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Ultrasound-Guided Continuous Continuous Erector Spinae Plane (ESP) block for postoperative analgesia in an anticoagulated patient undergoing a Whipple procedure
Nicholas Eglitis, Ban Tsui, Jean Louis Horn. Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford CA
Introduction: Recently Erector Spinae Plane (ESP) blocks have been used successfully to relieve pain for several conditions including thoracic neuropathic pain1, laparoscopic bariatric surgery2, thoracic surgery3, and open abdominal surgery4. We describe a case where bilateral ESP catheters were placed and successfully managed postoperative pain in a very anxious patient receiving therapeutic enoxaparin undergoing a Whipple procedure.
A 69 year-old woman with past medical history significant for hypertension, anxiety, BRCA1-positive breast cancer status post lumpectomy and subsequent double mastectomy, was recently diagnosed adenocarcinoma of the head of the pancreas. She was scheduled for a Whipple procedure after completing 4 cycles of neoadjuvant chemotherapy. The patient was taking therapeutic enoxaparin for treatment of a right internal jugular thrombus. Thoracic epidural analgesia (TEA) was not an option, so bilateral ESP catheters were planned for post-operative pain control. The catheters were placed under direct ultrasound guidance using an out-of-plane approach deep to the erector spinae muscles at the level of the T8 transverse process. We used normal saline for hydrodissection of the facial plane deep to the erector spinae muscles. Each catheter was threaded 5-7 cm past the needle tip into the space created and were secured at the skin. 15mL of 0.375% bupivacaine was injected into each catheter before induction of general anesthesia. General endotracheal anesthesia was maintained with 1 MAC of isoflurane in 50% oxygen, and 15mg of methadone was administered prior to intubation with an additional 5mg before skin incision. The patient was extubated uneventfully at the end of the case. In the PACU, the patient received 25mcg of fentanyl x2 for grimacing. 0.1% ropivacaine infusion pumps were then connected to the catheters as well as a hydromorphone PCA. Each catheter was automatically bolused 10mL every 90 minutes with a demand of 5mL every 30 minutes for breakthrough pain. Her pain on arrival to the floor on POD#0 was 3/10. Her worst pain score on POD#1 was 5/10 with a median pain score of 0. She received a total of 2mg of hydromorphone via her PCA on POD#1. Her worst pain score on POD#2 was also 5/10 with a median pain score of 0. She received 0.8mg of hydromorphone on POD#2 and the PCA was discontinued. The catheters were discontinued on POD#3.
This is the first description of ESP catheters for pain management following a Whipple. The Whipple is a major open abdominal surgical procedure associated with moderate to severe postoperative pain. Although Thoracic Epidural Analgesia (TEA) has been used to facilitate postoperative pain control, it is often avoided due to hemodynamic effects and postoperative coagulopathy. Since ESP blocks are performed in a more superficial and compressible site and distant from deep central neuraxial and paravertebral (PVB) spaces, most experts would likely have less concern preforming ESP among patients with mild coagulopathy. ESP catheters are easier to place than TEA or PVB, with reproducible spread easily to multiple levels. Given the time for diffusion of the local, there is probably less sympathectomy than with TEA or PVB.
Bilateral ESP catheters are a valid alternative to TEA or PVB for effective pain management after the Whipple procedure.
1) Forero M, et al. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med 2016 Sep-Oct; 41(5):621-7
2) Chin KJ, et al. The Erector Spinae Plan Block Provides Visceral Abdominal Analgesia in Bariatric Surgery: A Report of 3 Cases. Reg Anesth Pain Med 2017 May/Jun; 42(3):372-376.
3) Scimia, et al. The Ultrasound Guided Continuous Erector Spinae Plane Block for Postoperative Analgesia in Video-Assisted Thoracoscopic Lobectomy. Reg Anesth Pain Med 2017 Jul/Aug; 42(4):537
4) Restrepo-Garces CE, Chin KJ, et. al., Bilateral Continous Erector Spinae Plane Block Contributes to Effective Postoperative Analgesia After Major Open Abdominal Surgery: A Case Report, A&A Case Reports, 12/2017, 9(11): 319-321