Anesthesia & Clinical Research
Open Access

Continuous Erector Spinae Plane Block for Anesthesia Management of Congenital Diaphragmatic Hernia in a Preterm Neonate

Pierre Goffin^* and Mathieu Georges ^*Correspondence: Dr. Pierre Goffin, Department of Anesthesia and Intensive Care, MontLegia Hospital, Groupe Santé CHC, Liège, Belgium, Tel: 0032499738866, Email:

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Introduction

Congenital Diaphragmatic Hernia (CDH) is a developmental defect of the diaphragm presents in about 1:3000 live births that allows abdominal viscera to herniate into the chest [1]. Most often locates in left side. Pulmonary hypertension and lung hypoplasia are responsible of neonatal morbidity and mortality.The successful management of congenital diaphragmatic hernia is truly a multidisciplinaryteam. Surgical repair is not urgent but is the key treatment. We described the use of a continuous Erector Spinae Plane Block (ESPB) for perioperative analgesia of thoracoscopy surgery for CDH repair. Informed consent was obtained from parents for this publication.

Case Presentation

A 9 days year-old, 2450 gr, former 34 weeks premature boy was postnatal diagnosed with Congenital Diaphragmatic Hernia. The prenatal obstetrical follow-up did not identify any abnormalities. A chest X-ray for respiratory distress at birth conduced to CDH diagnose. He was secondary transferred to our hospital for care. Diaphragmatic defect was left side located and 15 mm wide. No other malformation was associated. The echocardiography demonstrated a light left to right shunt but no pulmonary hypertension. The clinical condition is stable with limited oxygen supplementation.

Surgical correction was scheduled. Induction of anesthesia was performed with sevoflurane and fentanyl in spontaneous ventilation. After intubation, patient was turned into right lateral decubitus position.

For regional anesthesia procedure, T7 level was determined by palpation of the inferior angle of scapula.Under aseptic condition, the probe was placed in a transverse orientation to determine vertebra level of T5 (Logiq P9 GE Healthcare, with Hockey stick probe, 15 MHz). Then, the probe was turned to longitudinal orientation and moved laterallyup to the identification of transverse process. The needle was inserted with an in-plane technique from cranial to caudal orientation up to contact with bone process.Two and half milliliter of ropivacaine 0.1% were injected deep to the erector spinae muscles to create a virtual hydro-dissected space.A catheter was inserted on 10 mm and skin fixed (Perifix® ONE Paed, B Braun, Melsungen, Germany. Tuohy needle 20 G and 24 G catheter).

The fourth surgical trocars levels were located from the mid-axillary to mid clavicular line, from T5 to T8 sensitive level. Standard anesthesia parameter (pulsoximetry, non-invasive blood pressure and ECG), invasive blood pressure and near-infrared spectroscopywere monitored throughout the procedure. The surgical thoracoscopy procedure was performed without any complication, intraoperative hemodynamic measurements remained stable. No other bolus of fentanyl was injected during surgery. At the end of surgery, the patient was transferred to neonatal intensive care unit and was extubated a few hours after. Breastfeeding was resumed four and half hours after awakening and the chest drain tube were removed on the first postop¬erative day.

Postoperatively ESPB catheter was infused at a rate of 2 ml/ hour with ropivacaine 0.025%, to administrate a maximum of ropivacaine 0.2 mg/kg/h. Multimodal analgesia was ensuring with complementary dose of paracetamol (7.5 mg/kg/6h). Patient was very comfortable according to pain score measure (Leuven Neonatal Pain Scale [2]). No morphine rescue was need for postoperative analgesia. Catheter was removed postoperatively at 48 hours with no reported complications. Patient was discharge 8 days after surgery without complication (Figure 1).

Figure 1: Image of our continuousErector Spinae Plane Block technique (ESPB) (TP: Transverse Process; ESM: Erector Spinae Muscles; Red point: Needle target for ESP block at the transverse process and ESM meeting point).

Discussion

Previous cases report ESPB in neonate and this block isexperimented in adult for analgesia in thoracic surgery [3]. Case report successful ESPB in neonate without use of catheter, providing enough analgesia through the perioperative period [4]. We have considered benefit to prolonged analgesia through catheter infusion. This is the first case in relating a continuous infusion for postoperative analgesia in a preterm neonate. ESPB is performed with LA deposition deep to the erector spinae muscle, superficial to thetip of the transverse process. The mechanismof analgesia is still controversial but seem to result from blockade of the ventral and dorsal rami of spinal nerve [5].

The volume of injected LA was 1ml/kg, adapted from Govender [5]. We used this volume to achieve four vertebral level, according the same author. It is markedly more than previous cases in neonate which injected 0.45-0.6 ml/kg approximately [4]. Possibly, LA spread to the paravertebral, epidural and intercostal spaces [6]. But we don’t observe any hypotension or upper or lower limbs paresis.

LA dosage in neonate is still difficult to appreciate because of lack of evidence. We adapted volume infusion to ensure enough spread effect (ESPB is a diffusion block) and concentration to maintain low dilution and limited LA toxicity [7].

ESPB seems interesting compared to paravertebral or epidural block. Because it is easy to perform, particularly in this age group (very good echogenicity), and reduces the risk associated with central block and of pneumothorax [8].

Conclusion

In conclusion, we have used the Erector Spinae Plane Block as part of a multimodal perioperative analgesic strategy in a preterm neonate. Our patient is the youngest to receive continuous ESBP in the current literature. Regional anesthesia technique has enhanced recovery after this thoracoscopic surgery with very comfortable patient and without observed any clinical complication, supporting the effectiveness of Erector Spinae Plane Block in a premature neonate to ensure continuous analgesia in thoracic surgery. Further studies will be needed to define the maximum safe dose of LA, the optimal volume and infusion rate for continuous Erector Spinae Plane Block in infants.

Conflicts of Interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding

The authors have no sources of funding to declare for this manuscript.

References

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