| Abstrakt: |
Rib fractures, affecting 10% of trauma patients, significantly impact morbidity and mortality by hampering respiratory mechanics due to pain, leading to ineffective coughing and shallow breathing. Optimal pain control is crucial for secretion clearance and preventing complications like atelectasis and pneumonia. Innovations like Erector Spinae Plane (ESP) blocks offer promising alternatives, particularly continuous ESP blocks with catheterization, providing advantages over neuroaxial blocks. These include suitability for patients with coagulopathy, and potentially reduced risks of pneumothorax or spinal cord injury. Such advancements are critical for enhancing outcomes and reducing complications associated with rib fractures, as demonstrated in our case report. A 69-year-old female patient presented to the emergency department with right-sided 4th, 5th, 6th, 7th, and 9th minimally displaced rib fractures and left-sided 3rd, 4th, 5th, and 6th anterior stepwise rib fractures following a fall from the same level. Imaging studies revealed no additional pathological conditions. The patient, who had isolated bilateral multiple rib fractures, was transferred to the thoracic surgery clinic for close observation. Under ultrasonographic guidance in the operating room, a bolus dose of bupivacaine and lidocaine was administered at T6 on the right hemithorax and T5 on the left hemithorax, followed by catheterization for continuous analgesia. The total volume administered was 30 ml, consisting of 75 mg of 0.5% bupivacaine, 100 mg of 2% lidocaine, and 10 ml of saline. An infusion of 0.15 ml/kg/hour of 0.125% bupivacaine was planned, with a maximum total dose adjusted not to exceed 3 mg/kg within 24 hours. The patient's VAS scores at rest, during movement, and coughing were recorded before and after the procedure at 0, 2, 6, 10, 14, 18, 24, and 72 hours. Post-procedure, the patient's VAS scores improved significantly: from 10 to 3 at rest and 4 during movement and coughing. Subsequent assessments showed VAS scores at rest not exceeding 2 and 4 during movement and coughing. Two doses of 1 g paracetamol were administered as supplementary analgesia. Catheters were safely removed on the 4th day without complications, and the patient was discharged after outpatient follow-up. Rib fractures necessitate effective analgesia due to their substantial morbidity and mortality risks and potential for chronic pain. While ESP block efficacy is supported by case reports, controlled randomized studies are lacking. Adhikary et al. and Palachick et al. demonstrated pain improvement and spirometry enhancement post-ESP block without complications. Meta-analyses favor thoracic epidural analgesia for rib fractures, though recent trials found comparable pain relief and spirometry values between epidural and ESP block, with fewer hypotensive events in ESP. Yayik et al. placed an ESP catheter for postoperative analgesia in a patient with rib fractures, yielding positive outcomes. Our review highlights ESP block's role in rib fracture analgesia, offering safety advantages over epidural. Multimodal analgesia, including ESP catheter placement and paracetamol, proved effective in our case. Further studies are warranted to determine the optimal regional technique, but ESP block stands out for its outpatient potential, ease of use, bilateral applicability, and fewer contraindications compared to neuroaxial techniques. [ABSTRACT FROM AUTHOR] |
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