A 71-year-old male patient (174 cm, 56 kg) with a 15-mm large mass in the upper pole of the left kidney was scheduled for the RAPN peritoneal approach. Rapid induction was achieved using fentanyl, propofol, and rocuronium, which were added after establishing peripheral intravenous access. Anesthesia was maintained using desflurane and remifentanil. After tracheal intubation, and assuming the right decubitus position, the anterior QLB and ESPB were performed (Fig. ). A convex probe (2–5 Hz) was placed on the L2 vertebral body, and we attempted to obtain the shamrock view, which overlooks the quadratus lumborum muscle (QLM), erector spinae muscle (ESM), psoas major muscle (PMM), and vertebral body. A 100-mm block needle (20-G Tuohy needle) was inserted using the in-plane technique; moreover, 30 mL of 0.25% ropivacaine was applied between the QLM and PMM as the anterior QLB. Subsequently, the ESPB was performed at the transverse process of Th10. From this point, the needle was inserted in the caudal-to-cephalad direction. After confirming that the needle reached the ESM, we injected 30 mL of 0.25% ropivacaine. The operation was performed via the peritoneal approach with six port holes. The operative and anesthetic times were 209 and 294 min, respectively.\nThe patient intraoperatively received intravenous fentanyl 300 μg and acetaminophen 1000 mg. Postoperative pain was managed in the ward using continuous intravenous infusion of 15 μg/h fentanyl combined with 15 mcg fentanyl for intravenous patient-controlled analgesia (IV-PCA) with a 10-min lockout.\nA pinprick test was performed 2 h post-surgery using the Semmes-Weinstein monofilament 2.0 g (SAKAI Medical Co., Tokyo, Japan) as part of the postoperative procedures by someone who did not perform the blocks. The pinprick test revealed that the anesthetized dermatomal range was Th7–Th12. However, tactile sensation was normal around the port site in the midline of the umbilicus. The numerical rating scale (NRS) was 0-0-0-0/10 at rest and 1-1-1-5/10 on movement at 2, 12, 24, and 48 h after surgery, respectively. IV-PCA was stopped at 20 h after surgery due to postoperative nausea and low NRS value. The total fentanyl amount postoperatively used was 450 μg. Acetaminophen was administered once at postoperative day (POD) 1. He was discharged without any adverse events at POD 6.
An 86-year-old female patient weighing 82 kg with 1-week-old right femoral neck fracture was scheduled for internal fixation or hemiarthroplasty. Medical history was significant for hearing loss, cerebrovascular event 7 years ago and severe aortic stenosis. Physical examination and laboratory tests were positive for Grade IV murmur on the aortic area and high serum creatinine (2.33 mg/dl). Peripheral arterial blood gases without O2 support were as follows: pH: 7.40, PaCO2: 38.3 mmHg PaO2: 66.7 mmHg and O2 saturation: 90%. Posterior-anterior chest X-ray showed right hilar widening, elevated left hemidiaphragm and an area of atelectasis/mass in the left basal segment. Initial electrocardiogram (ECG) revealed atrial fibrillation-flutter and a follow-up ECG demonstrated sinus rhythm. Patient was classified as being American Society of Anesthesiology Class 4. The patient and family were informed of the high risk of morbidity and mortality and written informed consent was obtained. After considering all comorbidities, general or spinal/epidural anaesthesia was considered to be of considerable risk. Therefore, a combination of peripheral nerve blocks was considered as alternatives. Premedication of 1 mg midazolam was performed. Invasive arterial pressure monitoring added to standard monitorisation plan.\nPatient was placed in the left lateral decubitus position. After aseptic precautions and skin preparation, the fourth lumbar vertebral spinous process was identified, and a low-frequency convex transducer was placed 4 cm lateral to the midline on the parasagittal plane. The transverse process and erector spinae muscles were visualised. A 10 cm 22G needle was advanced using the out-of-plane technique. After contact with the transverse process, local anaesthetic (0.5% bupivacaine 20 ml, 2% lidocaine 8 ml and 12 ml isotonic saline) was administered. Thereafter, the transducer was placed in the transverse plane on the flank of the patient cranial to the iliac crest. The fourth lumbar vertebral transverse process, erector spinae psoas and quadratus lumborum muscles were identified. A 15 cm 22G needle was inserted on the posterior corner of the convex probe. Twenty millilitres of local anaesthetic (0.5% bupivacaine 10 ml, 2% lidocaine 4 ml and 6 ml isotonic NaCl) was administered between the quadratus lumborum and psoas muscles. This ratio of LA was chosen considering toxic levels of each component and is customised for this patient.\nFollowing blocks, the patient was placed in the supine position. After 20 min, pinprick test revealed sensory block between T10 and L4 dermatomes. The patient was able to move her feet; however, there was no movement of the hip joint. The patient had no pain. There was no sensorial or motor block on the contralateral side, possibly excluding the presence of epidural spread. Surgery commenced at 35th min following nerve block. Partial hip prosthesis was performed in 2 h. Twenty-five micrograms of fentanyl was administered once for arterial line placement and once because of the slight increase in blood pressure, making the total administered dose 50 mcg. Interventions involving the medial aspect of the femur, innervated by the obturator nerve, led to mild pain and increments of 10 mg of intravenous ketamine was given totalling 40 mg. Post-operative analgesia plan included paracetamol that was administered every 8 h. Examination at postoperative 12th h revealed no pain at rest or on movement. Numeric Rating Scale was ≤2/10 for the first 16 post-operative hours during which time rescue analgesia was not required.