Bloqueio do plano do eretor da espinha para analgesia pós‐operatória de cirurgia de fratura de múltiplas costelas: relato de caso

Use of fascial plane blocks for traumatic rib fractures: a scoping review

BACKGROUND

The primary cause of morbidity and mortality in traumatic rib fractures is respiratory complications due to compromised respiratory mechanics secondary to pain and opioid-related respiratory depression. Thoracic epidural analgesia (TEA) provides effective analgesia but may not be possible in patients due to spinal cord injuries, thoracic vertebral fractures, and coagulopathy. New thoracic fascial plane blocks provide new options for patients with multiple rib fractures (MRFs).

OBJECTIVE

Our primary objective was to assess the effectiveness of thoracic fascial plane blocks for patients with MRFs by looking at pain control, opioid consumption, and respiratory function postblock compared with preblock.

EVIDENCE REVIEW

Literature was searched using keywords and controlled terms, based on the two concepts "rib fractures" and "fascial plane blocks". Terms were searched in PubMed, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, Google Scholar and ClinicalTrials.gov from inception to October 11, 2023, using medical subject headings (MeSH) and free-text terms without date or language restrictions. The terms included rib fractures, thoracic trauma, chest injuries, fascial plane blocks, PEC 1, PEC 2, PEC 3, pectoralis plane, serratus anterior plane (SAPB) and erector spinae plane block.

FINDINGS

The available evidence shows that erector spinae plane block and SAPB are effective blocks to provide analgesia and reduce opioid requirements in patients with unilateral or bilateral rib fractures.

CONCLUSIONS

More randomized control studies are needed to compare these blocks with paravertebral block or TEA to see if they provide analgesia, improve respiratory function, and reduce opioid requirements.

Systemic Analgesia versus Continuous Erector Spinae Plane Block (ESPB) Infusion During Paediatric Nephrectomy: A Randomized, Controlled Trial

Purpose

A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy.

Methods

Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T₉ (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours.

Results

A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points.

Conclusion

Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.

Bilevel opposite direction ESP block with indwelling catheter in the management of severe lung cancer pain

One of the biggest challenges faced by pain physicians is that cancer patients present with unrelieved pain despite multimodal drug regimes. Regional anesthesia methods and indwelling catheters become significant when pain control cannot be achieved with these regimens. Ultrasound-guided erector spinae plane (ESP) block has provided analgesia for acute postoperative and chronic cancer pain. This is a case of a 58-year-old male with no significant medical history prior to being diagnosed with lung cancer two years ago who is having severe pain in the entire hemithorax after the diagnosis. ESP block with the indwelling catheter was administered at two different levels in opposite directions, one from the T5 level in the caudal-cranial direction and one from the T7 in the cranial-caudal direction, provide adequate analgesia between T2-T12 dermatomes. Bilevel opposite direction ESP block with an indwelling catheter may result in better analgesia in oncologic patients where pain control cannot be achieved with opioids.

Effects of continuous erector spinae plane block on postoperative pain in video-assisted thoracoscopic surgery: a randomized controlled study

BACKGROUND

The aim of this prospective, randomized, controlled study was to evaluate the analgesic effect of ultrasonography (USG) guided continuous erector spinae plane block (ESPB) for postoperative analgesia in video-assisted thoracoscopic surgery (VATS).

METHODS

Eighty American Society of Anesthesiologists (ASA) physical status I-III patients aged 18-75 and who were to undergo VATS were included in this study. Randomization was performed in 2 groups, continuous ESPB (ESPB Group) and no intervention (Control Group). 20 mL of 0.25% bupivacaine was administered for the block. Immediately after surgery, the patient received continuous infusion of 0.125% bupivacaine at 4 mL h^-1 via the catheter inserted for the block. Patients in both groups received tramadol via an intravenous patient-controlled analgesia device. Tramadol and meperidine consumption, visual analog scale pain scores and opioid-related side effects were recorded at 0, 1, 4, 8, 12, 24, 36, and 48 h postoperatively.

RESULTS

The use of continuous ESPB in VATS significantly decreased the amount of tramadol used in the first 48 h postoperatively (P < 0.001). There was a statistically significant difference in the number of meperidine rescue analgesia administered between the ESPB and Control Groups (P < 0.001). While the incidences of nausea and itching were higher in Control Group, there were no differences in terms of the other side effects between the groups.

CONCLUSIONS

This study shows that USG-guided continuous ESPB provides adequate analgesia following VATS as part of multimodal analgesia. Continuous ESPB significantly reduced opioid consumption and opioid-related side effects compared to those in the Control Group.

Assessing outcome measures used after rib fracture: A COSMIN systematic review

PURPOSE

The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

METHODS

Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies.

CONCLUSION

The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.