The effect of ultrasound-guided intercostal nerve block,single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized,double-blinded,clinical trial

Study objectiveThe study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection paravertebral block (PVB) after thoracoscopic surgery.DesignRandomized, controlled, double- blinded study.SettingOperating room, postoperative recovery room and ward.PatientsSeventy-five patients, aged 18–75 years, ASA I–II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.InterventionsPatients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.MeasurementsCumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.Main resultsThere was a significant difference in median [interquartile range, IQR] morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 [9–15] mg; ICNB, 18 [13.5–22.1] mg; ESPB, 22 [15–25.1] mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, −7.5; 95% confidence interval [CI], −12 to −4.5; p = 0.000) and PVB group vs ICNB group (median difference, −6; 95% CI, −9 to −3; p = 0.001), but not for ICNB vs ESPB (median difference, −3; 95% CI, −6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (<4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p < 0.05).ConclusionsUltrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery.     

Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind,randomized controlled trial

Purpose

The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery.

Methods

A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10–15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded.

Results

The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred.

Conclusion

The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

     

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: A randomized,placebo-controlled trial

Study objectiveThe aim of this study was to evaluate the effect of ultrasound-guided erector spinae plane (ESP) block on postoperative pain in radical prostatectomy, which leads to both visceral and somatic pain.DesignProspective, randomized, placebo controlled, double-blinded.SettingUniversity hospital.PatientsA total of ASA I-III, 50 patients aged 18–65 who were scheduled for elective open radical prostatectomy surgery.InterventionsPatients were randomly allocated to receive an ultrasound-guided ESP block, with either local anesthetic (10 mL of 1% lidocaine +10 mL of 0.5% bupivacaine) or placebo bilaterally.MeasurementsThe primary outcome was morphine consumption in the first 24 h after surgery. The secondary outcomes were NRS pain scores at rest and coughing, intraoperative remifentanil consumption and need for rescue analgesic during the first 24 h after surgery.Main resultsBoth NRS scores for post-anesthesia care unit and NRS_rest scores for 1st hours were lower in Group ESPB (p < 0.001 and p = 0.033, respectively). Cumulative morphine consumption at 24 h post-surgery was similar between the groups (p = 0.447). Rescue analgesic requirement was higher in the placebo injection group than in the ESPB group at the 1st postoperative hour (p = 0.002).ConclusionsIn open radical prostatectomies, except for the first hour, ESP block is ineffective for pain scores and on morphine consumption compared to the placebo injection group in the postoperative period.     

Bilateral ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal fusion: A randomized controlled trial

Study objectiveSpinal fusion surgery is associated with severe postoperative pain. We examined whether bilateral ultrasound-guided erector spinae plane block could alleviate postoperative pain in patients undergoing lumbar spinal fusion.DesignBlinded, randomized, controlled study.SettingTertiary university hospital, operating room, postoperative recovery room and ward.PatientsSixty patients with American Society of Anesthesiologists grade I or II scheduled for lumbar spinal fusion surgery were randomized into the erector spinae plane block group (ESPB group) and the control group in a 1:1 ratio.InterventionsPre-operative ultrasound-guided bilateral erector spinae plane block was performed in the ESPB group, while sham subcutaneous infiltration was performed in the control group.MeasurementsThe primary outcome was pain intensity at rest within 12 h postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included NRS pain scores at rest and on movement, postoperative opioid consumption and proportions of patients requiring opioid during the first 48 h after surgery.Main resultsThe ESPB group (n = 30) showed significantly lower pain scores at rest at 4 h after surgery (estimated mean difference − 1.6, 95% confidence interval [CI] -2.4 to −0.8, p < 0.001), at 8 h (−1.3, 95% CI -1.9 to −0.6, p < 0.001), and at 12 h (−0.7, 95% CI -1.3 to −0.1, p = 0.023). The two groups showed similar pain scores at rest at 24 h after surgery (estimated mean difference − 0.2, 95% CI -0.8 to 0.5) and 48 h (−0.3, 95% CI -0.8 to 0.2). The ESPB group also showed significantly lower pain score on movement at 4 h after surgery (−1.5, 95% CI -2.5 to −0.6). The ESPB group showed a significantly smaller proportion of patients requiring sufentanil within 12 h after surgery (p = 0.020), and the group consumed significantly less sufentanil during that period (p = 0.042).ConclusionsBilateral ultrasound-guided erector spinae plane block improves postoperative analgesia in patients undergoing lumbar spinal fusion.     

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized,controlled study

Study objectiveWe aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.DesignA prospective, blinded, randomized, controlled study.SettingA tertiary university hospital, operating room and intensive care unit.PatientsForty children aged 2–10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).InterventionsGroup B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.MeasurementsThe MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.Main resultsBilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.ConclusionUltrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.     

Impact of ultrasound-guided erector spinae plane block on postoperative quality of recovery in video-assisted thoracic surgery: A prospective,randomized, controlled trial

Study objectiveRegional anesthesia improves postoperative analgesia and enhances the quality of recovery (QoR) after surgery. We examine the efficacy of ultrasound-guided erector spinae plane block (ESPB) on QoR after video-assisted thoracic surgery (VATS).DesignProspective, randomized, double-blinded, placebo-controlled trial.SettingSingle institution, tertiary university hospital.PatientsAdult patients who scheduled for VATS under general anesthesia were enrolled in the study.InterventionsWe randomly allocated patients to receive preoperative ultrasound-guided ESPB with 25 ml of either 0.5% ropivacaine (ESPB group) or normal saline (Control group).MeasurementsThe primary outcome was QoR as measured by the 40-item QoR questionnaire (QoR-40) score at postoperative day 1. Secondary results were post-anesthesia care unit (PACU) discharge time, acute postoperative pain, cumulative opioid consumption, the incidence of postoperative nausea or vomiting (PONV), and patient satisfaction.Main resultsThe global QoR-40 score at postoperative day 1 (median, interquartile range) was significantly higher in the ESPB group (174, 170 to 177) than the control group (161.5, 160 to 165), estimated median difference 11 (95% CI 9 to 13, P < 0.001). Compared with the control group, single-injection of ESPB reduced PACU discharge time, acute postoperative pain, and cumulative opioid consumption. Correspondingly, the median patient satisfaction scores were higher in the ESPB group than the control group (9 versus 7, P < 0.001).ConclusionPreoperative single-injection thoracic ESPB with ropivacaine improves QoR, postoperative analgesia, and patient satisfaction after VATS.     

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

Study objectiveErector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.DesignA meta-analysis of randomized controlled trials.SettingPerioperative setting.PatientsPatients undergoing lumbar spine surgery under general anesthesia.InterventionsWe searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.MeasurementsThe primary outcome was opioid consumption in the first 24 h after surgery.Main resultsTwelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = −14.55; 95% confidence interval (CI), −21.03 to −8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0−10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = −1.24 days; 95% CI, −2.31 to −0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.ConclusionsESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required.PROSPERO registration number: CRD42021233362.     

Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum

Aim of the StudyPostoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA.MethodsThirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage.ResultsPain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5–7 days postoperatively.ConclusionUltrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay.Level of evidenceIII     

Posteromedial quadratus lumborum block versus transversus abdominal plane block for postoperative analgesia following laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveOur hypothesis was that a pre-operative posteromedial quadratus lumborum (QL) block would reduce postoperative morphine consumption and provide superior analgesia in the setting of multimodal analgesia compared with a lateral transversus abdominis plane (TAP) block for laparoscopic colorectal surgery.DesignA randomized controlled study.SettingA single tertiary hospital. March to August 2018.Patients80 ASA I–II colorectal cancer patients undergoing laparoscopic radical resection were enrolled. 77 patients (group QL 38, group TAP 39) were included in the analysis.InterventionPre-operatively, patients were randomized to receive either a QL or TAP block (0.375% ropivacaine 20 ml bilaterally for each group).MeasurementsThe primary outcome was cumulative morphine consumption 24 h postoperatively. Secondary outcomes included postoperative pain scores, clinical recovery, and side-effect profiles of the blocks.Main resultsFor the primary outcome measure, morphine consumption 24 h postoperatively was significantly lower in the QL group than in the TAP group (estimated median difference −8 mg, adjusted 95% confidential interval −12 to −6 mg, P < 0.001). The pain visual analogue scores at rest and during movement were found to be statistically significantly lower in the QL group than in the TAP group 8, 12, and 24 h postoperatively (P < 0.006). The QL group reported higher overall satisfaction scores regarding postoperative analgesia than the TAP group (P = 0.014). One patient in the QL group experienced moderate back pain close to the needle entry site postoperatively. There was no statistically significant difference in postoperative nausea and vomiting, bowel recovery or length of hospital stay between the groups.ConclusionsThe pre-operative bilateral, ultrasound-guided posteromedial QL block reduces morphine consumption and improves analgesia in the setting of multimodal analgesia compared with the lateral TAP block after laparoscopic colorectal surgery.     

Erector spinae plane block for postoperative analgesia in robotically-assisted coronary artery bypass surgery: Results of a randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing robotically-assisted minimally invasive direct coronary artery bypass surgery (RAMIDCAB).DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial.SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital.PatientsSixty-four patients undergoing RAMIDCAB surgery via left-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program.InterventionsAt the end of surgery, patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading dose of 30 ml and three additional doses of 20 ml each, interspersed with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial.MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included location and severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events.Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-groups, 67 mg (35–84) versus 71 mg (52–90) (p = 0.25), respectively. Likewise, no differences were detected in secondary and safety endpoints.ConclusionsFollowing RAMIDCAB surgery, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.     

Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind,prospective randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing minimally invasive mitral valve surgery (MIMVS).DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial.SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital.PatientsSeventy-two patients undergoing video-assisted thoracoscopic MIMVS via right-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program.InterventionsAt the end of surgery, all patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading of dose 30 ml and three additional doses of 20 ml with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal postoperative analgesia including dexamethasone, acetaminophen and patient-controlled intravenous analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial.MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events.Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-group, 41 mg (30–55) versus 37 mg (29–50) (p = 0.70), respectively. Likewise, no differences were detected for secondary and safety endpoints.ConclusionsFollowing MIMVS, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.     

The effect of preoperative erector spinae plane vs. paravertebral blocks on patient-controlled oxycodone consumption after video-assisted thoracic surgery: A prospective randomized,blinded, non-inferiority study

Study objectiveTo investigate the effective analgesia for video-assisted thoracic surgery.DesignIn this prospective non-inferiority study, we evaluated the postoperative analgesic effect of preoperative ultrasound-guided Erector Spinae Plane blocks (ESPB) on T4 and T6 levels in patients undergoing video-assisted thoracic surgery in comparison with paravertebral block (PVB) at the same intervertebral spaces.SettingA university hospital.Patients66 patients scheduled to undergo video-assisted thoracic surgery under general anesthesia were included.InterventionsPatients were randomly allocated to receive ultrasound-guided ESP blocks on T4 and T6 levels (Group ESPB, n = 33) or PVB (Group PVB, n = 33) with 30 mL 0.4% ropivacaine 30 min before anesthesia induction. A continuous flurbiprofen (8 mg/h) was infused postoperatively through a single-use infusion device and intravenous oxycodone supplied as analgesic rescue if needed, with bolus of oxycodone (1 mg) and lockout time being 10 min.MeasurementsThe primary outcome was the postoperative oxycodone consumption at 48 h.Main resultsIntraoperative use of sufentanil and remifentanil were comparable between these two groups. Pain scores, oxycodone rescue and Quality of Recovery (QoR) 15 on postoperative day 1 and 2 were equivalent between these two groups. Postoperative oxycodone consumption was 7.9 ± 8.7 boluses in ESPB group and 6.9 ± 6.3 boluses in PVB group at 48 h. The cumulative 48 h difference i.e. Oxycodone boluses_{with ESPB} minus Oxycodone boluses_{with PVB} was 2 (95% CI -1, 5.6). The lower limit of the 95% CI for this difference was −1, which was within the predefined non-inferiority margin of −10 (Δ).ConclusionsUltrasound-guided ESPB applied before video assisted thoracic surgery was non-inferior in analgesic effect compared with PVB in terms of pain score, analgesic rescue consumption and quality of recovery.Brief summary statementPreoperative Erector spinae plane blocks (ESPB), when in combination with round-the-clock NSAIDs, offered equivalent analgesia and quality of recovery after video assisted thoracic lung surgery compared with paravertebral blocks. Patients who received ESP blocks had similar consumption of oxycodone and length of hospital stay.     

Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis

Study objectiveThe erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB).DesignWe systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology.Results14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I² = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I² = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p < 0.001; I² = 96%) subgroups. The ESPB significantly reduced pain scores at rest or movement at various time points postoperatively compared with non-block group, and reduced the rate of postoperative nausea and vomiting (OR 0.48; 95%CI 0.27 to 0.86; p = 0.01; I² = 0%). In contrast, there were no significative differences reported in any of the outcomes for ESPB versus TPVB strata.ConclusionsESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.     

Feasibility of combined paravertebral block and subcostal transversus abdominis plane block in postoperative pain control after minimally invasive esophagectomy

ObjectivesSubcostal transversus abdominis plane (TAP) block and paravertebral block (PVB) offer postoperative analgesia for laparoscopic and thoracoscopic surgery, respectively. We investigated the early postoperative analgesic effects of PVB in combination with subcostal TAP block in patients undergoing minimally invasive esophagectomy (MIE) for esophageal cancer.MethodsSeventeen patients undergoing MIE without nerve block for postoperative analgesia and 16 patients undergoing MIE with PVB and subcostal TAP block for postoperative analgesia were enrolled for the study. The surgeon performed PVB with bupivacaine at T4, T6, and T8 levels under video-assisted thoracoscopy at the end of the thoracoscopic stage. The anesthesiologist responsible for the anesthesia performed ultrasound-guided bilateral subcostal TAP with bupivacaine at the end of the surgery. Postoperative morphine consumption, pain severity, vital capacity, intensive care unit (ICU) stay, and complication rate were compared between groups.ResultsThe group receiving nerve blocks consumed less morphine on postoperative Day 0 (p = 0.016), experienced lower levels of pain at postoperative 0 hour (p = 0.005) and 2 hours (p = 0.049), and had a shorter ICU stay (p = 0.02). No between-group differences in postoperative vital capacity and respiratory complications were observed.ConclusionPVB in combination with subcostal TAP block could reduce morphine consumption and pain severity in the early postoperative period but did not offer other clinical benefits in MIE.     

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

IntroductionTransversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions.MethodsSeventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA.ResultsThe cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects.ConclusionContinuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.     

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery—a double blinded,randomized controlled study

Background contentPosterior cervical spine surgery (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS.PurposeTo assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS.Study designProspective, randomized controlled, double-blinded study.Patient sampleEighty-six patients requiring sub-axial PCSS with or without instrumentation were randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control).Outcome measuresDemographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded.MethodsAfter anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15 ml of 0.25% bupivacaine and 8 mg Dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia.ResultsThere were 43 patients in each group; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs. 308.6±189.78; p<.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs. 59.53±3.75 mg, p<.001), surgical duration (124.77±26.63/ 156.74±37.01 min; p<.01) and intraoperative blood loss (310.47±130.73 ml vs. 429.77±148.50 ml; p<.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 h) when compared to controls (16.86±6.18/ 23.05±8.88 h; p<.001).ConclusionIn patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multimodal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization.     

竖脊肌平面阻滞对腰椎后路手术患者术后早期康复的影响

目的评价超声引导下竖脊肌平面阻滞(erector spine plane block,ESPB)对腰椎后路手术患者术后早期康复的影响。方法择期全麻下行腰椎手术的患者65例,年龄45~65岁,性别不限,ASA分级I或Ⅱ级,体质量指数(BMI)18.5~28.0 kg/m 2,采用随机数字表法分为超声引导竖脊肌平面阻滞组(ESPB组,32例)和对照组(GA组,33例)。2组均采用静-吸复合麻醉,术后采用舒芬太尼行静脉自控镇痛(PCIA)。ESPB组全麻诱导前于俯卧位行竖脊肌平面阻滞。当VAS评分≥4分时,肌内注射曲马多补救镇痛。分别于术前1 d,术后第1天、2天时,采用QoR-15量表评估患者恢复质量。记录术后1 h、6 h、12 h、24 h、48 h的VAS评分,术后48 h内PCIA舒芬太尼用量、补救镇痛情况和恶心及呕吐发生情况。结果与GA组相比,ESPB组术后第1天、2天时QoR-15评分升高,术后1 h、6 h和12 h VAS评分降低,PCIA舒芬太尼用量减少,补救镇痛率和术后恶心呕吐发生率降低。以上差异均有统计学意义(P<0.05)。结论超声引导竖脊肌平面阻滞可促进腰椎后路手术患者术后早期康复。     

Anesthesia management with ultrasound-guided thoracic paravertebral block for donor nephrectomy: A prospective randomized study

Study objectiveTo determine the efficacy of ultrasound-guided thoracic paravertebral block intraoperatively and 24 hours postoperatively in patients undergoing donor nephrectomy.DesignProspective randomized controlled study.SettingPrivate foundation university hospital; November 2014 to June 2015.PatientsThirty-two patients undergoing donor nephrectomy (exclusion criteria: coagulation disorders, allergy to local anesthetics, and unwillingness to participate). The final study population comprised 30 patients (15 male, 15 female) randomly assigned to either Group P (paravertebral block, n = 14) or Group M (morphine, n = 16).InterventionsIn Group P, a unilateral paravertebral catheter was inserted 1 day preoperatively; on the day of surgery, a single-level unilateral paravertebral block was administered through the catheter before general anesthesia. Infusion of bupivacaine continued intraoperatively and postoperatively. Patients in Group M received only general anesthesia, and morphine patient-controlled analgesia was begun postoperatively.MeasurementsIntraoperative analgesic and anesthetic requirement, postoperative numerical rating scale pain scores, additional analgesic consumption during the postoperative period, and incidence of complications related to thoracic paravertebral block (TPVB) like pleural puncture, pneumothorax, epidural spread, injection into the subarachnoid space, intravascular injection, and Horner's syndrome and rate of opioid related adverse reactions like nausea and vomiting, itching, constipation, and respiratory depression.ResultsIntraoperative remifentanil consumption was significantly higher in Group M, and postoperative morphine consumption was significantly lower in Group P (P < .001). During the first 24 hours postoperatively, the mean numerical rating scale pain scores were similar and there were no significant differences between the 2 groups. There were no statistically significant differences in the additional analgesic consumption and rate of adverse reactions between the 2 groups. We didn't detect any complication related to TPVB in group P.ConclusionsContinuous thoracic paravertebral block provides good intraoperative stability with a low anesthetic requirement and reduces postoperative morphine consumption for up to 24 hours. Ultrasound guided technique enhanced the safety of TPVB and provides analgesia without major complications.     

Subcostal transversus abdominis plane block for postoperative analgesia in liver transplant recipients

Background

Postoperative pain treatment in orthotopic liver transplant (OLT) patients is a challenge. We performed a pilot study on ultrasound-guided transversus abdominis plane (TAP) block in OLT patients. To test the efficacy of this technique, which is noveI to OLT patients, we compared morphine consumption, pain scores, and time to extubation with a matching control group.

Methods

Seventeen patients who underwent OLT underwent bilateral ultrasound-guided TAP block using a subcostal approach with levobupivacaine (0.5%; 20 mL each) followed by postoperative morphine patient-controlled analgesia (PCA). The control group of 17 patients had only morphine PCA. We recorded the total morphine consumption, postoperative pain, and time to extubation.

Results

The total amount of morphine consumption over 24 hours was 45.9 ± 33.9 mg in the TAP group and 71.8 ± 39.9 mg in the control group (P < .005). Median pain scores were 1 in the TAP group and 2 in the control group (not significant [NS]). Median time to extubation was 60 minutes in the TAP group and 97 minutes in the control group (P = NS).

Conclusion

Initial evaluation of subcostal TAP block after OLT showed significant reduction in postoperative morphine consumption.     

Comparison of femoral nerve block and fascia iliaca block for analgesia following reconstructive knee surgery in adolescents

Study ObjectiveTo compare the femoral nerve block with the fascia iliaca block for postoperative analgesia in adolescents undergoing reconstructive knee surgery.DesignRandomized, single-blinded study.SettingFull-service pediatric medical center.Patients23 ASA physical status I and II patients, aged 8 to 16 years, undergoing anterior cruciate ligament (ACL) repair.InterventionsPatients received either fascia iliaca or femoral nerve block prior to reconstructive surgery.MeasurementsPain scores by visual analog scale (VAS; 0-10) and morphine use were routinely recorded through to discharge from the hospital. Pain scores were assessed on days 1 and 2 at home post-discharge.Main resultsThere was no difference between the femoral nerve block and the fascia iliaca nerve block in VAS pain scores or postoperative morphine consumption.ConclusionEither the femoral nerve block or the fascia iliaca block, followed by patient-controlled analgesia with morphine, provides efficacious analgesia for adolescents undergoing ACL reconstruction.