Erector spinae plane block for postoperative analgesia in liver transplantation

Dear Editor, The increasing use of fascial plane block procedures has been reported to facilitate pain control in many surgical procedures.[1] Thoracic epidural analgesia (TEA) is the gold standard for pain control in the management of most upper abdominal surgeries, as well as routine liver resection.[2] Neuraxial procedures are contraindicated in patients with coagulopathy due to liver disease or in patients who develop intraoperative coagulopathy during liver transplantation because of the increased risk of neurologic sequelae secondary to epidural hematomas. Although there are limited data in the literature,[3] we have used erector spinae plane block (ESPB) for postoperative analgesia in liver transplant donors and recipients for pain resulting from hepatic resection. A 46-year-old male patient (body mass index 22.35 kg/m²) who had liver cirrhosis due to Hepatitis B for three years and gave written consent before the procedure was scheduled for a liver transplant operation from a cadaver donor. After standard American Society of Anesthesiologists monitoring (electrocardiogram, noninvasive blood pressure, pulse oximetry) was applied, the block procedure was started while the patient was in a sitting position with nasal cannula oxygen therapy, following the necessary sterilization and decontamination rules. T7 spinous process was identified by palpation. The US probe (GE ML6-15-D Matrix Linear) was placed on the T7 spinous process. The ultrasound probe was placed parasagittal to 2–3 cm lateral to the spinous processes on the patient’s back and the fascial plane between the transverse process and the erector spinae muscle was visualized. A 22-G 80 mm block needle (Stimuplex Ultra®, Braun, Melsungen, Germany) was directed from cranial to caudal [Figure 1]. The fascia under the erector spinae muscle was hydrodissected with 5 mL saline. The fascial plane between the transverse process and the erector spinae muscle was separated. In total, 30 mL of 0.25% bupivacaine with epinephrine (1/200,000) was injected after negative aspiration. The same procedure was then repeated on the opposite side under ultrasound guidance. Vital signs were stable and no other complications occurred. The patient was extubated in the intensive care unit 2 h after surgery. A patient-controlled analgesia (PCA) pump was programmed with tramadol (5 mg/mL IV PCA, bolus dose 10 mg, lockout interval 20 min) for multimodal analgesia.Figure 1: T6-T7 level ESP block US image. ESM: Erector spinae muscle, TP: Transverse processOn the second postoperative day, the patient was mobilized. Pain was assessed using the visual analog scale (VAS: 0; no pain, 10; worst possible pain), with a peak VAS score of 3/10. The patient used the PCA pump 6 times on the first day and 11 times on the second day, and did not require additional analgesics. No postoperative complications were observed. Perioperative care of transplant recipients has changed significantly in recent years. Prior to these developments, patients typically remained intubated for the first 12 h after liver transplantation, a period characterized by severe postoperative pain. In contrast, ERAS protocols advocate early extubation within the first 6 h.[4] These changes highlight the importance of optimizing postoperative pain management strategies. Although TEA is the gold standard, alternative approaches for postoperative analgesia have been sought because of the potential neurological complications associated with epidural hematoma, especially in patients with coagulopathy due to liver disease or those who develop intraoperative coagulopathy during liver transplantation. European Society of Regional Anaesthesia and Pain Therapy recommends the use of regional techniques with low bleeding risk as an alternative analgesic method in cases with high bleeding risk such as perioperative bleeding disorder or liver dysfunction. High-risk blocks include neuraxial blocks, deep peripheral nerve blocks, and low-risk blocks include superficial peripheral nerve blocks. ESPB is categorized as a low-risk block.[5] The application of ESPB within a multimodal analgesic approach has the potential to significantly reduce the dependence on opioid-based analgesia and consequently reduce the incidence of postoperative nausea and vomiting. ESPB is characterized by easy applicability, low complication rate, and effective analgesia. We suggest that this block may be an important component of multimodal analgesia in liver transplantation surgery. However, more detailed studies are needed to definitively determine the safety, simplicity, and efficacy of ESPB in liver transplantation surgery. Informed consent Written informed consent for the procedure and future publishing were obtained from the patient. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.