case report analgesia of multiple rib fracturesurgery: Continuous erector spinae plane block forpostoperative DEANESTESIOLOGIA REVISTABRASILEIRA

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RevBrasAnestesiol.2019;69(1):91---94

REVISTA

BRASILEIRA DE

ANESTESIOLOGIA

^Publicação^Oﬁcial^da^Sociedade^Brasileira^deAnestesiologia www.sba.com.br

CLINICAL INFORMATION

Continuous erector spinae plane block for

postoperative analgesia of multiple rib fracture surgery: case report

Ahmet Murat Yayik

^a

, Ali Ahiskalioglu

^b^,∗

, Erkan Cem C ¸elik

^a

, Aysenur Ay

^a

, Atila Ozenoglu

^c

aRegionalTrainingHospital,DepartmentofAnesthesiologyandReanimation,Erzurum,Turkey

bAtaturkUniversitySchoolofMedicine,DepartmentofAnesthesiologyandReanimation,Erzurum,Turkey

cRegionalTrainingHospital,DepartmentofThoracicSurgery,Erzurum,Turkey

Received19June2018;accepted5August2018 Availableonline10September2018

KEYWORDS Erectorspinaeplane block;

Ultrasound;

Ribfracture;

Postoperative analgesia

Abstract

Introduction:The erectorspinaeplaneblock isanewly describedandeffectiveinterfascial plane block for thoracicand abdominal surgery. This case report describes a patient with multipleribfracturesundergoingultrasound-guidedcontinuouserectorspinaeplaneblockfor analgesia.

Casereport: A37-year-oldmalepatientwastakenforsurgicalﬁxationofmultipleribfractures.

Attheendofthesurgery,usingultrasound-guidedlongitudinalparasagittalorientation3cmto thelateralaspectoftheT5spinousprocessandanin-planetechnique,20mL0.25%bupivacaine wasadministeredbetweentheerectorspinaemuscleandthetransverseprocess,andacatheter was theninsertedinthesameplane.Before theendofsurgery,1g paracetamoland50mg dexketoprofenwereadministered.Postoperativeanalgesiawasappliedwithpatientcontrolled analgesiamethodusing0.25%bupivacaineviathecatheter.Thepatient’sVisualAnalogueScale scoreatrestintheﬁrst24hwas0.Thepatientwasmonitoredfor3dayswithVisualAnalogue Scale<4,andthecatheterwasremovedonpostoperativeday4.Noopioidrequirementother thanparacetamolanddexketoprofenoccurredduringthistime.Nopostoperativecomplications wererecorded.

Discussion: Theerectorspinaeplaneblockisanalternativetoparavertebral,intercostal,epidu- ral orotherregional techniques.Itmay be asuitabletechniqueinanesthesiaand algology practiceduetoprovidinganalgesiainthepostoperativeperiodwithacatheterintheerector spinaeplane.

∗Correspondingauthor.

E-mail:aliahiskalioglu@hotmail.com(A.Ahiskalioglu).

https://doi.org/10.1016/j.bjane.2018.08.001

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92 A.M.Yayiketal.

PALAVRAS-CHAVE Bloqueiodoplanodo eretordaespinha;

Ultrassom;

Fraturadecostela;

Analgesia pós-operatória

Bloqueiodoplanodoeretordaespinhaparaanalgesiapós-operatóriadecirurgiade fraturademúltiplascostelas:relatodecaso

Resumo

Introduc¸ão:Obloqueiodoplanodoeretordaespinhaéumbloqueiodoplanointerfacialrecen- tementedescritoeeﬁcazparacirurgiatorácicaeabdominal.Nesterelatodescremosocaso deumpacientecomfraturademúltiplascostelas,submetidoaobloqueiocontínuodoplanodo eretordaespinhaguiadoporultrassomparaanalgesia.

Relatodecaso:Pacientedosexomasculino,37 anos,encaminhado parafixaçãocirúrgicade fraturademúltiplascostelas.Aofinaldacirurgia,usandoaorientaçãoparassagitallongitudinal guiadaporultrassom3cmemrelaçãoàfacelateraldoprocessoespinhosoT5eatécnicano plano,20mldebupivacaínaa0,25%foramadministradosentreomúsculoeretordaespinhaeo processotransverso,eumcateterfoientãoinseridonomesmoplano.Antesdofinaldacirurgia, 1gdeparacetamole50mgdedexcetoprofenoforamadministrados.Aanalgesiapós-operatória foiaplicadacomométododeanalgesiacontroladapelopaciente,combupivacaínaa0,25%

viacateter.NaEscalaVisualAnalógica,oescoredopacienteemrepousonasprimeiras24hfoi zero.OpacientefoimonitorizadoportrêsdiascomaEscalaVisualAnalógica<4,eocateterfoi removidonoquartodiadepós-operatório.Excetoporparacetamoledexcetoprofeno,nãohouve necessidadedeoutroagenteopioideduranteessetempo.Nãohouveregistrodecomplicac¸ão pós-operatória.

Discussão: Obloqueiodoplanodoeretordaespinhaéumaalternativaàstécnicasparaverte- brais,intercostais,epiduraisououtrastécnicasregionais.Podeserumatécnicaadequadana práticadeanestesiaealgologiadevidoaofornecimentodeanalgesianoperíodopós-operatório medianteumcateternoplanodoeretordaespinha.

Introduction

ErectorSpinaePlaneBlock(ESPB)isanewlydescribedand effectiveinterfascialplaneblockforthoracicandabdominal surgery.ItwasﬁrstdescribedbyForeroetal.in2016,effec- tivenessbeingreportedinfourcases.¹Althoughitwasﬁrst usedfor thoracicanalgesia,variousauthorshave reported itsuseinabdominalsurgerywithapplicationatthelevelof the7thvertebraandbelow.^2---4

AlthoughESPBresemblestheclassicparavertebralblock procedure, it involves the injection of local anesthesia between the target erector spinaemuscle and the trans- verse process of the thoracic vertebrae. Cadaver studies have shown the effectiveness of the block as a result of administration of local anesthetics to the paravertebral space in this region. In contrast to other plane blocks, it has been shown to provide visceral analgesia in addi- tion to somatic analgesia due tospreading paravertebral space.⁵

ThemainadvantageofESPBisthatitislessinvasivethan thoracicepidural analgesia.Whileit exhibits an analgesic effectat several levels with a single injection at the T5 level, catheterapplications to the region have also been reported. We describe a case of ESPB catheter adminis- trationforpostoperativeanalgesiainapatientundergoing surgeryformultipleribfractures.

Case report

A37year-oldmalepatientwithnoknownchronicdisease wastakenforsurgicalﬁxationofmultipleribfractures.The patientwaspremedicatedwith2mgmidazolam. Anesthe- siawasinducedwith2.5mg.kg⁻¹propofol,50mcgfentanyl and0.6mg.kg⁻¹rocuronium,whilemaintenanceofanesthe- sia was provided withsevoﬂurane in O2-air mixture. The patientwasplacedin therightlateral decubitusposition.

The 3rd, 4th, 5th, 6th, 7th and 8th ribs were exposed such as to include the fracture lines. The 3rd and 6th ribs were ﬁxed with steel wire and the other ones with thehelp ofaplate. ESPcatheterapplicationwasplanned for postoperative analgesia once the surgical procedure was completed. Under sterile conditions, USG probe was placed3cmlaterallytothespinousprocessattheT5level withlongitudinal parasagittalorientationwiththepatient in the lateral decubitus position (Fig. 1A---C). The trapezius muscle, rhomboid muscle, erector spinae muscle and transverseprocesswerevisualized.Withthein-planetechnique, 100mm sonovisibleblock needle(Stimuplex^® Ultra 360,22G/100mm,BBraun,Germany)wasadvancedcepha- ladtocaudaddirection.Weenteredbeneaththedeepfascia oftheerectorspinaemuscle,andthelocationofthenee- dle was conﬁrmed using hydrodissection with2mL saline solution.Followinginjectionof20mLof0.25%bupivacaine,

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Erectorspinaeplaneblockcatheter 93

Figure1 (A)PatientandultrasoundsetupforESPblock.(B)Surgicalsite.(C)SonographicimageforESPblock(TM,Trapezius Muscle;RMM,RhomboidMajorMuscle;ESM,ErectorSpinaeMuscle;T5,Transversprocessof5thvertebra).(D)Afterlocalanesthetic inﬁltration,whitearrowsindicatethecatheterposition.

theperipheralnerveblockcatheterwasinsertedtoremain atadepthof5cm.Patient-controlledanalgesia(PCA)was startedutilizing0.25%bupivacaineviathecatheter.Senso- rialareaoftheblockwascoveredT2-T9,3cmlateraltothe thoracicspinetomidclavicularline,alsoaxillaandmedial upperpartofthearmwithlossofcoldsensationtest.Imme- diatelybeforetheendofsurgery,1gparacetamoland50mg dexketoprofentrometamolwasadministeredintravenously.

Paracetamol1ganddexketoprofen50mgweregivenevery 6 and12h respectively. Pain evaluationwasperformed in motionandatrestusingaVisualAnalogScore(VAS)at1,2, 4,8,12and24h.Theat-restVASscoreintheﬁrst24hwas 0,withamaximumof4inactivemovement.Nopostopera- tive complications were recorded. No opioid requirement occurredduringhospitalization,andthecatheterwaswith- drawnonthe4thdaypostoperatively.

Discussion

ParavertebralspacewasﬁrstdescribedbySelheimin1905.

Clinical application of paravertebral block with various approachesgraduallyhavingbegantoenterintouse after 1978.⁵Variousprocedureshavebeentodatedescribedfor paravertebralblock.Thedevelopmentandwideuseofsono- graphic techniques has greatly facilitated the prevention and avoidance of complications in anesthetic and algol- ogypractice.Withtheintroductionofultrasonographyinto regionalanesthesiapractice,interfascialplaneblockshave becomeincreasinglypopular.The latestoftheseblocksto bereportedintheliteratureistheESPBdescribedbyFor- eraetal.in2016.¹ESPBhasbeendescribedforthoracicand abdominalanalgesiainvariouscases.

Thedorsalandventralrootsemergingfromtheanterior and posterior horns of the medulla spinalis combine and emergefromtheintervertebralforamina.Afterthespinal nerve emergesfrom the paravertebral space, the ventral ramiofthespinalnervesdivideintoventralanddorsalrami andcontinuebetweentheinnermostintercostalmuscleand theinternalintercostalmusclesatthethoraciclevel.Atthe

levelof the midaxillaryline it providessomatic sensation inthe skin covering thechest by giving lateralcutaneous branches. The dorsal rami give sensation on the skin of the back, passing between the erector spinae muscles (m. spinalis, m. longissimus thoracis and m. iliocostalis), the rhomboid major muscle and trapezius muscle to the level of the 6th thoracic vertebra and passing only the trapeziusmusclebeneaththe6ththoracicvertebra.During paravertebral space blocks, both somatic and visceral blockisestablishedbyblockingtheramicommunicantesin additiontotheventralanddorsalrami,whichalsoemerge fromtheintervertebralforamina.²

OurreviewoftheliteraturerevealedthatESPBhasbeen applied in Video-Assisted Thoracoscopic Surgery (VATS), pulmonarylobectomy, thoracic ribfractures,mastectomy, axillary sentinel lymph node biopsy, abdominal surgery^2,4 andincasesofneuropathicpaininthethoracicregion.³In ourcase,erectorspinaeblockwasappliedtoapatientwith multipleribfractures.Thepatient’sVASscoreintherecov- eryroomfollowingESPBappliedintheperioperativeperiod was0.ESPBprovideseffectiveanalgesiastartingwithinmin- utes.Foreroetal.reportedasimilardermatomallevelof sensoryblock.^1,3

Although there has been no consensus regarding the assessment of the sensory block in studies of paravertebral block variants, including ESPB, retrolaminar and paraspinal blocksanalgesic effectiveness has been shown by evaluating postoperative pain levels with VAS. These variant blocks have been developed in order to prevent complicationssuchaspneumothorax,epiduralinjectionor intrathecalinjection-relatedneuronaldamage,whileestab- lishingeffectiveparavertebralblock.

ESPB allows catheter insertion which is important for continuousanalgesia.In ourcase, effective postoperative analgesiawasestablishedbythecatheterbeneaththeerec- tor spinae muscle plane and combined with multimodal analgesiautilizingparacetamolanddexketoprofen.

ESPB is reliable and simple to perform. However, randomizedclinicalstudiesareneededtoassesstheeffec- tivenessofESPB.Itmaybeasuitableinacuteandchronic

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94 A.M.Yayiketal.

painmanagementduetoprovidingexcellentanalgesiavia catheterintheerectorspinaeplane.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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