The Effect of Single-Shot Erector Spinae Plane Block (ESPB) on Opioid Consumption for Various Surgeries: A Meta-Analysis of Randomized Controlled Trials

Opioid-sparing effects of ultrasound-guided erector spinae plane block for video-assisted thoracoscopic surgery: a randomized controlled study

BACKGROUND

The erector spinae plane block (ESPB) is a new analgesic method used in thoracic surgery. However, few studies have characterized their effects on perioperative opioid consumption. We aimed to evaluate the effects of ESPB on perioperative opioid consumption in patients who underwent video-assisted thoracoscopic surgery (VATS).

METHODS

This was a randomized, observer-blinded clinical trial at a single-centre academic hospital. Eighty patients were scheduled for thoracoscopic segmentectomy or lobectomy by VATS for lung cancer. Forty participants were randomly assigned to ESPB or control group. All patients received intravenous patient-controlled postoperative analgesia. Perioperative opioid consumption, visual analogue scale (VAS) scores, and adverse events were recorded.

RESULTS

Intraoperative and postoperative opioid consumption and static/dynamic VAS scores were significantly lower in the early hours after VATS in the ESPB group (p < 0.05) than the control group. No significant differences were observed in adverse effects between the two groups.

CONCLUSIONS

ESPB reduced intraoperative opioid consumption and early postoperative pain in patients undergoing VATS. Our findings support the view that ESPB is a safe and highly effective option for regional analgesia for VATS.

TRIAL REGISTRATION

http://www.chictr.org.cn , ChiCTR1800019335.

Ultrasound-guided erector spinae plane block versus thoracic epidural block for postoperative analgesia in pediatric Nuss surgery: a randomized noninferiority trial

PURPOSE

Thoracic epidural anesthesia (TEA) is often used for analgesia after thoracic surgery. Erector spinae plane block (ESPB) has been proposed to provide adequate analgesia. We hypothesized that ESPB would be noninferior to TEA as a part of multimodal analgesia in pediatric patients undergoing the Nuss procedure.

METHODS

Patients aged 7-18 years and scheduled for the Nuss procedure were randomly allocated to receive bilateral single-shot ESPB or TEA and a multimodal analgesic regimen including parent-controlled intravenous analgesia (PCIA). At 6 h, 12 h, 18 h, and 24 h postoperatively, pain was evaluated using the numeric rating scale (NRS) and opioid consumption was assessed by counting the number of PCIA boluses. The joint primary outcomes were the average pain score and opioid consumption at 24 h after surgery. The secondary outcomes were the NRS scores and the number of opioid boluses administered at different postoperative time points, adverse events, and recovery quality.

RESULTS

Three hundred patients underwent randomization, and 286 received ESPB (147 patients) or TEA (139 patients). At 24 h postoperatively, ESPB was noninferior to TEA in terms of the average NRS score (mean difference, - 0.1, 95% confidence interval [CI], - 0.3-0.1, margin = 1, P for noninferiority < 0.001) and the number of opioid boluses administered (mean difference, - 1.1, 95% CI, - 2.8-0.6, margin = 7, P for noninferiority < 0.001). Adverse events and patient recovery were comparable between groups.

CONCLUSIONS

The results demonstrate that combined with a multimodal analgesia, ESPB provides noninferior analgesia compared to TEA with respect to pain score and opioid consumption among pediatric patients undergoing the Nuss procedure.

Evaluation of the Erector spinae plane block for postoperative analgesia in laparoscopic ventral hernia repair: a randomized placebo controlled trial

BACKGROUND

The Erector spinae plane block (ESPB) reduces postoperative pain after several types of abdominal laparoscopic surgeries. There is sparse data on the effect of ESPB in laparoscopic ventral hernia repair. The purpose of this study was to test the postoperative analgesic efficacy of an ESPB for this procedure.

METHODS

In this prospective, double-blind, randomized controlled study, adult patients undergoing laparoscopic ventral hernia repair were randomly assigned to either bilateral preoperative ESPB with catheters at the level of Th7 (2 × 30 ml of either 2.5 mg/ml ropivacaine or saline), with postoperative catheter top ups every 6 h for 24 h. The primary outcome was rescue opioid consumption during the first hour postoperatively. Secondary outcomes were total opioid consumption at 4 h and 24 h, pain scores, nausea, sedation, as well as Quality of Recovery 15 (QoR-15) and the EuroQol-5 Dimensions (EQ-5D-5L) during the first week.

RESULTS

In total, 64 patients were included in the primary outcome measure. There was no significant difference in rescue opioid consumption (oral morphine equivalents (OME)) at one hour postoperatively, with the ESPB group 26.9 ± 17.1 mg versus 32.4 ± 24.3 mg (mean ± SD) in the placebo group (p= 0.27). There were no significant differences concerning the secondary outcomes during the seven-day observation period. Seven patients received a rescue block postoperatively, providing analgesia in five patients.

CONCLUSION

We found no difference in measured outcomes between ESPB and placebo in laparoscopic ventral hernia repair. Future studies may evaluate whether a block performed using higher concentration and/or at a different thoracic level provides more analgesic efficacy.

TRIAL REGISTRATION

NCT04438369 ; 18/06/2020. .

Effect of liposomal bupivacaine for preoperative erector spinae plane block on postoperative pain following video-assisted thoracoscopic lung surgery: a protocol for a multicenter, randomized, double-blind, clinical trial

Background

There is still a controversy about the superiority of liposomal bupivacaine (LB) over traditional local anesthetics in postoperative analgesia after thoracic surgery. This study aims to determine the effect of LB versus bupivacaine hydrochloride (HCl) for preoperative ultrasound-guided erector spinae plane block (ESPB) on postoperative acute and chronic pain in patients undergoing video-assisted thoracoscopic lung surgery.

Methods

This multicenter, randomized, double-blind, controlled trial will include 272 adult patients scheduled for elective video-assisted thoracoscopic lung surgery. Patients will be randomly assigned, 1:1 and stratified by site, to the liposomal bupivacaine (LB) group or the bupivacaine (BUPI) HCl group. All patients will receive ultrasound-guided ESPB with either LB or bupivacaine HCl before surgery and patient-controlled intravenous analgesia (PCIA) as rescue analgesia after surgery. The numeric rating scale (NRS) score will be assessed after surgery. The primary outcome is the area under the curve of pain scores at rest for 0-72 h postoperatively. The secondary outcomes include the total amount of opioid rescue analgesics through 0-72 h postoperatively, time to the first press on the PCIA device as rescue analgesia, the area under the curve of pain scores on activity for 0-72 h postoperatively, NRS scores at rest and on activity at different time points during the 0-72 h postoperative period, Quality of Recovery 15 scores at 72 h after surgery, and NRS scores on activity on postsurgical day 14 and postsurgical 3 months. Adverse events after the surgery are followed up to the postsurgical day 7, including postoperative nausea and vomiting, fever, constipation, dizziness, headache, insomnia, itching, prolonged chest tube leakage, new-onset atrial fibrillation, severe ventricular arrhythmia, deep venous thrombosis, pulmonary embolism, pulmonary atelectasis, cardiac arrest, ileus, urinary retention, chylothorax, pneumothorax, and organ failure. Analyzes will be performed first according to the intention to treat principle and second with the per-protocol analysis.

Discussion

We hypothesize that LB for preoperative ultrasound-guided ESPB would be more effective than bupivacaine HCl in reducing postoperative pain in video-assisted thoracoscopic lung surgery. Our results will contribute to the optimization of postoperative analgesia regimens for patients undergoing video-assisted thoracoscopic lung surgery.Clinical trial registration:http://www.chictr.org.cn, identifier ChiCTR2300074852.

Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy

BACKGROUND

The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS).

METHODS

Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery.

RESULTS

A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups.

CONCLUSIONS

When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

The Shining Star of the Last Decade in Regional Anesthesia Part-II: Interfascial Plane Blocks for Cardiac, Abdominal, and Spine Surgery

The sine qua non of enhanced recovery after surgery protocols designed to improve the perioperative experiences and outcomes of patients is to determine the most appropriate analgesia management. Although many regional techniques have been tried over the years in this purpose, interfacial plane blocks have become more popular with the introduction of ultrasound technology into daily practice and they have great potential to support effective postoperative pain management in many surgeries. The current article focuses on the benefits, techniques, indications, and complications of interfascial plane blocks applied in cardiac, abdominal, and spine surgeries.

Bilateral Erector Spinae Plane Block for Man o' War Stings: A Case Report

INTRODUCTION

The Portuguese man o' war, an aquatic invertebrate, is responsible for a large proportion of cnidarian stings worldwide. Cnidaria is a phylum that contains the genus Physalia. These injuries result in severe pain and skin irritation, which are often difficult to control. Traditionally, cnidarian stings have been treated by emergency physicians with warm water, vinegar and, in severe cases, opioids. However, no concrete guidelines have been established for pain management in man o' war stings.

CASE REPORT

Regional anesthesia (RA) is an increasingly used method of pain control in the emergency department. In the case of a 41-year-old female experiencing severe pain from a Portuguese man o' war sting, RA with an erector spinae plane block (ESPB) provided her with rapid and long-lasting pain relief.

CONCLUSION

The standard of care has yet to be defined when managing pain from Physalia physalis stings. Although this is the first documented use of ESPB for treatment of cnidarian stings, RA should be considered by any emergency physician when treating injuries caused by a Portuguese man o' war.

Erector spinae plane block for peri-operative analgesia in a patient undergoing surgery for Ewing's sarcoma of the clavicle

The erector spinae plane block is a regional anaesthetic technique originally developed to manage thoracic neuropathic pain. It is popular because of its ease of learning and its applicability in various types of surgeries, providing both cutaneous and visceral analgesia. We report a case of a 30-year-old man who underwent excision of Ewing's sarcoma of the clavicle with brachiocephalic vein repair and pectoralis major myocutaneous flap reconstruction under general anaesthesia, with bilateral erector spinae plane block, with catheter insertion on the side of the lesion. The operation necessitated peri-operative anticoagulation, and so erector spinae blocks were performed to provide analgesia where epidural insertion was contraindicated. Adequate pain relief was achieved during the entire postoperative stay. The erector spinae plane block is thought to work due to the direct spread and diffusion of local anaesthetic into the posterior rami of spinal nerves located deep to the erector spinae muscles, and anterior spread into paravertebral space with additional effect potentially due to systemic absorption This case highlights the role of the erector spinae plane block in complex clavicular surgery requiring peri-operative anticoagulation, and potentially obviates the need for neuraxial analgesia.

Analgesic efficacy of the bilateral erector spinae plane block for colorectal surgery: a randomized controlled trial

BACKGROUND

Colorectal cancer is quite common, and surgery is the most effective treatment for most patients. However, postoperative pain management is generally inadequate in most patients. This study aimed to determine the effect of ultrasonography (USG)-guided preemptive erector spina plan block (ESPB), as part of multimodal analgesia, on postoperative analgesia in patients undergoing colorectal cancer surgery.  METHODS: This is a prospective, randomized, single-blind trial. This study included 60 patients (ASA I-II) who underwent colorectal surgery at the hospital of Ondokuz Mayis University. The patients were divided into the ESP group and control group. Intraoperatively, all patients were administered intravenous tenoxicam (20 mg) and paracetamol (1 g) as part of multimodal analgesia. Intravenous morphine via patient-controlled analgesia was administered in all groups postoperatively. The primary outcome was the total morphine consumption in the first 24 h after surgery. The secondary outcomes included visual analog scale pain scores at rest and coughing and deep inspiration in the first 24 h and at 3 months postoperatively; number of patients requesting rescue analgesia; incidence of nausea and vomiting and need for antiemetics; intraoperative remifentanil consumption; postoperative first oral intake; time to first urination, first defecation, and first mobilization; hospitalization time; and incidence of pruritus.

RESULTS

Morphine consumption in the first 6 h postoperatively, total amount of morphine consumed in the first 24 h postoperatively, pain scores, intraoperative remifentanil consumption, incidence of pruritus, and postoperative antiemetic requirement were lower in the ESP group than in the control group. First defecation time and hospitalization time were shorter in the block group.

CONCLUSIONS

As a part of multimodal analgesia, ESPB reduced postoperative opioid consumption and pain scores in the early postoperative period and in the 3rd month.