Bi-level erector spinae plane catheters for multiple rib fractures in a high-risk patient

Matthew H Thompson, Gemma Hodson, Toby W Ashken, Su Cheen Ng


Rib fractures are associated with significant morbidity and mortality. Most of the morbidity stems from poorly controlled pain and therefore immobility and weak respiratory effort. Moreover, the number of injured ribs correlates with increasing risk of associated morbidity and mortality. We describe the analgesic management of an elderly co-morbid patient on oral anticoagulant therapy presenting with extensive multilevel rib fractures. According to the Western Trauma Association 2017 risk stratification, her mortality was as high as 20%. When a large number of ribs are involved, single level regional blocks may not provide sufficient local anesthetic spread to cover the extensive injury. Therefore, we employed erector spinae plane catheters at two levels. We believe that our therapeutic approach provided comprehensive, reliable and continuous analgesia, leading to a successful outcome in the case of our patient.


analgesia; erector spinae block; regional; catheter; multiple rib fractures

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Sirmali M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24(1):133-138.

May L, Hillerman C, Patil S. Rib fracture management. BJA Education 2016; 16(1):26-32.

Battle C, Hutchings H, Lovett S, et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care 2014; 18(3):R98.

Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003; 196(4):549-555.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000; 48(6):1040-1046.

Brasel KJ, Moore EE, Albrecht RA., et al. Western Trauma Association critical decisions in trauma. J Trauma Acute Care Surg 2017; 82(1):200–203.

AAGBI Working Party. Regional anesthesia and patients with abnormalities of coagulation: The Association of Anaesthetists of Great Britain & Ireland The Obstetric Anaesthetists' Association Regional Anaesthesia UK. Anaesthesia 2013; 68(9):966-972.

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(5):585-593.

Yang HM, Choi YJ, Kwon HJ, O J, Cho TH, Kim SH. Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia 2018; 73(10):1244-1250.

Hamilton DL. Reducing the risk of pneumothorax following erector spinae plane block. J Clin Anesth 2019; 56:3.

Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread of local anesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011; 66(11):1023-1030.


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ISSN: 2360-6975