P250 Erector spinae block for rib fracture pain management in elderly patients with respiratory failure: a case series in intensive care

<h3>Background and Aims</h3> Pain management in elderly patients with rib fractures and respiratory compromise is challenging. Regional techniques such as erector spinae plane (ESP) block offer opioid-sparing analgesia with improved respiratory outcomes. We present two ICU-managed cases where ESP block was successfully used for rib fracture pain management. <h3>Methods</h3> Case 1: A 75-year-old woman with asthma sustained right-sided R4-R11 rib fractures with haemopneumothorax following a fall. She was initially managed with systemic analgesia, but following chest drain insertion, developed hypoxia and reduced consciousness. The planned thoracic epidural was abandoned. She was intubated and admitted to ICU. On day 2, a right-sided ultrasound-guided ESP block at T7 was performed using an 18G Tuohy needle and catheter. Bolus 25 mL of 0.25% bupivacaine was given, followed by an infusion of 0.1% levobupivacaine with fentanyl 2 mcg/mL at 8 to 10 mL/hr. Case 2: An 82-year-old man with COPD, hypertension, and alcohol dependence presented with multiple right rib fractures (R3-R7) and type 2 respiratory failure after a fall. He was admitted to ICU for nebulisation, steroids, magnesium, and pain control. A right-sided ESP catheter was inserted at T5 under ultrasound guidance. A similar bolus and infusion technique was used. <h3>Results</h3> Both patients reported significant pain relief following the ESP block. The technique facilitated improved ventilation, enhanced participation in chest physiotherapy, and avoided further respiratory deterioration or escalation of ventilatory support. There were no procedural complications. Both catheters remained effective for 3–4 days, contributing to improved mobility, clinical recovery, and successful hospital discharge. <h3>Conclusions</h3> ESP block is a safe and effective analgesic option in elderly patients with rib fractures, particularly when thoracic epidural is contraindicated. It provides stable, opioid-sparing pain relief that supports ventilation, recovery, reduced respiratory complications and early discharge from hospital. Its simplicity, safety profile, and impact on respiratory function make it an invaluable tool in multimodal pain strategies.