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Continuous Erector Spinae Plane Catheter for Analgesia After Infant Thoracotomy: A Case Report

Kaplan, Irem MD; Jiao, York MD; AuBuchon, Jacob Daniel MD; Moore, Robert P. MD

doi: 10.1213/XAA.0000000000000799
Case Reports
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The erector spinae plane block is an emerging technique for the provision of thoracolumbar analgesia with reported pediatric applications. We describe the placement of a continuous erector spinae plane catheter at the T5-T6 level in a 7-month-old infant who was undergoing thoracotomy for left upper lobectomy due to congenital pulmonary airway malformation. This technique resulted in outstanding analgesia without the need for opioid rescue analgesia. This block has a low degree of technical difficulty and is placed in area devoid of nearby critical structures and could be used in a number of potentially painful interventions.

From the Department of Anesthesiology, St Louis Children’s Hospital/Barnes Jewish Hospital, Washington University in St Louis, St Louis, Missouri.

Accepted for publication April 10, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Robert P. Moore, MD, Department of Anesthesiology, St Louis Children’s Hospital/Barnes Jewish Hospital, Washington University in St Louis One Children’s Place, Suite 5s-31, St Louis, MO 63110. Address e-mail to robertpmoore@wustl.edu.

Inadequate analgesia after thoracotomy can result in a multitude of adverse pulmonary and cardiovascular events and necessitate intensive care unit (ICU) admission.1,2 In infants, these events can be especially concerning and have life-long repercussions. The erector spinae plane (ESP) block is an emerging technique for the provision of thoracolumbar analgesia with reported pediatric applications.3,4 We describe the placement and use of a continuous ESP catheter placed at T5-T6 in a 7-month-old female infant, weighing 7.06 kg, who was undergoing thoracotomy at the interspace between the fifth and sixth ribs for left upper lobectomy due to congenital pulmonary airway malformation. This is the first description of this technique in an infant.

The choice of erector spinae catheter was made after consideration was given to the large field of desired coverage including a T5-T6 incision and distal chest tube insertion site at T9 in a small infant. The choice of ESP was buttressed by the ability to place the block under vision without entering the neuraxis or coming in close proximity to the pleura. Before adoption of ESP, the thoracic epidural infusion of a large volume of dilute local anesthetic would have been used to provide analgesia and almost always required the use of supplemental opiate medications. In general, other regional techniques such as epidural or paravertebral analgesia may require opiate rescue analgesia.1,2 The possibility of avoiding rescue therapy further supported the choice of ESP blockade.

The mechanism of the ESP block involves apparent local anesthetic spread to the paravertebral space after deposition in the layer deep to the erector spinae muscle and superficial to the tip of the transverse process of the spine.3 Multiple dermatomes are targeted as dorsal, and ventral rami of the thoracic spinal nerves are anesthetized, as well as the sympathetic chain. Clinically, analgesia is achieved across the anterior, lateral, and posterior thoracic wall, and along multiple dermatomes. In this patient, we anticipated the ability to obtain analgesia from the T3-T10 dermatomes.

The patient’s family has provided written consent and written Health Insurance Portability and Accountability Act authorization to publish this case report.

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METHODS

After induction of general anesthesia with endotracheal tube intubation, the patient was positioned in the right lateral decubitus position and a high-frequency linear ultrasound probe was placed approximately 1 cm lateral to the thoracic spinous processes. This allowed for the identification of transverse processes, trapezius, rhomboids, and erector spinae as shown in Figure 1. A pediatric 50-mm 20-gauge Tuohy needle (B Braun Medical, Bethlhem, PA) was inserted in-plane, cephalad-to-caudal direction until the T6 transverse process was encountered and withdrawn slightly to allow for injection in the fascial plane beneath the erector spinae muscle (Figure 2). This site of injection was chosen to allow for direct observation of the spread of local toward the planned incision and chest tube sites. The ESP was dilated with an injection of 2 mL of 0.2% ropivacaine. Subsequently, a 24-gauge catheter was passed into the space under direct ultrasound guidance. The angle of approach was fairly shallow, with the ESP being encountered at 2 cm and with 3 cm of catheter left in the space (Figure 3). Once the catheter was secured (Figure 4), 0.2% ropivacaine was infused at a rate of 1 mL/h. This infusion was continued throughout the surgery. The infant was maintained with a balanced anesthetic including sevoflurane and boluses of intravenous fentanyl (25 and 30 μg) that were administered by the anesthesia team in anticipation of skin incision and skin closure.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

Postoperatively, the patient appeared comfortable and was stable on blow by oxygen. In the recovery suite, standardized nursing assessments yielded Face, Legs, Activity, Cry, Consolability (FLACC) scores of 0–2 on a 10-point scale over the 1-hour and 10-minute recovery room stay, with interventions being limited to relaxation and pacifier use. Based on comfort level, stable vital signs, limited oxygen requirement, and the absent need for rescue medications, the patient was sent to the inpatient ward obviating the need for planned ICU admission that typically follows this intervention in an infant.

Postoperatively, the ESP catheter infusion of ropivacaine was continued at 1 mL/h for the duration of therapy until planned catheter removal on postoperative day 3. Adjustment of this rate would have been considered in the setting of inadequate analgesia or side effects. The patient was maintained on scheduled acetaminophen 15 mg/kg orally every 8 hours for the first 48 hours postoperatively, with ketorolac 3.6 mg intravenously every 6 hours being added on postoperative day 1 per protocol. Throughout the duration of ESP catheter infusion, the patient was able to tolerate mild-to-moderate palpation of the incision and chest tube site, did not experience hypotension or symptoms suggestive of local anesthetic toxicity, had no recorded adverse events, did not receive any opioids, and did not exceed a FLACC of 2. Within 4 hours of catheter removal, the documented FLACC score rose to 4 from a 0 at the time of removal. Two doses of 0.7 mg of oxycodone were administered on postoperative day 4 in the setting of discomfort.

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DISCUSSION

In this infant, the use of an erector spinae catheter was very effective in achieving postoperative pain control in the setting of a thoracotomy and allowed for transfer to the floor from the post-anesthesia care unit without the need for ICU admission. Additionally, opioid rescue analgesia was not required while the catheter was in place. These drugs are often required in the setting of regional analgesia after similar interventions.1,2 This outcome suggests excellent spread of local throughout the fascial plane from a single injection site. A modest amount of local anesthetic with an approximate 0.3 mL/kg bolus and 0.15 mL/kg/h infusion led to excellent analgesia. These rates were chosen based on the experience with ESP and other truncal catheters placed in toddlers and adolescents and typically result in excellent spread of local that can be confirmed by ultrasonographic observation.

In addition to providing outstanding analgesia, the ESP catheter might have a safety benefit in this population, because the block has a low degree of technical difficulty, is superficial, and potentially avoids the risks associated with epidural or paravertebral placement. In infants, the ESP catheter can easily be advanced under ultrasound visualization (as shown in Figure 3), further reducing the risk associated with catheter advancement.

This case supports the benefit of ESP catheter placement in infants and adds to a growing body of literature suggesting benefit for the technique after interventions associated with a high degree of anticipated thoracic or abdominal discomfort especially when neuraxial techniques might be counterindicated or impractical. This technique could be used for a number of interventions in infants and children. Further study should be pursued to validate these observations.

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DISCLOSURES

Name: Irem Kaplan, MD.

Contribution: This author helped review the literature, and write and edit the manuscript.

Name: York Jiao, MD.

Contribution: This author helped review the literature, and write and edit the manuscript.

Name: Jacob Daniel AuBuchon, MD.

Contribution: This author helped review the literature, and edit the manuscript.

Name: Robert P. Moore, MD.

Contribution: This author helped review the literature.

This manuscript was handled by: Mark C. Phillips, MD.

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REFERENCES

1. Davies RG, Myles PS, Graham JMA comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy–a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96:418426.
2. Abd El-Aziz MA, Elnakera AM, Salah AAPost-thoracotomy pain relief in pediatric patients epidural versus inter-pleural analgesia. Res Opin Anesth Intensive Care. 2015;2:132139.
3. De la Cuadra-Fontaine JC, Concha M, Vuletin F, Arancibia HContinuous erector spinae plane block for thoracic surgery in a pediatric patient. Paediatr Anaesth. 2018;28:7475.
4. Muñoz F, Cubillos J, Bonilla AJ, Chin KJErector spinae plane block for postoperative analgesia in pediatric oncological thoracic surgery. Can J Anesth. 2017;64:880882.
5. Soto RG, Fu ESAcute pain management for patients undergoing thoracotomy. Ann Thorac Surg. 2003;75:13491357.
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