Thoracic epidural analgesia is still considered the gold standard for postoperative analgesia in major open abdominal surgery1; however, concerns regarding side effects such as hypotension and motor blockade, as well as the risk of major complications such as epidural hematoma and abscess, have led some to question its role.2,3 Abdominal wall blocks such as the transversus abdominis plane (TAP) block have been proposed as alternatives,4 nevertheless they have their own limitations: dermatomal coverage is limited,5,6 catheter techniques are cumbersome to perform given the proximity to the surgical field,4,5 and a recent meta-analysis found the TAP block to be marginally effective in this context.7
The erector spinae plane (ESP) block is a novel paraspinal plane block first described for thoracic analgesia when performed at the T5 level,8,9 but more recently has also been shown to be effective in providing extensive somatic and visceral abdominal analgesia when performed at the T7-9 level.10,11 Bilateral continuous ESP blockade may therefore represent a valuable alternative to thoracic epidural analgesia. To illustrate this potential, we report a case in which bilateral ESP catheters were used to provide successful postoperative analgesia after major open abdominal surgery.
Written informed consent was obtained for this report.
A 55-year-old man (82 kg, 178 cm) was scheduled for an open radical cystoprostatectomy with ureter and neobladder reconstruction, after recurrence of a bladder adenocarcinoma that had previously been resected via a transurethral approach. His only comorbid condition was well-controlled hypertension, for which he was taking losartan, and his physical examination was unremarkable. The patient expressed concerns regarding adequate postoperative pain control but declined epidural analgesia due to the perceived risks. After a thorough discussion, the patient agreed to a bilateral continuous ESP blockade.
The ESP block was performed before induction of anesthesia and after institution of IV access and electrocardiogram, noninvasive blood pressure, and pulse oximetry monitoring. Premedication consisted of oral acetaminophen 1 g and IV midazolam 2 mg. The patient was placed in a prone position and, using an aseptic technique, a high-frequency (12–15 MHz) linear-array transducer (MTurbo, Sonosite, Bothell, MA) was placed in a longitudinal parasagittal orientation approximately 3 cm from the midline and the plane between the tip of the T8 transverse process and the overlying erector spinae muscle was identified. The skin was anesthetized with 3 mL of lidocaine 2%, and a 17 G Tuohy needle was inserted in-plane to the ultrasound beam and in a cranial-to-caudal direction to contact the tip of the T8 transverse process. Correct needle tip position was confirmed by hydrodissection with 3 mL of lidocaine 2% and visualizing linear fluid spread that lifted the erector spinae muscle off the transverse process (Figure 1A). Ten milliliters of bupivacaine 0.25% was injected and a multiorifice catheter (Portex Epidural MiniPacks, Smiths Medical, Ashford, UK) was inserted 5 cm beyond the needle tip (Figure 1B). This procedure was repeated on the other side. The catheters were fixed in place with skin adhesive (Histoacryl, B. Braun, Melsungen, Germany) and a sterile dressing. A rate-adjustable elastomeric pump (Baxter Latinoamerica, Bogota, Colombia) containing bupivacaine 0.1% was attached to each catheter. The initial infusion rate was set at 6 mL/h on each pump and commenced before incision.
The patient was turned back into a supine position and anesthesia was induced with propofol 120 mg, lidocaine 60 mg, fentanyl 100 μg, and rocuronium 50 mg IV. After intubation, anesthesia was maintained with sevoflurane 0.6 minimum alveolar concentration in an air–oxygen mixture and IV remifentanil infusion at 0.08 to 0.1 μg/kg/min. Dexamethasone 8 mg and hydromorphone 0.4 mg were administered IV before surgical incision with additional hydromorphone 0.2 mg before incision of the peritoneum as part of a preventative analgesic strategy. Surgery lasted 6 hours. The estimated blood loss was 250 mL. There was no hemodynamic instability apart from a transient 15% decrease in mean arterial pressure after induction of anesthesia, which was readily treated with a single dose of etilefrine 2 mg IV. After wound closure and before extubation, an additional bolus of 10 mL of 0.25% bupivacaine was injected into each ESP catheter.
The patient was extubated and transferred to the postanesthetic care unit where he received an additional 0.2 mg hydromorphone and was started on patient-controlled analgesia (PCA) IV with morphine and metamizole (a nonopioid analgesic with cyclooxygenase-inhibitory properties) 2 g IV every 8 hours. Once fully awake, he reported a dynamic numerical rating scale (NRS) pain score of 3/10 intensity and resting NRS pain score of 1–2/10. At this time, he also had loss of cold sensation (tested with ice) from T5 to L2 dermatomes extending over the anterolateral abdominal wall (Figure 2A). Sensory testing posterior to the mid-axillary line was not performed due to the difficulty of turning the patient into a lateral position. The patient remained in the postanesthetic care unit for 3.5 hours and was then transferred to a step-down intensive care unit.
During the first 72 hours, he remained on IV PCA morphine and IV metamizole, with infusion of 0.1% bupivacaine at 6 mL/h into each ESP catheter via the elastomeric pumps. The patient was assessed each morning by the acute pain service team. He continued to have a demonstrable loss of sensation to cold from T5 to L2 (Figure 2B, C), and dynamic and resting NRS pain scores of 3/10 and 1–2/10 respectively during this time. Oral intake was started on postoperative day (POD) 3, at which time the IV metamizole was discontinued and oral acetaminophen 1 g every 6 hours and pregabalin 75 mg every 12 hours were added in its place to the analgesic regimen. The bilateral ESP catheter infusions were continued until POD 5, whereupon they were removed after administering a 10 mL bolus of a 1:1 mixture of lidocaine 1% and bupivacaine 0.25% (which is the standard injectate for most regional anesthetics in our institution) through each catheter. The morphine PCA was also discontinued at this time and the patient was prescribed oral tramadol 50 mg every 8 hours instead. The patient’s opioid requirements were 10, 8, and 4 mg of morphine IV during POD 0, 1 and 2 respectively. There were no PCA opioid demands on POD 3 to 5 and there was no evidence of rebound pain after cessation of the ESP blocks. He did not experience any side effects of therapy, including nausea, vomiting, pruritus, or hypotension, during his postoperative course and was discharged home on POD 6.
The ESP block was first described for the treatment of chronic thoracic neuropathic pain, with injection at T5. A catheter inserted at this level can be an effective alternative to thoracic epidural analgesia after thoracic surgery.8,9 More recent reports have illustrated that the ESP block can also be used to provide analgesia for laparoscopic abdominal surgery by injection at a lower thoracic level of T7–T9.10,11 In a fresh cadaver model, injection of 20 mL of fluid at T7 produced spread extending up to the C7-T2 transverse processes cranially and down to the L2-3 transverse processes caudally.10 This is consistent with the observed dermatomal coverage from T5 to L2 in our patient and suggests that the ESP block may even be suitable for pelvic or hip surgery if performed at a lower vertebral level.
As described in earlier reports,8,10,11 the ESP block is a relatively simple technique to perform, with easily identified sonographic landmarks, and end points for needle placement and local anesthetic injection. A catheter is easily inserted into the plane once this has been distended by injection. This case demonstrates the feasibility of utilizing bilateral catheters to cover surgery crossing the midline. It is notable that the extent and intensity of analgesia were maintained with a continuous infusion regimen of dilute local anesthetic at only 6 mL/h. However, more study is required to determine the optimal infusion rate, the benefits of adding patient-controlled boluses, and whether a programmed intermittent bolus regimen may offer any advantages over continuous infusion.
One potential advantage of the ESP block over other abdominal wall blocks is that injection at a single level may reliably cover both upper and lower abdominal areas, as well as the lateral abdominal wall, which is supplied by the lateral cutaneous branches of intercostal nerves. There is also early evidence that it may provide both visceral and somatic analgesia.11 In addition, unlike TAP or rectus sheath blocks, ESP block catheters can be readily inserted preoperatively as the injection site is distant from the anterior abdominal wall. For the same reason, ESP blocks are always feasible in the postoperative period regardless of wound dressings or disruption of tissue planes by air and surgery, as long as the patient can be turned into a lateral position to access the back.
Potential advantages of continuous bilateral ESP blocks over epidural analgesia include the lack of hypotension, which may otherwise hinder adequate intraoperative and postoperative dosing and thus compromise perioperative analgesia, and a minimal risk of serious complications such as epidural hematoma or epidural abscess. These considerations, combined with the analgesic efficacy observed in our report, indicate that this technique may therefore be an alternative option to thoracic epidural analgesia after open abdominal surgery in selected patients.
In summary, this report demonstrates the successful use of continuous bilateral ESP blockade for major open abdominal surgery and should provide impetus for further investigation into its utility in this context.
Name: Carlos Eduardo Restrepo-Garces, MD.
Contribution: This author helped conduct the study, and write and revise the manuscript.
Name: Ki Jinn Chin, MBBS (Hons), MMed, FRCPC.
Contribution: This author helped analyze the data, and write and revise the manuscript.
Name: Patricia Suarez, MD.
Contribution: This author helped conduct the study, and write the manuscript.
Name: Alejandro Diaz, MD.
Contribution: This author helped conduct the study, and write the manuscript.
This manuscript was handled by: Raymond C. Roy, MD.
1. Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev. 2016;7:CD001893.
2. Chilvers CR, Nguyen MH, Robertson IK. Changing from epidural to multimodal analgesia for colorectal laparotomy: an audit. Anaesth Intensive Care. 2007;35:230–238.
3. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012;37:310–317.
4. Ganapathy S, Sondekoppam RV, Terlecki M, Brookes J, Das Adhikary S, Subramanian L. Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane block with thoracic epidural analgesia in patients undergoing abdominal surgery: a randomised, open-label feasibility study. Eur J Anaesthesiol. 2015;32:797–804.
5. Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med. 2017;42:133–183.
6. Niraj G, Kelkar A, Hart E, Kaushik V, Fleet D, Jameson J. Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients. J Clin Anesth. 2015;27:579–584.
7. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a meta-analysis. Anesth Analg. 2015;121:1640–1654.
8. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–627.
9. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. A A Case Rep. 2017;8:254–256.
10. Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017;72:452–460.
11. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017;42:372–376.