Erector Spinae Plane Catheter for Postoperative Analgesia After Thoracotomy in a Pediatric Patient: A Case Report

Fascial plane blocks in pediatric anesthesia: A narrative review

Regional anesthesia techniques have become a cornerstone of pain management in the adult population, providing adequate analgesia while minimizing systemic side effects. Despite the numerous benefits demonstrated in pediatric studies, the implementation of regional anesthesia in children remains insufficiently adopted in clinical settings. One primary concern preventing broader application is the potential for complications of these techniques in pediatric patients, which understandably raises apprehension among clinicians. However, the introduction of fascial plane blocks in the literature has led to a significant advancement in this field. These regional anesthesia techniques are increasingly being incorporated into routine clinical practice, as they are relatively easy to learn and apply and safe techniques. Fascial plane blocks provide adequate pain management while minimizing opioid consumption, which not only helps reduce the risk of opioid-related side effects but also contributes to a more comfortable perioperative and postoperative experience for young patients. These blocks can significantly enhance patient recovery and satisfaction by facilitating analgesia. This narrative review briefly summarizes different indications of fascial plane blocks and their effectiveness in managing pain among pediatric patients, illuminating critical points to consider when applying these techniques.

Perioperative and Anesthetic Considerations in Vascular Rings and Slings

Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.

Epidural-Like Effect of a Continuous Right-Sided Erector Spinae Plane Blockade for Complicated Pediatric Abdominal Surgery

The erector spinae plane block (ESPB) is increasingly gaining popularity in pediatric anesthesiology as it provides an alternative to neuraxial anesthesia in those with relative and absolute contraindications. Recent studies show craniocaudal spread in cadavers and multi-level spread impacting neural structures in live subjects. We present a case report of a pediatric patient with a history of abdominal surgeries, contraindication to neuraxial anesthesia, and thoracic vertebrae fractures. Bilateral ESPB catheters were initially placed but the left catheter was accidentally dislodged. Each ESPB catheter was initially programmed to flow at rate of 2 cc/h of ropivacaine 0.1% for a max combined rate of 4 cc/h. Once the left ESPB catheter was dislodged, the right ESPB catheter was programmed to flow at 4 cc/h which surprisingly continued to provide adequate bilateral analgesia for the patient without the need for additional narcotics. In cases where a unilateral ESPB catheter is the only option due to catheter displacement or contamination, administering a higher volume of local anesthetic may still yield satisfactory pain relief for managing postoperative discomfort following abdominal surgery.

Erector spinae plane block for thoracoscopy in a paediatric patient

We present the case of a 9 year old patient with a clinical history of epilepsy and various hospitalizations due to aspirative broncopneumonia among others, who was admitted to our hospital because of septic shock secondary to pneumonia of the lower left lobule associated with a parapneumonic pleural effusion and a complicated clinical course. During her stay, the patient undergoes surgical debridement using video assisted thoracoscopic surgery (VATS) under general anaesthesia and the hydropneumothorax is drained. For the procedure an ecoguided erector spinae plane block is performed and combined with general anaesthesia. On one hand this block permitted reduction of perioperative opioid administration and improved the patient's respiration, on the other hand it permitted avoiding the use of drugs, which can lower seizure threshold and increase the risk of convulsions. This case illustrates the importance of locoregional anaesthesia, a technique on the rise in the field of paediatric anaesthesia.

Can ultrasound-guided erector spinae plane block replace thoracic epidural analgesia for postoperative analgesia in pediatric patients undergoing thoracotomy? A prospective randomized controlled trial

BACKGROUND

Many analgesic modalities have been investigated in pediatrics for thoracotomy. We studied the analgesic efficacy of unilateral continuous ultrasound-guided erector spinae plane block (ESPB) compared to a thoracic epidural in pediatric patients undergoing thoracotomy.

MATERIALS AND METHODS

A prospective, randomized, observer-blinded, controlled study. Pediatric patients (2-7 years) scheduled for right or left thoracotomy under general anesthesia (GA) were enrolled in the study. We randomly assigned patients into two groups: The thoracic epidural analgesia (TEA) group received GA with an epidural catheter. The ESPB group received GA with a unilateral ultrasound-guided erector spinae plane catheter. The primary outcome was postoperative cumulative opioid consumption for 24 h.

RESULTS

The total intraoperative fentanyl requirement was 35.4 ± 11.44 μg in the TEA group and 30.4 ± 9.08 μg in the ESPB group (t-value - 1.53013, P value: 0.134). The total postoperative fentanyl requirement was comparable in both the groups and clinically nonsignificant (44 ± 2.82 in the TEA group vs. 44.25 ± 13.72 in the ESPB group, t-value = -0.02412, P = 0.981). The median (IQR) Face, Legs, Activity, Cry, and Consolability (FLACC) score at 0, 2, 4, 8, 12, and 24 h time points in the ESPB was equivalent to the TEA group. At 6 h time point, the TEA group had a significantly lower FLACC score than the ESPB group (1[1.75, 1] in the TEA group and 2 [2, 1] in the ESPB group, P value = .02, U = 117.5, z-score = -2.218). The complications were higher in the TEA group (urine retention 20% and hypotension 40%) than in the ESPB group (0 and 0%).

CONCLUSIONS

This study shows that the ESPB provides similar postoperative analgesia to the TEA in pediatric patients undergoing thoracotomy. The ESPB is simpler, faster, and has a lower complication rate.

Ambulatory Erector Spinae Plane Continuous Nerve Catheter for Acute Pain Management Following Rib Resection for Slipping Rib Syndrome in an Adolescent: A Case Report

Continuous regional analgesia techniques for ambulatory management of postoperative thoracic and abdominal wall pain are limited. We report the placement of an erector spinae plane (ESP) catheter in a pediatric patient who underwent rib resection for slipping rib syndrome and was discharged on postoperative day 1 with an elastomeric pump for continued regional analgesia in the ambulatory setting. The patient required minimal opioids while the catheter was in place and experienced a functional level that surpassed her preoperative state. Ambulatory ESP peripheral nerve catheters are a feasible and potentially effective option for the treatment of acute postsurgical pain in children.

Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial

OBJECTIVE

Several nerve block procedures are available for post-thoracotomy pain management.

DESIGN

In this randomized trial, the authors aimed to determine whether the analgesic effect of preoperative ultrasound-guided erector spinae plane block (ESPB) might be superior to that of intraoperative intercostal nerve block (ICNB) in pain control in patients undergoing minithoracotomy.

SETTING

University hospital.

PARTICIPANTS

Sixty consecutive adult patients scheduled to undergo minithoracotomy for lung resection were enrolled.

INTERVENTIONS

Patients were allocated randomly in a 1:1 ratio to receive either single-shot ESPB or ICNB.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the intensity of postoperative pain at rest, assessed with the numeric rating scale (NRS). The secondary outcomes were (1) dynamic NRS values (during cough); (2) perioperative analgesic requirements; (3) patient satisfaction, on the basis of a verbal scale (Likert scale); and (4) respiratory muscle strength, considering the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) variation from baseline. The ESPB group showed lower postoperative static and dynamic NRS values than the ICNB group (p < 0.05). Total remifentanil consumption and requirements for additional analgesics were lower in the ESPB group (p < 0.05). Patient satisfaction was higher in the ESPB group (p < 0.001). A significant overall time effect was found in MIP and MEP variation (p < 0.001); ESPB values were higher at all points, reaching a statistically significant level at the first and sixth hours for MIP, and at the first, 12th, 24th, and 48th hours for MEP (p < 0.05).

CONCLUSIONS

ESPB was demonstrated to provide superior analgesia, lower perioperative analgesic requirements, better patient satisfaction, and less respiratory muscle strength impairment than ICNB in patients undergoing minithoracotomy.