2026 Clinician Corner - Erector spinae plane catheters: a potentially safer alternative in anticoagulated rib fracture patients

Abstract 

An 86-year-old woman presented to the emergency department following a ground-level fall with fractures of the left posterior ribs 9–11 and right posterior ribs 5–8. She was admitted, and multimodal pain management, including acetaminophen, methocarbamol, oxycodone, and hydromorphone, was initiated. On the second day of hospitalization, she developed somnolence and confusion attributed to opioid administration. She was unable to receive a thoracic epidural due to recent clopidogrel administration, and bilateral erector spinae plane catheters were shown to be a reasonable alternative. This intervention provided effective pain relief, leading to improved mental status, pain control, and incentive spirometry. 

Keywords:  Anticoagulation; erector spinae plane block; regional anesthesia; rib fractures

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Faculty credentials/disclosure 

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report. 

Process

Click the "add to cart/begin" button, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.  You must achieve 100% on the quiz with unlimited attempts available.

  • By completing this process, you are attesting that you have read the journal article.

Expiration date:

Credit eligibility for this article is set to expire on July 1, 2027.

Learning Objectives

After completing the article, the learner should be able to:

  • Identify the clinical scenarios in which erector spinae plane (ESP) blocks and catheters may serve as a potentially safer analgesic alternative for rib fracture patients who are anticoagulated or at high risk for neuraxial bleeding. 

  • Compare the analgesic benefits and risk profiles of ESP blocks with other regional anesthesia techniques (e.g., thoracic epidural, paravertebral block) in elderly patients. 

  • Apply strategies to reduce systemic opioid exposure in rib fracture management, including the use of regional anesthesia to minimize complications such as delirium and respiratory depression in older adults. 

Key Points 

  • Erector spinae plane (ESP) blocks offer reasonably safe, effective analgesia for rib fracture pain in patients who are anticoagulated or at high risk for neuraxial bleeding. 

  • Compared with thoracic epidural and paravertebral blocks, ESP blocks have a lower procedural risk profile, making them particularly valuable in elderly, high-risk patients

  • ESP catheter use reduces systemic opioid requirements, mitigating adverse effects such as delirium and respiratory depression. 

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Course summary
Available credit: 
  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance
Course opens: 
07/01/2026
Course expires: 
07/01/2027
Cost:
$25.00

Meredith Malone, BA1, and Amy Coffman, MD2 

 

1College of Osteopathic Medicine, Rocky Vista University, Parker, Colorado, USA; 

2US Anesthesia Partners, Austin, Texas, USA 

 

Corresponding author: Meredith Malone, BA, Rocky Vista University College of Osteopathic Medicine, 8401 S. Chambers Rd., Parker, CO 80134 (e-mail: [email protected]) 

 

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report. 

Accreditation

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation

AMA PRA Category 1 Credit™

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABS CC

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

ABIM MOC

 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Available Credit

  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance

Price

Cost:
$25.00
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