João Falle Gomes dos Santos Erica Viviana Guimarães Carvalho , Joana Luísa Borges Marques,Maria block for ductus arteriosus closure: two casereports anesthesia General combined with erector spinaeplane CASE REPORTS

RevBrasAnestesiol.2020;70(2):171---174

CASE REPORTS

General anesthesia combined with erector spinae plane block for ductus arteriosus closure: two case reports

Erica Viviana Guimarães Carvalho

, Joana Luísa Borges Marques, Maria João Falle Gomes dos Santos

HospitaldeBraga,DepartamentodeAnestesiologia,Braga,Portugal

Received29May2019;accepted3January2020 Availableonline7February2020

KEYWORDS Newborn;

Neonatalintensive careunit;

Localanesthetics;

Surgery;

Regionalanesthesia

Abstract

Background: Failureofductusarteriosusclosureinpretermneonatesresultsinaleft-to-right shuntthatleadstovariableseveritiesofhemodynamicandrespiratorydistress.Whenmedical therapyfails,surgicalligationvialeftlateralthoracotomyremainsanalternativeapproachand canbeperformedintheoperatingroomoratthebedsidewithalowmortalityrate.Opioid- based anesthesia isa frequent choice among anesthesiologists who manage patent ductus arteriosus casesbasedonthesuppressionofthestress responseandmaintenance ofhemo- dynamicstability.Thisrationalesuggeststhatregionalanesthesiamayalsobeanadvantageous techniqueandmaybenefitearlierweaningfromventilation.Blockingafferentsignalsbefore incisionmayalsomodulatethelong-termconsequencesofalteredsensoryperceptionandpain responses.

Casereport: Wepresenttwocasesofgeneralanesthesiacombinedwitherectorspinaeplane blockaspartofmultimodalanesthesiainprematuretwinsundergoingpatentductusarteriosus closure.

Discussion: Inthesecases,theuseoferectorspineplaneblockcombinedwithgeneralanes- thesiawasefficienttominimizethenegativeimpactofsurgeryandallowedareductioninthe amountofintraoperativeopioiduseforpatentductusarteriosusclosure.

©2020SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).

∗Correspondingauthor.

E-mail:erica.carvalho@hb.min-saude.pt(E.V.Carvalho).

https://doi.org/10.1016/j.bjane.2020.02.011

©2020SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

172 E.V.Carvalhoetal.

PALAVRAS-CHAVE Neonato;

Unidadedeterapia intensivaneonatal;

Anestesialocal;

Cirurgia;

Anestesiaregional

Anestesiageralassociadaabloqueiodoplanodomúsculoeretordaespinhapara encerramentodepersistênciadecanalarterial:doisrelatosdecaso

Resumo

Justificativa: A persistência do canal arterial em neonatos prematuros resulta em shunt esquerdo-direito com alterac¸ões hemodinâmicas e desconforto respiratório de gravidade variável.Quandootratamentoclíniconãoébemsucedido,oencerramentocirúrgicoviatoraco- tomialateralesquerdacontinuasendoaabordagemalternativa,epodeserrealizadonocentro cirúrgicoouàbeira leitocombaixa taxademortalidade.Anestesiabaseada em opioidesé frequentementeescolhidapelosanestesiologistasnoscasosdeencerramentodecanalarterial devidoàsupressãoderespostaaoestresseemanutenc¸ãodaestabilidadehemodinâmica.Essa justificativasugere queaanestesiaregionaltambémpodeserumatécnicavantajosaeque promovedesmamemaisprecocedoventilador.Obloqueiodosestímulosaferentes antesda incisãotambémpodemodularosefeitosalongo-prazo,tantodapercepc¸ãosensorial,quanto dasrespostasàdor.

Relatodecaso: Apresentamos doiscasos de anestesia geral associada a bloqueio do plano domúsculo eretor daespinha como partede anestesiamultimodal em gêmeosprematuros submetidosaencerramentodecanalarterialpersistente.

Discussão: Nosdoiscasosdescritos,obloqueiodoplanodomúsculoeretordaespinhaassociado àanestesiageralfoieficienteparaminimizaroimpactonegativodacirurgia,epossibilitoua reduc¸ãonaquantidadedeopioideusadodurantecirurgiaparaencerramentodepersistência canalarterial.

©2020SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by- nc-nd/4.0/).

Introduction

The Ductus Arteriosus (DA) is anormal fetal blood vessel connection between the aortaand pulmonary arterythat normally constricts soon after birth and becomes closed within 72 hours. Failure toclosing it results in a left-to- rightshuntthroughtheDAandmaycausecongestiveheart failure.DelayedocclusionoftheDAisacommonfindingin pretermnewborns,asitremainsopeninapproximately80%

ofthosebornfrom25to28weeksgestation.¹

In newborns, when medical therapy with nonsteroidal anti-inflammatorydrugsfailstoclosetheDA,surgicalclo- surevialeftlateralthoracotomyisacommonprocedurethat canbeperformedeitherintheoperatingroomoratthebed- sideintheintensivecareunitwithalowmortalityrate.²The aimofsurgicalclosureistodecreasethepulmonaryvascular overload.

Therearelimitedcase descriptionsregardingtheanes- theticmanagementof PDAclosure, andtheserange from inhalational to intravenous anesthesia. Most describe the useofhighdosesoffentanyl(10to100␮g.kg^-1)²toensure effective analgesia and hemodynamic stability. Neverthe- less,regionalanesthesiatechniquesinextremelylowbirth weight(ELBW) newbornsundergoingthis surgeryhavenot beendescribedintheliterature.

First described byForero et al.,³ Erector SpinaePlane (ESP)blockisaparaspinalfascialplaneblockinwhichLocal Anesthetic(LA)isinjectedbetweentheerectorspinaemus- cle and the underlying transverse processes.The deposit of LA in this plane allows a cranio-caudal dispersion of anesthetic that covers several dermatomes and produces analgesiaviaahypotheticalmechanismofanteriordiffusion

oftheLAtotheventralanddorsalramiofspinalnerves.³To date,ESPblockhasnotbeendescribedinELBWneonates.

The objective of these case reports is todescribe the application ofESPblock inPatentDuctus Arteriosus(PDA) closureaspartofmultimodalanesthesiaforopioidreduction inpretermnewborns.

Reports

Informedconsentforpublicationwasobtainedfromthepar- ents.

Case 1

Aprematurenewbornwhowas25weeks+3daysold(post- menstrualage29weeks+1day),weighed0.900kgandhad severalcomorbidities(infantrespiratorydistresssyndrome, acuterenalfailureandhyperbilirubinemiaofprematurity) wassuggestedtoundergoPDAclosureaftermedicaltherapy failure(threedosesofibuprofen).Onehourbeforesurgery, thepatientwasintubatedwitha3.0mmuncuffed orotra- chealtubewith0.1mgmorphineintheNeonatalIntensive CareUnit(NICU)andkeptundermechanicalventilation.The patientwasmonitoredaccordingtotheAmericanSocietyof Anesthesiologists (ASA) standard (except capnography, as monitor wasnot available in theNICU) andwith cerebral NearInfraredSpectrometry(NIRS).Thebaselinevitalsigns wereaHeartRate(HR)of140---155beatsperminute(bpm), aMeanArterialPressure(MAP)of48---51mmHgandaNIRS valueof52.Incorrelationwithcerebraloximetry,NIRScan actasameasureofinterventionsthatinfluencevariations

Generalanesthesiacombinedwitherectorspinaeplaneblockforductusarteriosusclosure 173

Fig.1 DepictsanultrasoundimageoftheESPblockinCase 1.Thestarrepresentsatransverseprocess,andthetriangles indicatetheneedle.

in cerebral oxygen saturation and cerebral blood volume changesduring surgicalPDAclosure at thebedside. Anes- thesiawasachievedwith1␮gfentanyl,2mgketamineand 1mgrocuronium.Afterpositioningthepatientintheright lateraldecubituspositionwithasteriletechniqueandafter havingobtainedparentalinformedconsent,ESPblockwas performedunderultrasoundcontrol(GEHealthcareLOGIQe, 6.7---18MHzhockey-stickprobe)attheT5transverselevel;

after negative aspiration, 1 mg 0.1% ropivacaine (Fig. 1) wasinjected to confirm the correctposition of theblock by visualizingthe LAlifting theerector spinaemuscleoff the transverseprocess. The spreadof LAbetween the T4 andT7transverseprocesseswasthereaftervisuallytracked withthetransducer.

Twenty minutes after induction, ketamine (2 mg) and fentanyl(1␮g)werereadministered,and5␮g.kg⁻¹.min⁻¹ dopamineinfusionwasinitiated.Duringincision,thepatient remainedstable(HR135---145bpmandMAP46mmHg).Duct closureoccurred 20minuteslater,withan increasein the NIRSvalueof64, whichwasattributedtothedecreasein left-to-right shunting. Surgery lasted 1 hour and 10 min- utesuneventfully,without theneedforopioidrescue.The patientwasextubated24hoursaftersurgery.

Case 2

Secondtwin,weighed0.860kg,withthesamecomorbidities ofthefirsttwin,wassuggestedtoundergoPDAclosureafter medicaltherapyfailure(threedosesofibuprofen).Onehour beforesurgery, the patient wasintubatedwith a3.0 mm uncuffedorotrachealtubewith0.1mgmorphineintheNICU and kept under mechanical ventilation. The patient was monitoredaccording totheASA standard (exceptcapnog- raphy)andwithcerebralNIRS.Thebaselinevitalsignswere anHRof140---162 bpm,aMAPof37---50mmHgandaNIRS value of 67.Anesthesia wasachieved with1␮g fentanyl, 1mgketamineand1mgrocuronium.Afterpositioningthe patientintherightlateraldecubituspositionwithasterile techniqueandhavingobtainedparentalinformedconsent, ESPblockwasperformedunderultrasoundcontrolwiththe sameequipmentattheleveloftheT5transverseprocess;

after negative aspiration, 1 mg 0.1% ropivacaine (Fig. 2) wasinjected to confirm the correctposition of theblock by visualizingthe LAlifting theerector spinaemuscleoff the transverseprocess. The spreadof LAbetween the T4

Fig.2 DepictsanultrasoundimageoftheESPblockinCase 2.Thestarrepresentsatransverseprocess,andthetriangles indicatetheneedle.

andT7transverseprocesseswasthereaftervisuallytracked withthetransducer.

The absence of an adrenergic responseto the incision observedin Case 1led usto notreadministerfentanyl in thiscase, butonly ketamine (2mg) twentyminutesafter induction.Nohemodynamicvariationwasobservedduring theincision. Duct closure occurred after22 minutes with hypotension (MAP 25 mmHg) and was associated with a decreaseintheNIRSvalueto42.Then,7.5␮g.kg⁻¹.min⁻¹ dopaminewasinitiatedwithcorrectionoftheMAPandNIRS tobaselinevalues.Vasopressorsupportwasfavoredtofluid bolus administration in order to avoid further pulmonary congestion.Surgery lastedone houruneventfully, without theneedfor opioidrescue.The patientwasextubated34 hoursaftersurgery.

Discussion

PDAis aseriouscondition inELBW neonates(birth weight

< 1000 g). The hemodynamic and respiratory implica- tions of left-to-right shunting are associated with severe complications, such as intraventricular hemorrhage, pul- monary hemorrhage, edema, necrotizing enterocolitis, decreasedrenalfunctionandchronic lungdisease,due to increasedpulmonarybloodflowandshuntingfromthesys- temiccirculation.¹

Closureof the PDAcan be performed in the operating room, but in these cases, it was performed in the NICU environment to avoid the destabilization associated with transportandtomaintainadequateventilationcontroland temperature.

The rationale for high-dose fentanyl use in closure of thePDAis to ensureanalgesia andstable hemodynamics, allowingoptimalsuppressionofsurgicalstressandadverse metabolic and hormonal responses; the use of fentanyl has been shown to have a positive impact on outcome.² However,fentanyl isalsoassociated withadverse effects, suchaschestwallrigidity, bradycardia,seizure-likeactiv- ity,hypothermia,highventilator-dependencyandtolerance afterprolongedtherapy.⁴

Despite the lack of data supporting the use of NIRSin pretermneonatesandduringcardiacprocedures,thewell- recognizedhemodynamicoscillationsandshiftsincerebral perfusionassociatedwithsurgicalclosureoftheDAjustify NIRSmonitoringbothduringandaftersurgery.⁵Theauthors considerNIRSimportantformanagingventilationandblood

174 E.V.Carvalhoetal.

pressure,especiallyintheabsenceofcapnographymonitor- ingandcontinuousmonitoringofbloodpressure.

ESP block is safe and simple to execute because the ultrasoundvisualizationoftheinjectionsiteguaranteesthat importantstructures,suchasneuraxial,pleuralandmajor vascular structures,remain far awayfromthe block. The craniocaudalspread ofLA along thefascial planepermits extensive,andthusmultiple,dermatomalcoveragefroma singleinjectionsite.

Before surgery, the technical difficulties and possible complicationsoftheblockwerediscussed.Thepoorossifi- cationoftransverseprocessescanbiastheultrasoundview inELBWnewborns;inaddition,LAsystemictoxicity,pneu- mothoraxandmuscleweaknessduetothespreadofLAwere themajorconcerns.

Inourcases,theuseofESPblockcombinedwithgeneral anesthesiaallowedareductionintheintraoperativedoses ofopioids usedand,thus, in the relatedadverse effects, whileprovidingeffectiveanalgesiaandminimizingthesur- gicalstressresponse.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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