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Abstract
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Background and Aims Pain control after thoracotomy is critical in preventing pulmonary morbidity. There has been growing interest in non-opioid/non-neuraxial analgesic techniques, providing effective pain relief with minimal complications, such as the erector spinae plane (ESP) block. Our report details application of a continuous ESP block in thoracic Ewing’s sarcoma resection.
Results An otherwise healthy 5-year-old underwent thoracotomy for extra-osseous Ewing’s sarcoma and 8th rib resection. General anesthesia with continuous ESP block at T7 level was chosen for intraoperative management. This involved a 0.5 mL/kg 0.2%-ropivacaine bolus through the ESP catheter before incision, followed by a 0.2 mL/kg/h infusion, that continued postoperatively. Postoperative analgesia included paracetamol and ketorolac, with rescue ESP bolus and intravenous morphine. The intraoperative period was uneventful. The child was extubated and transferred to intermediate care. Following a 48-hour stay, he transferred to the infirmary. Perineural catheter removal occurred after chest tube removal (6th day). Throughout hospitalization, the patient maintained satisfactory pain control, reporting maximum pain of 4/10 on the first day. Only two boluses of intravenous morphine were required during the entire hospitalization.
Conclusions Historically, epidurals have been the cornerstone of post-thoracotomy analgesia. The ESP is an increasingly recognized alternative. Its superficial depth and distance from critical structures make it particularly appealing in neonates and infants, while also minimizing opioids. There remains a paucity of regional anesthesia data in pediatric thoracic surgery. Adequate spread and analgesia have been reported with a 0.3-0.5 ml/kg volume. The optimal local anesthetic dose for ESP block remains however uncertain and further research is needed.
Thoracic CT scan depicting the size of the tumor before chemotherapy. Occupying the entire left hemi-thorax, an extra-osseous Ewing’s sarcoma can be seen, causing a mass effect on the mediastinum, with contralateral deviation, and on the diaphragmatic hemi-dome, which reverses its convexity, pushing the structures of the upper left quadrant, namely the spleen, left kidney and stomach downward
Thoracic CT scan depicting the size of the tumor after 10 cycles of VDC/IE (Vincristine, Doxorubicin, Cyclophosphamide/Ifosfamide, Etoposide), with tumor reduction. The mass extends longitudinally close to the posterolateral aspect of the 6th to 9th left ribs, and there is evidence of periosteal reaction of the left 8th rib, without clear imagiological evidence of erosion or bone invasion
Intraoperative depiction of the size of the incision (left) and depiction of the surgical specimen with a ruler for sizing (right)