consumption was determined over the first 5 postopera-

Bilateral
tive days with conversion of all administered intravenous and

164.2

0.5%
Male
oral opioids to oral morphine milligram equivalents (MMEs) in

24.9

0.04
Yes
No

No
15
67
mg/kg/day [23].

-
Parametric continuous data were presented as means and

Bilateral
Female
standard deviations. Nonparametric data were presented as

0.2%
16.6
21.9

0.09
115

Yes

Yes
medians and interquartile ranges. Categorical variables were
9.1

No
15
presented as frequencies and percentages. Repeated measures
analysis of variance (ANOVA) was used to determine the sta-

Bilateral (6), unilateral (2) Bilateral

Female

tistical trends for pain score and opioid use observed for post- 172.2

0.5%
35.7
19.5

22.7

0.06
106

Yes

Yes
No
operative days. All statistical analysis was performed using
Python (Python Software Foundation, Wilmington, DE).

Results

0.5% (4), 0.2% (4)

15.1 (15.0, 18.9)

0.11 (0.06, 0.16)

11.8 (7.5, 14.8)

Yes (3), no (5)

Entire cohort

129.6 ± 34.7

The study cohort included eight patients, ranging in age from

41.3 ± 31.9

20.9 ± 6.7

1 to 19 years (median age 11.8 years) and a median weight of 8 (100%)

41.3 kg. The demographic data for the cohort are summarized Early removal of catheter due to catheter disconnect Yes (2)
2/6

in Table 1. Comorbid conditions which generally precluded the

use of neuraxial anesthesia included coagulation disturbances
Table 1. Demographic Data of the Study Cohort

or vertebral and spinal abnormalities such as tethered spinal

cord, spina bifida, and myelomeningocele. All the patients un-
derwent complex colorectal and genito-urologic procedures
including exploratory laparotomy, lysis of intra-abdominal
Initial bolus (0.5% or 0.2% ropivacaine)

adhesions, colostomy placement or revision, posterior sagittal

anorectoplasty, and bowel resection.
The QL catheters were bilateral in six patients and unilat-
Demographic or catheter data

Initial infusion rate (mL/kg/h)

eral in two patients. The QL catheter characteristics are out-

lined in Table 2. The median procedure time for QL catheter
placement was 15 min (interquartile range (IQR): 11.5, 18.0
Gender (male/female)

min). There were no patient-related complications during QL

QL block laterality

QL block success

catheter placement or subsequent use. Following placement, a

Time in ICU (h)
ICU admission

bolus dose of the local anesthetic was administered through the

(kg/m2)
Height (cm)
Weight (kg)
Age (years)

catheter (median volume of 0.5 mL/kg, IQR: 0.3, 0.7) of either

0.2% ropivacaine or 0.5% ropivacaine. The local anesthetic
used for continuous infusion was 0.2% ropivacaine in five pa-
BMI

tients, 0.1% ropivacaine in two patients, and 1.5% chloropro-

Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org 427
QL Catheters for Postoperative Pain Management J Clin Med Res. 2022;14(10):425-431

Table 2. Quadratus Lumborum Catheter Characteristics

Number of patients 8
QL block laterality (bilateral/unilateral) 6/2
QL block medication initial bolus (0.5% or 0.2% ropivacaine) 4/4
QL block medication infusion concentration (0.2% ropivacaine, 0.1% ropivacaine, 1.5% chloroprocaine) (5/2/1)
QL block success 8 (100%)
QL block complications noted 0
Initial bolus dose (mL/kg) 0.51 (0.3, 0.69)
Infusion rate (mL/kg/h) 0.11 (0.06, 0.16)
Early removal of catheter due to catheter disconnect 2
Procedure time (min) 15.0 (11.5, 18.0)
Data are listed as the number, mean (SD) or median (IQR). QL: quadratus lumborum; SD: standard deviation; IQR: interquartile range.

caine in one patient. The infusion rate of the local anesthetic ICU stay time of 15.1 h (IQR: 15.0, 18.9 h). The median time to
agent was a median of 0.11 mL/kg/h (IQR: 0.06, 0.16). In one first ambulation following surgery was 51.8 h (IQR: 21.1, 68.7
patient, the infusion was decreased from 6 mL/h to 3 mL/h as h). The time to first intake was 32.7 h (IQR: 17.3, 54.7 h). The
the parents noted subjective concerns that the patient was sleepy first flatus or bowel movement occurred at 24.8 h (IQR: 16.7,
while the patient stated that they felt flushed and dizzy. The 42.2 h) postoperatively. Daily median pain scores were ≤ 2.1
success rate was judged as 100% with patients generally main- during the first 5 postoperative days. The QL catheter infusion
taining median pain scores ≤ 2 during the postoperative course was supplemented with intravenous opioids (nurse-controlled
(Fig. 1). Other than early removal of catheter (n = 2, 25%), no analgesia (NCA) or patient-controlled analgesia (PCA)), with
complications were documented. Catheters remained in place six patients receiving hydromorphone and two patients re-
for a median of 79.3 h (IQR: 15.1, 110.7 h). Early removal of ceiving morphine. If needed, patients were transitioned to the
the catheter was necessitated in two patients by disconnection opioid oxycodone once they were able to tolerate oral intake.
of the infusion tubing or disruption of the sterile barrier of the The median opioid requirements in oral MME were 1.2, 1.0,
bio-occlusive dressing of the catheter. One additional patient 1.1, 0.5, and 0.6 MME/kg on the first 5 postoperative days,
required removal of one side of their bilateral catheters due to respectively. No statistical trends were found for pain score
inadvertent disconnection of the infusion tubing. and opioid use observed for the postoperative days. Adjunctive
Postoperative outcome data are listed in Table 3. Three analgesic agents are listed in Table 4. Acetaminophen was used
patients were admitted to the ICU after surgery with a median in all eight patients while diazepam was used in six patients.

Figure 1. Postoperative pain scores (a) using a 0 - 10 visual analogue score and opioid requirements (b) expressed as oral
MMEs. MME: morphine milligram equivalent. Data are listed as median and interquartile ranges.

428 Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org
Pooley et al J Clin Med Res. 2022;14(10):425-431

Table 3. Postoperative Course Table 4. Postoperative Analgesic Adjuncts

Postoperative event Hours, median (IQR) Agent Number (%)

Time to first ambulation 51.8 (21.1, 68.7) Acetaminophen 8 (100)
Time to first oral intake 32.7 (17.3, 54.7) Diazepam 6 (75)
Time to first flatus or bowel movement 24.8 (16.7, 42.2) Ketorolac or ibuprofen 3 (37.5)
IQR: interquartile range. Intraoperative methadone 2 (25)
Postoperative ketamine infusion 2 (25)
Discussion
28]. When compared to epidural anesthesia, advantages of the
The QLB has gained popularity as a nonopioid adjunct in QLB include the provision of unilateral blockade, avoidance
lower thoracic and abdominal surgery, owing to its efficacy, of motor blockade, lack of urinary retention, and placement
opioid-sparing properties, and avoidance of neuraxial access. in patients who are not candidates for neuraxial techniques
While several studies have demonstrated the utility of the QLB including those with spinal dysraphism and coagulation dis-
in various surgical procedures, predominantly in the adult pop- turbances. These latter comorbid conditions are common in
ulation, the limited published data also support its efficacy in patients with anorectal malformations.
the pediatric population. Our retrospective study summarizes Limitations of our current study are inherent to its retro-
the characteristics and safety profile of a novel technique us- spective nature and include a lack of standardization of the in-
ing QL catheters as a means of providing prolonged analge- traoperative anesthetic technique, the postoperative analgesic
sia (up to 5 days) following colorectal surgery in children and regimen, and the technique of the QLB. Additionally, there was
adolescents. To date, this is the first study outlining the use some variation in the surgical procedure which would likely
of QL catheters with a continuous infusion as opposed to a impact the postoperative course and analgesic requirements.
single shot technique. This technique allows the feasibility of Some of these issues are mitigated to some degree as the tech-
continuing the use of the regional anesthetic technique for up nique for QL catheter placement and use (bolus and continu-
to 3 - 5 days following the surgical procedure as compared to ous infusion techniques) did not vary significantly as they fol-
12 - 18 h of analgesia following a single bolus technique [24]. lowed the structured clinical practice of our acute pain service.
Our retrospective review suggests that the QLB with continu- Additionally, there was standardization for the assessment of
ous infusions can be performed safely and efficiently in anes- postoperative pain including routine use of pain scores.
thetized patients with a high success rate, and it may serve as Our preliminary data support the use of QL catheters as an
a useful analgesic adjunct for children undergoing open colo- adjunctive to the analgesic regimen following major colorectal
rectal surgery. procedures in infants and children. Our cohort is the first report
As the QLB (continuous infusion or single bolus tech- regarding the use of continuous infusions using QL catheters in
nique) is our current standard for providing postoperative an-
pediatric-aged patients. The catheters were effective adjuncts
algesia following major colorectal surgery in infants and chil-
to postoperative analgesia as judged by the postoperative pain
dren, a comparable control group was not available during the
scores and opioid requirements. As noted in our cohort, the
same time period at our institution. To evaluate the analgesia
primary concern was inadvertent catheter disconnects which
efficacy, it is necessary to compare our data (patient scores and
may result in a risk of infectious complications thereby neces-
opioid requirements) to that from a published cohort of similar
sitating catheter removal. However, other potential adverse ef-
patients that did not receive a QLB [25]. George et al reported
an average 24-h postoperative pain score of 4.5 in 148 children fects that may occur in larger cohorts include motor blockade
who underwent laparoscopic and open colorectal surgery with- due to spread of the local anesthetic to the lumbar plexus and
out the use of adjunctive regional anesthesia [25]. The median sympathetic blockade with hypotension due to spread of local
postoperative pain score was 2.1 in our cohort of patients dur- anesthetic to the paravertebral and epidural space. Addition-
ing the first 24 postoperative hours with a reduction in the need ally, whenever local anesthetic infusions are used postopera-
for systemic opioids [26]. The analgesic efficacy of the QLB tively, attending to local anesthetic dosing is required due to
in our cohort is likely attributable to analgesic coverage of so- the potential for LAST.
matic abdominal pain. However, persistent opioid requirement
may be secondary to the visceral pain component which may Acknowledgments
not be completely controlled by the QLB. This was the case
in our patient cohort who received both nonopioid adjunctive
agents as well as opioids during the postoperative period. None to declare.
Although our regional anesthesia practice, specifically
that use continuous postoperative infusions, initially focused
on the use of neuraxial techniques such as epidural analgesia,
Financial Disclosure
our practice has mirrored that of the adult population with a
transition over the past 5 - 6 years to an increased use of pe- This research did not receive any specific grant from agencies
ripheral nerve blockade including continuous infusions [27, in the public, commercial, or not-for-profit sectors.

Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press Inc™ | www.jocmr.org 429
QL Catheters for Postoperative Pain Management J Clin Med Res. 2022;14(10):425-431

Conflict of Interest and Techniques. Anesthesiology. 2019;130(2):322-335.

8. Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani
N, Nixon AM, Chin KJ. A radiologic and anatomic as-
None to declare. sessment of injectate spread following transmuscular
quadratus lumborum block in cadavers. Anaesthesia.
Informed Consent 2017;72(1):73-79.
9. Elsharkawy H, El-Boghdadly K, Kolli S, Esa WAS, De-
Grande S, Soliman LM, Drake RL. Injectate spread fol-
As a retrospective cohort study, patients were deemed as ex- lowing anterior sub-costal and posterior approaches to
posed to no more than minimal risk and the need for individual the quadratus lumborum block: A comparative cadaveric
written informed consent was waived. study. Eur J Anaesthesiol. 2017;34(9):587-595.
10. Sondekoppam RV, Ip V, Johnston DF, Uppal V, Johnson
Author Contributions M, Ganapathy S, Tsui BCH. Ultrasound-guided lateral-
medial transmuscular quadratus lumborum block for
analgesia following anterior iliac crest bone graft har-
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