豎脊肌平面阻斷術在兒童肝臟切除術上的應用──病例報告

Erector spinae plane block for pediatric hepatectomy: a case report

背景：豎脊肌平面阻斷術是一種創新的神經阻斷方式，具有類似脊椎旁神經阻斷術的效果。在施行上較為簡易、較少併發症，並且在凝血功能障礙的病人中不是絕對禁忌症。案例介紹：一位1歲7個月大，體重11公斤的男孩被診斷出患有肝母細胞瘤。在完成化療後，接受S4b和S5的肝臟切除術。本次鎮痛策略採用多模式鎮痛，包括術中remifentani的持續輸注、propacetamol、fentanyl和右側豎脊肌平面阻斷術。手術完成後，將病人姿勢調整成左側臥位，將超音波的線性探頭以矢狀方向擺在胸椎第八節的位置，在確認回抽沒有血液的情況下，注射了6毫升0.33％濃度的ropivacaine。但由於局部麻醉劑沒有順利向尾側擴散，在同側胸椎第九節的位置，以同樣的手法加強注射了2毫升。完成豎脊肌平面阻斷術後，氣管內管順利拔除，並將病人送至恢復室觀察。疼痛指數為零（FLACC量表：0）。討論：單側豎脊肌平面阻斷術與多模式鎮痛策略對於兒童肝臟切除手術有很好的疼痛緩解。豎脊肌平面的導管置放是可以考慮用來延長術後止痛的時間。

Background: Erector spinae plane block is an innovative inter-fascial plane block featuring the alike effects of paravertebral block, less technically challenging to perform, less complications and not absolutely contraindicated in patients with coagulopathy. Case presentation: A 1-year-7-month-old, 11 kg boy was diagnosed with a huge hepatoblastoma. After the chemotherapy, he was undergoing S4b and S5 segmental hepatectomy. Multimodal analgesia includes intraoperative remifentanil infusion, propacetamol, fentanyl and right-side erector spinae plane block. At left lateral decubitus position, a linear ultrasound probe was placed lateral to the T8 spinous process in a sagittal paramedian orientation for erector spinae plane block needling. After negative aspiration of heme, a total of 6 ml 0.33% ropivacaine was administrated. As the inter-facial space enlarged upward but not downward, he received additional 2 ml of 0.33% ropivacaine at ipsilateral T9 level to reinforce the effect. Endotracheal tube was removed smoothly after surgery and transferred him to the post-anesthesia care unit with clear consciousness and total pain relief (FLACC scale: 0). Discussion: Single-shot thoracic erector spinae plane block with multimodal analgesia strategy had a good pain relief in this case, who could smoothly extubate after hepatectomy. Erector spinae plane block with catheter indwelling could be considered to extent postoperative analgesia duration.