Ultrasound-guided erector spinae plane block improves analgesia after laparoscopic hepatectomy: a randomised controlled trial

Erector spinae plane block for laparoscopic surgeries: a systematic review and meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a novel analgesic technique that can reduce post-operative pain and postoperative opioid consumption in laparoscopic surgeries.

METHODS

We searched PubMed, Scopus, and Web of Science on November 17th, 2023 for clinical trials comparing ESPB with other analgesic techniques or placebo for laparoscopic surgeries. We meta-analyzed post-operative pain at rest, postoperative opioid consumption, time to first rescue analgesic request, and postoperative nausea and vomiting using a random effects model.

RESULTS

ESPB significantly reduced opioid consumption compared to placebo (SMD, (95CI), p-value; -1.837, (-2.331, -1.343), < 0.001) and also compared to transversus abdominis plane block (TAPB) (SMD, (95CI), p-value; -1.351, (-1.815, -0.887), < 0.001) but not quadratus lumborum plane block (QLB) (SMD, (95CI), p-value; 0.022, (-0.241, 0.286), 0.869). ESPB also significantly reduced participant-reported pain scores at rest at 24h post-operation compared to placebo (SMD, (95CI), p-value; -0.612, (-0.797, -0.428), < 0.001) and TAPB (SMD, (95CI), p-value; -0.465, (-0.767, -0.162), < 0.001), however, there was a significant increase in pain score compared to QLB (SMD, (95CI), p-value; 1.025, 0.156, 1.894), 0.021). A statistically significant increase in time to first rescue analgesic in ESPB groups compared to placebo and TAPB groups was observed in our meta-analysis. There was a lower post-operative nausea and vomiting rate in the ESPB groups compared to placebo groups, yet a comparable rate with QLB and TAPB groups was observed in the meta-analysis.

CONCLUSION

ESPB is an effective and safe analgesic technique for managing post-operative pain and opioid consumption in laparoscopic surgeries compared to placebo, reducing postoperative nausea or vomiting as well. Compared to other techniques, ESPB has a similar efficacy to QLB, except for the pain score at 24 h post-operation, but appears to be superior to TAPB as an analgesic technique in laparoscopic surgeries, with a similar safety profile.

TRIAL REGISTRATION

Prospero registration ID: CRD42024508363. Link: https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Clinical Trial Study Protocol: A Prospective Blinded, Randomized, Controlled Clinical Trial Protocol to Assess the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block on Postoperative Analgesia and Recovery Quality in Laparoscopic Donor Hepatectomy

Introduction

Liver transplantation is considered an effective treatment for end-stage liver disease. Laparoscopic donor hepatectomy (LDH) has become a new standard procedure. And it is important to minimize the pain of the donor. Good postoperative analgesia can reduce the occurrence of postoperative complications and promote the early recovery of the donor. Ultrasound-guided transversus abdominis plane (TAP) block can provide effective analgesia for liver donors and reduce postoperative opioid consumption. This study aims to use ultrasound-guided TAP block for LDH to improve postoperative analgesia for donors while reducing opioid consumption and improving patient rehabilitation quality.

Methods/Analysis

This study is a prospective blinded, randomized, controlled clinical trial with a concealed allocation of patients (living liver donors) scheduled to receive laparoscopic partial hepatectomy 1:1 to receive local infiltration anesthesia or TAP block. This study will recruit a total of 80 patients. The primary outcome is the dosage of opioids within 24 hours after surgery.

Ethics and Dissemination

This trial has been approved by the Institutional Review Board of Beijing Friendship Hospital of China Capital University. This trial study protocol was approved on 8 May 2023. The trial will start recruiting patients after being registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2300071694.

Rescue analgesia with a transversus abdominis plane block alleviates moderate-to-severe pain and improves oxygenation after abdominal surgery: a randomized controlled trial

Background

Abdominal surgery is a common surgical procedure that is frequently associated with substantial postoperative pain. However, rescue analgesia using opioids is associated with several adverse effects. The transversus abdominis plane block (TAPB) has been demonstrated to be effective as part of multimodal analgesia. This study aims to evaluate the effects of rescue analgesia using the TAPB following abdominal surgery.

Methods

Ninety patients undergoing abdominal surgery and reporting a numeric rating scale (NRS) score of cough pain ≥4 on the first postoperative day were randomized to receive either sufentanil or TAPB for rescue analgesia. Pain scores and arterial oxygen pressure (PaO2) were evaluated before and after the administration of rescue analgesia. Sleep quality and gastrointestinal function were assessed postoperatively. The primary outcome was the degree of pain relief on coughing 30 min after the administration of rescue analgesia.

Results

Patients of both groups reported a significantly reduced NRS score on coughing 30 min after receiving rescue analgesia (P paired < 0.001 for both groups). Notably, the degree of pain relief was significantly higher in the TAPB group than in the sufentanil group [median (interquartile range), -3 (-4 to -2) vs. -2 (-2 to -1), median difference = -1; 95% confidence interval, -2 to -1; P < 0.001]. Moreover, patients in the TAPB group experienced less pain than those in the sufentanil group during the following 24 h. When evaluated, PaO2 increased significantly after rescue analgesia was administered in the TAPB group (P paired < 0.001); however, there were no significant intragroup differences in the sufentanil group (P paired = 0.129). Patients receiving the TAPB experienced better quality of sleep than those receiving sufentanil (P = 0.008), while no statistical differences in gastrointestinal function were observed between the two groups.

Conclusion

Rescue analgesia with the TAPB on the first postoperative day alleviated pain, enhanced oxygenation, and improved sleep quality in patients undergoing abdominal surgery; however, its effect on gastrointestinal function requires further research.

Clinical Trial Registration

This study was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=170983, ChiCTR2200060285) on 26 May 2022: Patients were recruited during the period between 30 May 2022 and 14 February 2023, and a follow-up of the last enrolled patient was completed on 16 March 2023.

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.

Efficacy of erector spinae plane block for postoperative analgesia after liver surgeries: a systematic review and meta-analysis

BACKGROUND

Data on the effectiveness of erector spinae plane block (ESPB) for patients undergoing liver surgeries is limited and inconclusive. We hereby aimed to systematically review if ESPB can provide adequate analgesia after liver surgery.

METHODS

PubMed, CENTRAL, Scopus, Embase, and gray literature were examined up to 25th April 2023 for randomized controlled trials (RCTs) comparing ESPB with control or spinal analgesia.

RESULTS

Nine RCTs were included of which three compared ESPB with spinal analgesia. 24-hour opioid consumption did not differ significantly between ESPB vs. control (MD: -35.25 95% CI: -77.01, 6.52 I2 = 99%) or ESPB vs. spinal analgesia (MD: 2.32 95% CI: -6.12, 10.77 I2 = 91%). Comparing pain scores between ESPB and control, a small but significant effect favoring ESPB was noted at 12 h and 48 h, but not at 6-8 h and 24 h. Pain scores did not differ between ESPB and spinal analgesia. The risk of postoperative nausea and vomiting was also not significantly different between ESPB vs. control or spinal analgesia. GRADE assessment shows moderate certainty of evidence.

CONCLUSION

ESPB may not provide any significant postoperative analgesia in liver surgery patients. There was a tendency of reduced opioid consumption with ESPB. Limited data also showed that ESPB and spinal analgesia had no difference in pain scores and 24-hour analgesic consumption.

A progress of research on the application of fascial plane blocks in surgeries and their future direction: a review article

Fascial plane blocks (FPBs) are gaining popularity in clinical settings owing to their improved analgesia when combined with either traditional regional anesthesia or general anesthesia during the perioperative phase. The scope of study on FPBs has substantially increased over the past 20 years, yet the exact mechanism, issues linked to the approaches, and direction of future research on FPBs are still up for debate. Given that it can be performed at all levels of the spine and provides analgesia to most areas of the body, the erector spinae plane block, one of the FPBs, has been extensively studied for chronic rational pain, visceral pain, abdominal surgical analgesia, imaging, and anatomical mechanisms. This has led to the contention that the erector spinae plane block is the ultimate Plan A block. Yet even though the future of FPBs is promising, the unstable effect, the probability of local anesthetic poisoning, and the lack of consensus on the definition and assessment of the FPB's success are still the major concerns. In order to precisely administer FPBs to patients who require analgesia in this condition, an algorithm that uses artificial intelligence is required. This algorithm will assist healthcare professionals in practicing precision medicine.

Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.

Effects of erector spinae plane block on opioid consumption in patients undergoing hand-assisted laparoscopic donor nephrectomy: a randomized controlled trial

BACKGROUND

The erector spinae plane block is a relatively new regional anesthesia technique that is expected to provide some benefits for postoperative analgesia. This study investigated the effects of erector spinae plane block on postoperative opioid consumption in kidney donors undergoing hand-assisted laparoscopic donor nephrectomy for renal transplantation.

METHODS

Fifty-two donors scheduled for elective hand-assisted laparoscopic donor nephrectomy were randomly divided into the block (25 donors) and control (27 donors) groups. Donors in the block group received 30 mL of 0.25% bupivacaine under ultrasound guidance, whereas the control group received no block treatment. The primary outcome measure was the amount of fentanyl administered via patient-controlled analgesia at 24 h. Secondary outcomes included the duration of stay, opioid consumption in the post-anesthesia care unit, and pain scores during the recording hours.

RESULTS

No significant differences were observed between the groups regarding total opioid consumption converted to intravenous morphine equivalent administered via patient-controlled analgesia (33.3±21.4 mg vs. 37.5±18.5 mg; P=0.27) and in the postanesthesia care unit (1.5±0.9 mg vs. 1.4±0.8 mg; P=0.55). The duration of stay in the postanesthesia care unit (86.3±32.6 min vs. 85.7±33.6 min; P=0.87) was similar between the groups. There was no significant difference between the groups in the postoperative donor-reported NRS pain scores (P>0.05 for all the time points).

CONCLUSIONS

Preoperative erector spinae plane block is not an effective strategy for reducing postoperative pain or opioid consumption in patients undergoing hand-assisted laparoscopic donor nephrectomy. Different block combinations are needed for optimal pain management in hand-assisted laparoscopic donor nephrectomy.

Effects of opioid-free anaesthesia compared with balanced general anaesthesia on nausea and vomiting after video-assisted thoracoscopic surgery: a single-centre randomised controlled trial

OBJECTIVES

Opioid-free anaesthesia (OFA) has emerged as a promising approach for mitigating the adverse effects associated with opioids. The objective of this study was to evaluate the impact of OFA on postoperative nausea and vomiting (PONV) following video-assisted thoracic surgery.

DESIGN

Single-centre randomised controlled trial.

SETTING

Tertiary hospital in Shanghai, China.

PARTICIPANTS

Patients undergoing video-assisted thoracic surgery were recruited from September 2021 to June 2022.

INTERVENTION

Patients were randomly allocated to OFA or traditional general anaesthesia with a 1:1 allocation ratio.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the incidence of PONV within 48 hours post-surgery, and the secondary outcomes included PONV severity, postoperative pain, haemodynamic changes during anaesthesia, and length of stay (LOS) in the recovery ward and hospital.

RESULTS

A total of 86 and 88 patients were included in the OFA and control groups, respectively. Two patients were excluded because of severe adverse events including extreme bradycardia and epilepsy-like convulsion. The incidence and severity of PONV did not significantly differ between the two groups (29 patients (33.0%) in the control group and 22 patients (25.6%) in the OFA group; relative risk 0.78, 95% CI 0.49 to 1.23; p=0.285). Notably, the OFA approach used was associated with an increase in heart rate (89±17 vs 77±15 beats/min, t-test: p<0.001; U test: p<0.001) and diastolic blood pressure (87±17 vs 80±13 mm Hg, t-test: p=0.003; U test: p=0.004) after trachea intubation. Conversely, the control group exhibited more median hypotensive events per patient (mean 0.5±0.8 vs 1.0±2.0, t-test: p=0.02; median 0 (0-4) vs 0 (0-15), U test: p=0.02) during surgery. Postoperative pain scores, and LOS in the recovery ward and hospital did not significantly differ between the two groups.

CONCLUSIONS

Our study findings suggest that the implementation of OFA does not effectively reduce the incidence of PONV following thoracic surgery when compared with traditional total intravenous anaesthesia. The opioid-free strategy used in our study may be associated with severe adverse cardiovascular events.

TRIAL REGISTRATION NUMBER

ChiCTR2100050738.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following open major hepatectomy: an open-label, randomised, controlled, non-inferiority trial

Background

Convincing clinical evidence regarding completely opioid-free postoperative pain management using erector spinae plane block (ESPB) in patients undergoing open major hepatectomy (OMH) is lacking. Herein, we aimed to compare the postoperative analgesic efficacy of the visualised continuous opioid-free ESPB (VC-ESPB) and conventional intravenous opioid-based postoperative pain management in hepatocellular carcinoma (HCC) patients undergoing OMH.

Methods

This open-label, randomised, controlled, non-inferiority trial enrolled patients with HCC undergone open major hepatectomy in Fujian Provincial Hospital and compared the postoperative analgesic efficacy of VC-ESPB (VC-ESPB group) and conventional intravenous opioid-based pain management regimen (conventional group). Patients were randomly assigned (1:1) to VC-ESPB group and conventional group. Patients were not masked to treatment allocation. The VC-ESPB group was treated with intermittent injections of 0.25% ropivacaine (bilateral, 30 mL each side) given every 12 h through catheters placed in the space of erector spinae and an opioid-free intravenous pump (10-mg tropisetron diluted to 100 mL with 0.9% normal saline [NS]) for postoperative pain management. The conventional group did not receive ESPB and was treated with a conventional intravenous opioid-based pump (2.5-μg/kg sufentanil and 10-mg tropisetron diluted to 100 mL with 0.9% NS). Patients in the VC-ESPB group underwent magnetic resonance imaging (MRI) to identify local anaesthetic diffusion after ESPB was performed under ultrasound guidance. The primary outcome was postoperative analgesic efficacy, which was indicated by the cumulative area under the curve (AUC) of the pain visual analogue scale scores (range, 0-10; a higher score indicates more pain) obtained at rest and at movement until 48 h postoperatively after leaving the post-anaesthesia care unit (PACU). Herein, an AUC of 26.5 was set as the noninferiority margin, which needed to be satisfied for both cumulative AUCPACU-48 h at rest and cumulative AUCPACU-48 h at movement. Per protocol participants were included in primary and safety analyses. This trial was registered with ChiCTR.org.cn (ChiCTR1900026583).

Findings

Between October 30, 2019, and May 1, 2023, 106 patients were enrolled and randomly assigned to the VC-ESPB group (n = 53) and the conventional group (n = 53). After the dropout (n = 5), a total of 101 patients (VC-ESPB group, n = 50; conventional group, n = 51) were analysed. Both the level of cumulative AUCPACU-48 h (at rest: 160.08 ± 38.00 vs. 164.94 ± 31.00; difference [90% CI], -4.861 [-16.308, 6.585]) and cumulative AUCPACU-48 h (at movement: 209.64 ± 28.98 vs. 212.59 ± 33.11; difference [90% CI], -2.948 [-13.236, 7.339]) were similar between the VC-ESPB and control groups within the first postoperative 48 h. The upper limit of the 90% CIs for the difference in cumulative ACUPACU-48 h at rest and at movement did not reach the upper inferiority margin (26.5). During the first postoperative 48 h, the rate of nonsteroidal anti-inflammatory drug rescue analgesia was similar between the VC-ESPB group and conventional group (n = 16, 32.0% vs. n = 11, 21.6%; P = 0.236). Treatment-related death was not observed in the VC-ESPB group (n = 0, 0%) and conventional group (n = 0, 0%). In VC-ESPB group, local site paralysis (n = 1, 2.0%) was observed in one patient and rash (n = 1, 2.0%) was observed in another patient. One patient in the conventional group was observed with rash preoperatively (n = 1, 2.0%). The VC-ESPB group had significantly lower rates of postoperative nausea (n = 2, 4.0%, vs. n = 9, 17.6%, P = 0.028), vomiting (n = 1, 2.0% vs. n = 8, 15.7%, P = 0.031) and lower incidence of major complications (n = 4, 8.0% vs. n = 6, 11.8%; P = 0.033).

Interpretation

This study demonstrates the noninferiority of VC-ESPB when compared with the conventional opioid-based approach for postoperative pain management after OMH, suggesting that it is feasible to achieve opioid-free postoperative pain management for OMH.

Funding

The Joint Funds for the Innovation of Science and Technology, Fujian Province, China; the Youth Scientific Research Project of Fujian Provincial Health Commission; the Fujian Research and Training Grants for Young and Middle-aged Leaders in Healthcare; and the Key Clinical Specialty Discipline Construction Program of Fujian, China.

Erector Spinae Plane Block and Chronic Pain: An Updated Review and Possible Future Directions

Chronic pain is a common, pervasive, and often disabling medical condition that affects millions of people worldwide. According to the Global Burden of Disease survey, painful chronic conditions are causing the largest numbers of years lived with disability worldwide. In America, more than one in five adults experiences chronic pain. Erector spinae plane block is a novel regional anesthesia technique used to provide analgesia with multiple possible uses and a relatively low learning curve and complication rate. Here, we review the erector spinae plane block rationale, mechanism of action and possible complications, and discuss its potential use for chronic pain with possible future directions for research.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BACKGROUND

Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.

METHODS

One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.

DISCUSSION

This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.

TRIAL REGISTRATION

Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Contrast Spread After Erector Spinae Plane Block at the Fourth Lumbar Vertebrae: A Cadaveric Study

INTRODUCTION

In recent years, the erector spinae plane block (ESPB) has seen widespread use to treat acute and chronic pain in the regions of the thoracic spine. While limited data suggest its increasing utilization for pain management distal to the thoracic, abdomen and trunk, the anesthetic spread and analgesic mechanism of ESPB at the level of the lumbar spine has not been fully described or understood.

METHODS

This is an observational anatomic cadaveric study to assess the distribution of solution following an ESPB block performed at the fourth lumbar vertebrae (L4) using ultrasound guidance to evaluate the spread of a 20 ml solution consisting of local anesthetic and methylene blue. The study was performed in an anatomy lab in a large academic medical center. Following injection of local anesthetic with contrast dye, cadaveric dissection was performed to better understand the extent of contrast dye and to determine the degree of staining to further predict analgesic potential. We reviewed the findings of other ESPB cadaveric studies currently available for comparison.

RESULTS

Following cadaveric dissection in an anatomy lab, the contrast dye was observed in the ESP space, and staining was found most cranially at L2 and extending caudally underneath the sacrum. Evaluating the depth of its spread, we found it to be confined to the posterior compartment of the spine sparing the nerve roots bilaterally, which is consistent with the only other cadaveric study of ESPB performed at L4.

CONCLUSION

Our results demonstrate the clinical utility of lumbar ESPB where posterior confinement of local anesthesia is preferred. However, further investigation is needed to determine the efficacy of ESPB in lower extremity analgesia which is predicated on ventral nerve root involvement.