Year : 2023 | Volume
| Issue : 1 | Page : 87-90
Managing acute pancreatitis pain with bilateral erector spinae plane catheters in a patient allergic to opioids and NSAIDS: A case report
Samaresh Das, Nilay Chatterjee, Subhro Mitra
Department of Anaesthetics and Intensive Care Medicine, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, BA21 4AT, United Kingdom
Consultant in Anaesthetics and Intensive Care Medicine, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, BA21 4AT
Source of Support: None, Conflict of Interest: None
|Date of Submission||08-Apr-2022|
|Date of Decision||28-Apr-2022|
|Date of Acceptance||02-May-2022|
|Date of Web Publication||02-Jan-2023|
Acute pancreatitis is one of the major causes of abdominal pain and is mainly related to either gallstone or heavy alcohol intake. We have managed a patient with acute pancreatitis with a bilateral erector spinae catheter because he was not suitable for other analgesics. A 72-year-old male with a known alcoholic patient was admitted with severe acute pancreatitis. He also had the chronic obstructive pulmonary disease (COPD) and oesophageal reflux disease. He was allergic to nonsteroidal anti-inflammatory medications and opioids. Therefore, his pain was managed successfully with bilateral erector spinae block with a continuous infusion with 0.125% levobupivacaine 1 ml/hr background infusion and 30 ml every 4 hours using a CADD Solis regional analgesia pump. Although erector spinae block is relatively new and to date, the optimal dose is not determined. We inserted the catheters at the T8 level; however, further study is needed to determine the ideal insertion site and drug volumes. We have mentioned key features, techniques, and management plans and reviewed the latest literature in this case report.
Keywords: Acute pancreatitis, analgesia, bilateral erector spinae block, pain
|How to cite this article:|
Das S, Chatterjee N, Mitra S. Managing acute pancreatitis pain with bilateral erector spinae plane catheters in a patient allergic to opioids and NSAIDS: A case report. Saudi J Anaesth 2023;17:87-90
|How to cite this URL:|
Das S, Chatterjee N, Mitra S. Managing acute pancreatitis pain with bilateral erector spinae plane catheters in a patient allergic to opioids and NSAIDS: A case report. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 1];17:87-90. Available from: https://www.saudija.org/text.asp?2023/17/1/87/364847
| Introduction|| |
Acute inflammation of the pancreas is one of the common causes of abdominal pain admitted to the hospital. The overall incidence in the UK is approximately 56 cases per 100,000 people per year. Most of the cases are related to gall stone (50%), and one-fourth of cases are related to alcohol consumption. The majority of hospital admissions are due to severe abdominal pain. The extreme cases are associated with complications such as respiratory failure, acute kidney injury (AKI) or kidney failure, ascites, and to the extent that need critical care admission. We have managed a patient admitted with severe pain due to acute pancreatitis who was allergic to commonly prescribed analgesic medications. We have managed the pain with a bilateral erector spinae catheter with an intermittent bolus of local anaesthetics with a CADD Solis pump.
| Case Description|| |
A 72-year-old male patient (BMI 26.5) presented with a previous history of chronic alcoholism (more than 70 units/day), chronic obstructive pulmonary disease (COPD) with regular bronchodilators and oesophageal reflux disease. He was admitted to the surgical ward with severe epigastric pain radiating to the right-back, nausea, and vomiting after binge drinking. His abdomen was mildly distended, tender and his initial pain score, Visual Analogue Scale (VAS) on admission was 9/10. He was tachypnic (RR 30/m) and tachycardic (HR 128/m). His initial CT scan of the abdomen revealed acute pancreatitis, peripancreatic collection, and hiatus hernia [Figure 1].
|Figure 1: CT scan showing oedematous pancreas with peripancreatic fluid collection|
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He was admitted to the surgical High Dependency Unit (HDU). He did not tolerate feeding because of abdominal distension and nausea: His initial investigations showed high WBC and CRP and elevated serum pancreatic specific amylase. On admission to HDU, we have started regular intravenous acetaminophen and oxycodone patient-controlled analgesia (PCA). He was allergic to NSAIDS (COPD) and morphine (gastric intolerance, respiratory insufficiency). After discussion with the substance-abuse team, we calculated the CIWA scoring system and started chlordiazepoxide as per the CIWA score. His pain was poorly controlled despite escalating doses of systemic analgesics, and he was not tolerating oral feeding. Gradually, his nausea and vomiting were worsened, and he started desaturating because of bronchospasm, which was managed with salbutamol nebulisation. In addition, his breathing was also affected by abdominal pain. On day 3, he was referred to the pain team because of inadequate response to systemic analgesics and his oxygen requirement was going high. A repeat CT scan revealed a large pseudocyst (19 × 15 cm) compressing the left lobe of the liver, ascites, and bilateral pleural effusion.
We reviewed his background medical illness, coagulation profile, and allergic history and explained the possible analgesia options in this condition (epidural, ESPB with bilateral catheter insertion). However, he refused the epidural and agreed to ESPB with catheter insertion. The procedure, pros and cons were explained to the patient, and written consent was obtained. The patient was transferred to the anaesthesia room, and the procedure was performed under all standard AAGBI monitoring. Pain score was noted before the procedure, and it was VAS 8-9/10. The procedure was performed while the patient was sitting with all aseptic precautions. A high-frequency linear probe was placed in a parasagittal position 2.5 cm from the midline.
The T8 transverse processes and erector spinae muscles were identified, and skin infiltrated with local anaesthesia (lidocaine 1%). An 18 G epidural needle was advanced in the erector spinae plane (between the transverse process of T8 and erector spinae fascia). Hydro dissection was performed using 10 ml of normal saline. A 20 G catheter was placed under direct ultrasound vision. A total volume of 20 ml of 1% lidocaine was injected through the catheter, and anaesthetic spread in the ESP was visualized with ultrasound imaging. The procedure was repeated on the opposite side. The bilateral catheter was fixed using the sterile technique [Figure 2]. A VAS was obtained at 30 minutes and 1 hour after local anaesthesia injection, and there was a significant improvement in the pain score (after 30 min, pain score was 3-4/10, and 1 hour was 1/10). A continuous infusion was started via a bilateral catheter with 0.125% levobupivacaine 1 ml/hr background infusion and 30 ml every 4 hours (CADD Solis regional analgesia pump). There was a significant reduction in oxycodone consumption within 10 hours, and it stopped during the next 24 hours after starting local anaesthetic infusion with the ESPB catheter. The patient's general condition gradually improved over the next 36 hours, and he started taking oral liquid. ESP catheters were removed on day 5, and his cyst was managed conservatively. After removing the catheters, his pain was controlled with paracetamol, oxycodone MR, and PRN oxycodone IR.
| Discussion|| |
Patients with pancreatitis usually need admission to the hospital due to severe abdominal pain, tenderness with nausea, vomiting, respiratory difficulties, and acute renal impairment. Various methods to control pain with pancreatitis are NSAIDs, opioids, and epidural analgesia. Although thoracic epidural analgesia can provide an adequate level of analgesia with acute pancreatitis pain, it is rarely used nowadays. The possible complications include hypotension, epidural hematoma, and epidural abscess in a critically ill patient. Our patient was allergic to morphine and NSAIDS (because of COPD and gastric intolerance). Although there were no contraindications of epidural analgesia, he refused to accept it.
Forero et al. described the first ESP block in 2016, and it is a safe alternative to pain management where epidural analgesia is indicated. The ESPB was found to be a helpful analgesic technique for various indications, such as rib fractures, herpes zoster, lumbar fractures, burns, back pain, renal colic, and lower abdominal surgeries.
The mechanism of ESP block with a local anaesthetic solution is to block both the ventral and dorsal rami causing both somatic and visceral analgesia. Local anaesthetic injected in ESP plane cause craniocaudal spread, which results in blockage of multiple nerve roots. In addition, a single injection of high volume (e.g., 30 ml) is associated with paravertebral spread causing visceral analgesia. In a case series, Gopinath described treating uncontrolled abdominal pain in pancreatitis by a single bolus of local anaesthetics in the erector spine muscle plane. Another recent case report by Mantuani et al. (2020) described successful analgesia by ESP blocks in ED for acute pancreatitis pain. Another recent case report demonstrated the successful use of ESP continuous catheters to control abdominal pain due to necrotising pancreatitis. However, they have used continuous infusion at the rate of 8 ml/hour bilaterally.
In our case, the patient was allergic to the usual analgesic (NSAIDS and morphine). His abdominal pain worsened due to the formation of pseudocyst and pleural effusion, and ascites. However, the pleural effusion ascites are common sequelae of acute pancreatitis, and it was not a massive collection of fluid. Those were managed conservatively. The analgesic options were very limited in our case, and we have successfully managed with an ESP catheter. In our case, we have given an intermittent bolus of local anaesthetics at 30 ml/4 hourly rather than continuous infusion. Although pneumothorax and local anaesthetic toxicity were reported as complications of ESP block, we did not encounter them in our case.
| Conclusion|| |
ESP block is a relatively new analgesia technique for lower abdominal and thoracic pain. However, the optimal dose of local anaesthetic solution for continuous catheters has not been determined. To date, no RCT has compared its efficacy in pancreatitis. As per the mechanism, intermittent bolus should work effectively rather than continuous infusion. In our case, we found ESP block at T8 with catheter insertion and intermittent high bolus was very useful for his abdominal pain. However, further study should be required to determine the level of catheter insertion, dose, and strength of the local anaesthetic solution. More research is needed to explore whether any additive will control the pain better with the local anaesthetic solution.
Declaration of patient consent
The patient parents gave consent that the images and other clinical features would be reported in the journal. He understands that his name and hospital identification number will not be published.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]