American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naive Patients

Intracardiac Mass

Erector Spinae Plane Block

A novel inter-fascial plane block first described in 2016. This technique has been used for analgesia for the following procedures:

- Video-assisted thoracoscopic surgery (VATS)

- Pulmonary lobectomy

- Thoracic rib and sternal fractures

- Mastectomy

- Axillary sentinel lymph node biopsy

- Abdominal surgery

- Hip surgery

- Thoracic neuropathic pain relief

Unique Contraindications:

- Localized active infectious process at injection site

- Extensive tissue depth between skin and transverse process limiting visualization of transverse process

Unique Complications:

- Pneumothorax

- Lower extremity motor weakness if performed at lower thoracic level

Technique:

- Transverse probe at midline of the spine and identify spinous process, lamina, transverse process and rib

- Slide probe laterally and center view over transverse process

- Rotate probe 90 degrees to parasagittal view of transverse process

- Insert needle from cranial to caudal direction and contact transverse process

- Inject local anesthetic aiming for pooling above transverse process and lifting of erector spinae muscle.  For this video, 30 ml of Ropivacaine 0.5% was used.

Tips:

- Other postural positions (i.e. prone or lateral) may facilitate placement

- Although the T5 transverse process had been the traditional plane of insertion, the block can be performed at any level

- Rostral spread 2-3 levels and approximately 5 levels caudally

- Ultrasound identification/differentiation of the target transverse process and its transition to its adjacent rib can ensure injection at the correct site

- Transverse process appears as blunt and flat while the rib is seen as round on ultrasound with pleura clearly seen in close proximity

- Constant visualization of the needle along its entire length until its contact to the transverse process may decrease the likelihood of a pneumothorax

- Consider use of weight-appropriate dose of local anesthetic to decrease the likelihood of LAST

Block Anesthesiologist:  Gloria Shih Cheng, M.D.

Synopsis:  Jose Enrique Lagueras Garcia, M.D.

Production: Sandy Thammasithiboon, M.D. / ST Film

References:

1. Altiparmak B, et al. 2019. Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: a prospective, randomized, control trial. J Clin Anesth. 54:61-65.
2. Altinpulluk EY, et al. 2019. Bilateral postoperative ultrasound-guided erector spinae plane block in open abdominal hysterectomy: a case series and cadaveric investigation. Rom J Anaesth Intensive Care. 26(1): 83-88.
3. Ahiskalioglu, et al. 2018. Erector spinae plane block for bilateral lumbar transverse process fracture in emergency department: a new indication. Am J Emerg Med. 36(10)1927.
4. Ciftci B, et al. 2019. Ultrasound-guided single shot preemptive erector spinae plane block for postoperative pain management.J Cardiothorac Vasc Anesth. 33(4): 1175-1176.
5. Elkoundi A, et al. 2019. Erector spinae plane block for pediatric hip surgery-a case report. Korean J Anesthesiol. 72(1):68-71.
6. Ince I, et al. 2018. Erector spinae plane block catheter insertion under ultrasound guidance for thoracic surgery: case series of three patients. Eurasian J Med. 50(3)204-205.
7. Jadon A, et al. 2018. Flouroscopic-guided erector spinae plane block: a feasible option. Indian J Anaesth. 62(10):806-808.
8. Jones MR, et al. 2019. Confirmation of erector spinae plane block analgesia for 3 distinct scenarios: a case report. A A Pract. 12(5): 141-144.
9. Luis-Navarro JC, et al. 2018. Erector spinae plane block in abdominal surgery: case series. Indian J Anaesth. 62(7): 549-554.
10. Kumar, A, et al. 2018. The use of liposomal bupivacaine in erector spinae plane block to minimize opioid consumption for breast surgery: a case report. A A Pract. 10(9)239-241.
11. Nath S, et al. 2018. USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: a report of two cases. Saudi J Anaesth. 12(3): 471-474.
12. Petsas D, et al. 2018. Erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy. J Pain Res. 11: 1983-1990.
13. Tulgar S, et al. 2019. Ultrasound-guided erector spinae plane block: indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureu 11(1): e3815.

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