CR3-190
Continuous erector spinae block as an alternative to thoracic epidural for thoracotomy in the pediatric patient: A Case Report.
Low A, Flack S
Seattle Children's Hospital, Seattle, Washington, USA
Introduction:
Analgesia for thoracotomy in the pediatric population is historically best managed with a thoracic epidural. Serious complications included epidural hematoma and abscess. Alternatives to epidural analgesia include transversus abdominis plane blocks and paravertebral blocks. We present the novel case of utilizing a continuous erector spinae catheter in a patient undergoing thoracotomy for tumor resection in whom a thoracic epidural was contraindicated.
Case Presentation:
We present the case of utilizing a continuous erector spinae catheter for analgesia in a 14 year old female with a left chest wall Ewing sarcoma undergoing thoracotomy and tumor resection. She was both anemic and thrombocytopenic prior to surgery and was therefore not a candidate for an epidural. We thus elected to place an erector spinae catheter for both surgical and post-operative analgesia.
After induction, the patient was positioned in the right lateral decubitus position and was prepped and draped in sterile fashion. 3-5 cm from midline, a Sonosite high frequency probe was placed in a para sagittal plane and the transverse process of T8, trapezius, rhomboid and erector spinae muscles and faschial planes were visualized. Under in-plane ultrasound guidance, a 5 cm 18g Tuohy needle was placed in the posterior fascial plane of the erector spinae in a cranial to caudal fashion. 20 mL of 0.2% Ropivacaine was injected and a 20g multiorifice catheter inserted 4 cm beyond the needle tip. An infusion of Ropivacaine 0.2% at 8 mL/h was then initiated. After initiation of the infusion, the patient received no additional opioid medication until arrival in the pediatric intensive care unit (PICU).
Postoperatively, the patient was started on a Hydromorphone 20 mcg/kg q 6 min PCA in addition to the erector spinae catheter. Given her malignancy she was not a candidate for NSAID’s or Acetaminophen. She was comfortable on arrival to the PICU and PCA usage during her postoperative course was minimal. She remained comfortable with a T5-T10 level to ice.
Discussion:
The erector spinae block is an attractive option for postoperative analgesia for major thoracic and abdominal surgeries, especially in patients who are not candidates for epidural analgesia (coagulopathy, significant scoliosis, cardiac pathology). The location of the block lends itself to catheter placement which is usually out of the field for major thoracic and abdominal surgeries. Erector spinae blocks seem to reliably provide both somatic and visceral analgesia Mechanism of action is thought to be via paravertebral spread of local anesthetic across multiple dermatome levels. In summary, this case report demonstrates the successful use of a continuous erector spinae catheter for both surgical and postoperative analgesia in a pediatric thoracotomy patient.
References
1. Forero et al. The erector spinae plane block. A novel analgesic technique in thoracic neuropathic pain. Regional Anesthesia and Pain Medicine. Vol 41; 5. Sept-Oct 2016.
2. Restrepo-Carces et al. Bilateral continuous erector spinae plane block contributes to effective postoperative analgesia after major open abdominal surgery: A case report. International Anesthesia Research Society. May 30, 2017.
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