Ultrasound-Guided Erector Spinae Plane Block for Pain Management in Hypertriglyceridemia-Induced Acute Pancreatitis: A Case Report

Abstract

Pain associated with acute pancreatitis is often severe and difficult to manage, traditionally requiring opioid-based analgesia. Opioids, however, are associated with adverse effects such as nausea, vomiting, ileus, sedation, and respiratory depression. Recent evidence suggests that ultrasound-guided erector spinae plane block (ESPB) provides effective visceral analgesia with reduced opioid requirement in hepatopancreaticobiliary pain. We report a case of recurrent acute pancreatitis secondary to hypertriglyceridemia in a 40-year-old woman, where ESPB was used as part of multimodal analgesia, resulting in significant pain relief and improved patient comfort. This case supports the role of ESPB as a safe and effective analgesic modality in acute pancreatitis.

Keywords

Acute pancreatitis; Erector spinae plane block; Hypertriglyceridemia; Pain management; Regional anesthesia

Introduction

Pain control is a cornerstone in the management of acute pancreatitis and remains a challenge in emergency and inpatient settings. Severe abdominal pain frequently necessitates opioid-based analgesia, which may be associated with significant adverse effects and variable efficacy. Hypertriglyceridemia-induced pancreatitis is often recurrent and associated with severe pain, making effective and sustained analgesia essential.

The ultrasound-guided erector spinae plane block (ESPB) is a novel regional anesthetic technique that provides both somatic and visceral analgesia by blocking the dorsal and ventral rami of spinal nerves. Recent emergency department–based studies, including the Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room (EASIER) trial, have demonstrated superior pain relief, reduced rescue analgesia, and higher patient satisfaction with ESPB compared to intravenous opioids in patients with hepatopancreaticobiliary pain, including acute pancreatitis. We describe the successful use of ESPB for pain management in a patient with hypertriglyceridemia-induced acute pancreatitis.

This report describes the use of an ultrasound-guided erector spinae plane block performed by emergency physicians in the emergency department for pain management in acute pancreatitis.

Case Report

A 40-year- Lady presented with complaints of severe left-sided upper abdominal and epigastric pain associated with nausea since today morning. She was a known case of type 2 diabetes mellitus, systemic hypertension, dyslipidemia, and had a history of recurrent hypertriglyceridemia-induced acute pancreatitis, with a similar episode two months prior. There was no history of alcohol consumption.

On examination,

the patient was conscious, oriented, afebrile, and clinically dehydrated.

PR : 100 bpm

BP : 150/90 mmhg

Spo2 : 100% @RA

Temp: Afebrile

CBG: 327 mg/dL.

S/E : CVS : S1 S2 + , No murmur

CNS : NFND

RS. : NVBS

PA. : Soft , Tenderness + over epigastric, left hypochondria region, Guarding +

Laboratory investigations revealed elevated serum lipase and markedly elevated serum triglyceride levels. computed tomography of the abdomen showed bulky distal body and tail of the pancreas with peripancreatic fat stranding, suggestive of acute pancreatitis, along with fatty liver changes.

Pain Management Intervention

On admission, the patient was initiated on intravenous paracetamol and tramadol as part of standard analgesic management for acute pancreatitis. Despite this, the patient continued to experience severe abdominal pain. Analgesia was subsequently escalated to intravenous fentanyl; however, pain control remained inadequate, with the patient continuing to require frequent rescue analgesia.

At this stage, the patient’s pre-procedure pain score was >7/10 on the Numerical Rating Scale (NRS). In view of persistent severe pain despite opioid escalation, and to minimize opioid-related adverse effects, a multimodal analgesic approach incorporating a regional anesthesia technique was planned.

After obtaining informed written consent, an ultrasound-guided bilateral erector spinae plane block (ESPB) was performed under strict aseptic precautions.

Procedure Note: Ultrasound-Guided Erector Spinae Plane Block

The patient was positioned in a sitting posture with slight forward flexion. Under aseptic precautions, a high-frequency linear ultrasound probe was used to identify the transverse process at the appropriate thoracic level. The erector spinae muscle was visualized superficial to the transverse process.

Using an in-plane ultrasound-guided technique, a 22-gauge spinal needle was advanced in a cranio-caudal direction until contact was made with the transverse process. After negative aspiration, 20 mL of 0.2% ropivacaine was injected on each side into the fascial plane deep to the erector spinae muscle, with ultrasound confirmation of adequate spread of the local anesthetic. The procedure was performed bilaterally and was uneventful.

Post-procedure Pain Assessment and Outcome

Following the erector spinae plane block, the patient demonstrated significant and sustained reduction in pain intensity. The post-procedure NRS pain score was <4/10 at 30 minutes, 1 hour, and 2 hours following the block. The patient reported marked improvement in comfort and ability to rest, with no further requirement for rescue opioid analgesia.

In view of stable pain control and hemodynamic stability, the patient was shifted to the ward after 2 hours of observation. No post-procedure complications such as hypotension, local anesthetic toxicity, hematoma, infection, or respiratory compromise were observed..

Hospital Course

In addition to ESPB, the patient was managed with standard treatment for hypertriglyceridemia-induced acute pancreatitis, including intravenous fluids, insulin and dextrose infusion, intravenous heparin, antiemetics, proton pump inhibitors, and supportive care. Serum triglyceride levels were serially monitored and showed a declining trend. The patient improved symptomatically, tolerated oral intake, and remained hemodynamically stable. She was discharged after five days of hospitalization in a clinically stable condition.

Discussion

Pain in acute pancreatitis results from pancreatic inflammation, peripancreatic nerve irritation, and visceral afferent stimulation. Opioids remain the most commonly used analgesics but are associated with adverse effects that may complicate clinical management.

The erector spinae plane block provides effective visceral analgesia through cranio-caudal spread of local anesthetic affecting multiple thoracic spinal segments. The EASIER trial demonstrated that ESPB resulted in significantly greater pain reduction, lower rescue analgesia requirements, and higher patient satisfaction compared to intravenous morphine in patients presenting with severe hepatopancreaticobiliary pain in the emergency department. The favorable safety profile and bedside feasibility of ESPB make it an attractive analgesic option in acute pancreatitis.

In the present case, ESPB provided effective opioid-sparing analgesia in a patient with recurrent hypertriglyceridemia-induced acute pancreatitis, consistent with emerging evidence from randomized trials (EASIER trial)and case series.

Importantly, the erector spinae plane block in this case was performed by emergency physicians in the emergency department setting, demonstrating the feasibility and effectiveness of bedside regional anesthesia for pain control in acute pancreatitis in the ED.

Conclusion

Ultrasound-guided erector spinae plane block is a safe and effective adjunct for pain management in acute pancreatitis. Its use can significantly reduce pain intensity and opioid requirements, improving patient comfort and overall care. ESPB should be considered as part of multimodal analgesia in patients presenting with severe pancreatitis-related pain.

This case highlights the expanding role of emergency physicians in performing ultrasound-guided regional anesthesia in the emergency department and supports the use of erector spinae plane block as a feasible analgesic option for acute pancreatitis in ED settings.

Conflict of Interest

None declared.

References

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