Ultrasound-guided thoracic erector spinae plane block for periprocedural analgesia in pigtail catheter insertion for palliative.

Dear Editor,

A pigtail catheter is an effective and safe method for draining pleural fluid in the palliative care setting. It is less invasive as compared to chest tube thoracostomy but associated with significant pain at the site of insertion in 45.09% of cases.[1] We describe the novel application of ultrasound-guided thoracic erector spinae plane block (TESPB) as a periprocedural analgesia technique for pigtail catheter insertion for palliative drainage of malignant pleural effusion (MPE).

A 48-year-old lady, weighing 50 kg, was admitted to our palliative care ward with a history of gradual onset of dyspnea on exertion over five days. She was a diagnosed case of carcinoma breast with metastasis to the vertebral column. She had undergone thoracentesis multiple times before and was on various medications for pain management, including non-steroidal anti-inflammatory drugs, gabapentin, and oral morphine. On examination, she was afebrile; her vitals were within normal limits except the room air saturation, which was 93%. On auscultation, she had decreased breath sounds on the right side. A chest X-ray and chest sonography revealed right-sided massive pleural effusion. We decided to insert a pigtail catheter for intermittent or continuous drainage of pleural fluid. The management plan was discussed with the patient and her relatives, and informed written consent was obtained.

In the procedure room, intravenous cannula and standard monitors were attached. She was placed in a sitting position on the table with both knees flexed and feet rested on a stool. A scout scan was performed, and a suitable area for performing right-sided TESPB and insertion of the pigtail catheter was marked. A high-frequency linear transducer (8–13 MHz) of the ultrasound machine (Edge II, FUJIFILM SonoSite, Inc. Bothell, Washington) was used to perform TESPB by modified transverse approach.[2] Under aseptic precautions and local infiltration, a 100 mm 21-gauge short beveled nerve block needle (Stimuplex® A, B. Braun Melsungen AG, Germany) was inserted and advanced in in-plane technique from lateral to the medial side to contact the right transverse process of the 5th thoracic vertebra. The interfacial plane below the erector spinae complex was identified and confirmed by hydro dissection. A volume of 20 mL of local anesthetic (LA, 10 mL of 2% lignocaine-adrenaline and 10 mL of 0.5% ropivacaine) and 8 mg dexamethasone (total volume 22 mL) was injected in 3–5 mL aliquots after negative aspiration for blood, air or pleural fluid. After 20 min, the block was assessed by spirit-soaked cotton and blunt tip needle in the desired dermatomes. After confirmation of procedural anesthesia, a curvilinear probe (2–5 MHz) was used to perform a percutaneous pigtail catheter insertion under real-time ultrasound guidance. A 12F polyurethane coiled end pigtail catheter (Indovasive, Biorad Medisys Pvt. Ltd., Karnataka, India) was inserted via modified Seldinger's technique at the 5th intercostal space in the midaxillary line. Following successful insertion, the catheter was connected to a urosac bag for ambulatory chest drainage.[3] The catheter was fixed with surgical suture, and a sterile dressing was applied. The patient received intravenous 1 g paracetamol and her regular oral medications. After drainage of 1000 mL pleural fluid, she became very comfortable and was able to perform deep breathing exercises and incentive spirometry. She didn't ask for any rescue analgesic until 24 h after the procedure. She was discharged home when stable and ambulatory after teaching pigtail care.

Ultrasound-guided pigtail drainage is a safe and convenient method of effusion drainage in MPE which provides temporary relief of symptoms and cardiopulmonary distress as well as it can also be used for pleurodesis if required.[4] LA infiltration is commonly used to insert a pigtail catheter. LA infiltration may have limited efficacy, suboptimal postprocedural analgesia, and short duration of action. TESPB is a novel interfacial plane block that has been used for various indications in acute and chronic pain management. Following a single-level injection in TESPB, LA is distributed in the craniocaudal fascial plane, anteriorly to the paravertebral and epidural spaces, and laterally to the intercostal space at several levels.[5] Thus, TESPB may provide superior analgesia as compared to LA infiltration during pigtail insertion. TESPB provides analgesia for incision, cannula and catheter insertion, suture fixation, and post-procedural analgesia. Adequate analgesia allowed the patient us to perform breathing exercises, thus helps in further drainage of pleural fluid. Although it seems promising, a randomized controlled trial is warranted to compare its efficacy and safety as compared to LA infiltration or other techniques.

To conclude, TESPB provided excellent pain relief during and after pigtail catheter placement for palliative thoracocentesis of MPE in our patient, which helped to improve patient satisfaction and early ambulation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.