Background and Aims Erector spinae plane block (ESPB) is a newly described interfascial block, consisting in injection of local anesthetic in plane between transverse process and erector spinae muscles. It has emerged as a good alternative for analgesia of entire hemithorax.

TRAM flap reconstruction is traditionally associated of severe pain, requiring opioid analgesia, with all known side effects.

This case reports an opioid-free anesthesia for TRAM flap reconstruction, using ESPB.

Methods Female, 53-years, ASA III, with hypertension, obesity and SAOS, admitted for TRAM flap reconstruction.

Bilateral ESPB was performed, under ultrasound guidance. It was injected 25 ml of ropivacaine 0,375% (2.6 mg/kg) and dexamethasone 4 mg on each side, at T4 level.

Under ASA standard and invasive blood pressure monitoring, a totally intravenous general anesthesia was maintained with propofol and ketamine.

Acetaminophen and ketorolac were administered 30 minutes before end of surgery. No complications recorded during intra-operative period and patient emerged comfortable from anesthesia.

Results On PACU, patient remained comfortable with maximum pain of 1/10 on NRS, without need of additional analgesics.

Postoperative analgesia consisted of acetaminophen and ketorolac every 8 hours and, during first 2 days, the worst pain recorded was 3/10, without need of opioid analgesia.

No complications of the ESPB was recorded and patient was discharge home after 4 days.

Conclusions ESPB is useful, easy and fast strategy that may be used as a valuable adjunct for postoperative analgesia in TRAM flap reconstruction, which pose a challenge in pain control.

Moreover, it offers an advantage in terms of reducing opioid requirements contributing for enhanced recovery.