Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in choledochal cyst resection surgery

Sir,

Choledochal cyst resection is not an uncommon surgery in pediatric age group. Opioids and epidural analgesia is mainstay for postoperative pain relief after the surgery. However, with opioids as these children are extubated and breathing spontaneously great care must be taken to avoid respiratory depression. Epidural analgesia is effective when properly placed and closely monitored. Nevertheless, a number of complications have been reported with epidurals. They include bradycardia, ventricular and atrial ectopics, transient apnea, and leakage around the epidural catheter.[1] The newly described technique ultrasound-guided erector spinae plane block (US-ESP) is a novel technique that anesthetizes the dorsal rami, ventral rami, and rami communicantes of the spinal nerves.[2]

We report here the use of bilateral US-ESP for a pediatric case being operated for Choledochal cyst excision surgery. A 9-year-old 25 kg 140 cm male child posted for excision of choledochal cyst and hepaticoduodenostomy. Routine investigations were within normal limits. The ultrasound report showed there is fusiform dilation of extrahepatic bile duct with mild right and left hepatic duct. We planned bilateral US-ESP and general anesthesia for the patient. General anesthesia was induced with sevoflurane, fentanyl (2 μg/kg), and rocuronium (0.8 mg/kg). After the induction, we performed the bilateral US-ESP blocks. The ESP block was performed as follows the patient was placed in the left lateral position, and a high-frequency linear ultrasound transducer was placed in a longitudinal orientation 1 cm lateral to the thoracic sixth spinous process. The deep plane to the erector spinae muscle was identified. The ESP block was administered by injection of 0.25% bupivacaine 30 mL in total (15 mL injected into each side) into the fascial plane below erector spinae muscles [Figure 1]. Anesthesia was maintained with sevoflurane, fentanyl, and rocuronium. Intraoperative period was eventless, and no additional analgesic was given. The surgery lasted for 3 h and patient was extubated on operating table. Following extubation and transfer to the postanesthesia care unit, the patient was noted to have a Wong–Baker FACES pain rating scale score of 2 (consistent with mild pain). Postoperative analgesia was initiated with intravenous tramadol 2 mg/kg and intravenous acetaminophen 15 mg/kg every 8 h. The pain was assessed every 4 h using the Wong–Bakers FACES. The patient continued to report only mild pain at the surgical site up to 48 h after surgery. US-ESP achieves extensive multidermatomal sensory block of the posterior, lateral, and anterior thoracic and abdominal wall depending on the site of intervention.[3] This paraspinal block is associated with much less complications as compared to epidural analgesia so recommended, especially in pediatric patients.[4]

Figure 1.

Identification of plane below erector spinae muscle and injection of drug

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