P106 Ultrasound-guided anterior quadratus lumborum and pudendal nerve blocks for postoperative analgesia in pediatric cloacal reconstruction: a case report

<h3>Background and Aims</h3> Cloacal malformations necessitate extensive pelvic-perineal reconstruction, often associated with significant postoperative pain. While caudal blocks are commonly employed, they may impact motor function and delay recovery. This case report evaluates the utility of combining ultrasound-guided anterior quadratus lumborum block (QLB) and pudendal nerve block (PNB) as part of a multimodal, opioid-sparing analgesic strategy in a pediatric patient undergoing cloacal repair. <h3>Methods</h3> A 2 year old female underwent cloacal reconstruction involving double-barrel colostomy, anorectovaginoplasty, and urethroplasty via combined abdominal and sacroperineal approaches. Following induction of general anesthesia, bilateral anterior QLBs were performed using an in-plane technique with a high-frequency linear probe, administering 3 mL of 0.25% ropivacaine per side. Subsequently, bilateral PNBs were executed using an out-of-plane approach, delivering 4 mL of 0.25% ropivacaine per side. Intraoperative opioid consumption, hemodynamic parameters, FLACC pain scores, and motor function were assessed perioperatively. <h3>Results</h3> The combined blocks resulted in stable intraoperative hemodynamics and reduced volatile anesthetic requirements, with no supplemental opioids needed intraoperatively. Postoperatively, the patient maintained low FLACC pain scores (0–2) over the first 48 hours without requiring rescue analgesia. Motor function was preserved, facilitating mobilization within 24 hours. No complications related to the nerve blocks were observed. <h3>Conclusions</h3> This case demonstrates that the combination of ultrasound-guided anterior QLB and PNB may provide effective, opioid-sparing analgesia in complex pediatric pelvic-perineal surgery. By addressing both somatic and visceral pain components while preserving motor function, this approach may serve as a valuable alternative to caudal blocks in multimodal analgesia protocols for high-complexity pediatric cases.