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

Objective: Unusual or unexpected effect of treatment Background: Rib fractures are a common traumatic injury with significant morbidity and mortality resulting from respirato- ry compromise. Regional anesthetic techniques have demonstrated efficacy in reducing morbidity and mortal- ity from rib fractures, but there is limited evidence comparing various techniques, and in complex trauma pa- tients 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 4th-11th rib fractures. He was initially man- aged with a continuous erector spinae plane catheter, which resulted in improved pain and incentive spirom-etry. 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 in- centive spirometry volumes. It also suggests that there may be limitations to its utility given the continued de- cline 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 safe- ty profile, ease of placement, and potential to be placed in patients with coagulopathy and on anticoagulation therapies.