Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children

Erector spinae plane blocks: A narrative update

The erector spinae plane block (ESPB) is perhaps one of the most interesting of the tissue plane blocks described recently. There has been an exponential increase in the number of publications for both adults and children over the past 5 years. Single-shot, intermittent bolus, and continuous infusion techniques have been used effectively. Both the efficacy and safety of the procedure are widely accepted, but the exact mechanism by which the local anesthetic spreads from the tip of the transverse process to block the dorsal and ventral rami of the spinal nerves is controversial and needs clarification. Anatomical differences in children, particularly in neonates and infants, may explain the spread in this age group. In most pediatric studies, erector spinae plane block was opioid sparing, and noninferiority was observed when compared with other regional techniques.

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.

Pain management for the Nuss procedure: comparison between erector spinae plane block, thoracic epidural, and control

Objective

Pectus excavatum is a congenital deformity characterized by a caved-in chest wall. Repair requires surgery. The less invasive Nuss procedure is very successful, but postoperative pain management is challenging and evolving. New pain management techniques to reduce opioid reliance include the erector spinae plane (ESP) block. We retrospectively examined opioid consumption after Nuss procedure comparing three pain management techniques: ESP block, thoracic epidural (TE), and patient-controlled analgesia (PCA).

Methods

This retrospective cohort study compared pain management outcomes of three patient groups. Seventy-eight subjects aged 10–18 years underwent Nuss procedure at our institution between January 2014 and January 2020. The primary outcome measure was opioid consumption measured in morphine milligram equivalents. Secondary measures included pain ratings and length of stay (LOS). Pain was quantified using the Numeric Pain Rating Scale. Analysis of variance was performed on all outcome measures.

Results

Average cumulative opioid use was significantly lower in the ESP block (67 mg) than the TE (117 mg) (p=0.0002) or the PCA group (172 mg) (p=0.0002). The ESP block and PCA groups both had a significantly shorter average LOS (3.3 and 3.7 days, respectively) than the TE group (4.7 days). ESP block performed best for reducing opioid consumption and LOS. Reduced opioid consumption is key for limiting side effects. This study supports use of ESP block as a superior choice when choosing among the three postoperative pain management options that were evaluated.

Conclusion

ESP resulted in reduced opioid consumption postoperatively and shorter LOS than TE or PCA for patients undergoing the Nuss procedure for surgical repair of pectus excavatum.

Erector Spinae Plane Block in pediatric cancer pain: Case report

The advent of the erector spinae plane block brought about new therapeutic options as part of a multimodal analgesia strategy, as evidenced in this case, which describes a five-year old pre-school patient who presented with severe abdominal cancer pain, secondary to an abdominal neuroblastoma, with partial high-dose opioid response, undergoing bilateral erector spinal plane block. The technique used did not give rise to complications and proved to be effective in blocking pain and reducing the dose of opioids 36 hours after the procedure. The paper discusses the variables involved in the mode of administration (continuous infusion vs. bolus) and the benefit for optimal analgesia in the pediatric oncology setting.

A prospective study of the quality and duration of analgesia with 0.25% bupivacaine in ultrasound-guided erector spinae plane block for paediatric thoracotomy

BACKGROUND AND AIMS

Pain of open thoracotomy is treated with systemic analgesics, thoracic epidural and paravertebral blocks which have associated adverse effects and complications. Research shows ultrasound guided erector spinae plane block (US-ESPB) as a simpler and safer alternative. As paucity of data of US-ESPB in paediatric thoracotomies exists. We aimed at studying the analgesic efficacy of US-ESPB for paediatric thoracotomy.

METHODS

In a prospective observational study, 30 children, 1-12 years age undergoing thoracotomy with decortication under general anaesthesia with US-ESPB were observed. At induction, patient received intravenous (IV) fentanyl 3 μg/kg for analgesia and standard general endotracheal anaesthesia was administered. US-ESPB was given at fourth thoracic vertebral level with 0.25% bupivacaine 0.3 ml/kg. Changes in haemodynamic parameters at skin incision, rib retraction, pleural incision, intercostal drain insertion, and skin closure were noted. Intraoperatively, additional fentanyl was administered, if required and its dose and time were noted. Postoperative pain was assessed by visual analogue scale (VAS) (0-10) for ≥6 years and by face, leg, activity, cry, consolability (FLACC) score (0-10) for <6 years at post extubation, 30 minutes and hourly postoperatively. Descriptive statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.

RESULTS

Additional analgesic was not required in 14/30 patients (46.67%) intraoperatively and within 6 hours (7.4 ± 1.26) post-operatively. Five of the remaining 16 patients, required IV 1 μg/kg fentanyl only once intraoperatively. Median pain score was 2 in first four postoperative hours.

CONCLUSION

US-ESPB provided effective supplemental intraoperative and postoperative analgesia in nearly half of the paediatric thoracotomy patients.

Anesthetic Techniques: Focus on Lumbar Erector Spinae Plane Block

Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in “Pubmed” and “Google Scholar” database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.

Early experience with erector spinae plane blocks in children

BACKGROUND

An erector spinae plane block is a relatively new regional anesthetic technique. Apart from case reports and small series, the literature regarding pediatric use is limited.

AIM

Our objective was to determine the efficacy of the erector spinae plane block in children by measuring the heart rate response to incision. Secondary objectives included feasibility, safety, opioid consumption, and pain scores. Furthermore, we reviewed this block in children published since 2016.

STUDY DESIGN

Case Series; Level of evidence, IV.

METHODS

With Institutional Review Board approval, a retrospective chart review was conducted on all patients who received erector spinae plane block for surgery between October 2017 and May 2019 at a single institution. Blocks were performed under anesthesia, using ultrasound guidance prior to surgical incision. Block details and hemodynamic and analgesic data were collected. In addition, a PubMed literature review was conducted to identify all erector spinae plane block related publications in patients ≤18 years of age.

RESULTS

About 164 patients, 2 days-19.4 years, weighing 2.3-94.7 kg, received erector spinae plane blocks. For more than 79% of single injection blocks, placement time was ≤10 minutes. Using a heart rate increase of <10% at skin incision as criterion, 70.1% of patients had a successful block. Only 20% required long-acting opioids intraoperatively. In a subset of infants who underwent gastrostomy surgery using a dose of 0.5 mL/kg, a local anesthetic spread of at least five dermatomes (0.1 mL/kg/dermatome) was achieved. Per the literature review, 33 publications described erector spinae plane block in 128 children. No complications were reported.

CONCLUSION

Erector spinae plane blocks are relatively easy to perform in children with no complications reported to date. The efficacy of the block for a broad spectrum of surgeries, involving incisions from T1 to L4, is encouraging.

Efficacy of bilateral erector spinae plane block in the management of pain: current insights

Erector spinae plane block (ESPB) is a newly described interfascial plane block, and the number of articles on the bilateral application of ESPB is increasing in the literature. In this paper, in addition to analyzing bilateral ESPB cases and studies published so far, we aimed to review the relevant anatomy, describe the mechanism of spread of the injectant, demonstrate varying approaches to ESPB, and summarize case reports and clinical trials, as well as provide current insight on this emerging and popular block. Randomized controlled studies, comparative studies of ESPB versus other methods, and pharmacokinetic studies of bilateral applications must be the next step in clearly understanding bilateral ESPB.