2019 FSA Posters

P019: ERECTOR SPINAE BLOCK: A NOVEL ANALGESIC APPROACH FOR MULTIPLE RIB FRACTURES
Marc Blanchard, MD, Ettore Crimi, MD, UCF Anesthesia Program Director, Manuel Turner, MD, UCF COM Anesthesia Faculty; University of Central Florida – Hospital Corporation of America Consortium, Department of Anesthesiology, Ocala Regional Medical Center, Ocala, FL

Introduction: Erector spinae plan block, initially described for management of thoracic neuropathic pain, has been recently proposed as an analgesic technique for rib fractures (1,2). Here we describe our experience with the erector spinae plane block and the insertion of an indwelling catheter for intermittent redosing in a patient with bilateral multiple traumatic rib fractures.

Case Presentation: A 67 year old male with past medical history significant for COPD, smoking and hypertension, presented to the trauma center after motor vehicle accident. CXR showed three rib fractures on the right side and two rib fractures on the left. The patient experienced severe pain (pain score 10/10), associated with hypoxemia requiring oxygen supplementation by Venturi mask. Acute Pain Service was consulted and decided to perform an erector spinae plane block with the additional insertion of an indwelling catheter for intermittent redosing. The erector spinae plane was identified by ultrasound and 0.25% Ropivacaine (30 ml) was injected. After hydrodissection of the plane, an epidural catheter was inserted under ultrasound guidance for local anesthetic redosing (3-5 mL’s of 0.25% Ropivacaine Q4-6 hours for pain score >5/10). Patient required only one additional bolus in the following 24 hours. Catheter was removed 48 hours post-insertion. Hypoxemia improved with decreased oxygen supplementation. Patient was discharged from the ICU with no pain 96 hours post-admission.  

Discussion: Ribs fractures, a common consequence of blunt chest trauma, are a significant cause of mortality and morbidity especially in the elderly patients, secondary to hypoventilation due to severe pain, impaired gas exchange in the injured lung underlying the fractures, and altered breathing mechanics (3). Multi-modal analgesia including regional anesthesia (thoracic epidural or paravertebral nerve block), i.v. opioids and oral adjuncts is essential to reduce complications. Erector Spinae block has been recently used for analgesia in multiple ribs fracture and has been associated with significant improvement in incentive spirometry volumes and decrease in pain scores without hemodynamic instability (2). Insertion of a catheter in the erector spinae plan allows redosing the local anesthetic solution with extension of pain relief.

Conclusion: In conclusion, our case supports the use of the erector spinae plane block as valuable, simple and safe technique in the analgesic management of traumatic rib fractures.

References:

1. Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474–475.

2. Adhikary, SD, Liu, WM, Cruz-Eng, H, Chin, KJ. The effect of erector spinae block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia. 2019 Feb 10. doi: 10.1111/anae.14579. [Epub ahead of print]

3. Bulger, EM, Ameson, MA, Mock, CN, Jurkovich, GJ. Rib Factures in the Elderly. J Trauma 2000;48(6):1040-1046.