Bilateral ESP block: How to defuse some pitfalls

Parascapular Sub-Iliocostalis Plane Block: Comparative Description of a Novel Technique for Posterior Rib Fractures

We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateral-posterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. No complications were reported. The efficacy of the PSIP block may potentially depend on different mechanisms of action: (1) direct action in the fracture site by craniocaudal myofascial spread underneath the erector spinae muscle (ESM); (2) spread to deep layers through tissue disruption caused by trauma, to reach the proximal intercostal nerves; (3) further medial spread through deeper layers to the midline to block the posterior and ventral spinal nerves; (4) medial spread below the ESM, to reach the posterior spinal nerves (more reliably than rhomboid intercostal / sub-serratus [RISS] block); and (5) lateral spread in the sub-serratus (SS) plane to reach the lateral cutaneous branches of the intercostal nerves; while avoiding significant negative hemodynamic effects associated with techniques such as the paravertebral block (PVB), erector spinae plane (ESP) block or its variations, or thoracic epidural analgesia (TEA). A comparative comprehensive overview of the regional techniques described for posterior chest trauma is presented, including TEA, PVB, ESP block, retrolaminar block, mid-point to transverse process block, costotransverse foramen block, RISS, and serratus anterior plane (SAP) block.

Efficacy of erector spinae plane block for postoperative analgesia in total mastectomy and axillary clearance: A randomized controlled trial

Background:

The erector spinae plane block is a newer technique of analgesia to the chest wall.

Objective:

The study was carried out to establish the efficacy and safety of this block in patients undergoing total mastectomy and axillary clearance.

Design:

Prospective randomized controlled study.

Setting:

Single tertiary care center, the study was conducted over a period of 1 year.

Patients:

65 patients were included; final analysis was done for 60 female patients undergoing total mastectomy and axillary clearance under general anesthesia were randomly allocated to two groups.

Intervention:

Group B (block group) received ultrasound-guided erector spinae plane block at T5 level with ropivacaine (0.5%, 0.4 mL/kg) while the control group did not receive any intervention. Postoperatively, patients in both groups received morphine via intravenous patient-controlled analgesia device. Patients were followed up for 24 h postoperatively.

Main Outcome Measures:

The 24-hour morphine consumption was considered as the primary outcome and secondary outcomes included time to first rescue analgesia, pain scores at 0, ½, 1, 2, 4, 6, 8, 12, and 24 h and characteristics and complications associated with block procedure.

Results:

The 24-hour morphine consumption was 42% lower in block group compared to control group [mean (SD), 2.9 (2.5) mg vs 5.0 (2.1) mg in group B and group C, respectively, P = 0.01]. The postoperative pain score was lower in group B vs group C at 0, 1/2, 1, 2, 4, 6, 12, and 24 h (P < 0.05). 26 patients in group C against 14 in group B used rescue analgesia within 1 h of surgery (P = 0.01).

Conclusion:

Erector spinae block may prove to be a safe and reliable technique of analgesia for breast surgery. Further studies comparing this technique with other regional techniques are required to identify the most appropriate technique.