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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
E. Yamak Altinpulluka,
Corresponding author
eceyamak@gmail.com

Corresponding author.
, D. García Simónb, M. Fajardo-Pérezb
a Anestesiología, Universidad de Estambul, Facultad de Medicina de Cerrahpasa, Estambul, Turkey
b Anestesiología, Hospital Universitario de Móstoles, Madrid, Spain
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    "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&#44;2</span></a>&#59; however&#44; concerns about side effects&#44; such as hypotension and motor blockade&#44; and the risk of major complications&#44; such as epidural haematoma and abscess&#44; have led some professionals to question this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a> The pain experienced after caesarean delivery using a Pfannenstiel incision has both a somatic and visceral component&#46; More recently&#44; erector spinae plane &#40;ESP&#41; block has been shown to provide extensive somatic and visceral abdominal analgesia when administered at the T7-9 level&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a> Therefore&#44; 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&#46;</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&#46;</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&#44; weight 70<span class="elsevierStyleHsp" style=""></span>kg and height 156<span class="elsevierStyleHsp" style=""></span>cm &#40;body mass index &#91;BMI&#93; 28&#46;8<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; who underwent emergency caesarean section at 38 weeks of pregnancy&#46; No previous sedative drugs had been administered&#46; Standard monitoring was performed using ECG&#44; non-invasive blood pressure&#44; pulse oximetry &#40;SpO<span class="elsevierStyleInf">2</span>&#41; and body temperature&#46; Surgery was performed under general anaesthesia&#46; The baby&#44; a boy&#44; was born 2<span class="elsevierStyleHsp" style=""></span>min after the start of the operation&#44; and weighed 3&#46;200<span class="elsevierStyleHsp" style=""></span>g&#44; with an Apgar score of 8 in the first minute&#44; and 9 at 5<span class="elsevierStyleHsp" style=""></span>min&#46; After the birth&#44; anaesthesia was deepened by administering 100<span class="elsevierStyleHsp" style=""></span>&#956;g fentanyl&#44; 5<span class="elsevierStyleHsp" style=""></span>mg morphine&#44; and increasing the inhalational anaesthetic dosage&#46; The patient was given 10<span class="elsevierStyleHsp" style=""></span>U intravenous <span class="elsevierStyleSmallCaps">&#40;IV&#41;</span> oxytocin&#44; 50<span class="elsevierStyleHsp" style=""></span>mg ranitidine and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron&#59; 15<span class="elsevierStyleHsp" style=""></span>U&#47;l oxytocin was added to the <span class="elsevierStyleSmallCaps">IV</span> solution&#46; After surgery&#44; ultrasound-guided ESP block was administered using a Sonosite SII and HFL38xi 13&#46;06<span class="elsevierStyleHsp" style=""></span>MHz linear transducer&#46; The nerve block was performed under aseptic conditions&#46; The transducer was placed longitudinally at the level of the transverse process of T9&#44; 3<span class="elsevierStyleHsp" style=""></span>cm away from the midline with the patient in the left lateral recumbent position&#46; A 22G 80<span class="elsevierStyleHsp" style=""></span>mm Braun Ultraplex<span class="elsevierStyleSup">&#174;</span> needle was advanced cranially in plane as far as the transverse process of T9&#46; A 20<span class="elsevierStyleHsp" style=""></span>ml bolus of 0&#46;25&#37; bupivacaine was injected in the deep fascial plane of the erector spinae muscle&#46; The procedure was repeated on the contralateral side&#46; 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&#46; At the end of the block&#44; the patient was extubated and transferred to the post-anaesthesia care unit&#46; After fifteen minutes&#44; the extent of the sensory loss was evaluated using the pin prick test from the T6-L1 dermatomes and a numerical rating scale &#40;NRS&#59; 0&#58; no pain&#44; 10&#58; worst pain imaginable&#41;&#44; which obtained a score of 2&#47;10&#46; The patient was satisfied with the postoperative pain management&#44; and did not present postoperative nausea and vomiting&#46; No nerve block-related complications were observed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">For postoperative analgesia&#44; the patient was given 1<span class="elsevierStyleHsp" style=""></span>g acetaminophen every 8<span class="elsevierStyleHsp" style=""></span>h&#44; as required&#44; and intravenous patient-controlled analgesia &#40;<span class="elsevierStyleSmallCaps">IV</span> PCA&#41; with morphine&#46; The patient was seen at 0&#44; 2&#44; 4&#44; 6&#44; 8&#44; 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&#46; The NRS pain score ranged from 1 to 3&#47;10 during the patient&#39;s hospital stay&#46; The patient was mobilised at approximately 8<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; Opioid requirements were 22&#46;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&#46; She was discharged on the second postoperative day&#46;</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&#44; achieving sensory loss from T6-L1 dermatomes&#46; Many different theories have been put forward to explain the mechanism of action of ESP block&#46; Based on Forero&#39;s hypothesis&#44; 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&#46; Anaesthetic spread could also be facilitated by the thoracolumbar fascia&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Pain management is needed after a caesarean section&#44; since postoperative pain has a negative effect on the start of breastfeeding and the care of the baby&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Opioids are usually administered for pain relief&#44; although these compounds are associated with dose-dependent side effects&#44; including nausea&#44; vomiting&#44; pruritus&#44; sedation and respiratory depression&#46; Although epidural analgesia provides excellent pain relief&#44; certain side effects make it unsuitable for all patients&#46; An alternative to epidural analgesia&#44; frequently used after abdominal surgery&#44; is ESP block&#46; The main drawback of ESP block is the limited local spread of the anaesthetic&#44; and little or no pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> If it were not for the urgency of the procedure in this case&#44; we would have preferred to perform spinal anaesthesia&#44; combined spinal and epidural anaesthesia&#44; or spinal anaesthesia plus ESP&#46; However&#44; in view of the situation and the theoretical effectiveness of the blockade for somatic and visceral pain&#44; the ESP block presented a good alternative postoperative post-caesarean technique&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">To conclude&#44; our main objective with this patient was to provide long-term postoperative analgesia with an ESP block&#44; and we obtained good sensory block and visceral analgesia&#46; Further studies are needed to determine if the choice of peripheral myofascial block is adequate&#44; as well as to compare the analgesic efficacy and safety of this technique&#46;</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&#46;</p></span></span>"
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        "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&#44; ambulation and breast-feeding&#46; The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al&#46; We performed post-operative bilateral erector spinae plane blocks with 20<span class="elsevierStyleHsp" style=""></span>ml bupivacaine 0&#46;25&#37; at the level of the T9 transverse process in a pregnant woman after caesarean section&#46; In this report&#44; we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La analgesia postoperatoria efectiva despu&#233;s de la ces&#225;rea de urgencia es importante porque proporciona una recuperaci&#243;n y deambulaci&#243;n temprana&#44; as&#237; como el inicio precoz de la lactancia materna&#46; El bloqueo del plano del erector del espinal guiado por ecograf&#237;a ha sido descrito originalmente por Forero et al&#46; para proporcionar analgesia tor&#225;cica&#46; Se realizaron bloqueos del plano del erector del espinal bilaterales postoperatorios con 20<span class="elsevierStyleHsp" style=""></span>ml de bupivaca&#237;na al 0&#44;25&#37; al nivel de T9 en una embarazada para analgesia postoperatoria tras ces&#225;rea&#46; En esta presentaci&#243;n describimos c&#243;mo el bloqueo del plano del erector del espinal bilateral en el nivel T9 proporciona analgesia postoperatoria efectiva y duradera para la cirug&#237;a abdominal inferior&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Yamak Altinpulluk E&#44; Garc&#237;a Sim&#243;n D&#44; Fajardo-P&#233;rez M&#46; Bloqueo del plano del erector del espinal para analgesia tras ces&#225;rea del segmento inferior&#58; informe de caso&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;284&#8211;286&#46;</p>"
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ISSN: 23411929
Original language: English
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