Key Clinical Message
ESP block can be a valid alternative to general anesthesia, specially in patients with contraindications to GA - above all in the current Covid 19 pandemy - thanks to the anesthetic mixture diffusion in the epidural space as described by Forero
Introduction
The ultrasound-guided erector spinae plane block (US-ESPB) at T5 transverse process is recently described as a technique for providing thoracic analgesia [1,2].
From recent literature it is known that the injection into the deep fascial plane to erector spinae muscle (the erector spinae plane, ESP) at the level of the T5 transverse process can produce profound analgesia of the ipsilateral hemithorax [3].
Anatomical dissection indicates that the likely action mechanism is the diffusion of local anaesthetic anteriorly through the connective tissues and ligaments spanning the adjacent transverse processes and into the vicinity of the spinal nerve roots (consistent with other reports of successful analgesia following injection into a similar tissue plane in the thorax [4,5].
ESP is widely used, particularly in thoracic surgery, for intra and postoperative analgesia. Erector Spinae Plane block that determines anaesthesia and not only analgesia has currently little clinical application. This case report shows that in certain cases ESP can also be used as an anaesthetic plan, as an effective and safe alternative to general anaesthesia. Moreover, it did not determine any discomfort of the patient, on the contrary, it improved the surgeons’ work.
Case report
It is here by declared that the patient has consented to the publication of this case report intended purely for scientific and clinical purposes, maintaining the privacy of the processing of her personal data
Our 25-year-old female pz came in our operative block, without comorbidity, to perform an intervention of capsulated under-apicalular lipoma exeresis, under fascial plane, localized in the left hemithorax of about 10 cm of diameter. The patient reported the story of Awareness during a previous surgery and categorically rejects a second GA. It is therefore decided for the execution of the US-ESPB. With the patient in sitting position, a high-frequency linear probe (12 MHz) was placed in longitudinal orientation at level of the T7 transverse process, 3 cm from the midline. A 22 gauge 50-mm block needle was inserted in plane, with a cephalad-to-caudad direction (Figure 1), until the tip laid into the plane to deep of the erector spinae muscle. After hydrolocalization with 3 mL of normal saline to open the plane, 20 mL of 0.75% ropivacaine and dexamethasone 8 mg were injected.
A sensory block (Hollmen 4) is obtained with an extension from T5 to L1 - tested with Pin Prick and Ice tests - for the entire duration of the surgery (30’) during which the pz was in prone position – in spontaneous breathing – sedated with 0,7 mcg/kg/h of dexmedetomidine 10 minutes before the surgery.
The vital parameters were stable throughout the duration of the intervention, on PA 110/70 mmHg, FC 70 bpm, SpO2 99% average.
The pz was collaborating and awakening to verbal stimulus throughout the intervention RASS scale -2
During the post-operative the pz reported Hollmen 3 analgesia at T1 (2h from the surgery); Hollmen 2 analgesia at T2 (6h from the surgery); Hollmen 1 analgesia at T3 (12h from the surgery).
Together with the full satisfaction of the pz, who reported NRS<2 at 24h post intervention with no analgesic necessity, even the surgeons were satisfied in proceeding with a constant plan of anaesthesia that did not alter the anatomical planes.