Quadratus lumborum block for analgesia following caesarean section under low-dose spinal anaesthesia in a parturient with dilated cardiomyopathy

Dear Editor, A 28-year-old, 152-cm-tall female, with a known prior diagnosis of idiopathic dilated cardiomyopathy (DCMP) was admitted to our institution at 37 weeks of gestation for safe confinement and a planned elective caesarean section (CS) in view of her heart disease. There was a history of aggra­vation of her cardiac symptoms, and she had developed dyspnoea on exer­tion (NYHA III) and pedal oedema in the previous month. A focused history revealed complaints of dyspnoea on exertion with similar aggravation of symptoms 5 years prior, following the vaginal delivery of her first child, when a diagnosis of DCMP was made, and treatment was started by a cardiologist. Her symptoms had been controlled by medication since then. Her detailed past treatment records were unavailable.
Preoperative evaluation revealed pallor and mild pedal oedema with normal systemic and airway examination. Heart rate was 70 min–1, with occasional premature ventricular complexes noted on the ECG. Blood pressure was 120/70 mmHg. She was receiving once daily furosemide 20 mg p.o., metoprolol 25 mg, telmisartan 40 mg in addition to salt restriction. A COVID-19 test was done within 72 hours before the planned surgery, considering the ongoing pandemic. Laboratory investigations revealed borderline hypokalaemia (serum potassium 3.4 mEq L–1). Echocardiography revealed severe left ventricular dysfunction with global hypokinesia and an LVEF of 25%.
The patient was posted for an elective CS in view of her poor functional status. An invasive arterial blood pressure monitoring was established in addition to standard monitors. A combined spinal-epidural anaesthesia (CSEA) set (18G Tuohy/27G spinal needle) was used in the L3–4 space in the sitting position. Four milligrams (0.8 mL) of 0.5% bupivacaine (heavy) with 20 µg fentanyl (total volume 1.2 mL) was injected after confirming a free flow of cerebrospinal fluid. The epidural catheter was then inserted and secured in place without injecting any test dose. The surgeon was asked to proceed only after a sensory level of T6 was achieved (final level was T5), to prevent any patient discomfort and detrimental sympathetic stimulation. Intraoperative vitals remained within normal limits with occasional ventricular premature contractions (< 5 per min). Three units of oxytocin were given as a bolus following delivery followed by a 7.5 U h–1 infusion. Surgery lasted 35 mins, and total fluid administered was 600 mL. Intraoperatively,...


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