Continuous Erector Spinae Plane Block for Analgesia after Thoracotomy for Lung Transplantation in an Anticoagulated Patient

Abstract

Lung transplant recipients are at particular high risk for postoperative respiratory failure as a result of poorly controlled pain, inadequate graft expansion, decreased cough, and reliance on systemic opioid therapy. Thoracic epidural and paravertebral blocks have been employed with the goal of improving postoperative pain control, improving pulmonary mechanics, and limiting the need for narcotic administration. These approaches require a needle position in proximity to the neuraxis and may cause significant hypotension that is poorly tolerated in transplant patients. Additionally, the use of anticoagulation or underlying clotting disorder limits the use of these regional blocks because of the concern of hematoma and subsequent neurologic injury. Ultrasound-guided continuous erector spinae plane (ESP) block has been shown to be efficacious for pain control following thoracotomy but has had minimal investigations following lung transplantation. In this study, we describe the effective use of a continuous erector spinae plane block to provide analgesia in a postoperative lung transplant recipient receiving systemic anticoagulation. The use of an ESP block with a more superficial needle tract that is further removed from the neuraxis allowed for a greater safety profile while providing efficacious pain control, decreased reliance on systemic narcotics, and improved oxygen saturation. The ESP block was effective in this case and thus may be a valuable alternative following lung transplantation for patients who are not candidates for thoracic epidural or paravertebral approaches.

A systematic review of opioid use and multimodal strategies in solid organ transplant recipients and living donors

“…Within this population, there were various assessments of nonopioid analgesic medications in the postoperative transplant setting. Eleven studies evaluated the impact of a single opioid‐sparing medication including pregabalin, continuous systemic lidocaine, and local anesthetics (single and continuous dosing) 18,37–46 . Furthermore, seven studies evaluated the impact of a multimodal analgesic strategies, and two assessed the impact of different education‐based interventions 19–21,47–52 …”

“…Six studies were published evaluating strategies to reduce opioid use in lung transplantation 18,40,43–46 . Three of the studies were single‐center case reports/series, two were single‐center retrospective cohort studies, and one was a single‐center prospective observational trial 18,40,43,46 . A local anesthetic was used to achieve opioid‐sparing effects universally in all included evaluations.…”

“…Eleven studies evaluated the impact of a single opioid-sparing medication including pregabalin, continuous systemic lidocaine, and local anesthetics (single and continuous dosing). 18,[37][38][39][40][41][42][43][44][45][46] Furthermore, seven studies evaluated the impact of a multimodal analgesic strategies, and two assessed the impact of different education-based interventions. [19][20][21][47][48][49][50][51][52] Efficacy outcomes were variable, but generally included evaluation of opioid use and PRPS.…”

“…Six studies were published evaluating strategies to reduce opioid use in lung transplantation. 18,40,[43][44][45][46] Three of the studies were singlecenter case reports/series, two were single-center retrospective TA B L E 6 Opioid minimization recommendations.…”

Thoracic Erector Spinae Plane Catheter as a Bridge to Patient-Controlled Thoracic Epidural Analgesia in Unilateral Lung Transplantation

“…It has been suggested that erector spinae plane (ESP) blocks may be an acceptable alternative to thoracic epidural analgesia in the postoperative period in thoracotomy and lung transplant patients [6][7][8]. In this case report, we describe an instance of an ESP block facilitating effective management of acute postoperative pain in lung transplant and used as a bridge to a thoracic epidural, which was eventually placed.…”