PR2-172
Continuous erector spinae plane block for high chest wall surgery
Jiao Y, AuBuchon J, Moore R
Washington University in Saint Louis, Saint Louis, MO, United states
Introduction: Erector spinae plane (ESP) block is an emerging truncal block. The existing data on its viability and efficacy is promising but scant, especially in the pediatric population (1,2). We present the case of a 7 year old boy with multiple rib osteochondromas of the second through fourth rib, in which we successfully placed an erector spinae plane catheter at a high thoracic level.
Methods: The patient was a 7 year old boy with history of widespread osteochondromas, who presented for excision of right ribs 2-4, chest wall reconstruction, and placement of a chest tube. A continuous paravertebral block was attempted after induction of general anesthesia, but was unsuccessful. The decision was then made to place ESP catheter prior to emergence. At the conclusion of surgery, the plane superficial to the erector spinae and deep to the rhomboid major was identified on ultrasound at the upper thoracic level. A needle was advanced into this plane at T3. Ten milliliters of ropivacaine 0.25% was used to dilate the plane, resulting in substantial cranio-caudal spread. An 18g catheter was threaded over the needle 1.5 cm into the space. Postoperatively, ropivacaine 0.2% was infused at 0.16 cc/kg/hr.
Results: The patient’s chief complaint after surgery was his foley catheter. He required 16 mcg/kg IV hydromorphone in the first 24 hours after surgery and 0.72 mg/kg oxycodone during the remainder of his hospital stay. The patient was able to tolerate mild to moderate palpation of his chest wound dressing on each postoperative day and participated in incentive spirometry despite his chest tube. The ESP catheter was removed on postoperative day 3. He was discharged home on postoperative day 4.
Discussion: Our case adds to a growing body of literature suggesting a role for the ESP block in cases where neuraxial techniques are contraindicated, impractical, or failed, and yet there is a high risk for significant truncal pain. One strong advantage of the ESP block is its low technical difficulty, given the relatively superficial target and absence of nearby critical structures. In our case we were unable to place a paravertebral catheter, but were subsequently able to successfully place an ESP catheter at the same vertebral location. In addition, our case is the first report of an ESP block above T5 and is the first report of a catheter placed in a pediatric patient. It corroborates the belief that this technique can provide effective analgesia at any level in the erector spinae’s thoracolumbar span.
Conclusion: We report a continuous erector spinae plane block which was utilized to provide excellent analgesia in a 7 year old patient after extensive upper chest wall surgery.
References:
1. Forero, M et al. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016 Sep-Oct;41(5):621-7
2. Munoz, F et al. Erector spinae plane block for postoperative analgesia in pediatric oncological thoracic surgery. Can J Anaesth. 2017 Aug;64(8):880-882
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