Opioid‐Free Anesthesia for a Child With Patau Syndrome With External Oblique Intercostal Fascial Plane Blocks

In this case, we describe a novel regional block used on a child undergoing an elective laparoscopic cholecystectomy. The child has Patau syndrome, or Trisomy 13, a congenital syndrome involving multiple systems. Children with Trisomy 13 usually suffer from cleft palate, congenital heart disease, seizures, developmental delay, and limb contractures [1]. Unfortunately, 90% die before 1 year of life [2]. The commonest cause of mortality is complex congenital heart disease and the occurrence of central apnea. Our patient is an 8-year-old girl weighing 24 kg with a number of challenges as a result of Patau syndrome. These include, but not limited to, epilepsy, PV stenosis, an unrepaired cleft palate, global developmental delay, hearing loss, and limb contractures. She presented with abdominal pain that comes on whenever she is fed through her gastrostomy tube and stops when feeding stops. This was secondary to gallstones, and a laparoscopic cholecystectomy was planned. While this child had general anesthetic before, there were all for diagnostic tests such as MRI scans. We were faced with the dilemma of a child with a theoretic risk of central apnea that may be triggered by opioids [3] and a plan for an opioid-free anesthetic was made. Despite the high risk of general anesthesia in this patient, this child had suffered two episodes of cholecystitis and pain relief was challenging, so it was decided that the procedure would be in her best interests. We used TIVA throughout the procedure with Propofol and remifentanil. She had dexamethasone and ondansetron as antiemetics. She had Co-amoxiclav pre-procedure and was on a maintenance infusion of 0.9% saline with 5% dextrose. As well as multimodal analgesics such as paracetamol, diclofenac, magnesium sulphate, and clonidine, we decided to utilize a regional anesthesia technique recently described in the literature. The External oblique intercostal plane block (EOI) would provide cover for the upper abdominal region. At the end of the procedure, prior to stopping TIVA, the block was performed bilaterally and under ultrasound guidance. A total of 15mls of 0.25% Levobupivacaine were given. Ketamine and IV lidocaine were two drugs with analgesic properties we considered but did not give (especially with the potential for local anesthetic toxicity when we have already given levobupivacaine). The child was extubated when awake at the end of the procedure and then transferred to HDU. Pain assessment in HDU was performed using a combination of FLACC score, vital signs, and input from her mother, who as helpful in interpreting her postures and sounds. As a result, good pain control was achieved using a combination of paracetamol, NSAIDs, and clonidine. She was discharged home after 4 days in hospital. There is a dearth of information on the anesthetic management of older children with Patau syndrome due to the high mortality rate. One of our most pressing issues was the risk of central apnea, and therefore, this child underwent extensive pre-operative assessment and planning. The EOI block was described as potentially covering the dermatomes T6-T10 in a study on cadavers and patients, which is ideal for surgeries on the gallbladder [4]. It was also described in adult patients who are obese where neuraxial analgesia may be technically difficult [5]. In one case report on a neonate, it was found to be as useful as an epidural block for surgery on the biliary tree [6]. An epidural infusion is a viable option for our patient but we anticipated difficulties in assessing the level of her block and motor block post-operatively. It should also be noted that Trisomy 13 patients have an increased incidence of neural tube defects. The EOI blocks were performed under ultrasound guidance. With the patient supine, we located the sixth rib about 2 cm medial to the anterior axillary line. The needle tip was placed in the fascial plane between the external oblique (the first muscle layer encountered) and the intercostal muscles (Figure 1). This was done bilaterally and at the end of the procedure to take advantage of its full analgesic duration. We considered inserting a catheter but decided against it due to potential susceptibility to local anesthetic toxicity in a child who may have increased risk of high plasma levels and lower seizure threshold. However, if the procedure was converted to an open cholecystectomy, the benefit of the catheter probably outweighs those risks. The application of opioid-free analgesia is not only beneficial for patients who may suffer dramatic consequences of opioids such as this child. Avoidance of opioids while achieving adequate analgesia for any child has a multitude of benefits from patient satisfaction to reduced hospital stay. Therefore, we recommend any anesthesiologist consider this block as part of their peri-operative plan for children undergoing upper abdominal procedures. We would like to thank this child's parents, who were gracious in consenting for this case report and were very enthusiastic for us to report on their child's care for other colleagues to learn. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.