plane block? Case of 2.5 month old infant we still need Do central blocks while we have erectorspinae DEANESTESIOLOGIA REVISTABRASILEIRA

RevBrasAnestesiol.2019;69(4):417---419

REVISTA

BRASILEIRA DE

ANESTESIOLOGIA

CLINICAL INFORMATION

Do we still need central blocks while we have erector spinae plane block? Case of 2.5 month old infant

Can Aksu

, Yavuz Gürkan

KocaeliUniversity,SchoolofMedicine,DepartmentofAnesthesiologyandReanimation,Kocaeli,Turkey

Received17October2018;accepted5December2018 Availableonline30April2019

KEYWORDS Erectorspinaeplane block;

Postoperative analgesia;

Pediatricsurgery;

Thoracotomypain;

Epiduralanalgesia

Abstract

Erector spinae plane block is gaining popularity both for its ease of application and as itscomparableeffectonpostoperativeanalgesiawithcentralregionaltechniqueslikepara- vertebral block or epidural anesthesia. Its use for many indications has been reported in theliteratureforpediatricpatients.Wewouldliketoshareourexperiencesina2.5-month infantscheduledforthoracotomyforagiantcongenitalcyst.Singleshoterectorspinaeplane blockwasdoneatT4levelbeforethestartofthesurgeryforbothsurgicalandpostoperative analgesia.Nocomplicationwasseenduringbothsurgeryandfollowupperiod.Erectorspinae planeblockwiththecombinationofparacetamolwasadequateforpainrelief.

©2019SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).

PALAVRAS-CHAVE Bloqueiodoplanodo eretordaespinha;

Analgesia pós-operatória;

Cirurgiapediátrica;

Dorpós-toracotomia;

Analgesiaepidural

Aindaprecisamosdebloqueioscentraisenquantotemosobloqueiodoeretorda espinha?Casodecrianc¸ade2,5mesesdeidade

Resumo

O bloqueio do plano do músculo eretor da espinha está ganhando popularidade, tanto pelafacilidadedeaplicac¸ãoquantopeloefeitocomparávelemanalgesiapós-operatóriacom técnicasregionaiscentrais,comoobloqueioparavertebralouaanestesiaperidural.Seuuso temsidorelatadonaliteraturaparamuitasindicac¸õesempacientespediátricos.Gostaríamos decompartilharnossasexperiências nocasodeumbebêde2,5mesesdeidadeprogramado paratoracotomiaparaexcisãodeumcistocongênitogigante.Obloqueiodoplanodoeretorda espinhadorsalcominjec¸ãoúnicafoirealizadononíveldeT4antesdoiníciodacirurgiapara

∗Correspondingauthor.

E-mail:dr.aksu@gmail.com(C.Aksu).

https://doi.org/10.1016/j.bjane.2019.03.001

0104-0014/©2019SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

418 C.Aksu,Y.Gürkan analgesiacirúrgicaepós-operatória.Nenhumacomplicac¸ãofoiobservadaduranteacirurgiae operíododeacompanhamento.Obloqueiodoplanodoeretordaespinhacomacombinac¸ão deparacetamolfoiadequadoparaoalíviodador.

©2019SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by- nc-nd/4.0/).

Introduction

Providinganalgesiaafterthoracotomyisachallengingtask becausethegoalisnotjustaboutrelievingasurgicalpain but also providing ideal conditions for normal pulmonary functions.Inadditioninadequatepainmanagementcanlead toprolongationofthestay intheICU, delayinthereturn todailyactivities,increaseinpulmonarycomplicationsand persistentorchronicpostoperativepain.¹

Thoracic Epidural Analgesia (TEA) and Paravertebral Block (PVB) has long been the most commonly preferred regional techniques for this purpose.¹ As these are more advanced regional anesthesia techniques, even in adult patients,theiruseforpediatricpatientsislimited.Although thetotalriskofmajorcomplicationsarelesswithPVBwhen compared to TEA, PVB has its own complication risks as pleuralpuncture.

Erector SpinaePlaneBlock (ESPB)wasfirst definedfor thoracic neuropathic pain but, till then, itsuse for post- operativeanalgesiaformanydifferentindicationsincluding thoracicprocedureshas beenreportedfor both adultand pediatric patients.^2---4 ESPB has gained popularity as it is thought to be a safer and easier alternative to central regionalanesthesiatechniques.Wewouldliketoshareour experienceanddiscusstheeffectivenessofESPBbyacase of2.5-monthold,4kginfantscheduledforthoracotomyfor congenitalleftpulmonarygiantcyst.

Case

Following sedation with oral midazolam (0.5mg.kg⁻¹) patientwas taken to the operating room. After standard electrocardiogram,pulse oxymeterand noninvasive blood pressuremonitarizationanesthesiainductionwasdonewith facemask8%sevofluraneand50%airinoxygen.A24gaugeiv cannulawasplacedandremifentanyl1␮g.kg⁻¹andpropo- fol2mg.kg⁻¹wereadministered.Afteradequateanesthesia wasmaintained patientwasintubatedwithoutusingmus- cle relaxant. Anesthesia maintenance was provided with Sevoflurane2%---3% inspired concentration,in combination withnitrous oxidein oxygen witha ratio of 2:1 in 3L of freshgas flow duetokeepthe minimumalveolar concen- tration 1.3.Afterwards, an arterial cannulation wasdone forinvasivebloodpressureandaninternal jugularcentral venous catheterwasplaced onthe leftside. Rectal tem- perature,inspiratoryandexpiratorygasanalysisandETCO2

monitorizationwerealsoprovided.

Caudal

Kocaeli university

Cranial

Needle Erector spinae

muscle

Transverse process

of T4

Figure1 Bupivacaineinjectedfortheblockperformance.

Followingtherightlateraldecubitispositionforsurgery, ErectorSpinaePlaneBlock(ESPB)wasperformedatT4due totheleveloftheplannedthoracotomy.EsaoteMyLab6US machine (Florence, Italy)withlarge bandwidth, multifre- quencylinearprobe(6---19MHz)anda22G,50mm,insulated facettypeneedle(BBraunSonoplex,Melsungen,Germany) was used. Bupivacaine 0.25% 1mL.kg⁻¹ injected for the blockperformanceafteridentifyingthesonoanatomyofthe blocksite(Fig.1).

Twentyminutes after the block, hypotension occurred andtreatedwithivvolumetherapy.Afterthisperiod,during thesurgery,hemodynamicparameterswerestable.Noaddi- tionalopioidwasused.Surgerylasted2hoursandattheend achestdrainwasinsertedatthe5thintercostalspace.Was administered15mg.kg⁻¹ivparacetamoltothepatient.The patientwastakentopediatricintensivecareunitintubated and sedated with midazolam infusion till the extubation period.Paracetamol15mg.kg⁻¹ivper6hwasprescribedfor postoperativefirst24hoursforroutineanalgesia;andpain managementfor rescueanalgesiawasplannedtobedone accordingtoFace,Leg,Activity,Cry,Consolability Revised (FLACC-R) score. If FLACC-R scores were greater than 2, tramadol1mg.kg⁻¹iv wasplannedasrescueanalgesiafor postoperative first24hours.Forthe postoperativesecond 24hours,acetaminophen15mg.kg^-1ivwasplannedasres- cueanalgesiaincaseofFLACCscoresbetween2and4,and tramadol1mg.kg^-1 ivasrescueanalgesicincaseofFLACC scoresgreaterthan4.

Dowestillneedcentralblockswhilewehaveerectorspinaeplaneblock? 419 Patient was extubated at postoperative 12th hour and

nocomplicationoccurred duringfollow up period.Dueto FLACC-Rpainscores (≤2at alltimes)noadditionalrescue analgesicwasusedfor48hours.

Discussion

ESPB is an interfascial plane block, where the transverse processmakesanaturalborderbetweentheblocksiteand majorcentralanatomicalstructures.Thereareafewstudies withcontroversialresultsintheliteratureforexactmecha- nismofactionofESPBandtheLAspreadinthisblockhasnot clearlyidentified.RecentlyAdhikaryetal.⁵showedepidural spreadasthemechanismofESPB,whichcouldexplainthe clinicaloutcomesofthecasereportspublished.

Foreffectivetreatmentofthoracotomypain,continuous analgesiaby epiduralor paravertebralcatheters hasbeen discussedinthecurrentliteratureandrecommendedasfirst linetherapy.¹Theircombinationwithnon-opioidanalgesics likeacetaminophenandNSAIDsisalsorecommended.Inour case,asingleshotESPBalongwithparacetamoladministra- tionhasfoundasanadequateanalgesiamethod.Alsowith thispreoperativelyESPB,thesurgerycouldbedonewithout theuseofanyotheropioiddrug.

Inconclusion,accordingtoourclinicalexperiencesand resultsofthepublishedstudiesintheliteraturealongwith thiscase report,wethinkthatESPBcouldbeasafernew alternativetoTEAandPVB.Futurestudieswithlargecase seriesarestillneededtoenlightenthisissue.

Funding

Theauthorshavenosourcesoffundingtodeclareforthis manuscript.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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