Thoracic Epidural as a Rescue Analgesic in a Patient with a Continuous Erector Spinae Plane Block for Rib Fractures: A Case Report

Patient: Male, 72-year-old Final Diagnosis: Hypercarbic respiratory failure • hypoxic respiratory failure • rib fracture Symptoms: Chest wall tenderness Clinical Procedure: Erector spinae plane block • thoracic epidural Specialty: Anesthesiology OBJECTIVE: Unusual or unexpected effect of treatment BACKGROUND: Rib fractures are a common traumatic injury with significant morbidity and mortality resulting from respiratory compromise. Regional anesthetic techniques have demonstrated efficacy in reducing morbidity and mortality from rib fractures, but there is limited evidence comparing various techniques, and in complex trauma patients various factors may preclude the use of neuraxial and other techniques. CASE REPORT: We report the case of a 72-year-old man who presented with left 4(th)–11(th) rib fractures. He was initially managed with a continuous erector spinae plane catheter, which resulted in improved pain and incentive spirometry. Unfortunately, he continued to decline and ultimately was rescued from impending respiratory failure by placement of a T6–T7 epidural catheter and epidural infusion of bupivacaine. CONCLUSIONS: This case report suggests that a continuous erector spinae plane block may be a useful regional anesthesia technique in the management of rib fractures through its potential to improve pain control and increase incentive spirometry volumes. It also suggests that there may be limitations to its utility given the continued decline of the patient, who was eventually rescued from respiratory failure by placement of a thoracic epidural. Unique to erector spinae plane blocks are the ability to be managed in the outpatient setting, improved safety profile, ease of placement, and potential to be placed in patients with coagulopathy and on anticoagulation therapies.