epinephrine 1: 200.000 were administered. The pa$ent was extubated and transferred to the ICU, where a local anesthe$c infusion (bupivacaine 0.1% without ...
Erector Spinae Plane Block For Anterior Approach Scoliosis Surgery In Neurofibromatosis Leonardo Cendales P, Carolina Perez P, Juan Pablo Vivas H, Carlos Largo P. Department Of Anesthesia, Rooselvelt Pediatric Hospital Introduc)on
Case
Discussion
Scoliosis is the skeletal altera.on most frequently found in pa.ents with Neurofibromatosis type 1. The erector spinae block (ESP) is a recently described technique for analgesic management of pa.ents with acute or chronic pain, there are no reports regarding this technique in pa.ents undergoing scoliosis surgery.
A pa.ent 15 years old, 34 kg, ASA 2 and with a previous diagnosis of neurofibromatosis type I presents scheduled for scoliosis correc.on surgery. X-‐ rays show thoracic scoliosis with a Cobb angle of 110 (Fig 1). The first procedure was performed using TIVA (total intravenous anesthesia). Basic ASA monitoring was used in addi.on to internal yugular and radial artery catheteriza.on. Intraopera.ve neurophysiological monitoring was also used during the procedure. A T6 and T7 corpectomy by anterior thoracotomy was performed by an orthopedic surgeon. At the end of the procedure, with the pa.ent posi.oned in the right lateral decubitus, using a M-‐turbo Sonosite® ultrasound, the T5 transverse process was located and a puncture was made using a #18 G X 90 mm Touhy needle. A catheter was advanced and hydrodisec.on performed to verify the posi.oning, then the catheter was fixed at 3 cms. 30 mL of Bupivacaine 0.25 % with epinephrine 1: 200.000 were administered. The pa.ent was extubated and transferred to the ICU, where a local anesthe.c infusion (bupivacaine 0.1% without epinephrine) was started through the catheter at 8 mL/h, in addi.on to Dipirone 600 mg / 8 hours and Morphine exclusively as a rescue dose. Pain was evaluated using the Visual Analogue Scale (VAS) at 2, 4, 8, 12, 24, 48 and 72 hours postop finding scores of 5/10 , 4/10, 8/10, 7/10, 7/10, 4/10, 2/10 respec.vely. In the 8 hour evalua.on a 1.5 mg dose of morphine was administered. At the 24 hour evalua.on with a VAS of 7/10 the decision was made to administer bolus of 10 mL of Bupivacaine 0.1% through the catheter, obtaining a reduc.on in the VAS score, therefore it was decided to increase the infusion rate to 9 mL/h. With the aforemen.oned adjustment the VAS score stayed between 2/10 and 4/10. Ader 72 hours the catheter was removed without any adverse outcomes.
Forero and colleagues described the ESP block for the first .me in 2016 for the treatment of pa.ents with neuropathic chest pain secondary to thoracotomy. Since then this technique has also be described as an analgesic op.on for pediatric popula.on in other surgical scenarios such as pectum excavatum surgery, thoracotomy and resec.ons of costal. In this case, we used this technique to provide analgesia for a pa.ent who underwent vertebrectomy for scoliosis correc.on surgery, obtaining excellent results in pain control up to 72 hours postop with minimal opioid use. To this date we find a limita.on in the fact that no reports or evidence sugges.ng op.mal volume doses for ESP in pediatric popula.on are found in the literature, finding case reports with volumes as high as 30 mL with excellent results.
Fig. 1
References -‐ Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–7. -‐ Plane ES, Edge S, Picu A. Con.nuous Erector Spinae Plane block for thoracic surgery in a pediatric pa.ent. :74–5. -‐ Muñoz F, Cubillos J, Bonilla AJ, Chin KJ. Erector spinae plane block for postopera.ve analgesia in pediatric oncological thoracic surgery. Can J AnesthCan d’anesthésie [Internet]. 2017;64(8):880–2.
Conclusion The ESP block is an excellent analgesic op.on for thoracic and scoliosis surgery, by itself or as part of a mul.modal approach, its success may depend on the local anesthe.c volume administered. There is a need for proper training in the use of the technique but once this is accomplished the procedure can be done safely regardless of the spine devia.on found in this pa.ents. Fig. 2
Erector Spinae Plane Block For Anterior Approach Scoliosis Surgery In Neurofibromatosis Leonardo Cendales P, Carolina Perez P, Juan Pablo Vivas H, Carlos Largo P. Department Of Anesthesia, Rooselvelt Pediatric Hospital
Introduc)on Scoliosis is the skeletal altera.on most frequently found in pa.ents with Neurofibromatosis type 1. The erector spinae block (ESP) is a recently described technique for analgesic management of pa.ents with acute or chronic pain, there are no reports regarding this technique in pa.ents undergoing scoliosis surgery.
Case
A pa.ent 15 years old, 34 kg, ASA 2 and with a previous diagnosis of neurofibromatosis type I presents scheduled for scoliosis correc.on surgery. X-‐ rays show thoracic scoliosis with a Cobb angle of 110. The first procedure was performed using TIVA (total intravenous anesthesia). Basic ASA monitoring was used in addi.on to internal yugular and radial artery catheteriza.on. Intraopera.ve neurophysiological monitoring was also used during the procedure. A T6 and T7 corpectomy by anterior thoracotomy was performed by an orthopedic surgeon. At the end of the procedure, with the pa.ent posi.oned in the right lateral decubitus, using a M-‐turbo Sonosite® ultrasound, the T5 transverse process was located and a puncture was made using a #18 G X 90 mm Touhy needle. A catheter was advanced and hydrodisec.on performed to verify the posi.oning, then the carheter was fixed at 3 cms. 30 mL of Bupivacaine 0.25 % with epinephrine 1: 200.000 were administered. The pa.ent was extubated and transferred to the ICU, where a local anesthe.c infusion (bupivacaine 0.1% without epinephrine) was started through the catheter at 8 mL/h, in adi.on to Dipirone 600 mg / 8 hours and Morphine exclusively as a rescue dose. Pain was evaluated using the Visual Analogue Scale (VAS) at 2, 4, 8, 12, 24, 48 and 72 hours postop finding scores of 5/10 , 4/10, 8/10, 7/10, 7/10, 4/10, 2/10 respec.vely. In the 8 hour evalua.on a 1.5 mg dose of morphine was administered. At the 24 hour evalua.on with a VAS of 7/10 the desi.on was made to administer bolus of 10 mL of Bupivacaine 0.1% through the catheter, obtaining a reduc.on in the VAS score, therefore it was decided to increse the infusion rate to 9 mL/h. With the aforemen.oned adjustment the VAS score stayed between 2/10 and 4/10. Ader 72 hours the catheter was removed without any adverse outcomes.
Discussion Forero and colleagues described the ESP block for the first .me in 2016 for the treatment of pa.ents with neuropathic chest pain secondary to thoracotomy. Since then this technique has also be described as an analgesic op.on for pediatric popula.on in other surgical scenarios such as pectum excavatum surgery, thoracotomy and resec.ons of costal. In this case, we used this technique to provide analgesia for a pa.ent who underwent vertebrectomy for scoliosis correc.on surgery, obtaining excellent results in pain control up to 72 hours postop with minimal opioid use. To this date we find a limita.on in the fact that no reports or evidence sugges.ng op.mal volume doses for ESP in pediatric popula.on are found in the literature, finding case reports with volumes as high as 30 mL with excellent results.
Conclusion
Fig. 2
The ESP block is an excellent analgesic op.on for thoracic and scoliosis surgery, by itself or as part of a mul.modal approach, its success may depend on the local anesthe.c volume administered. There is a need for proper training in the use of the technique but once this is accomplished the procedure can be done safely regardless of the spine devia.on found in this pa.ents. References • Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–7. • Plane ES, Edge S, Picu A. Con.nuous Erector Spinae Plane block for thoracic surgery in a pediatric pa.ent. :74–5. • Muñoz F, Cubillos J, Bonilla AJ, Chin KJ. Erector spinae plane block for • postopera.ve analgesia in pediatric oncological thoracic surgery. Can J AnesthCan d’anesthésie [Internet]. 2017;64(8):880–2.
Fig. 1
