Bilateral Single-shot Quadratus Lumborum Block as an alternative of epidural analgesia 
Authors: Luísa Ferreira1, Ana Vaz2, Ana Oliveira3, Carlos Almeida4, Clarinda Neves5, José Pedro Assunção6
1,2,3- Anesthesiology residents 4,5- Anesthesiologists; 6- Dir. Of Anesthesiology department 
Introduction: In open abdominal surgery, advantages of the epidural catheter in postoperative analgesia are recognized, although there are relative/absolute contraindications. Bilateral single-shot quadratus lumborum block (QLB) produces sensitive block from T6-L1 which promotes visceral and somatic pain relief for several hours.1,2 
Case report: Female patient, 41 years old, ASA III, with Charcot's disease, ascites, hyperthermia and leucocytosis. The patient underwent laparotomy for bilateral anexectomy, hysterectomy, appendectomy and omentectomy, in the context of left ovarian tumor. Regarding the patient’s morphological alterations of the spine and the probable infection, no epidural catheter was placed. A general anesthesia was performed, with multimodal analgesia in the intraoperative period. In the PACU, the patient presented NRS 9/10 pain. A QLB type 2 was performed with ropivacaine 0.375%, 18 ml, ultrasound guided. Immediately after block the patient reported pain EN 0/10, without requirement of aditional analgesic therapy during 20 hours. By this time NRS started to increase, parecoxib 40mg 2id and tramadol 75mg 3id were added to the analgesic regimen. Up to 48h post-operatively the patient needed 5mg of morphine iv as rescue. 
Discussion: Epidural analgesia isn´t always applicable and postoperative pain control in patients undergoing open abdominal surgery is very difficult without using high doses of opioids. The bilateral QLB allows the use of high doses of LA and a long duration of the block (without catheter placement that could suffer from bacterial colonization in this patient if epidural catheter or bilateral QLB catheters were used). Theoretically, risk of hypotension exists because LA enters paravertebral space, therefore strict and extended surveillance is necessary in PACU2.
Learning points: This case suggests the effectiveness of Bilateral Single-shot Quadratus Lumborum Block in the control of intense postoperative pain, allowing good pain control and decreasing the use of intravenous analgesia. 
References: 1. Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol. 2013;29:550–2. 2. El-Boghdadly K., Elsharkawy H., Short A., Chin K. J. Quadratus lumborum block nomenclature and anatomical considerations. Regional Anesthesia and Pain Medicine. 2016;41(4):548–549. doi: 10.1097/AAP.0000000000000411. 


11 / Single shot bilateral quadratus lumborum block, a suboptimal alternative when neuroaxial or perineural catheterization are hazardous