Bi-level erector spinae plane catheters for multiple rib fractures in a high-risk patient

Abstract

Rib fractures are associated with significant morbidity and mortality. Most of the morbidity stems from poorly controlled pain and therefore immobility and weak respiratory effort. Moreover, the number of injured ribs correlates with increasing risk of associated morbidity and mortality. We describe the analgesic management of an elderly co-morbid patient on oral anticoagulant therapy presenting with extensive multilevel rib fractures. According to the Western Trauma Association 2017 risk stratification, her mortality was as high as 20%. When a large number of ribs are involved, single level regional blocks may not provide sufficient local anesthetic spread to cover the extensive injury. Therefore, we employed erector spinae plane catheters at two levels. We believe that our therapeutic approach provided comprehensive, reliable and continuous analgesia, leading to a successful outcome in the case of our patient.

Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review

“…Screening of abstracts resulted in 77 papers, following which 40 studies were excluded due to incorrect block or injury, surgical fixation, or for being presented in a conference abstract format. Of the 37 studies included, 10 were case reports, [18][19][20][21][22][23][24][25][26][27] 12 were case series, [28][29][30][31][32][33][34][35][36][37][38][39] 5 were cohort studies, 7,40-43 2 were randomized controlled trials (RCT), 44,45 1 was a prospective interventional study, 46 and 7 were letters to the editor. [47][48][49][50][51][52][53] The majority of studies were published after 2020, with 29% being published in 2022.…”

“…Twenty-eight studies reported objective changes in pain score post administration of ESB using various scoring scales including Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Defence and Veteran Pain (DVP) score, and a 4 point verbal score. 7,[18][19][20][21][22][23][24][25][27][28][29][30][31]33,34,[36][37][38][39]42,[44][45][46][47][48][49]53 Due to the heterogeneity of scales and time points used to evaluate pain, an average weighted percentage change in pain scores was calculated. The mean reduction in pain scores from pre-block baseline was approximately 40% within the first 24 hours.…”

“…Elawamy et al 45 in a comparative RCT demonstrated 6 cases of hypotension, 2 cases of bradycardia, and 3 vascular punctures in a cohort of 30 patients receiving thoracic paravertebral blocks (TPVB), with no complication demonstrated in the ESB cohort. Seven studies 19,20,25,33,35,40,43 included patients on prophylactic/therapeutic anticoagulation or had ESB administered in the setting of coagulopathy. Three papers, 38,44,45 including both RCTs, excluded this patient cohort.…”

Retrolaminar Continuous Nerve Block Catheter for Multiple Rib Fractures: A Case Report

“…9 Today, most clinicians utilize the ESP block for unilateral rib fractures, citing "wide coverage" of chest wall analgesia while avoiding the pitfalls of neuraxial anesthesia. 10,11 Indeed, dye studies in cadavers suggest that while both the ESP and retrolaminar blocks achieve epidural and neural foraminal spread, the ESP block also reaches the intercostal nerves. 12 Nevertheless, the clinical utility of a retrolaminar block for rib fractures should not be overlooked.…”