Bilateral Ultrasound-Guided Transversus Abdominis Plane Block as the Sole Anesthetic for Diverting Transverse Colostomy in a Two-Day-Old Neonate with Anorectal Malformation: A Case Report
Author(s): Okky Hudaya*, Kohar Hari Santoso, Arie Utariani
Abstract
Background: Atresia ani, part of the spectrum of anorectal malformations, usually requires surgery within the first days of life and a diverting transverse colostomy is the common first stage procedure to relieve the obstruction. Because newborns have very little physiological reserve, the anesthetic technique must control surgical pain without destabilizing breathing or circulation. An ultrasound guided Transversus Abdominis Plane (TAP) block anesthetizes the abdominal wall while leaving the airway untouched and spontaneous breathing preserved; for this reason, we considered it for a high risk infant. Case Presentation: A two day old full term boy weighing 2.3 kg presented with increasing abdominal distension and had not passed meconium since delivery; examination revealed atresia ani. Vital signs and preoperative laboratory results, including coagulation tests, were normal. Because general anesthesia posed a substantial risk for this low birth weight neonate, the transverse colostomy was performed under a bilateral ultrasound guided TAP block alone (ropivacaine 0.2%,0.5 mL/kg per side) with light intravenous midazolam sedation. Heart rate, blood pressure and oxygen saturation remained stable throughout the 45 minute procedure and general anesthesia was never needed. Face, Legs, Activity, Cry and Consolability (FLACC) pain scores stayed at 0-1 without any opioid and the infant left the (Neonatal Intensive Care Unit) NICU in good condition on postoperative day 3. Conclusion: In this neonate, TAP block was satisfactory for colostomy formation and for postoperative analgesia without need of opioids and airway instrumentation and systemic effects of general anesthesia. In specifically chosen neonates undergoing lower abdominal surgery, this block can be an effective substitution to general anesthesia in the hands of a skilled surgeon and may lead to easier outcomes.