Relationship between injectate volume and disposition in erector spinae plane block: a cadaveric study

Acute Pain Management with Ultrasound-Guided Erector Spinae Plane Block and Serratus Anterior Plane Block in Patients Undergoing Coronary Artery Bypass via Mini-thoracotomy: A Randomized Controlled Trial

OBJECTIVE

This study was designed to examine the analgesic efficacy of erector spinae plane (ESP) block or combined ESP and superficial serratus anterior plane (SAP) block in patients undergoing elective coronary artery bypass via mini-thoracotomy.

DESIGN

Randomized controlled study.

SETTING

Operating room, intensive care unit, and ward.

PATIENTS

Fifty-four patients undergoing elective coronary artery bypass via mini-thoracotomy.

INTERVENTIONS

Eligible patients were randomly allocated to single-ESP block (ESP group) or combined ESP and superficial SAP block (ESP+SAP group).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was dynamic numerical rating scale (NRS) scores (on coughing) for the surgical incision site 6 hours after skin closure. Secondary outcomes included dynamic NRS scores for surgical incision at 12, 18, 24, and 48 hours postoperatively plus NRS scores for the chest tube, hydromorphone consumption, quality of recovery, and adverse events within 48 hours postoperatively. The ESP+SAP group had lower dynamic NRS scores for surgical incision at postoperative 6 hours (mean difference: -2.1, 95% CI -2.8 to -1.4, adjusted p < 0.001) and 12 hours (-1.3, 95% CI -2.0 to -0.7, adjusted p < 0.001) compared to the ESP group. The ESP+SAP group also showed lower dynamic NRS scores for the chest tube at 6 hours (-1.4, 95% CI -2.0 to -0.9, adjusted p < 0.001) and 12 hours (-1.2, 95% CI -1.7 to -0.6, adjusted p < 0.001) postoperatively. Linear mixed-model analysis showed that NRS scores for the surgical incision and chest tube were lower in the ESP+SAP group compared to the ESP group (both p < 0.05).

CONCLUSION

Compared with ESP block alone, ESP combined with superficial SAP block reduced pain scores in patients undergoing coronary artery bypass via mini-thoracotomy.

Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction

BACKGROUND

Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction.

METHODS

Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed.

RESULTS

122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001).

CONCLUSIONS

Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.

Spread of local anaesthetic after erector spinae plane block: a randomised, three-dimensional reconstruction, imaging study

BACKGROUND

Spread of local anaesthetic solution in the paravertebral space after erector spinae plane block (ESPB) is variable. We evaluated whether paravertebral spread of local anaesthetic is affected by patient position after ESPB.

METHODS

We randomised 84 patients to receive ESPB at T7 with a mixture of 0.375% ropivacaine and radiocontrast dye (30 ml). Participants were positioned supine, prone, or lateral for 30 min after ESPB before computed tomography scanning. The primary outcome was paravertebral space local anaesthetic spread, with secondary assessments of craniocaudal spread and distribution to neural foramina, and intercostal and epidural spaces. Loss of sensation to cold was recorded.

RESULTS

Local anaesthetic-contrast mix reached the paravertebral space, intercostal space, and neural foramina in 96.5%, 94.2%, and 77.9% of individuals, respectively. Epidural space spread occurred in 20 cases. Prone positioning consistently allowed paravertebral and intercostal spread in all patients, with more thoracic level spread compared with supine positioning (5.0 [1.9] vs 3.1 [1.7], difference [95% confidence interval, CI]: 1.9 [0.8-3.0] levels, P<0.001 for paravertebral space spread; 2.8 [1.9] vs 1.4 [1.4], difference [95% CI] levels: 1.4 [0.4-2.5], P=0.004 for neural foramina spread; 4.3 [1.3] vs 3.2 [1.5], difference [95% CI] levels: 1.0 [0.1-1.9], P=0.019 for intercostal space spread). Local anaesthetic-contrast extended to the intercostal space further in the prone than in the lateral position group (4.3 [1.3] vs 2.6 [1.5] thoracic levels, difference [95% CI]: 1.7 [0.8-2.6], P<0.001). Sensory block in ventral dermatomes was variable in all participants.

CONCLUSIONS

Prone positioning after ESPB significantly enhanced local anaesthetic-contrast spread to the paravertebral space, intercostal space, and neural foramina, suggesting that gravity plays a substantial role in spread.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov (NCT06142630).

The Erector Spinae Plane Block with 20 or 30 mL of 0.25% Bupivicaine Provides Equivalent Postoperative Analgesia after Mastectomy: A Prospective Randomized Trial

Objective

Analgesia management following breast surgery is a critical concern. The erector spinae plane block (ESPB) is a regional anaesthesia technique that is frequently used for analgesia after breast surgery. However, there is no consensus on the volume. Therefore, the aim of this study was to compare ESPB performed using 20 mL vs. 30 mL.

Methods

The study included 43 female patients with American Society of Anesthesiologist class I-II physical status. Participants were randomized into two groups: 20 mL ESPB and 30 mL ESPB. Ibuprofen (400 mg) 3x1 was ordered, and a fentanyl patient-controlled analgesia device was attached intravenously to the participants. If the pain score was ≥4, meperidine (0.5 mg kg-1) was administered.

Results

Postoperative fentanyl use was similar between the groups. There was no difference in the amount of rescue analgesic use between the groups. The static and dynamic numerical rating scores were similar between the groups. No statistical difference was noted in terms of nausea, vomiting, or itching between the groups.

Conclusion

A similar analgesic effect is achieved by performing ESPB using 20 or 30 mL of local anaesthetic at the same concentration.

Programmed intermittent bolus versus continuous infusion for catheter-based erector spinae plane block on quality of recovery in thoracoscopic surgery: a single-centre randomised controlled trial

BACKGROUND

Regional anaesthesia techniques, including the erector spinae fascial plane (ESP) block, reduce postoperative pain after video-assisted thoracoscopic surgery (VATS). Fascial plane blocks rely on spread of local anaesthetic between muscle layers, and thus, intermittent boluses might increase their clinical effectiveness. We tested the hypothesis that postoperative ESP analgesia with a programmed intermittent bolus (PIB) regimen is better than a continuous infusion (CI) regimen in terms of quality of recovery after VATS.

METHODS

We undertook a prospective, double-blinded, randomised, controlled trial involving 60 patients undergoing VATS. All participants received ESP block catheters and were randomly assigned to CI or PIB of local anaesthetic regimen for postoperative analgesia. The primary outcome was Quality of Recovery-15 (QoR-15) score 24 h after surgery. Secondary outcomes included postoperative respiratory function, opioid consumption, verbal rating pain score, time to first mobilisation, nausea, vomiting, and length of hospital stay.

RESULTS

Overall QoR-15 scores at 24 h after VATS were similar (PIB 115.5 [interquartile range 107-125] vs CI 110 [93-128]; Δ<6, P=0.29). The only quality of recovery descriptor showing a significant difference was nausea and vomiting, which was favourable in the PIB group (10 [10-10] vs 10 [7-10]; P=0.03). Requirement for rescue antiemetics up to 24 h after surgery was lower in the PIB group (4 [14%] vs 11 [41%]; P=0.04). There were no differences in other secondary outcomes between groups.

CONCLUSIONS

Delivering ESP block analgesia after VATS via a PIB regimen resulted in similar QoR-15 at 24 h compared with a CI regimen.

Differential nerve blockade to explain anterior thoracic analgesia without sensory blockade after an erector spinae plane block may be wishful thinking

Ultrasound-guided erector spinae plane block (ESPB) is currently used as a component of multimodal analgesic regimen in a multitude of indications but the mechanism by which it produces anterior thoracic analgesia remains a subject of controversy. This is primarily the result of ESPB's failure to consistently produce cutaneous sensory blockade (to pinprick and cold sensation) over the anterior hemithorax. Nevertheless, ESPB appears to provide 'clinically meaningful analgesia' in various clinical settings. Lately, it has been proposed that the discrepancy between clinical analgesia and cutaneous sensory blockade could be the result of differential nerve blockade at the level of the dorsal root ganglion. In particular, it is claimed that at a low concentration of local anesthetic, the C nerve fibers would be preferentially blocked than the Aδ nerve fibers. However, the proposal that isolated C fiber mediated analgesia with preserved Aδ fiber mediated cold and pinprick sensation after an ESPB is unlikely, has never been demonstrated and, thus, without sufficient evidence, cannot be attributed to the presumed analgesic effects of an ESPB.