Background and aims Despite the reduced invasiveness of video-assisted thoracoscopic surgery (VATS) compared to the thoracotomic approach, postoperative pain is still considered moderate-severe, with a chronic pain rate of 22% to 63%. Yet there is currently no consensus on the best strategy for treating pain for VATS.
We describe the perioperative pain management of a 7-year-old, 30-kg child who underwent VATS decortication for left empyema and chest drain insertion, a painful procedure that might benefit from a unilateral regional technique.
Methods After lung isolation with a bronchial blocker, we positioned the child laterally and proceeded with an erector spinae plane (ESP) block as it is more superficial and further from the infected pleural space, compared to the paravertebral block (PVB). Moreover, it was difficult to visualise the endpoint for PVB as the pleura is stuck down from inflammation and a chest drain was in-situ. 16 mls of 0.25% levobupivacaine was deposited beneath the erector spinae muscle above the T4 transverse process under in-plane ultrasound-guidance using a 50 mm 22G echogenic needle (figure 1).
Results Long lasting analgesia was achieved with minimal opioids intraoperatively (1 mg morphine) and post-operatively (0.1 mg/kg morphine in the first 24 hours).
Conclusions The ESP block is a simpler, safer alternative to thoracic epidural or paravertebral block, as its sonographic target is easily visualized, and the site of injection is distant from the neuraxis, pleura, and major vascular structures. This is especially useful in VATS decortication for empyema, as multi-dermatomal analgesia is achieved even with a single block distant from the surgical site.
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