Continuous Erector Spinae Plane Block for Postoperative Analgesia After Intestinal Resection and Hernia Repair Surgery: A Case Report

Introduction

Erector spinae plane block (ESPB) was initially presented in 2016 in the literature by Forero et al [1]. It has since become more popular due to its relatively safe, straightforward, and efficient nature. Originally, this block was used in thoracic surgery, where it has been shown to be effective in providing pain relief after surgery [2–4]. The block is administered by injecting the local anesthetic behind the muscles, away from the nerve roots or spinal cord, in contrast to epidural analgesia. This case report details the successful implementation of a continuous bilateral erector spinae plane block for rescue pain management in a patient who underwent major abdominal surgery, emphasizing the benefits of this technique being used for high-risk, polymorbid individuals requiring immediate application of anticoagulant therapy.

Case Report

We report the case of a 64-year-old man admitted to Riga 1st Hospital for a planned hernioplasty is reported. He had previously undergone a hernia plastic surgery in another hospital, due to a hernia of the anterior abdominal wall.

The patient’s body mass index (BMI) was 44.8, with a height of 173 centimeters and a weight of 134 kilograms. His comorbidities included pulmonary arterial hypertension stage II, gout, and chronic obstructive pulmonary disease, which were poorly managed and resulted in a provoked deep vein thrombosis episode in 2019, because of which he was administered rivaroxaban 20 mg daily. To ensure that both the patient and the surgeon could be adequately prepared for the surgery, it was necessary to perform a CT of the patient’s abdomen. This scan visualized a major ventral hernia at the mesogastric level, with a neck measuring 10 × 10 cm at the linea alba. The hernia contained omental fat and ileal loops, showing no signs of incarceration (Figure 1). The patient, who was ASA III on the ASA Physical Status Classification System, consulted an anesthesiologist before surgery to ensure adequate preparation and to submit the consent for general anesthesia and regional analgesia, if necessary. At the time of his visit, the patient had not been using his prescribed anticoagulants, prompting the prescription of low-molecular-weight heparin 3500 IU/d injections subcutaneously 5 days before surgery. The patient was informed and agreed to the risks inherent to the procedure.

The patient arrived at the hospital on the day of the surgery and was premedicated with midazolam 7.5 mg orally. General anesthesia was initiated with 0.2 mg of fentanyl, 200 mg of propofol, and 20 mg of cisatracurium, followed by tracheal intubation. General anesthesia was maintained with sevoflurane 0.9% in an oxygen-air mixture, and additional doses of fentanyl and cisatracurium were administered as needed. The surgery began, a midline incision was made, and upon entering the abdominal cavity, it was found that the mesh patch sewn during the previous hernioplasty had grown and stuck to the wall of the small intestine, resulting in adhesions and a distinct conglomerate. The small intestine, including the serosal layer, was penetrated, making mesentery-intestinal loop separation impossible (Figure 2). Multiple adhesions, luminal abnormalities, and 1.5-cm strictures damaged a 1.5-meter-long intestinal segment. Further inspection of the abdominal cavity revealed ischemic changes in the sigmoid colon. A 4-cm segment of the sigmoid colon had black patchy discolorations and an infiltrated mesentery, suggesting ischemic-necrotic alterations (Figure 3). Considering that it was impossible to safely separate the mesh patch and the small intestine, as well as the ischemic changes of the sigmoid intestine, the decision was made to perform resections of the small intestine and sigmoid, with the subsequent construction of anastomoses. After bowel resection and the creation of anastomoses, anterior abdominal hernioplasty was performed. Originally, a transversus abdominis release (TAR) was planned; however, owing to the unanticipated scope of the surgery based on intraoperative findings, the length of the surgery, and the patients’ comorbidities, the surgical herniorrhaphy strategy was changed. Hernia repair was conducted with a bi-component 20×15 cm mesh that was attached to the anterior abdominal wall’s aponeurosis in sublay (retrorectus) technique, sealing the hernia gate.

The total duration of the surgery was 7 hours 30 minutes, and the anesthesia lasted 8 hours 15 minutes. During the surgery, the patient remained hemodynamically stable. Intraoperatively, he received a total of 350 mg of propofol, 0.7 mg of fentanyl, and 50 mg of cisatracurium. For postoperative pain relief, 30 minutes before the end of the surgery, he was given paracetamol 1 g, metamizole 1 g, and dexketoprofen 50 mg i.v. Following the surgery, he was extubated and transferred to the ICU.

Upon admission to the ICU, in addition to the previously received pain medications, he received analgesia via a continuous infusion of 0.01 mg/ml fentanyl at a rate of 5 ml/h.

The next morning, around 10 hours after surgery, he was administered a subcutaneous injection of low-molecular-weight heparin 3500 IU/d for anticoagulant therapy, to prevent any thrombotic event, considering that he was high risk and had an episode of deep venous thrombosis in his medical history. He also underwent pain assessment using the Numeric Rating Scale (NRS), resulting in a score of 8–9 points despite the administration of a continuous fentanyl infusion. The most severe discomfort occurred in the umbilical area. Given the inadequate pain relief, a decision was made to perform a bilateral erector spinae plane block with the insertion of catheters for continuous analgesia. This choice was made after assessing the patient’s comorbidities and considering the recently administered anticoagulant treatment necessitated by the major abdominal surgery. Following an explanation of the process, the patient, who was awake and alert, understood it and gave full consent to the procedure.

The procedure was performed at the bedside under strict sterile conditions. The patient was positioned to the left side and using ultrasound guidance with a curvilinear probe, a Tuohy 18G needle was inserted using the parasagittal approach, bilaterally at the L3–L4 level, beneath the erector spinae muscles, in a caudal-cranial direction. The position of the needlepoint was verified by the observable spreading of fluid elevating the erector spinae muscle from the bony outline of the transverse process. Once it was determined that there was no reverse blood flow, catheters were inserted up to Th11 level, corresponding to the dermatomal region requiring analgesia (Figure 4).

To confirm the correct insertion, 3 ml of the contrast agent iohexolum (647 mg/ml) was injected into each catheter. Catheter localization was verified by X-ray imaging. The patient’s position and misalignment with the X-ray machine resulted in the dye appearing on the ribs on the right side of the image, which is lateral to the aim of the ESPB (Figure 5).

Following the localization assessment, a 20-ml bolus of 0.125% bupivacaine was given bilaterally, followed by the initiation of continuous bupivacaine infusion at a rate of 5 ml/h in each catheter. The fentanyl infusion was then discontinued. In addition to bupivacaine infusion, the patient was given paracetamol 1 g every 8 h and metamizole 1 g every 8 h. Throughout the bupivacaine infusion, the patient’s NRS score was 1–2 points at rest, and no additional doses of fentanyl were required.

The catheters were withdrawn on the fourth postoperative day, and the patient rated the pain as 1 point while still having paracetamol and metamizole administered. Then, he was transferred to the surgical unit. Prolonged ESPB was performed without complications.

Three days after transfer to the surgical unit, his health deteriorated, and a control CT imaging was done, which visualized a hematoma that had developed in the parasigmoid area. Surgical removal was decided on, and drainage was implemented. Following the lack of improvement in the patient’s condition, 4 days later, another control CT imaging was done, which revealed a 0.8-cm defect in one of the anastomoses and excess fluid where the hematoma used to be located. We decided to perform an additional surgery, during which we decided to preserve the anastomosis, as it was located in the posterolateral wall, and to create a colostomy. Reoperations were done in a way to preserve the initial hernioplasty, and had no negative effect on the results of the initial surgery. The patient’s condition gradually improved. He was discharged after 33 days in the hospital. No further complications after the hospitalization have been reported.

Discussion

Epidural analgesia is frequently given for major abdominal surgeries. Extensive research and meta-analyses have shown that the failure rate of epidural analgesia can range from 15% to 30% [5]. This case demonstrated that an erector spinae plane block can be a safe and efficient mode of pain relief in patients undergoing major abdominal surgery. It can also be an alternative when epidural anesthesia is contraindicated. The appropriate administration of medications through a continuous infusion was a critical aspect of the effectiveness of this block, which resulted in prolonged and sufficient pain relief. It has been reported that performing this block as a single injection does not provide adequate long-term analgesia [6].

Several papers have documented this method’s efficacy for pain reduction, even suggesting it as a better option to retrolaminar block or epidural analgesia [7,8]. The primary advantages of ESPB are its ease of use, relative safety, and extensive coverage area, all of which were decisive reasons for our patient’s use.

The safety of this block was a major concern given that the patient needed immediate anticoagulants in the perioperative period. ESPB has been performed in patients who use dual antiplatelet treatment and has been demonstrated to be safe for patients with coagulopathies [9,10]. According to Chin et al, ESPB is a safe procedure since the catheters are placed relatively distant from the neural and cardiovascular systems, reducing the risk of serious bleeding and hematoma.

Conclusions

This case report demonstrates that a continuous bilateral erector spinae plane block catheter insertion can be a reliable and efficient approach for providing prolonged pain relief following major abdominal surgery. This strategy can be an alternative to epidural analgesia.