Transversus abdominis plane (TAP) block via the “lumbar triangle of Jean-Louis Petit” was originally described in 2001 and facilitates surgery in the ilioinguinal-iliohypogastric region.1 Such blocks have increased in popularity due to the rapid development of ultrasound guidance.2,3 The extension of anesthesia to the thoracolumbar plexus (T10 to L1) provides suitable surgical conditions in a wide variety of pelvic procedures. Extracorporeal life support (ECLS) is a method used for refractory acute heart failure.4 Venoarterial access is required for cardiac support by cannulation of large vessels including peripheral access to the femoral vein and artery (cut-down cannulation or percutaneous cannulation). Whereas such peripheral access can be performed under general anesthesia or local anesthesia, in patients with cardiogenic shock, general anesthesia is often poorly tolerated, and local anesthesia may not be adequate. We describe the use of a combination of TAP and genitofemoral nerve block to facilitate successful femoral venoarterial ECLS implantation in a patient with acute heart failure.
The patient reviewed and gave written permission for the authors to publish the report.
A 63-year-old man presented with ST-segment elevation myocardial infarction caused by stenosis of the left main coronary artery. An early revascularization strategy was attempted by percutaneous coronary intervention 3 hours before. The patient developed cardiogenic shock within 24 hours of admission but was hemodynamically stabilized with inotropic support alone (dobutamine). Transthoracic echocardiography (TTE) identified significant left ventricular (LV) systolic dysfunction (25% ejection fraction) with akinesis of the anterior wall. The patient required prolonged catecholamine support and was discharged after 1 month. Three weeks later, the patient remained symptomatic with ease of fatigue, persistent dyspnea (New York Heart Association functional class III), and was readmitted to the intensive care unit (ICU) for global acute heart failure with breathlessness and pulmonary edema. A TTE indicated severe LV systolic dysfunction with significant dilation (LV end-diastolic diameter 62 mm). Doppler analysis revealed a restrictive mitral valvular inflow pattern with ischemic mitral regurgitation (effective regurgitant orifice 20 mm2). Right ventricular function was normal, despite severe pulmonary hypertension (systolic pulmonary artery pressure of 80 mm Hg). Inotropic support (15 μg/kg/min dobutamine, 0.6 μg/kg/min enoximone, and norepinephrine) was initiated but failed to provide rapid improvement of hemodynamic variables, and the patient subsequently developed acute kidney injury (creatinine clearance of 47 mL/min). Mechanical circulatory support with peripheral percutaneous venous-arterial ECLS was discussed.5 Due to this serious pulmonary hypertension and LV dysfunction, the patient was considered at high risk for general anesthesia, and we decided to perform the procedure under regional anesthesia with ultrasound-guided TAP block. The patient was transferred to the cardiac operating room.
No premedication was used, but light intraoperative sedation with remifentanil target-controlled infusion was added (target of 2 mg/mL) to achieve a sedation level at which the patient responds to gentle shaking, corresponding to a Ramsay sedation score of 4 or 3. Spontaneous breathing was preserved throughout the procedure. The probe (linear-array transducer) was laterally positioned and oriented to obtain a transverse view of the abdominal layers. A 100-mm, 21-gauge IM needle was introduced by in-plane insertion, and a combination of 15 mL of 0.5% levobupivacaine (75 mg: 1 mg/kg) and 15 mL of 2% lidocaine (300 mg: 4 mg/kg) were injected with intermittent aspiration. The correct placement of the needle was confirmed by expansion of the solution between the aponeurosis of the internal oblique and the transversus abdominis muscles. To reinforce skin anesthesia, a supplementary ultrasound-guided block of the femoral branch of the genitofemoral nerve was performed with a combination of 5 mL of 0.5% levobupivacaine and 5 mL of 2% lidocaine. Local anesthetic solution was injected laterally to the femoral artery, caudal to the inguinal ligament, between the fascia lata and the superficial part of the fascia iliaca. Thirty minutes after induction anesthesia, the TAP block provided unilateral analgesia of the anterior abdominal wall and the anterior superior part of the thigh from the T7 to L2 dermatomes. Percutaneous cannulations of the femoral artery and vein were performed by a cardiac surgeon. At the end of the procedure, the correct position of the venous cannula in the right atrium was confirmed by TTE.
After ECLS rescue therapy, the patient was transferred to the cardiothoracic ICU. After 4 days of ECLS support, the patient was fitted with a long-term LV assist device with continuous flow by centrifugal pumps Heartware® (HeartWare International Inc., Framingham, MA).6 The patient left the cardiothoracic ICU after 31 days. He is still on the waiting list for a heart transplantation.
This case report describes the successful use of TAP block for the insertion of peripheral cannulae for mechanical circulatory support in a patient in cardiogenic shock with severe pulmonary hypertension due to LV dysfunction and mitral valve disease.
The management of anesthesia in such patients remains a challenge because of the risk of right-sided heart failure. Recently, Stuart-Smith7 reported a case of uncemented bipolar hemiarthroplasty successfully performed under TAP block in a patient with severe cardiac dysfunction. TAP block has also been used successfully for various inguinal surgical procedures in several patients with heart failure.8 This technique provided unilateral analgesia of the entire abdominal wall with a single large bolus injection of local anesthetic.1 A TAP block was effective at blocking these 2 main branches of L1 and providing better pain control than that from conventional iliohypogastric/ilioinguinal nerve blocks, particularly with the ultrasound-guided technique.9 Yet Abdallah et al.10 reported that evidence supporting the use of the ultrasound-guided TAP block technique is limited and suggested that further studies with various surgical procedures involving the inguinal area should be conducted. In our case, cannulation of the femoral vessels was surgically performed and required perfect anesthesia of the femoral access site. To obtain sufficient analgesia in the inguinal region, we added an ultrasound-guided genitofemoral nerve block for the femoral component. The technique was easy and consisted of delivering local anesthetic solution laterally to the femoral artery, between the inguinal ligament and the fascia iliaca. This terminal branch, from the upper part of the lumbar plexus, passes through the psoas major muscle and divides laterally to the external iliac artery. Its genital and femoral branches are not blocked with conventional TAP block, which may have been responsible for previous reports of anesthesia failure.11
In summary, this case report suggests that ultrasound-guided TAP block with blockade of the femoral component of the genitofemoral nerve can be used for anesthesia in patients undergoing femoral arteriovenous implantation of ECLS. This strategy provided suitable analgesia of the inguinal region compatible with the management of a patient with severe heart failure and at risk of death under general anesthesia. Because of inconsistent results from comparative studies using the TAP block approach,10 we suggest that further research should be conducted in randomized trials comparing the 2 anesthesia strategies for these high-risk patients.
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