Continuous erector spinae plane block in paediatric patient undergoing thoracotomy surgery

The ESP block is a novel block during which an area local anesthetic is deposited between the erector spinae muscle and the underlying transverse process. It is an easier technique than the ultrasound-guided paravertebral block, which is technically challenging, time-consuming, and related to important risks.[1] We describe two cases of thoracotomy surgery performing ultrasound-guided continuous erector spine plane (ESP). In both cases, we obtained parental informed consent for publication. Case 1 was of a 2-year-old male child weighing 10 kg ASA I having empyema thoracis scheduled for thoracotomy under general anesthesia. After induction of anesthesia, continuous ESPB was performed at the level of the T5 transverse process. After placing a linear USG probe (M-Turbo, Fujifilm Sonosite, Inc, Bothell, WA, USA) parallel to the vertebral axis, we found the T5 transverse process and three associated muscles (trapezius, rhomboid major, erector spinae muscle). From this point, a 19-G Tuohy needle was inserted toward the three muscles and the transverse process of T5 in a cephalad-to-caudal direction. We administered two ml saline to confirm the location of the needle (deep to ESP). Thereafter 5 ml of 0.125% bupivacaine was injected. This also facilitated the insertion of epidural catheter in the desired plane. We fixed the catheter using double tunnelling [Figure 1] with 2 cm of the catheter in the fascial plane between the muscle and transverse process. Double-tunneling allows the catheter to circle the bridge of skin created between two loops of the catheter. Catheter dislodgement is prevented due to the tightening of the bridge of the skin in case any untoward force pulls it. Intraoperatively, hemodynamically stable no systemic analgesics were needed apart from the scheduled paracetamol. The patient was extubated, and emergence from anesthesia was uneventful. He had a maximum FLACC (face, legs, activity, cry, consolability) scale score of 1 in 24 h. Postoperative multimodal analgesia consisted of intravenous paracetamol 15 mg/kg every 6 h combined with an intermittent bolus dose of bupivacaine 0.125% 5 ml injected via an indwelling catheter every 8 h for 3 days. He was discharged without any complications. Case 2 was of a 5-year-old male child weighing 14 kg having hydatid cyst ASA I who was scheduled for thoracotomy under general anesthesia. After induction of anesthesia, ultrasound-guided ESPB was performed; postoperative multimodal analgesia was performed according to the acute pain service protocol of our hospital, as in Case 1. The FLACC score was maintained between 0 and 1 for a week after surgery. The patient was discharged without any complications.

Figure 1.

Ultrasound image showing the needle (arrow) on the top of the transverse process T5. ESM: erector spinae muscle, RMM: Rhomboid major muscle, TM: Trapezius muscle, TP5: transverse process of T5. Catheter fixation double tunneling method

The use of the ESP block is limited to the thoracic region in the pediatric population, and to date, there is no recommendation about the optimal dose of local anesthetic for use in an ESP block in children. Hernandez et al.[2] used a volume of 0.2 ml/kg of 0.25% bupivacaine to perform an ESP block for inguinal hernia repair in a 2-month-old male patient. They also reported that adequate anesthetic spread and analgesia with a volume of 0.2–0.3 ml/kg in pediatric patients undergoing thoracic surgery. Continuous ESP block as an adjunct to general anesthesia provides effective surgical analgesia and satisfactory postoperative pain control in pediatric thoracotomy surgery.

Consent

Taken from the parent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.