Introduction

Perioperative pain management for neonatal thoracotomies is complicated due to the difficulty of achieving adequate pain relief without causing opioid-induced respiratory depression. Premature neonates often have associated cardiac and respiratory conditions, which result in a tenuous respiratory status at baseline, making this balance even more challenging to accomplish. In low-resource settings, the complexity of the care of these patients is further compounded by other factors. Decreased availability of opioids sometimes limits their use as the primary analgesic, and limited quantities of ventilators reduce the ability to provide prolonged mechanical ventilation (1). The risks associated with prolonged intubation, such as ventilator-associated pneumonia, are also higher in low- and middle-income countries (2), and there is often a shortage of trained staff to manage ventilated patients post-operatively (1). For these reasons, strong pain management and early extubation of neonates after major thoracic surgeries have an immense potential benefit to the patient and hospital system. 
Previous studies have provided evidence that regional anesthesia can be a successful strategy to reduce opioid consumption in the perioperative period for neonates undergoing thoracotomies. In a prospective randomized control study examining 40 neonates undergoing tracheoesophageal fistula (TEF) repair, the use of ultrasound-guided erector spinae plane (ESP) blocks resulted in significantly decreased analgesic consumption and greater heart rate stability in the 24-hour post-operative period (3). A second report described positive results in 16 neonates who underwent type C TEF repair, for which none of the patients required opioids post-operatively (4). In a third case, an ESP block catheter was used for pain control until chest tube removal in a neonate who underwent thoracotomy for congenital cystic adenomatoid malformation. The patient only received one dose of morphine post-operatively and was discharged home on post-operative day (POD) 3 (5). However, these studies were performed in middle or high sociodemographic index countries, where there are no major deficits in trained staff, equipment, or drugs. In this study, we describe a case in which an ESP block was successfully used in a resource-limited setting for the perioperative pain management of a neonate who underwent thoracotomy for TEF repair, and in whom rapid extubation was the goal. The hospital is located in a rural town of 2,000 people in a country with a low-middle sociodemographic index and within a region that contains a majority of least developed countries, as defined by the United Nations. At this hospital, there are a limited number of trained anesthesiologists and limited availability of ventilators and other life-sustaining technologies. This case was further complicated by the presence of severe pulmonary hypertension, placing the patient at highly elevated anesthetic and surgical risk. This report highlights the benefits of regional anesthesia in limited anesthesia capacity environments for complex patients.

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Case presentation

Patient information and clinical findings
The institutional review board of the primary authors’ institution does not require approval for case reports. However, written consent was obtained from the patient’s guardian for the use of their child’s de-identified information. A 5-day-old, 2.9-kg infant born at 38 weeks required thoracotomy for TEF type C repair. On arrival to the operating room, the patient was stable on 2 L/min supplemental oxygen therapy via nasal cannula with an oxygen saturation of 95%.

Diagnostic assessment
Pre-operative work-up for associated congenital abnormalities was significant for an echocardiogram suggestive of severe pulmonary hypertension of unclear etiology without associated cardiac lesions. 

Therapeutic intervention
A combined intravenous and inhalational induction with ketamine (6 mg) and sevoflurane was used to maintain spontaneous respiration before and during intubation. A total of 8 μg of fentanyl was given during intubation attempts in order to reduce the sympathetic response to laryngoscopy. A 3.0-mm endotracheal tube was secured on the third attempt. Thirty milligrams of paracetamol was also administered following intubation as an adjunct analgesic. The patient was then placed in the left lateral decubitus position for ultrasound-guided right-sided ESP block. After prepping and draping in the normal sterile fashion, a high-frequency linear transducer probe was used to identify the transverse process at the level of T6. The needle was inserted in-plane in a cranial-to-caudal orientation until the needle tip contacted the transverse process. Six milliliters of 0.125% bupivacaine (7.5 mg) and 1.5 μg of dexmedetomidine were injected to spread deep to erector spinae muscle and superficial to the transverse process, as demonstrated in Figure 1.

 

Figure 1.

Erector spinae plane block. Example demonstrating needle insertion in-plane in a cranial-to-caudal orientation and injection of local anesthetic deep to the erector spinae muscle and superficial to the transverse process.

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Before skin incision, another 5 μg of fentanyl was given. Pressure-controlled ventilation at an FiO2 of 0.46 with 1.1% sevoflurane was maintained throughout the procedure with pulse oximetry ranges of 95–97% and 30–34.2 mmHg ETCO2. Some episodes of hypotension (mean arterial pressure <38 mmHg) necessitated intervention with boluses of 5 μg phenylephrine and 90 mg calcium gluconate. The duration of surgery was 2 hours 55 minutes, and the patient received no additional opioid medications after incision. At the end of the procedure, reversal of paralysis was performed with neostigmine and atropine. The neonate was hemodynamically stable and demonstrated adequate respiratory mechanics, so the decision was made to extubate. 

Outcome 
Following pediatric intensive care unit (PICU) arrival, the patient was managed on a course of scheduled paracetamol. No scheduled opioid medication was initiated, and he did not require any rescue opioid analgesic in the first POD. His need for analgesic medication was evaluated by his bedside providers who examined him for signs of discomfort, such as crying and inability to be soothed, as well sustained elevations in heart rate or blood pressure. The patient demonstrated none of these signs and remained stable from a respiratory and hemodynamic standpoint throughout the rest of the day and evening. No additional opioid medications were administered. Unfortunately, the next morning (17 hours after PICU arrival), the patient had a choking/aspiration event in the setting of a gastric tube that had migrated. This led to respiratory failure, PH crises, and cardiac arrest, necessitating reintubation. He subsequently developed pneumonia and an anastomotic leak, which were managed, and he was extubated again on POD 9. However, his respiratory condition deteriorated again, and he expired on day 19 of life (POD 14). 

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Discussion

Novel techniques in the field of surgical pain management are frequently undertaken in the vacuum of highly resourced medical facilities in wealthy nations. Scant attention is paid to the challenges of translating such advances to resource-limited environments, in which the vast majority of humanity lives and receives their healthcare. For instance, effectively managing pain for neonatal thoracotomies in these settings is complicated by limited critical care capacity, which necessitates early extubation and therefore an opioid-minimizing strategy (1-2). 
Opioid-sparing regional techniques, such as an ESP block as in our case, may offer a strong approach to addressing thoracotomy pain in adults, children, and even neonates (3-5). With a single-shot ESP block, our patient had very low intraoperative opioid consumption (2.8 μg/kg), with no opioids following incision. There were no opioids administered post-operatively until the patient’s cardiac arrest and intubation (after which opioids were utilized for sedation, not pain management). Unfortunately, no standardized pain scale was used to evaluate or document pain in this case. There is also no standard Enhanced Recovery After Surgery (ERAS) or standard pain management protocol at this institution from which to assess the impact of ESP in this single-patient report. The only data available in this case were the overall utilization of opioids intra-operatively and post-operatively, both of which were very low. However, previous studies performed at institutions in middle and high sociodemographic index countries have also provided evidence that ESP blocks result in excellent pain control and reduce opioid consumption in neonates undergoing major surgeries.
The prospective control study, including 40 neonates in which ESP blocks were utilized for TEF repair, demonstrated significantly lower Face, Legs, Activity, Cry, Consolability (FLACC) scores and analgesic consumption in the 24-hour post-operative period in those who underwent ESP blocks compared to those received systemic analgesia only. In the case series of 16 neonates, with an average age of 38 post-menstrual weeks, who underwent ESP blocks for TEF repair, only 2 required intraoperative analgesia beyond paracetamol, and none post-operatively (4). 
The anesthetic and analgesic regimen utilized in this case report achieved the early goals of analgesia and early extubation, giving this patient the best chance for recovery. In contrast, poorly controlled post-thoracotomy pain would impair adequate respiration and result in atelectasis, hypoxia, and potentially respiratory failure. Tragically, our patient suffered from severe complications that were initiated by a post-operative aspiration event related to a dislodged G-tube. Leaving this patient intubated post-operatively for more time due to his severe pulmonary hypertension and potential for decompensation might have prevented his initial aspiration event and led to a different outcome. However, in an environment where there are a limited number of ventilators and other life-sustaining technologies, leaving the patient intubated post-operatively is not always an option. The institutional practice is to extubate this patient population in the operating room (OR), and this was performed successfully. In addition to limited resources, there are also risks associated with prolonged intubation. In the aforementioned prospective study of 40 neonates undergoing TEF repair, the average patient age was 12.65 days, and the decision to extubate in the OR was made on a case-by-case basis (3). In the 16-neonate case series, extubation strategy was not discussed (4), and neither of these studies discussed when the patients were actually extubated in their perioperative course. 
As surgical capacity in resource-limited settings such as rural Kenya continues to develop, attempting more complex surgeries in smaller and smaller patients, anesthetic and analgesic techniques must similarly evolve to address such challenging issues. Low-risk, low-cost, effective, and eminently teachable regional anesthetic techniques such as ESP blocks offer an excellent option in a multitude of surgical settings. In the future, implementing a protocol or other pathway for regional anesthesia in thoracotomy patients at this institution for more patients to receive ESPs could be very beneficial. Further studies would need to be performed in low-resource settings using such protocols to determine if the benefits of less opioid use are consistent and if there is any impact on overall hospital resources.

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Conclusion

Pertrochanteric fractures show a decrease in NSA after fixation with a risk of varus malunion. Reduction in slight valgus may allow the fracture to collapse into a near-anatomical position, avoiding malunion. The position of the implant within the femoral head plays an active role in preventing fracture collapse and surgeons may reduce the risk of varus malunion by minimizing the TAD intra-operatively.

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Author contributions
MD led in the writing, reviewing & editing of the original draft. RH led in conceptualization, methodology, project administration and resources. All authors equally contributed in data curation and formal analysis.

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References

1. Dohlman LE, Kwikiriza A, Ehie O. Benefits and barriers to increasing regional anesthesia in resource-limited settings. Local Reg Anesth. 2020; 13: 147-58.

2. Arabi Y, Al-Shirawi N, Memish Z, et al. Ventilator-associated pneumonia in adults in developing countries: a systematic review. Int J Infect Dis. 2008; 12(5): 505-12. 

3. Eskander AM, Elsharaky HRM, Abo Elanin KM, et al. Ultrasound-guided erector spinae-plane block for postoperative pain in neonates undergoing tracheoesophageal fistula repair. Menoufia Med J. 2022; 35(3): 63.

4. Rahil O. 132 Single shot erector spinae plane block in newborns undergoing open type C esophageal atresia repair. Reg Anesth & Pain Med. 2021; 70(Suppl 1): A69. 

5. Adler AC, Yim MM, Chandrakantan A. Erector spinae plane catheter for neonatal thoracotomy: a potentially safer alternative to a thoracic epidural. Can J Anesth. 2019; 66(5): 607-8.