Case Report
Erector spinae plane block for analgesia after lower segment caesarean section: Case report
Bloqueo del plano del erector del espinal para analgesia tras cesárea del segmento inferior: informe de caso
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Yamak Altinpulluk, D. García Simón, M. Fajardo-Pérez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Yamak Altinpulluk" "email" => array:1 [ 0 => "eceyamak@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "García Simón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Fajardo-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Anestesiología, Universidad de Estambul, Facultad de Medicina de Cerrahpasa, Estambul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Anestesiología, Hospital Universitario de Móstoles, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo del plano del erector del espinal para analgesia tras cesárea del segmento inferior: informe de caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Thoracic epidural analgesia is still considered the gold standard for postoperative analgesia in major open abdominal surgery<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a>; however, concerns about side effects, such as hypotension and motor blockade, and the risk of major complications, such as epidural haematoma and abscess, have led some professionals to question this technique.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> The pain experienced after caesarean delivery using a Pfannenstiel incision has both a somatic and visceral component. More recently, erector spinae plane (ESP) block has been shown to provide extensive somatic and visceral abdominal analgesia when administered at the T7-9 level.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> Therefore, bilateral ESP block in the transverse process of T9 can provide effective analgesia after caesarean delivery and reduce the incidence of opioid-related adverse effects.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Written informed consent was obtained for this report.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 24-year-old woman, weight 70<span class="elsevierStyleHsp" style=""></span>kg and height 156<span class="elsevierStyleHsp" style=""></span>cm (body mass index [BMI] 28.8<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), who underwent emergency caesarean section at 38 weeks of pregnancy. No previous sedative drugs had been administered. Standard monitoring was performed using ECG, non-invasive blood pressure, pulse oximetry (SpO<span class="elsevierStyleInf">2</span>) and body temperature. Surgery was performed under general anaesthesia. The baby, a boy, was born 2<span class="elsevierStyleHsp" style=""></span>min after the start of the operation, and weighed 3.200<span class="elsevierStyleHsp" style=""></span>g, with an Apgar score of 8 in the first minute, and 9 at 5<span class="elsevierStyleHsp" style=""></span>min. After the birth, anaesthesia was deepened by administering 100<span class="elsevierStyleHsp" style=""></span>μg fentanyl, 5<span class="elsevierStyleHsp" style=""></span>mg morphine, and increasing the inhalational anaesthetic dosage. The patient was given 10<span class="elsevierStyleHsp" style=""></span>U intravenous <span class="elsevierStyleSmallCaps">(IV)</span> oxytocin, 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron; 15<span class="elsevierStyleHsp" style=""></span>U/l oxytocin was added to the <span class="elsevierStyleSmallCaps">IV</span> solution. After surgery, ultrasound-guided ESP block was administered using a Sonosite SII and HFL38xi 13.06<span class="elsevierStyleHsp" style=""></span>MHz linear transducer. The nerve block was performed under aseptic conditions. The transducer was placed longitudinally at the level of the transverse process of T9, 3<span class="elsevierStyleHsp" style=""></span>cm away from the midline with the patient in the left lateral recumbent position. A 22G 80<span class="elsevierStyleHsp" style=""></span>mm Braun Ultraplex<span class="elsevierStyleSup">®</span> needle was advanced cranially in plane as far as the transverse process of T9. A 20<span class="elsevierStyleHsp" style=""></span>ml bolus of 0.25% bupivacaine was injected in the deep fascial plane of the erector spinae muscle. The procedure was repeated on the contralateral side. The spread of the anaesthetic in the fascial plane was observed on the ultrasound image and extended longitudinally over three levels in a caudal and cranial direction. At the end of the block, the patient was extubated and transferred to the post-anaesthesia care unit. After fifteen minutes, the extent of the sensory loss was evaluated using the pin prick test from the T6-L1 dermatomes and a numerical rating scale (NRS; 0: no pain, 10: worst pain imaginable), which obtained a score of 2/10. The patient was satisfied with the postoperative pain management, and did not present postoperative nausea and vomiting. No nerve block-related complications were observed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">For postoperative analgesia, the patient was given 1<span class="elsevierStyleHsp" style=""></span>g acetaminophen every 8<span class="elsevierStyleHsp" style=""></span>h, as required, and intravenous patient-controlled analgesia (<span class="elsevierStyleSmallCaps">IV</span> PCA) with morphine. The patient was seen at 0, 2, 4, 6, 8, 12 and 24<span class="elsevierStyleHsp" style=""></span>h after surgery to evaluate the quality of pain relief and the volume of rescue analgesic used. The NRS pain score ranged from 1 to 3/10 during the patient's hospital stay. The patient was mobilised at approximately 8<span class="elsevierStyleHsp" style=""></span>h after surgery. Opioid requirements were 22.9<span class="elsevierStyleHsp" style=""></span>mg <span class="elsevierStyleSmallCaps">IV</span> morphine over 24<span class="elsevierStyleHsp" style=""></span>h during the first 48<span class="elsevierStyleHsp" style=""></span>h after the ESP block. She was discharged on the second postoperative day.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">We successfully performed bilateral ESP nerve block in a pregnant woman undergoing caesarean section, achieving sensory loss from T6-L1 dermatomes. Many different theories have been put forward to explain the mechanism of action of ESP block. Based on Forero's hypothesis, it can be argued that relief of chest pain could be due to both the dorsal and ventral spinal nerves that originate in direct proximity to the costotransversal foramina. Anaesthetic spread could also be facilitated by the thoracolumbar fascia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Pain management is needed after a caesarean section, since postoperative pain has a negative effect on the start of breastfeeding and the care of the baby.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Opioids are usually administered for pain relief, although these compounds are associated with dose-dependent side effects, including nausea, vomiting, pruritus, sedation and respiratory depression. Although epidural analgesia provides excellent pain relief, certain side effects make it unsuitable for all patients. An alternative to epidural analgesia, frequently used after abdominal surgery, is ESP block. The main drawback of ESP block is the limited local spread of the anaesthetic, and little or no pain relief.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> If it were not for the urgency of the procedure in this case, we would have preferred to perform spinal anaesthesia, combined spinal and epidural anaesthesia, or spinal anaesthesia plus ESP. However, in view of the situation and the theoretical effectiveness of the blockade for somatic and visceral pain, the ESP block presented a good alternative postoperative post-caesarean technique.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To conclude, our main objective with this patient was to provide long-term postoperative analgesia with an ESP block, and we obtained good sensory block and visceral analgesia. Further studies are needed to determine if the choice of peripheral myofascial block is adequate, as well as to compare the analgesic efficacy and safety of this technique.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1024772" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec982671" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1024773" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec982672" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case report" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-23" "fechaAceptado" => "2017-11-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec982671" "palabras" => array:5 [ 0 => "Pain" 1 => "Analgesia" 2 => "Caesarean section" 3 => "Regional anaesthesia" 4 => "Erector spinae plane block" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec982672" "palabras" => array:5 [ 0 => "Dolor" 1 => "Analgesia" 2 => "Cesárea" 3 => "Anestesia regional" 4 => "Bloqueo del plano del erector del espinal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Effective postoperative analgesia after emergency caesarean section is important because it provides early recovery, ambulation and breast-feeding. The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al. We performed post-operative bilateral erector spinae plane blocks with 20<span class="elsevierStyleHsp" style=""></span>ml bupivacaine 0.25% at the level of the T9 transverse process in a pregnant woman after caesarean section. In this report, we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La analgesia postoperatoria efectiva después de la cesárea de urgencia es importante porque proporciona una recuperación y deambulación temprana, así como el inicio precoz de la lactancia materna. El bloqueo del plano del erector del espinal guiado por ecografía ha sido descrito originalmente por Forero et al. para proporcionar analgesia torácica. Se realizaron bloqueos del plano del erector del espinal bilaterales postoperatorios con 20<span class="elsevierStyleHsp" style=""></span>ml de bupivacaína al 0,25% al nivel de T9 en una embarazada para analgesia postoperatoria tras cesárea. En esta presentación describimos cómo el bloqueo del plano del erector del espinal bilateral en el nivel T9 proporciona analgesia postoperatoria efectiva y duradera para la cirugía abdominal inferior.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Yamak Altinpulluk E, García Simón D, Fajardo-Pérez M. Bloqueo del plano del erector del espinal para analgesia tras cesárea del segmento inferior: informe de caso. Rev Esp Anestesiol Reanim. 2018;65:284–286.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Forero" 1 => "S.D. Adhikary" 2 => "H. Lopez" 3 => "C. Tsui" 4 => "K.J. 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