Introduction

 The link between Wilms tumor and von Willebrand Disease (vWD) in the pediatric population is well established, with various approaches to regional anesthesia described for tumor resection. These approaches include epidural placement (1), wound catheters (2), and ESP blocks (3) in pediatric patients undergoing major abdominal surgery. We present a novel approach to regional anesthesia in the coagulopathic pediatric patient via multilevel rectus sheath block combined with the external oblique block.

Case report

A 4-year-old boy at risk for catastrophic bleeding presented with multiple episodes of epistaxis, anemia, and thrombocytopenia in the setting of a large, rapidly growing, abdominal mass, likely a Wilms tumor. The patient was scheduled for tumor resection and hematology was consulted to optimize the patient’s coagulation status prior to surgery. The patient was started on Humate P along with a transfusion goal of Hgb >9 and Plts >100 prior to surgery. On the day of surgery, he was also started on a Thromboxane (TXA) bolus and infusion prior to incision. Despite patient’s EBL exceeding 100cc/kg during the resection, his coagulation status stabilized by the end of the case. We elected to perform multi-level bilateral rectus sheath blocks in conjunction with a right-sided external oblique block to cover the extended portion of the incision, using 45mg ropivacaine with 16mg dexmedetomidine. After surgery, the patient was extubated in the operating room and reported “no hurt” in PACU with an observed FACES scale: “no pain” at 24 hours. 

Discussion

In recent literature, few analgesic interventions in the coagulopathic pediatric patient undergoing major abdominal surgery have been described; We provide an additional method, the external oblique combined with rectus sheath blocks, to limit the risk of devastating bleed and adequate analgesia provision in this unique population.