Combined transversus abdominis plane block and rectus sheath block in laparoscopic peritoneal dialysis catheter insertion.

End-stage renal disease (ESRD) patients undergoing laparoscopic peritoneal dialysis catheter insertion (LPDCI) presents a real challenge to the anesthesiologists due to the associated comorbidities. ESRD patient can be labeled as a syndromic patient due to the involvement of many other body systems in the disease. Usually, those patients are suffering from all side effects of chronic longstanding diabetes mellitus as well as cardiorespiratory diseases. Anesthesia for LPDCI includes understanding the background of ESRD and the associated comorbidities. The background includes risk assessment, optimization of preexisting diseases, and education. Optimization of the preexisting disease states is important preoperative in spite of the difficulties encountered. We believe that glycemic control is important preoperatively as well as the cardio-respiratory systems. We understand the difficulties encountered, but at least we bring the patient to a satisfactory statue with less risk of anesthesia exposure. Education is very important regarding explaining to the patients and relatives the risks of anesthesia and the options of the anesthetic techniques. That help in enhancing recovery of those patients as well as the patient will tolerate the truncal blockade technique if remains an option. Preoperative risk assessment is important and can be performed using different tools such as Physiologic and Operative Severity Scoring for the enumeration of Morbidity/mortality, Lee index (ischemic heart disease, cerebrovascular accident, heart failure, high-risk surgery, and creatinine level >177 μmol/L), cardiovascular risk calculator (type of surgery, functional status, creatinine level, American Society of Anesthesiologists and age), walk test, cardiopulmonary exercise test, general surgery, and acute kidney injury risk index). These risk assessment tools will determine the morbidity and or mortality associated with LPDCI in ESRD patients.[1] Anesthesia for LPDCI can be either general or regional anesthesia. The choice of the anesthetic technique depends on the risk stratification performed preoperatively. In our practice, we perform general anesthesia (GA) if the patient tolerates it with low-risk. GA includes the use of rocuronium to facilitate tracheal intubation and sugammadex to reverse its effect with continuous neuromuscular transmission monitoring. Ultrasound guided (USG) truncal blockade is our technique of choice in the case of high risk for GA encountered. In our practice, we have noticed that those patients tolerate the procedure very well with the combination of transverses abdominis plane (TAP) and rectus sheath (RS) blocks. Besides local anesthetic infiltration to the sites of ports insertion. Usually, the three ports inserted one on each hypochondrium and the third port sub umbilical in the midline. Furthermore, the patient receives an intravenous continuous infusion of dexmedetomidine 4 μg/ml at a dose of 0.5-1 μg/kg/h for intraoperative sedation. Postoperative pain relief is achieved by the truncal blocks performed intraoperatively and by local anesthetic instillation within the intraperitoneal cavity. We have introduced the LPDCI ladder which summarizes the perioperative management of those patients [Figure 1]. USG unilateral posterior and unilateral subcostal TAP blocks were used effectively for LPDCI.[2]

Figure 1

Laparoscopic peritoneal dialysis catheter insertion (ladder)

We believe that the combination of TAP and RS blocks provides safe and effective anesthetic technique for high-risk ESRD patients undergoing LPDCI.