Erector spinae plane block versus fascia iliaca block after total hip arthroplasty: a randomized clinical trial comparing analgesic effectiveness and motor block

Background

Ultrasound-guided, supra-inguinal fascia iliaca block (FIB) provides effective analgesia after total hip arthroplasty (THA), but is complicated by high rates of motor block. The erector spinae plane block (ESPB) is a promising motor-sparing technique. In this study, we test the analgesic superiority of FIB over ESPB, while also comparing motor impairment.

Methods

In this randomized, observer-blinded clinical trial, patients scheduled for THA with spinal anesthesia were randomly assigned to receive either ultrasound-guided FIB or ESPB preoperatively. Primary outcome was morphine consumption at 24 hours after surgery. Secondary outcomes were: pain scores; assessment of sensory and motor block; incidence of postoperative nausea and vomiting and other complications; and development of chronic post-surgical pain.

Results

Sixty patients completed the study. There were no statistically-significant differences in morphine consumption at 24 hours (p = 0.68) or pain scores at any time point. FIB produced more reliable sensory block in the femoral nerve (p = 0.001) and lateral femoral cutaneous nerve (p = 0.018) distributions. However, quadriceps motor strength was better preserved in the ESPB group when compared to the FIB group (p = 0.002). No differences were observed for hip adduction motor strength (p = 0.253). No differences between groups were observed in terms of side effects or chronic pain incidence.

Consclusions

ESPB may represent a promising alternative to FIB for postoperative analgesia after THA. ESPB and FIB offer similar opioid-sparing benefits within the first day after surgery, but ESPB results in less quadriceps motor impairment.

Comparing the efficacy and safety of continuous epidural analgesia in abdominal and urological surgery between two opioids with different kinetic properties: morphine and sufentanyl

BACKGROUND

Ample evidence is now available showing the analgesic efficacy of a local anaesthetic-opioid combination to control postoperative pain. This retrospective study aimed to analyze any improvement in the ability of sufentanyl, a highly lipophilic opioid, and morphine, a poorly lipophilic opioid, to control postoperative pain at rest and in motion when combined with ropivacaine 0.2%.

METHODS

In this retrospective study, 171 patients who underwent major abdominal or urological surgery were evaluated. The therapeutic protocol provided for continuous epidural perfusion (5 mL/h) of ropivacaine 0.2% + morphine 0.03 mg/mL or ropivacaine 0.2% + sufentanyl 0.75 mug/mL for 48 h. Pain at rest (numeric rate scale, NRS) and in motion (NRSm) was evaluated by means of the NRS upon waking and at 3, 6, 12, 24, 36, and 48 hs, providing for the administration of a rescue dose if NRS >4. The overall analgesic effect was evaluated by comparing the area under the NRS curve (AUC) of both treatments using the Mann Whitney U test. Any differences between treatments in terms of NRS and NRSm in time were evaluated using ordinal logistic regression. To compare the frequency of patients who reported NRS >4 at least once during the follow-up period, logistic regression was used. Finally, the frequency of patients who required at least one additional drug or reported side effects was compared using Fisher's exact test.

RESULTS

While both groups showed a comparable overall analgesic effect, the baseline values of NRS and NRSm were lower for the sufentanyl group (P<0.001), perhaps as a result of its quicker onset due to higher lipophilicity. No statistically significant difference was observed in the frequency of patients requiring administration of an additional analgesic drug (P=0.136) or in the incidence of complications (P=0.799).

CONCLUSION

Both protocols providing a combination of a local anaesthetic and an opioid demonstrated an excellent safety and efficacy profile. The differing lipophilicity of the opioids did not cause any clinically or statistically significant differences in terms of efficacy or safety, other than a reduced onset time of sufentanyl, ensuring better pain control upon waking. We therefore believe that morphine should be the standard opioid for neuraxial use, although these results must be confirmed in the setting of a randomized controlled clinical trial.

Ultrasound guidance for locoregional anesthesia: a review

Although regional anaesthesia has become safer, there are an increasing number of articles regarding complications of regional blocks. During the last few years, many authors have suggested the use of ultrasound to minimize the appearance of complications. This review was performed, through a Medline research, to evaluate articles concerning ultrasound and locoregional anaesthesia published until April 2005. A total of 39 articles were reviewed. Technical procedures, the use of ultrasound guidance in epidural anesthesia, the application of this technique for peripheral nerve blocks, and its indications in pregnancy and in pediatric patients were considered. In these articles, all of the authors focused on the advantages of ultrasound guidance. With the help of this technique, correct catheter placement as close to the target as possible was obtained; the spread of local anesthetic administered around the nerve and its roots can be visualized, reducing the doses needed; in addition, it is possible to avoid the most common complications, such as intravascular injection, dura mater puncture, hematoma formation, and nerve injury. Ultrasound guidance is useful in facilitating peripheral and neuroaxial blocks and offers direct visualization of the target, adjacent structures, and local anesthetic spread. The advantages also include a decreased rate of complications and faster onset of blocks. Finally, ultrasound measurements can even result in suggestions to modify established block technique.