Ultrasound guided erector spinae plane block for post-operative pain control after caesarean section

Can Erector Spinae Plane Block Replace Intrathecal Morphine in Cesarean Section? A Prospective Randomized Controlled Study on Opioid Consumption

OBJECTIVES

After cesarean, optimal analgesia is important for early mobilization, mitigating thromboembolic risks, and mother-infant communication. Our study compared the postoperative analgesic effects of intrathecal morphine (ITM) and erector spinae plane block (ESPB) in elective cesarean section under spinal anesthesia.

METHODS

Eighty-two patients were randomized into ESPB and ITM groups. Both groups received spinal anesthesia with 10 mg of heavy bupivacaine. In the ITM group, ITM (100 mcg) was added. The ESPB group received bilateral T10 level ESPB with 20 mL 0.25% bupivacaine postoperatively. Postoperative pain control included intravenous paracetamol 4x1 g, intravenous patient-controlled analgesia with tramadol, and diclofenac 75 mg for rescue analgesia when Numeric Rating Scale (NRS) >4. NRS, tramadol consumption, and side effects were recorded 24 hours postoperatively. The primary outcome of this study is to compare 24-hour postoperative opioid consumption after cesarean sections. Secondary outcomes include postoperative pain scores, rescue analgesia needs, and side effects.

RESULTS

NRS scores ≤4 at all time intervals and were comparable among groups. The total 24-hour tramadol consumption was significantly higher in the ESPB group (median: 75; Q1, Q3 [40, 140]) compared with ITM (50 [27.5, 60], P = 0.008). Tramadol consumption was similar among groups during 0 to 6 and 6 to 12 hours. In the 12 to 24 hours, tramadol consumption was significantly higher in the ESPB group (22.5 [15, 57.5]) compared with ITM (15 [12.5, 25], P = 0.005). In the ITM group, nausea and vomiting were observed in 3 patients and itching in 1 patient; no adverse effects were observed in the patients in the ESPB group.

CONCLUSION

For patients undergoing cesarean section under spinal anesthesia, ITM reduced opioid consumption more effectively than ESPB. ESPB is not recommended as a primary analgesic option for cesarean sections.

Erector spinae plane block in Caesarean sections: A scoping review

Background

Pain management for Caesarean section focuses on multimodal analgesia with a growing interest in the use of regional techniques. Currently, there is no gold standard peripheral regional analgesia technique for Caesarean section. The Erector Spinae Plane Block is a relatively new fascial plane block that may be used to provide analgesia for numerous surgical procedures of the trunk. In recent years it is the fascial plane block that has accumulated the most enthusiasm and debate. Its use in Caesarean section has grown over the past three years.

Objective

To determine the scope of literature published on ESPB in Caesarean sections and to identify deficits in the literature to guide future research.

Methodology

This study was conducted using Arksey and O'Malley's framework for scoping reviews. This included a search of four databases searching for articles published between 2016 and 2022. Studies involving patients receiving ESPB as part of an analgesic strategy after a Caesarean section were included.

Findings

Sixteen articles were included for final review. The most common primary outcomes measured were postoperative pain scores and analgesia consumption. Six ESPB studies recorded a statistically significant reduction in pain scores while three studies described a statistically significant reduction in postoperative analgesia consumption.

Conclusion

The use of ESPB for Caesarean section is gaining momentum however insufficient evidence currently exists to support its widespread use. Further research is required to evaluate the potential benefits of ESPB in specific patient cohorts and in terms of its efficacy about multidimensional patient-centric outcomes.

The effectiveness of erector spina plane, quadratus lumborum blocks, and intrathecal morphine for analgesia after cesarean: a randomized study

OBJECTIVE

This prospective randomized study was conducted at Ataturk University Medical Faculty Hospital, Department of Anesthesia and Reanimation, from June 2022 to May 2023. The aim of this study was to compare the effectiveness of ultrasound-guided erector spinae plane block, quadratus lumborum block, and intrathecal morphine to decrease postoperative pain after cesarean section.

METHODS

Sixty-term pregnant women who were scheduled for elective cesarean sections with spinal anesthesia were included. Patients were randomly divided into three groups (n=20 for each group): Group 1: Patients were administered intrathecal morphine during spinal anesthesia; Group 2: Patients performed bilateral erector spinae plane block postoperatively; and Group 3: Patients performed bilateral quadratus lumborum block postoperatively. In the postpartum care unit, patients received intravenous Patient-Controlled Analgesia. The Patient-Controlled Analgesia devices were set to administer an intravenous bolus of 25 μg fentanyl, with a lockout interval of 10 min. Opioid consumption and maximum pain score in the 24 postoperative hours were recorded.

RESULTS

Patients in Group 1 had a longer time to first analgesic requirement compared to Group 2 (p=0.017). Opioid consumption and resting and moving visual analog score scores in the first 24 h postoperatively were similar between groups.

CONCLUSION

All three methods, including intrathecal morphine, erector spinae plane block, and quadratus lumborum block, are efficacious and comparable in providing postoperative analgesia after cesarean under spinal anesthesia.

A randomised controlled trial of the non-inferiority of erector spinae plane block vs. thoracic paravertebral block for laparoscopic nephro-ureterectomy

Erector spinae plane block and paravertebral block can provide analgesia for abdominal surgery. It is unclear whether erector spinae block is inferior to paravertebral block. We aimed to determine whether sufentanil dose and pain intensity (11-point scale) to 24 h after erector spinae block exceeded those after paravertebral block by no more than 5 μg and 1 point, respectively. We randomly allocated 166 adults to 0.4 ml.kg^-1 ropivacaine 0.375% before scheduled laparoscopic nephroureterectomy, 83 each to erector spinae or paravertebral injection. We measured incision pain and intra-abdominal pain at rest and on movement 0.5 h, 2 h, 6 h, 18 h, 24 h and 48 h after surgery. Median (IQR [range]) cumulative sufentanil dose after erector spinae block was 15 (5-30 [0-105]) μg vs. 20 (10-50 [0-145]) μg after paravertebral block, median (95%CI) difference 5 μg (0-10), erector spinae non-inferiority p < 0.001. Median (IQR [range]) pain were 1.5 (1.0-2.0 [0.0-5.3]) after erector spinae block vs. 2.0 (1.0-2.5 [0.0-6.0]) after paravertebral block, median (95% CI) difference 0.3 (0.0-0.5), erector spinae non-inferiority p < 0.001. Adverse events did not differ between groups. Erector spinae block analgesia was not inferior to paravertebral block analgesia after laparoscopic nephroureterectomy.

Erector spinae plane block for analgesia after cesarean delivery: a systematic review with meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a regional block that may be used for several surgeries. However, the evidence regarding obstetrical procedures is not pooled in the literature.

OBJECTIVES

To assess whether ESPB improves the postoperative pain after cesarean section by a systematic review and meta-analysis.

METHODS

The protocol of this review was registered on PROSPERO (CRD42020192760). We included randomized controlled trials from databases until August 2020. The primary outcome was pain measured on a visual analogic scale; secondary outcomes were analgesic duration, postoperative opioid dose within the 24 hours, nausea/vomiting. The risk of bias and the GRADE criteria to assess quality of evidence were analyzed.

RESULTS

From 436 retrieved studies, three were selected. There was no difference in the pain scores between ESPB and controls at rest after surgery at 4 h (mean difference [MD] = 0.00; 95% CI: -0.72 to 0.72; I² = 0%; very low certainty), 12 h (MD = -1.00; 95% CI: -2.00 to -0.00; I² = 0%, low certainty) and 24 h (MD = -0.68; 95% CI: -1.56 to 0.20; I² = 50%; very low certainty). There was a smaller consumption of tramadol with ESPB compared with controls (MD = -47.66; 95% CI: -77.24 to -18.08; I² = 59%; very low certainty). The analgesic duration of ESPB was longer than the controls (MD = 6.97; 95% CI: 6.30 to 7.65; I² = 58%; very low certainty).

CONCLUSION

ESPB did not decrease the postoperative pain scores when compared to other comparators. However, ESPB showed a lower consumption of tramadol and a longer blockade duration, although the quality of evidence of these outcomes were very low.

Evaluation of ultrasound-guided bilateral low thoracic erector spinae plane block for postoperative analgesia in cesarean delivery patients: a prospective, randomized, controlled clinical trial

BACKGROUND

Erector spinae plane block (ESPB) is a recently described block. In many reports, ESPB has been reported to provide effective postoperative analgesia in patients undergoing cesarean delivery (CD). Herein, we compared the effectiveness of ESPB and control group in postoperative analgesia in patients undergoing CD under spinal anesthesia.

METHODS

This assessor blinded, prospective, randomized, efficiency study was conducted in the postoperative recovery room and ward at a tertiary university hospital. Eighty-six patients (ASA II-III) were recruited. Following exclusion, 80 patients were randomized into two equal groups (block and control group). Standard multimodal analgesia was performed in the control group while ESPB block was performed in the intervention (ESPB) group. Opioid consumption was measured and pain intensity between groups was compared using Numeric Rating Scores (NRS).

RESULTS

NRS was lower in Group ESPB at 3rd and 6th hours. There was no difference between NRS scores at other hours. Opioid consumption was lower in Group ESPB.

CONCLUSION

When added to multimodal analgesia, bilateral ultrasound guided low thoracic ESPB leads to improve the quality of analgesia in the first 24 hours in patients undergoing CD.

Subarachnoid block and ultrasound-guided transversalis fascia plane block for caesarean section: A randomised, double-blind, placebo-controlled trial

BACKGROUND

After caesarean section, maternal postoperative comfort is critical to allow the new mother to care for her baby. Insufficient pain relief during the postoperative period may delay maternal/infant bonding and, in addition, such pain has been linked to subsequent depression and chronic pain. Caesarean section is commonly performed with a Pfannenstiel incision, and a transversalis fascia plane (TFP) block provides postoperative analgesia in the T12 and L1 dermatomes.

OBJECTIVE

The aim of this study was to investigate the effect of the TFP block on postoperative opioid consumption and pain scores in patients undergoing caesarean section under spinal anaesthesia.

DESIGN

A randomised controlled, double-blind study.

SETTINGS

Single-centre, academic hospital.

PARTICIPANTS

Sixty patients undergoing caesarean section.

INTERVENTIONS

The TFP group (n = 30) received an ultrasound-guided bilateral TFP block with 20 ml of 0.25% bupivacaine. The control group (n = 30) received 20 ml of saline bilaterally. Postoperative analgesia was given every 6 h with intravenous paracetamol 1 g and patient-controlled analgesia (PCA) with morphine.

MAIN OUTCOME MEASURES

Postoperative visual analogue pain scores, morphine consumption, rescue analgesia and opioid-related side effects were evaluated.

RESULTS

In the TFP group, the visual analogue pain scores were significantly lower at rest for 2 h after the operation (P = 0.011) and during active movement at 2, 4 and 8 h postoperatively (P = 0.014, <0.001 and 0.032, respectively). Morphine consumption in the first 24 h after surgery was significantly higher in the control group compared with the TFP group (38.5 ± 11.63 and 19.5 ± 8.33 mg, respectively; P < 0.001). The incidence of postoperative nausea and constipation were statistically higher in the control group than in the TFP group (P < 0.05). Patient satisfaction was significantly higher in the TFP group (P = 0.027).

CONCLUSION

A postoperative TFP block can reduce opioid consumption and relieve acute pain after a caesarean section under spinal anaesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04172727.

Comparison of Analgesic Effect Between Erector Spinae Plane Block and Transversus Abdominis Plane Block After Elective Cesarean Section: A Prospective Randomized Single-Blind Controlled Study

BACKGROUND

This study compared the analgesic efficacy of a bilateral erector spinae plane (ESP) block with that of a bilateral transversus abdominis plane (TAP) block after elective cesarean delivery.

METHODS

Sixty mothers scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either ESP block or TAP block. The ESP group received ESP block at the level of the ninth thoracic transverse process with 20 mL of 0.25% bupivacaine at the end of surgery. The TAP group received an ultrasound-guided TAP block with 20 mL of 0.25% bupivacaine on completion of delivery. The primary outcome was the duration of analgesia achieved by each block. Secondary outcome measures were the postoperative pain severity, total tramadol consumption, patient satisfaction.

RESULTS

The median (interquartile range) duration of block was longer in the ESP group than in the TAP group (12 hours [10, 14] vs 8 hours [8, 8], p<0.0001). In the first 24 hours, the mean visual analog pain score at rest was lower by 0.32 units in the ESP group. The median tramadol consumption in the first 24 hours was significantly higher in the TAP group than in the ESP group (125 mg [100, 150] vs 100 mg [75, 100, p=0.003]).

CONCLUSION

Compared with the TAP block, the ESP block provides more effective pain relief, has a longer duration of analgesic action, prolongs time to first analgesic requirement, is associated with less tramadol consumption, and can be used in multimodal analgesia and opioid-sparing regimens after cesarean section.

Analgesic Efficacy of Erector Spinae Plane Block Compared with Intrathecal Morphine After Elective Cesarean Section: A Prospective Randomized Controlled Study

BACKGROUND

We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia.

METHODS

In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups.

RESULTS

No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly.

CONCLUSION

ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.