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Year : 2020  |  Volume : 64  |  Issue : 12  |  Page : 1086-1089  

Erector spinae plane block as analgesic adjunct for traumatic rib fractures in intensive care unit

Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Malaysia

Date of Submission05-Sep-2020
Date of Decision11-Oct-2020
Date of Acceptance26-Nov-2020
Date of Web Publication12-Dec-2020

Correspondence Address:
Dr. Zhi Yuen Beh
Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_1110_20

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How to cite this article:
Beh ZY, Lim SM, Lim WL, Sitaram PN. Erector spinae plane block as analgesic adjunct for traumatic rib fractures in intensive care unit. Indian J Anaesth 2020;64:1086-9

How to cite this URL:
Beh ZY, Lim SM, Lim WL, Sitaram PN. Erector spinae plane block as analgesic adjunct for traumatic rib fractures in intensive care unit. Indian J Anaesth [serial online] 2020 [cited 2021 Mar 5];64:1086-9. Available from: https://www.ijaweb.org/text.asp?2020/64/12/1086/303230


We would like to share a case series of four morbidly obese patients with traumatic rib fractures requiring respiratory support in the intensive care unit (ICU) and they received erector spinae plane (ESP) block[1] as analgesic adjunct. They were males with median age (interquartile range, IQR), 56 (42–61) years and median body mass index, BMI (IQR) 35.2 (33.0–36.9) kg/m2. They had sustained polytrauma [Table 1] secondary to motor vehicle accidents with multilevel rib fractures and other injuries. They also had multiple comorbidities, required oxygen therapy with non-invasive ventilatory (NIV) support, therefore, being closely monitored in ICU. They received multimodal analgesia regime—intravenous patient-controlled analgesia (PCA) morphine, regular doses of paracetamol, tramadol plus nonsteroidal anti inflammatory drugs (NSAIDs) or coxib since hospital admission. Despite the above analgesic regime, they still experienced severes pain. The median pain scores using numerical rating scale (NRS) were 6.5/10 (IQR 5.25–7.75) at rest and 9/10 (IQR 7.25–10) during movement. The mean daily morphine consumption prior to block was 48 mg (±8 mg). ESP block was given on day 2 of ICU admission because of unsatisfactory pain control, poor cough effort with difficulty to perform chest physiotherapy and requiring NIV support.
Table 1: Case description

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The blocks were performed using a 10-5 MHz 38 mm linear probe (Sonosite M-Turbo, Bothell, Washington, USA) and an 80 mm, 18-gauge Tuohy epidural needle (Perifix® Filter set, BBraun, Melsungen, Germany) with in-plane needling technique. Patients were placed either in sitting or lateral position, adjusted according to their comfort level as they had multiple injuries and skin wound affecting the positioning. The transverse process of the 3rd or 4th thoracic vertebra was identified. Muscle layers of trapezius, rhomboids major, and erector spinae were identified, and the fascial plane beneath the erector spinae muscle was entered with the Tuohy epidural needle inserted from cranial to caudal direction. The needle placement was confirmed with pumping effect within the fascial plane following hydrodissection and small boluses of local anaesthetic. A total bolus of 40 ml of ropivacaine 0.375% was delivered within the fascial plane and an indwelling Perifix epidural catheter was threaded-in and anchored with 4 cm tip in the fascial plane with transparent film dressing (3M™ Tegaderm™, Maplewood, Minnesota, USA) [Figure 1]. ESP block is a fascial plane block which relies on high volume low concentration local anaesthetic to exert its analgesic efficacy. Luftig et al.[2] recommended a 40 ml local anaesthetic regime for patient above 70 kg in unilateral ESP block. All patients experienced significant pain reduction within 30 min after the block [Figure 1]. A continuous infusion of 8 ml/h ropivacaine 0.2% was run with intermittent bolus of 10 ml ropivacaine 0.2% every 12 h. The intermittent bolus was delivered manually by a trained staff nurse to avoid patient confusion with the PCA morphine device plus no available programmed infusion pump. The median pain scores after ESP block were 2/10 (IQR 2 – 2) at rest and 4/10 (IQR 4.0–4.75) during movement. The pain score remained mild to moderate over the next few days. As patients also had other injuries [Table 1], it would be difficult to achieve zero pain score although other injury sites were not the predominant pain area. Therefore, the mean daily morphine consumption only reduced gradually after ESP block [Table 1]. The median length of ICU stays were 6.5 days (IQR 6–7.75). The median duration of NIV support was 2.5 days (IQR 2–3).
Figure 1: (a) Poor sonoanatomy of the erector spinae plane (ESP) despite optimal adjustment of the ultrasound settings, probe selection and manipulation. The ESP is located deeper (>4 cm). The 18G Tuohy needle is vaguely seen in the trajectory pathway. (b) Sonoanatomy of ESP with catheter in a thin lady (unrelated case), a stark difference of sonoanatomy between a lean and an obese patient. (c) Patient B is on non-invasive ventilator support. Inset – The monitors showed drastic reduction of blood pressure after the ESP block because his pain was alleviated and stress response attenuated

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Traumatic rib fractures are very painful. Inadequate pain control would impair breathing, adequate coughing with clearance of pulmonary secretions and compliance with chest physiotherapy. Consequently, patient would be at risk of secondary pulmonary complications, that is, atelectasis, pneumonia, respiratory failure, and the need for respiratory support. Effective analgesia may help to improve a patient's respiratory mechanics and to avoid intubation of the trachea for ventilatory support and therefore may dramatically alter the course of recovery. Multimodal systemic analgesics with intravenous patient-controlled opioid has been the mainstay of pain management and they are usually sufficient for healthy individuals with one to two fractured ribs.[3] However, for more than three to four fractured ribs, studies and experience have reaffirmed that regional techniques like thoracic epidural, thoracic paravertebral, serratus anterior plane, and intercostal blocks provide superior analgesia.[3],[4] Regional techniques are particularly useful in elderly patients, patients with multiple rib fractures, and in patients with severe pain or compromised pulmonary function.[3] However, epidural analgesia and paravertebral block may not be feasible in the presence of anti-coagulation, multisystem trauma, haemodynamic instability, or in patients unable to be optimally positioned.[3] ESP block was the most feasible regional technique in our case series because patients were obese. The quality of the ESP sonoanatomy was already below average and located deeper (>4 cm) [Figure 1] despite optimal adjustment of the ultrasound settings (knob), probe selection, and probe manipulation. The paravertebral space which is anatomically located deeper than ESP could not be properly visualised during scout scan, therefore we did not attempt paravertebral blocks. A literature review showed that there are three case reports[5],[6],[7] and one retrospective cohort study[8] about the use of ESP block for pain relief in rib fractures.


We thank Dr Siew Gee Ho for helping us to trace the clinical progress and outcome of the above-mentioned cases.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block. A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 1
Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. The authors reply to the optimal dose and volume of local anesthetic for erector spinae plane blockade for posterior rib fractures. Am J Emerg Med 2018;36:1103-4.  Back to cited text no. 2
Thiruvenkatarajan V, Cruz Eng H, Adhikary SD. An update on regional analgesia for rib fractures. Curr Opin Anesthesiol 2018;31:601-7.  Back to cited text no. 3
Beard L, Hillermann C, Beard E, Millerchip S, Sachdeva R, Gao Smith F, et al. Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures. Reg Anesth Pain Med 2020;45:351-6.  Back to cited text no. 4
Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth 2017;118:474-5.  Back to cited text no. 5
Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med 2018;36:1391-6.  Back to cited text no. 6
Nandhakumar A, Nair A, Bharath VK, Kalingarayar S, Ramaswamy BP, Dhatchinamoorthi D. Erector spinae plane block may aid weaning from mechanical ventilation in patients with multiple rib fractures: Case report of two cases. Indian J Anaesth 2018;62:139-41.  Back to cited text no. 7
[PUBMED]  [Full text]  
Adhikary SD, Liu WM, Fuller E, Cruz-Eng H, Chin KJ. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: A retrospective cohort study. Anaesthesia 2019;74:585-93.  Back to cited text no. 8


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  [Table 1]


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