Case 3#

52 year old male who suffered a bike vs auto, intubated in the field with R rib fractures 2-8, R pneumothorax s/p chest tubes in ICU. He was found to have a pulmonary embolism and is on therapeutic heparin infusion. He was unable to be extubated for past 2 days. When sedation was lightened during spontaneous breathing trials (SBT), patient noticed to have rapid shallow breathing, hypertension, grimicing.

You are consulted for peripheral nerve block for analgesia, which ICU team believes will help with extubation. What is the best option?

  • A. Thoracic Epidural

  • B. Paravertebral Block

  • C. Erector Spinae Plane Block

  • D. Serratus Anterior Block

  • E. Intercostal Nerve Block

Answer

C. Erector Spinae Plane Block

Erector spinae plane block is a peripheral plane block with better safety profile than epidural & paravertebral block, especially on patients who need anticoagulation. Typically catheter placed in this scenario for prolonged analgesia.

  • Low risk of pneumothorax.

  • Should not cause concern for epidural hematoma.

  • Similar to thoracic epidural, provides analgesia 3-4 spinal root levels above & below the block site.

  • Patient needs to be positioned sitting or lateral, which may be difficult in this situation.

Explanation:

A. Thoracic Epidural: High risk for epidural hematoma in anticoagulated patient. Generally avoided in this scenario. Thoracic epidurals have bilateral coverage.

B. Paravertebral Block: Vascular region, so similar risk to thoracic epidural. Also has risk of pneumothorax since paravertebral space is adjacent to posterior pleura. Paravertebral blocks have unilateral coverage and do not extend as many levels.

C. Erector Spinae Plane Block: Best Answer.

D. Serratus Anterior Block: Reasonable alternative if patient cannot be repositioned. However, does not cover posterior rib fractures. Does not spread as many levels.

E. Intercostal Nerve Block: Not practical to block individual intercostal nerves for many levels. Also local anesthetic absorption is high & highest risk of local anesthetic toxicity among options.

Local Anesthetic Vascular Absorption (most to least):

IV > Intercostal > Caudal > Epidural > Brachial Plexus > Subcutaneous