# Ultrasound-Guided Multilevel Bilateral Rectus Sheath Blocks with Liposomal Bupivacaine, Bupivacaine, and Dexamethasone PF for Postoperative Pain Management After a Pediatric Abdominal Aortic Aneurysm Repair

## TL;DR

A new ultrasound-guided pain management technique using a drug combination reduced opioid use and improved recovery after complex pediatric abdominal surgery.

## Contribution

A novel multilevel rectus sheath block technique using liposomal bupivacaine, bupivacaine, and dexamethasone PF for postoperative pain in pediatric abdominal aortic aneurysm repair.

## Key findings

- Ultrasound-guided rectus sheath blocks with the drug combination provided prolonged opioid-sparing analgesia.
- No local anesthetic systemic toxicity was observed in the patient.
- Early functional recovery was achieved with minimal opioid requirements.

## Abstract

What are the main findings?
•Ultrasound-guided multilevel bilateral rectus sheath blocks utilizing a combination of liposomal bupivacaine, bupivacaine, and dexamethasone PF provided prolonged, opioid-sparing analgesia following open pediatric AAA repair.•There was no evidence of local anesthetic systemic toxicity observed in association with this analgesic approach.

Ultrasound-guided multilevel bilateral rectus sheath blocks utilizing a combination of liposomal bupivacaine, bupivacaine, and dexamethasone PF provided prolonged, opioid-sparing analgesia following open pediatric AAA repair.

There was no evidence of local anesthetic systemic toxicity observed in association with this analgesic approach.

What is the implication of the main finding?
•This multilevel rectus sheath block technique (using liposomal bupivacaine, bupivacaine, and dexamethasone PF) may represent a safe and effective alternative to neuraxial techniques for complex pediatric abdominal surgery.•It is particularly relevant for patients in whom anticoagulation therapy or the need for neurologic monitoring makes epidural or paravertebral blocks a high-risk option.

This multilevel rectus sheath block technique (using liposomal bupivacaine, bupivacaine, and dexamethasone PF) may represent a safe and effective alternative to neuraxial techniques for complex pediatric abdominal surgery.

It is particularly relevant for patients in whom anticoagulation therapy or the need for neurologic monitoring makes epidural or paravertebral blocks a high-risk option.

Background/Objectives: Abdominal aortic aneurysms (AAAs) are exceedingly rare in pediatric patients but carry a significant risk of rupture, necessitating urgent surgical repair. Postoperative pain management following open AAA repair is particularly challenging and ultrasound-guided rectus sheath blocks (RSBs) offer a targeted and lower-risk alternative for midline abdominal incisions. Methods: We present an 8-year-old male who underwent open infrarenal AAA repair. Multilevel bilateral ultrasound-guided RSBs were performed at T7, the umbilicus and T12 using a mixture of liposomal bupivacaine, bupivacaine, and dexamethasone preservative free (PF). Results: Postoperative pain scores remained consistently low through postoperative day (POD) 6, with minimal opioid requirements. Functional recovery was rapid, with sitting achieved by POD 1 and ambulation by POD 2. Plasma bupivacaine concentrations remained within safe limits throughout hospitalization. Conclusions: Multilevel bilateral RSBs with liposomal bupivacaine, bupivacaine, and dexamethasone PF provided prolonged opioid-sparing analgesia, facilitated early mobilization, and supported enhanced recovery in this complex pediatric surgical case.