Bilateral Erector Spinae Catheters for Postoperative Analgesia in a 3-Year-Old Undergoing Resection of a Large Neuroblastoma Tumor in the Posterior Mediastinum
By Nellie Forman, MD; Justin Libaw, MD; Zhe Chen, MD
Department of Anesthesia and Perioperative Care, University of California San Francisco
San Francisco, California
The erector spinae plane (ESP) block has become a popular analgesic technique in adults for thoracic and abdominal procedures, but less data is available in children. The ESP block may confer benefits over epidural, paravertebral, or other fascial plane techniques in that it is relatively easy to perform, with less potential for serious complications, and can provide visceral and somatic coverage of several dermatomal levels.1 Continuous ESP blocks can be considered for children undergoing thoracic and/or abdominal surgeries in cases where epidural placement may be contraindicated.
A 3-year-old, 14-kg, female presented for resection of an 8.8 x 11 x 10 cm posterior mediastinal mass consistent with neuroblastoma. She underwent neoadjuvent chemotherapy, but her repeat imaging showed minimal tumor burden reduction. The surgical plan included right thoracotomy, with the possibility of sternotomy, left thoracotomy, and/or laparotomy. Cardiothoracic surgery and perfusion were on standby to initiate cardiopulmonary bypass due to the risk for cardiovascular collapse during tumor manipulation. Surgery was done with neuromonitoring of somatosensory and motor evoked potentials due to encasement of tumor around the descending aorta and risk of spinal cord ischemia. After induction of anesthesia, bilateral ESP catheters were placed. The patient ultimately only required a right thoracotomy for surgical resection. Post-operatively, ropivicaine 0.1% was infused at 6 mL/hr through the right-sided ESP catheter, which provided good pain control with the majority of FLACC scores being 0. No medication was infused through the left-sided ESP catheter and it was removed on post-operative day 1. Sedation with a fentanyl infusion was stopped on post-operative day 3 and the patient was extubated. The chest tube remained in place until post-operative day 4 and FLACC scores remained 0. Only two doses of intravenous morphine 1 mg were required while the chest tube was in place and sedation was stopped. The right ESP catheter was removed on post-operative day 5 and the patient was discharged on post-operative day 6.
Neuroblastoma is the most common extracranial solid tumor in children. Since this tumor arises from progenitor cells of the sympathetic nervous system, it can invade the intervertebral foramina or spinal canal in 10-15% of cases, and even present with spinal cord compression.2 The choice of regional technique needed to address several clinical challenges in this patient: the possibility of full heparinization for bypass, the potential for significant blood loss with subsequent coagulopathy, as well as concern for neuroforaminal involvement. ESP catheters should be considered for pain management in non-cardiac surgery where epidural placement may be contraindicated. There are several case reports reflecting the effectiveness of single shot and continuous infusion ESP blocks in pediatric patients undergoing thoracic surgery.3-5 One challenge encountered in very young children is the smaller maximal dose of local anesthetic that can be given based on weight. The optimal volume and concentration of local anesthetic needed to achieve adequate dermatomal spread in small infants and toddlers is still unknown. A large, retrospective series of 164 children proposed that infants require 0.1 mL/kg of 0.25% bupivacaine with epinephrine per dermatomal level.6 To date, almost 300 children have received ESP blocks, reported in retrospective case reports or series, with no complications.
The erector spinae plane block can be a useful method for postoperative analgesia in pediatric patients undergoing non-cardiac surgery and with a contraindication to thoracic epidural placement.
1. Mostafa SF, et al. Paediatr Anaesth. 2019;29(12):1201-1207.
2. Trahair T, et al. J Pediatr. 2017;188:294-298.
3. Hernandez MA, et al. Reg Anesth Pain Med. 2018;43(2):217-219.
4. Gaio-lima C, et al. Rev Esp Anestesiol Reanim. 2018;65(5):287-290.
5. De la cuadra-fontaine JC, et al. Paediatr Anaesth. 2018;28(1):74-75.
6. Holland EL, Bosenberg AT. Paediatr Anaesth. 2020;30(2):96-107.