Erector spinae plane block for postoperative analgesia in robotically-assisted coronary artery bypass surgery: Results of a randomized placebo-controlled trial

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).

Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents: A retrospective cohort analysis and a new standardised definition for success rate

BACKGROUND

Chest wall surgery for the correction of pectus excavatum or pectus carinatum has gained increased interest in recent years. Adequate pain treatment, respiratory physiotherapy and early ambulation are key to improving the outcomes. Although thoracic epidural analgesia is highly effective, its safety is controversial, leading to extensive scrutiny and questioning of its role.

OBJECTIVES

We hypothesise that thoracic epidural analgesia is effective and well tolerated to use in adolescents, with a high success rate and low pain scores.

DESIGN

Observational retrospective cohort study.

SETTING

All adolescent cases in a high-volume academic tertiary chest wall surgery centre between March 1993 and December 2017 were included.

PATIENTS

A total of 1117 patients aged from 12 to 19 years of age and receiving either Ravvitch, Nuss or Abramson chest wall reconstruction for pectus excavatum were identified in our institutional chest wall surgery database. After applying selection and exclusion criteria, 532 patients were included in the current analysis.

MAIN OUTCOME MEASURES

The primary endpoint of this study was the safety of epidural analgesia, assessed by the incidence of acute adverse events. Secondary endpoints were block success rates using a specific novel definition, and analgesic efficacy using recorded postoperative pain scores.

RESULTS

More than 60% of patients experienced one or more adverse events. However, all events were minor and without consequences. No serious or long-term adverse events were detected. The success rate of thoracic epidural placement was 81%. Low postoperative pain scores were observed.

CONCLUSION

Thoracic epidural analgesia is an extremely effective pain control technique, with a surprisingly high number of minor adverse events but safe with regard to serious adverse events.

TRIAL REGISTRATION

The local research ethics committee approved and registered this study on 16 May 2022 (registration number: S66594).

Effect of Continuous Erector Spinae Plane Block on Postoperative Recovery in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized Controlled Clinical Trial

OBJECTIVE

To investigate whether continuous erector spinae plane block (ESPB) improves the quality of recovery (QoR) and decreases postoperative acute and chronic pain in patients undergoing minimally invasive cardiac surgery.

METHODS

This was a single-center, double-blind, prospective, randomized, placebo-controlled trial. A total of 120 patients were randomized to groups at a 1:1 ratio. They received general anaesthesia and an ESP catheter (ropivacaine or normal saline) before surgery, and received patient-controlled intravenous analgesia with sufentanil and continuous ESPB with a pulse injection of 8 mL (ropivacaine or normal saline) per h after 20 mL of the experimental drug was administered at the end of surgery. The primary outcome was the 15-item quality of recovery scale (QoR-15) score at 24 h after surgery. The secondary outcomes included the severity of pain, sufentanil consumption, incidence of rescue analgesia, and proportion of patients with chronic pain.

RESULTS

The QoR-15 score was greater in the ESPB group than in the control group at 24 h after surgery [112 (108-118) vs. 109 (101-114), P=0.023]. ESPB was associated with a lower cough visual analogue scale (VAS) score (44 vs. 47, P=0.001), resting VAS score (28 vs. 35.5, P=0.003), sufentanil consumption (104.8 µg vs. 145.5 µg, P=0.000), and incidence of rescue analgesia (20.0% vs. 43.3%, P=0.006).

CONCLUSION

Continuous ESPB mildly improved the QoR-15 score in patients undergoing minimally invasive cardiac surgery and reduced postoperative pain scores, opioid consumption, and the incidence of rescue analgesia.

The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery.

DESIGN AND SETTING

The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375).

PARTICIPANTS

Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate.

CONCLUSIONS

Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.

Assessment of catheter position using chest CT in adults undergoing erector spinae plane analgesia for rib fractures: a retrospective cohort study

BACKGROUND

Continuous erector spinae plane (ESP) analgesia is a common adjuvant for patients with traumatic rib fracture pain and success relies on the ESP catheter remaining within the correct fascial plane for the duration of its placement. However, knowledge on postplacement position of indwelling ESP catheters is largely absent. We hypothesized that migration of over-the-needle ESP catheters was common and detectable with coincidental postprocedure CT.

METHODS

In this single-center retrospective cohort study, adults admitted to the surgical intensive care unit for traumatic rib fractures between January 2020 and July 2022 were screened. Those receiving continuous ESP analgesia via indwelling catheter and undergoing subsequent chest CT were included. The primary outcome was the proportion of catheters that migrated outside the ESP. The secondary outcome was the distance between the catheter tip and the nearest transverse process (TP) or fascial plane.

RESULTS

160 medical records were screened for eligibility and 15 patients (18 catheters) met the inclusion criteria. 16 of 18 catheters reviewed were found outside the ESP. Furthermore, catheter position was reported as intramuscular in 14 catheters and subcutaneous in 4 catheters. The median distance between catheter tip and the nearest TP (or the ESP) was 23.20 mm sagittally and 25.05 mm axially.

CONCLUSIONS

Most ESP catheters were found superficial to the fascial plane in the days following their placement. The median distance between the catheter and the ESP is between 23 and 25 mm. Prospective studies should address catheter migration concerns and propose solutions to this common issue.