Relief of refractory renal colic in emergency department: A novel indication for ultrasound guided erector spinae plane block Muhammed Enes Aydin a , Ali Ahiskalioglu a, ⁎, Erdal Tekin b , Fatih Ozkaya c , Elif Oral Ahiskalioglu a , Atif Bayramoglu b a Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey b Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey c Department of Urology, Ataturk University School of Medicine, Erzurum, Turkey abstract article info Article history: Received 12 November 2018 Accepted 22 December 2018 Available online xxxx Plane blocks have become very popular in recent years with the introduction of ultrasonography into the regional anesthesia and algology practice. Erector spinae plane (ESP) block involves injection of local anesthetics between erector spinae muscles and transverse process of vertebrae and can block the dorsal and ventral rami of thoracolumbar spinal nerves. The primary factor in the great popularity of this block is easy sonographic identi- fication of landmarks and lower complication rate compared to paravertebral or central neuroaxial blocks. These characteristics mean that it will in all probability be widely used in the future, not just for anesthetists, but also for emergency physicians. Here we first report a novel indication for ESP block in emergency department; renal colic. © 2018 Elsevier Inc. All rights reserved. 1. Introduction Most of the applications to the emergency department cause acute pain and the duration of analgesia is an important clinical indicator in determining the quality of care of emergency department patients [1,2]. Acute renal colic is a serious cause of flank pain and is one of the most common urological emergency cases. Urolithiasis is the first cause in the differential diagnosis of flank pain and is characterized by the presence of stones in the kidney and urinary tract. The reported prevalence of renal colic varies between 5% and 15% according to the geographic distribution of the disease [3]. The risk of recurrence is high and reaches 40% in 5 years and up to 50% in 10 years. The cost as- sociated with urolithiasis reaches $ 6 million per year in Unites States (US), resulting in more than one million emergency services per year [3]. The severity of pain varies depending on the individual pain thresh- old and the hydrostatic pressure above the obstruction. Nausea and vomiting accompany the pain in half of the cases. In emergency services, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics (fen- tanyl, meperidine), hydration, calcium channel blockers, alpha blockers and phosphodiesterase inhibitors can be used in the treatment of renal colic pain. In spite of the patients who had taken analgesic medication before coming to the emergency department for serious pain, paren- teral opioids were used in 72% of patients who presented to the emer- gency department with renal colic [4]. ESP block for the first time described by Forero et al. [5] for thoracic and abdominal region has found widespread use from acute pain to postherpetic neuralgia [6] such as rib fracture [7], transverse process fracture [8] and in emergency department. Although there are publica- tions on the use of subcutaneous paravertebral block [9], twelfth inter- costal nerve block [10] and trigger point injection [11,12] for renal colic, regional anesthetic techniques are quite limited. In this case, we report a new indication for the ESP block in the emer- gency department and also in the literature; renal colic. 2. Cases 2.1. Case 1 Patient was a 56-year-old male (178 cm, 95 kg) who was admitted to emergency department with left renal colic. A pelvic and abdominal CT scan was performed then ureteral stone was diagnosed in the left mid-lower ureter. The patient had severe flank pain with a visual ana- logue scale (VAS) score of 10/10 in the last 2 h. Initially he was treated with 100 μq fentanyl, 50 mg dexketoprofen trometamol and 1 g paracet- amol after hydration. Then 50 μq fentanyl was administered 1 h of after initial medication. Despite administration of NSAID and opioids, patient had persistent flank pain. Therefore, we decided to advance an ultrasound-guided ESP block at T8 level for intractable acute pain treat- ment of renal colic. The patient was placed in the seated position then the transverse process and the erector spina muscle were visualized in the sagittal plane with multifrequency linear probe placed longitudinal parasagittal orientation at 3 cm lateral of the midline at T8 vertebra level American Journal of Emergency Medicine xxx (xxxx) xxx ⁎ Corresponding author at: Ataturk University School of Medicine, Yakutiye Research Hospital Department of Anesthesiology and Reanimation, Palandöken, 25070 Erzurum, Turkey. E-mail address: ali.ahiskalioglu@atauni.edu.tr (A. Ahiskalioglu). YAJEM-57987; No of Pages 3 Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Please cite this article as: M.E. Aydin, A. Ahiskalioglu, E. Tekin, et al., Relief of refractory renal colic in emergency department: A novel indication for ultrasound guided e..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2018.12.042 https://doi.org/10.1016/j.ajem.2018.12.042 0735-6757/© 2018 Elsevier Inc. All rights reserved.