Background and aims A 31-year-old gentleman presented with intra-abdominal sepsis secondary to perforated appendicitis. His past medical history was notable for congenital pulmonary stenosis and pulmonary valvuloplasty. The latest echocardiogram was over 4 years ago and demonstrated severe pulmonary regurgitation with right ventricular dilatation, but preserved function. Since then the patient reported worsening exercise tolerance, limited to 1 flight of stairs by breathlessness. A difficult open appendicectomy was performed under general anaesthesia and was complicated by high oxygen requirements. Multi-modal analgesia included a unilateral transversus abdominus plane block. We were asked to review the patient in the post-anaesthetic care unit due to severe generalised abdominal pain, preventing coughing and deep breathing with type 2 respiratory failure.

Methods With sepsis and right ventricular pathology as relative contraindications to epidural blockade, we elected to perform an ultrasound-guided transmuscular quadratus lumborum block with 30 ml 0.25% levobupivacaine. A catheter was placed and 5 ml/hr ropivacaine infusion continued.

Results Excellent analgesia was achieved, with resolution of type 2 respiratory failure. The infusion was continued for 2 days post-operatively, providing loss to cold in dermatomes T9-L1. The patient was extremely satisfied.

Conclusions The transmuscular quadratus lumborum block can provide excellent post-operative analgesia for patients undergoing open appendicectomy.