Ultrasound guided erector spinae plane block -An effective rescue analgesia for pediatric open upper abdominal surgery.

Dear Editor,

The erector spinae plane block (ESPB), since its initial description in 2016,[1] has also been described as a modality for intraoperative and postoperative analgesia in thoracoscopic, laparoscopic, and open thorocoabdominal surgeries in pediatric patients.[2] We would like to report the use of ESPB as a rescue analgesic, in a 4-year-old male child weighing 15 kg, who underwent right sided adrenalectomy for a functioning adreno-cortical tumor. Written informed consent was obtained from the parent for the purpose of publication.

The surgical plan was robotic-assisted laparoscopic adrenalectomy. Our analgesic plan included intravenous fentanyl, paracetamol, and ketorolac. After 5 h of surgery, surgeons planned to open the abdomen due to difficult dissection and bleeding, with a subcostal incision extending from T7 to T10 on the right side. Intraoperative surgical response was managed with IV fentanyl (total dose of 45 mcg). A single-shot right sided ESPB was performed for postoperative analgesia at the end of surgery. In the same left lateral position, after aseptic precautions, a high frequency linear transducer probe (6 to 15 MHz SonoSite S series; Bothell, WA, USA) was placed in longitudinal para-sagittal direction 2 cm lateral and parallel to the T7 to T10 spinous process marked [Figure 1a]. The probe was moved laterally to visualize the tip of transverse process T9 [Figure 1b]. A 5 cm 20 G needle was inserted in-plane, caudal-cranial direction, to reach below erector spinae muscle (ESM). After negative aspiration, 1 ml of normal saline was injected to confirm the spread of saline. Once cranio-caudad spread was confirmed, 10 ml of 0.25% bupivacaine (0.5 ml/kg) was deposited below the ESM sheath [Figure 1c]. Following the block, infiltration with local anesthetic (4 ml of 0.25% bupivacaine) was done at the laparoscopic port sites before extubation. Later the child was extubated and shifted to pediatric intensive care unit (PICU). In PICU, child had stable vital signs with no tachycardia, respiratory rate 15/min, alert and comfortable with FLACC (Face, Legs, Activity, Cry, Consolability) scale of 0. No rescue analgesic (IV fentanyl) was used for 24 h postoperatively. Paracetamol (IV) 10 mg/kg was administered every 6 h for 48 h. No side effects of the block were reported.

Figure 1

(a) Patient in left lateral position, probe oriented in sagittal direction over the marked spinous process from T7 to T10. In-plane insertion of needle from caudad direction. (b) Para-sagittal ultrasonographic visualization of flat hyperechoic transverse process from T7 to T10.(c) Needle tip above the T9 transverse process. Local anesthetic drug lifting up ESM with cranio-cephalad spread from T7 to T10

In the ESPB, the drug is deposited deep to the ESM sheath and superficial to transverse process, as close as possible to the origin of the dorsal rami of the spinal nerves in the targeted dermatomes and a cephalocaudal distribution of drug is expected.[1] We chose ESPB as a rescue analgesic technique rather than caudal anesthesia to avoid bilateral sensory block, urinary retention, and early ambulation.[3] Lower thoracic epidural can be a better alternative, but it has been reported with unrecognized dural taps, multiple attempts, total spinal anesthesia, and nerve injuries in pediatric population.[4] Our experience with this patient emphasizes the utility of the ESPB as a rescue analgesic modality during unplanned conversion from minimally invasive surgical approach to an open surgical approach.

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Conflicts of interest

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