1- Interno de Anestesiologia, Centro Hospitalar de Lisboa Central
2- Interno de Anestesiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro
3- Assistente Hospitalar, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central
4- Chefe de Serviço, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central
- Euroanaesthesia 2015 (Berlin, Germany)
To achieve a complete sensory block of the lower limb one must anesthetize up to five nerves. To overcome the unpractical aspect of this, we can choose to perform a lumbar plexus block (LPB). In children this technique is not widely used, in detriment of the neuraxial techniques. Multiple techniques to approach the lumbar plexus have been described, mostly with aid of ultrasound guidance or the nerve stimulator.
We report a case of a ten year-old girl with a right osteoarticular hip dysplasia and a history of myelomeningocele, proposed for a femur osteotomy and open reduction of the hip dislocation. Given her medical history we decided to execute a LBP, for intra operative anesthesia and short post operative analgesia, using the “Shamrock Method” – a new ultrasound-guided approach that has been recently described. After general anesthesia was performed, the patient was proper positioned and a curved ultrasound transducer was placed transversally in the left abdominal flank, just above the iliac crest. Then, tilting and moving the probe caudally, we tried to identify the described pattern of a “tree leaves shamrock” – the psoas muscle anteriorly, the quadrates lumborum muscle at the apex of the tranverse process of L4 and the erector spinae muscle posteriorly. With the help of an electrical nerve stimulator, twitching of the patella (quadriceps) at 0.5 mA was observed. With a posterioranterior ultrasound approach and with the needle in-plane, we injected 10 ml of 0.5% ropivacaine between the hyper echoic oval structures of the lumbar plexus nerves, in the medial and posterior part of the psoas muscle. During the surgery the patient had mild tachycardia (<125 bpm) attributed to blood loss (total of 700 ml) due to an accidental artery laceration. Complementary analgesia was made with 525gr of intravenous paracetamol and 15 mg of ketorolac. In the recovery room, and after 8 hours since the anesthetic was injected, the patient reported right lower limb paresthesias and no pain at all. In the nursery, she remain the night also with no particularly complains.
With this case, the first one described in the literature of the LPB via the Shamrock approach in a child so far, we intend to highlight the potential that this new technique has in the pediatric regional anesthesia, mainly in the cases of anatomical neuraxial deformities.
Palavras Chave: Lumbar Plexus Block, analgesia pos surgery