Anesthetic management in patients with RDEB is challenging, and an anesthetic plan has to be determined depending on individual conditions . In the present case, general, neuraxial, and large-dose local anesthesia posed potential risks of serious complications. General anesthesia had to be avoided because of the presence of difficult airway and critical airway obstruction. Although neuraxial anesthesia could be applicable in a patient with RDEB , we found no intact areas at the potential puncture site.
To the best of our knowledge, this is the first report of anesthetic management with ultrasound-guided subcostal TAPB in a patient with RDEB. TAPB is a technique that can provide efficient somatic analgesia by anesthetizing the anterior branch of the spinal nerve , and the use of ultrasound is advantageous . Since patients with RDEB usually have low amounts of fat deposits due to malnutrition, we consider that performing ultrasound-guided subcostal TAPB may be feasible in this patient population.
When using subcostal TAPB for peritoneal dialysis catheter placement, physicians should remember that it is ineffective for visceral pain and does not always cover the area innervated by lateral cutaneous branches . In the current case, the patient complained of mild pain when the surgeons incised her lateral abdominal wall on the blocked side (Fig. 1, incision D). To manage visceral pain due to manipulation of the peritoneum, we administered repeated low doses of fentanyl, careful not to cause respiratory suppression. The patient did not complain of visceral pain during the manipulation of the peritoneum. We consider that visceral pain during peritoneal catheter surgery can be controlled with low doses of fentanyl .
Although she reported in the postoperative interview that she experienced considerably less pain during this procedure than during the initial catheter placement, we consider that the moderate pain associated with incision A (Fig. 1) should have been avoided. Li et al.  reported superior analgesia and patient satisfaction with TAPB than with local anesthesia during the placement of a peritoneal dialysis catheter. It is possible that bilateral subcostal TAPB would have improved the quality of analgesia in the present case. However, we avoided bilateral TAPB because it would require a near maximum dose of lidocaine combined with epinephrine. As Griffiths et al.  reported, TAPB is associated with high risk of local anesthetic systemic toxicity (LAST). Moreover, as Yamamoto et al. reported , management of peritoneal dialysis catheter surgery with TAPB may require additional local anesthesia intraoperatively. Therefore, we chose to perform TAPB to the left side, which was exposed to more invasive manipulation, to allow surgeons to utilize additional local anesthesia intraoperatively. Although we believe that the patient’s pain was almost entirely controlled with additional local anesthesia, ketamine, and fentanyl, considering the course of the original catheter, right-sided rectus sheath block could have provided better analgesia. This technique may be safer than TAPB because it requires a smaller dose of local anesthetic and is associated with lower plasma concentration after the procedure .
We selected 0.5% lidocaine combined with epinephrine for several reasons. As this patient developed hypoalbuminemia (1.9 g/dL), which increases free plasma local anesthetics concentrations and the risk of LAST, lidocaine was considered a safer option than ropivacaine due to its lower protein binding ratio. Furthermore, adding epinephrine can decrease the absorption speed and increase the maximum dose of lidocaine, as well as achieve longer analgesic duration . In this regard, we selected 0.5% lidocaine combined with epinephrine.
Although dexmedetomidine could be useful, we chose a combination of ketamine and propofol in the current case. Either choice can provide analgesic and sedative effects without respiratory suppression; however, ketamine was considered more suitable to immediately treat intraoperative pain due to its rapid onset. We used propofol both for sedation and to weaken the ketamine’s adverse effects .
In this report, we presented a case of anesthetic management with ultrasound-guided subcostal TAPB in a patient with RDEB. It is suggested that subcostal TAPB can be a useful option for peritoneal dialysis catheter placement in patients with RDEB.