Erector spinae plane block in kidney transplantation

What is it about?

Perioperative anesthesia and pain management can be challenging for anesthesiologists in kidney transplant patients. These patients are usually complicated due to comorbidities related to chronic kidney disease. Main issues in postoperative pain management for renal transplant patients include dose adjustment, prevention of further renal damage, and maintaining graft perfusion. Accordingly, regional analgesia techniques can be considered in order to avoid the adverse effects of anesthetics and systemic analgesics. In this report, our experience of erector spinae plane (ESP) blocks in three cases of living donor kidney transplantations are presented. Informed consents were obtained from the patients. Patients' clinical presentations are shown in Table 1 . Following standard monitorization, all patients were premedicated with 2 mg intravenous (iv) midazolam. The ESP blocks were performed in the prone position prior to the anesthesia induction in two cases (Case-1 and Case-3). Case-2 received ESP block in the lateral position following the anesthesia induction. Using ultrasound guidance (Esaote MyLab™Seven, Florence, Italy) a linear probe was placed in cephalo-caudad direction on the level of T8-T9 spinous process, then slid 2–3 cm laterally in the parasagittal plane to visualize T9 transverse process and overlying erector spinae muscle. Following antiseptic skin preparation, block needle (SonoPlex STIM®, Pajunk®, Germany) was advanced using the in-plane technique in cephalo-caudad direction. After confirmation of the proper needle tip placement with 2–3 mL of isotonic saline, 30 mL of 0.375% bupivacaine was injected for unilateral ESP block and the spread of local anesthetic under erector spinae muscle was seen. General anesthesia was induced with iv 1–2 mg/kg propofol, 0.6 mg/kg rocuronium, and maintained with sevoflurane, oxygen, and air mixture and iv infusion of remifentanil (0.05 μg/kg/min). The kidney was placed into the iliac fossa through the hockey stick incision. Patients were extubated immediately after surgery in the operating room, and then transferred to intensive care unit for close follow-up. All patients were administered IV 1 g paracetamol and 50 mg tramadol when the surgeons started to put fascial sutures, and IV 50 mg tramadol injection was repeated in every eight hours for 24 h in the postoperative period. The pain intensity was monitored using the Numeric Rating Scale (NRS) and never rated more than 3 points. All three kidneys had immediate diuresis after transplantation. Significant decrease in creatinine levels was observed and the patients were discharged from hospital without any complications. Pain management of patients with end-stage renal disease may be insufficient due to limited options of systemic analgesics. In this context, regional analgesia techniques can be helpful to overcome these limitations. The ESP block is a new method introduced to clinical practice [ 1 ], and has found a broad range of indications, including acute postoperative and chronic pain management [ 2345 ]. Recently, ESP was performed in a patient in the postoperative period of renal transplantation surgery, and significant reduction in NRS scores and analgesic consumption was observed in 2 h following the ESP block intervention [ 6 ]. It is thought that, ESP block shows its analgesic effect by the spread of local anesthetic to the paravertebral and epidural space as well as around the somatic nerves [ 5 ]. In conclusion, preoperative ESP block is a promising method for analgesia in kidney transplantation surgeries covering the whole perioperative period, without disrupting graft function. More studies are needed to investigate the effects of this technique in kidney transplantation.

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