American Society of Regional Anesthesia and Pain Medicine February 2018 - 16

How I Do It: Erector Spinae Block for Rib Fractures:
The Penn State Health Experience
INTRODUCTION
Rib fractures are common in multitrauma
patients and require effective analgesia
to prevent respiratory complications. At
the Penn State Health Milton S. Hershey
Medical Center, all multitrauma patients
with rib fractures are referred to the acute
pain medicine service (APMS) once they
have been assessed and stabilized by the
trauma surgery service. APMS performs a
detailed history and physical examination,
focusing on location of fractures,
Hillenn Cruz Eng, MD
Ki Jinn Chin, MBBS, MMed, FRCPC
Sanjib Adhikary, MBBS
medications, patient's current coagulation
Assistant Professor
Associate Professor
Associate Professor
status, allergies, and other injuries,
Department of Anesthesiology and
Department of Anesthesia
Department of Anesthesiology and
including trauma to internal abdominal
Perioperative Medicine
University of Toronto
Perioperative Medicine
organs, spine, pelvis, or limbs. APMS also
Penn State Health
Toronto, Canada
Penn State Health
evaluates history of prior surgeries or
Hershey, Pennsylvania
Hershey, Pennsylvania
disease and mental status. An analgesic
plan is formulated with the goals of
optimizing respiratory function, minimizing opioid consumption,
2016, our practice has evolved to incorporate ESP blockade as the
and preventing cognitive dysfunction. Therefore, the plan usually
first-line intervention in patients with multiple rib fractures.
includes an interventional regional anesthesia procedure.
Single-Shot ESP Versus Continuous Catheter Block. We initially
Until recently, APMS performed mainly thoracic epidural, thoracic
began with single-shot ESP blocks for rib fractures. However, we
paravertebral, and intercostal blocks to provide rib fracture
found that although this improved the pain and effectiveness of
analgesia.1,2 In general, patients with one to two rib fractures were
breathing significantly, the pain often recurred within 2 to 3 hours
considered for intercostal
of the block, despite the
blocks, whereas patients with
use of long-acting local
three or more rib fractures
anesthetics. We postulated
were considered for thoracic
that systemic absorption
epidural or paravertebral
of local anesthetic may
blocks. However, the latter
be a contributing factor to
two techniques are not
the shorter-than-expected
always feasible because of
duration. This led to our
various factors, including
current practice of inserting
pre-existing anticoagulation or antiplatelet therapy, hemodynamic
a catheter in all our patients, which has allowed us to provide
instability, or other associated injuries (eg, vertebral fractures).
prolonged analgesia.

"The erector spinae plane (ESP) block
was described in 2016 as a novel regional
anesthetic technique for acute and
chronic thoracic pain."

The erector spinae plane (ESP) block was described in 2016
as a novel regional anesthetic technique for acute and chronic
thoracic pain.3,4 It is a paraspinal fascial plane block that involves
injection of local anesthetic deep in the erector spinae muscle and
superficial to the tips of the thoracic transverse processes. The
site of injection is distant from the pleura, major blood vessels,
and spinal cord; hence, performing the ESP block has relatively
few contraindications. The ESP block is less difficult to perform
relative to thoracic epidural anesthesia and thoracic paravertebral
block. Also, significant cranial-caudal spread occurs from a single
injection point, which is an additional advantage in the setting
of multiple rib fractures. The mechanism of analgesic action is
believed to result from diffusion of local anesthetic anteriorly to the
ventral and dorsal rami of spinal nerves. Since its description in

16

Continuous Catheter Infusion Regimens. We initially used a
continuous infusion regimen of ropivacaine 0.2% at 8-10 ml/h
with patient-controlled regional analgesia (PCRA) boluses of 8 ml
every 60 minutes. However, we observed that patients reported
significantly lower pain scores at rest and improved respiration
after the bolus doses. We have therefore moved to a programmed
intermittent bolus regimen of 15 ml of 0.2% ropivacaine every 3
hours with additional patient-controlled boluses of 5 ml every 60
minutes, resulting in superior analgesia and patient satisfaction.
THE ESP BLOCK TECHNIQUE
Patient Selection. Any patient with three or more rib fractures,
either unilateral or bilateral, is a candidate for ESP blockade. A
thorough history, physical exam, and informed consent are carried

American Society of Regional Anesthesia and Pain Medicine
2018



Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine February 2018

No label
American Society of Regional Anesthesia and Pain Medicine February 2018 - No label
American Society of Regional Anesthesia and Pain Medicine February 2018 - 2
American Society of Regional Anesthesia and Pain Medicine February 2018 - 3
American Society of Regional Anesthesia and Pain Medicine February 2018 - 4
American Society of Regional Anesthesia and Pain Medicine February 2018 - 5
American Society of Regional Anesthesia and Pain Medicine February 2018 - 6
American Society of Regional Anesthesia and Pain Medicine February 2018 - 7
American Society of Regional Anesthesia and Pain Medicine February 2018 - 8
American Society of Regional Anesthesia and Pain Medicine February 2018 - 9
American Society of Regional Anesthesia and Pain Medicine February 2018 - 10
American Society of Regional Anesthesia and Pain Medicine February 2018 - 11
American Society of Regional Anesthesia and Pain Medicine February 2018 - 12
American Society of Regional Anesthesia and Pain Medicine February 2018 - 13
American Society of Regional Anesthesia and Pain Medicine February 2018 - 14
American Society of Regional Anesthesia and Pain Medicine February 2018 - 15
American Society of Regional Anesthesia and Pain Medicine February 2018 - 16
American Society of Regional Anesthesia and Pain Medicine February 2018 - 17
American Society of Regional Anesthesia and Pain Medicine February 2018 - 18
American Society of Regional Anesthesia and Pain Medicine February 2018 - 19
American Society of Regional Anesthesia and Pain Medicine February 2018 - 20
American Society of Regional Anesthesia and Pain Medicine February 2018 - 21
American Society of Regional Anesthesia and Pain Medicine February 2018 - 22
American Society of Regional Anesthesia and Pain Medicine February 2018 - 23
American Society of Regional Anesthesia and Pain Medicine February 2018 - 24
American Society of Regional Anesthesia and Pain Medicine February 2018 - 25
American Society of Regional Anesthesia and Pain Medicine February 2018 - 26
American Society of Regional Anesthesia and Pain Medicine February 2018 - 27
American Society of Regional Anesthesia and Pain Medicine February 2018 - 28
American Society of Regional Anesthesia and Pain Medicine February 2018 - 29
American Society of Regional Anesthesia and Pain Medicine February 2018 - 30
American Society of Regional Anesthesia and Pain Medicine February 2018 - 31
American Society of Regional Anesthesia and Pain Medicine February 2018 - 32
American Society of Regional Anesthesia and Pain Medicine February 2018 - 33
American Society of Regional Anesthesia and Pain Medicine February 2018 - 34
American Society of Regional Anesthesia and Pain Medicine February 2018 - 35
American Society of Regional Anesthesia and Pain Medicine February 2018 - 36
American Society of Regional Anesthesia and Pain Medicine February 2018 - 37
American Society of Regional Anesthesia and Pain Medicine February 2018 - 38
American Society of Regional Anesthesia and Pain Medicine February 2018 - 39
American Society of Regional Anesthesia and Pain Medicine February 2018 - 40
American Society of Regional Anesthesia and Pain Medicine February 2018 - 41
American Society of Regional Anesthesia and Pain Medicine February 2018 - 42
American Society of Regional Anesthesia and Pain Medicine February 2018 - 43
American Society of Regional Anesthesia and Pain Medicine February 2018 - 44
American Society of Regional Anesthesia and Pain Medicine February 2018 - 45
American Society of Regional Anesthesia and Pain Medicine February 2018 - 46
American Society of Regional Anesthesia and Pain Medicine February 2018 - 47
http://www.brightcopy.net/allen/asra/18-04
http://www.brightcopy.net/allen/asra/18-3
http://www.brightcopy.net/allen/asra/18-2
http://www.brightcopy.net/allen/asra/18-1
http://www.brightcopy.net/allen/asra/17-4
http://www.brightcopy.net/allen/asra/17-3
http://www.brightcopy.net/allen/asra/17-2
http://www.brightcopy.net/allen/asra/17-1
http://www.brightcopy.net/allen/asra/16-4
http://www.brightcopy.net/allen/asra/16-3
http://www.brightcopy.net/allen/asra/16-2
http://www.brightcopy.net/allen/asra/16-1
http://www.brightcopy.net/allen/asra/15-4
http://www.brightcopy.net/allen/asra/15-3
https://www.nxtbook.com/allen/asra/15-2
https://www.nxtbook.com/allen/asra/15-1
https://www.nxtbookmedia.com