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Shaker EH, Elshal MM, Gamal RM, Zayed NOA, Samy SF, Reyad RM, Shaaban MH, Abd Alrahman AAM, Abdelgalil AS. Ultrasound-guided continuous erector spinae plane block vs continuous thoracic epidural analgesia for the management of acute and chronic postthoracotomy pain: a randomized, controlled,double-blind trial. Pain Rep 2023; 8:e1106. [PMID: 38027467 PMCID: PMC10631608 DOI: 10.1097/pr9.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Postthoracotomy pain (PTP) is a severe pain complicating thoracic surgeries and its good management decreases the risk of PTP syndrome (PTPS). Objectives This randomized controlled study evaluated the efficacy of ultrasound-guided continuous erector spinae plane block (ESPB) with or without dexmedetomidine compared with thoracic epidural analgesia (TEA) in managing acute postoperative pain and the possible emergence of PTPS. Methods Ninety patients with chest malignancies planned for thoracotomy were randomly allocated into 3 equal groups. Group 1: TEA (20 mL of levobupivacaine 0.25% bolus, then 0.1 mL/kg/h of levobupivacaine 0.1%), group 2: ESPB (20 mL of levobupivacaine only 0.1% bolus every 6 hours), and group 3: ESPB (20 mL of levobupivacaine 0.25% and 0.5 μg/kg of dexmedetomidine Hcl bolus every 6 hours). Results Resting and dynamic visual analog scales were higher in group 2 compared with groups 1 and 3 at 6, 24, and 36 hours and at 8 and 12 weeks. Postthoracotomy pain syndrome incidence was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. The grading system for neuropathic pain score was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. Itching, pruritis, and urine retention were higher in group 1 than in ESPB groups. Conclusion Ultrasound-guided ESPB with dexmedetomidine is as potent as TEA in relieving acute PTP and reducing the possible emergence of chronic PTPS. However, the 2 techniques were superior to ESPB without dexmedetomidine. Erector spinae plane block has fewer side effects compared with TEA.
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Affiliation(s)
- Ehab Hanafy Shaker
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Mamdouh Mahmoud Elshal
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Reham Mohamed Gamal
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Norma Osama Abdallah Zayed
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Samuel Fayez Samy
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Raafat M. Reyad
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
| | - Mohammed H. Shaaban
- Department of Diagnostic & Interventional Radiology, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Ahmed Salah Abdelgalil
- Department of Anesthesia, Intensive Care, and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt
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Kekul O, Ustun YB, Kaya C, Turunç E, Dost B, Bilgin S, Ozkan F. Analgesic efficacy of the bilateral erector spinae plane block for colorectal surgery: a randomized controlled trial. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:43. [PMID: 37386681 DOI: 10.1186/s44158-022-00073-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/07/2022] [Indexed: 07/01/2023]
Abstract
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.
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Affiliation(s)
- Ozgenur Kekul
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Yasemin Burcu Ustun
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Cengiz Kaya
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Esra Turunç
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - Burhan Dost
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sezgin Bilgin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Fatih Ozkan
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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The Lack of Analgesic Efficacy of Nefopam after Video-Assisted Thoracoscopic Surgery for Lung Cancer: A Randomized, Single-Blinded, Controlled Trial. J Clin Med 2022; 11:jcm11164849. [PMID: 36013087 PMCID: PMC9409862 DOI: 10.3390/jcm11164849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Nefopam is a centrally acting non-opioid analgesic, and its efficacy in multimodal analgesia has been reported. This study aimed to assess the analgesic efficacy of intraoperative nefopam on postoperative pain after video-assisted thoracoscopic surgery (VATS) for lung cancer. Participants were randomly assigned to either the nefopam or the control group. The nefopam group received 20 mg of nefopam after induction and 15 min before the end of surgery. The control group received saline. The primary outcome was cumulative opioid consumption during the 6 h postoperatively. Pain intensities, the time to first request for rescue analgesia, adverse events during the 72 h postoperatively, and the incidence of chronic pain 3 months after surgery were evaluated. Ninety-nine patients were included in the analysis. Total opioid consumption during the 6 h postoperatively was comparable between the groups (nefopam group [n = 50] vs. control group [n = 49], 19.8 [13.5–25.3] mg vs. 20.3 [13.9–27.0] mg; median difference: −1.55, 95% CI: −6.64 to 3.69; p = 0.356). Pain intensity during the 72 h postoperatively and the incidence of chronic pain 3 months after surgery did not differ between the groups. Intraoperative nefopam did not decrease acute postoperative opioid consumption or pain intensity, nor did it reduce the incidence of chronic pain after VATS.
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Jeong H, Choi JW, Sim WS, Kim DK, Bang YJ, Park S, Yeo H, Kim H. Ultrasound-guided erector spinae plane block for pain management after gastrectomy: a randomized, single-blinded, controlled trial. Korean J Pain 2022; 35:303-310. [PMID: 35768985 PMCID: PMC9251398 DOI: 10.3344/kjp.2022.35.3.303] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Open gastrectomy causes severe postoperative pain. Therefore, we investigated the opioid-sparing effect of the ultrasound-guided bilateral erector spinae plane block (ESPB) after open gastrectomy. Methods Adult patients undergoing open gastrectomy were randomly assigned to either the ESPB group (ESPB + fentanyl based intravenous patient-controlled analgesia [IV-PCA]) or a control group (fentanyl based IV-PCA only). The primary outcome was total fentanyl equivalent consumption during the first 24 hour postoperatively. Secondary outcomes were pain intensities using a numeric rating scale at the post-anesthesia care unit (PACU) and at 3, 6, 12, and 24 hour postoperatively, and the amount of fentanyl equivalent consumption during the PACU stay and at 3, 6, and 12 hour postoperatively, and the time to the first request for rescue analgesia. Results Fifty-eight patients were included in the analysis. There was no significant difference in total fentanyl equivalent consumption during the first 24 hour postoperatively between the two groups (P = 0.471). Pain intensities were not significantly different between the groups except during the PACU stay and 3 hour postoperatively (P < 0.001, for both). Time to the first rescue analgesia in the ward was longer in the ESPB group than the control group (P = 0.045). Conclusions Ultrasound-guided ESPB did not decrease total fentanyl equivalent consumption during the first 24 hour after open gastrectomy. It only reduced postoperative pain intensity until 3 hour postoperatively compared with the control group. Ultrasound-guided single-shot ESPB cannot provide an efficient opioid-sparing effect after open gastrectomy.
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Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Jeong Bang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soyoon Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyean Yeo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Raghu C, Ragavendran S, Prasad SR, Arasu T, Nagaraja PS, Singh N, Manjunath N, Muralikrishna N, Yogananth N. Comparison of epidural analgesia with ultrasound-guided bilateral erector spinae plane block in aorto-femoral arterial bypass surgery. Ann Card Anaesth 2022; 25:26-33. [PMID: 35075017 PMCID: PMC8865342 DOI: 10.4103/aca.aca_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Thoracic Epidural Analgesia (TEA) was compared with ultrasound-guided bilateral erector spinae plane (ESP) block in aorto-femoral arterial bypass surgery for analgesic efficacy, hemodynamic effects, and pulmonary rehabilitation. Design: Prospective randomized. Setting: Tertiary care centre. Participants: Adult patients, who were scheduled for elective aorto-femoral arterial bypass surgery. Interventions: It was a prospective pilot study enrolling 20 adult patients who were randomized to group A (ESP block = 10) and group B (TEA = 10). Monitoring of heart rate (HR) and mean arterial pressure (MAP) and pain assessment at rest and deep breathing using visual analog scale (VAS) were done till 48-h post-extubation. Rescue analgesic requirement, Incentive spirometry, oxygenation, duration of ventilation and stay in Intensive Care Unit (ICU) were reported as outcome measures. Statistical analysis was performed using unpaired Student T-test or Mann-Whitney U test. A value of P < 0.05 was considered significant. Results: HR was lower in group B than group A at 1 and 2 h post- surgery and at 0.5, 16, 20, and 32 h post-extubation (P < 0.05). MAP were lower in group B than A at 60, 90, 120, 150, 180, 210, 240, 270 minutes and at 0 hour post-surgery and at 4 hours, every 4 hours till 32 hours post-extubation (P < 0.05). Intraoperative midazolam and fentanyl consumption, ventilatory hours, VAS at rest, incentive spirometry, oxygenation, and ICU stay were comparable between the two groups. VAS during deep breathing was more in group A than B at 0.5, 4 hours and every 4 hours till 44 hours post-extubation. The time to receive the first rescue analgesia was shorter in group A than B (P < 0.05). Conclusion: Both ESP block and TEA provided comparable analgesia at rest. Further studies with larger sample size are required to evaluate whether ESP block could be an alternative to TEA in aorto-femoral arterial bypass surgery.
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Turan A, Cohen B, Elsharkawy H, Maheshwari K, Soliman LM, Babazade R, Ayad S, Hassan M, Elkassabany N, Essber HA, Kessler H, Mao G, Esa WAS, Sessler DI. Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial. J Clin Anesth 2021; 77:110640. [PMID: 34969004 DOI: 10.1016/j.jclinane.2021.110640] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery. BACKGROUND ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown. METHODS Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption. RESULTS Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006. CONCLUSION Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02996227.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America.
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, United States of America; Division of Anesthesiology, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hesham Elsharkawy
- Department of Outcomes Research, Cleveland Clinic, United States of America; Pain Center, Anesthesiology Department, MetroHealth, Case Western Reserve University, OH, United States of America
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Loran Mounir Soliman
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch of Galveston, TX, United States of America
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Manal Hassan
- Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, United States of America
| | - Hani A Essber
- Department of Outcomes Research, Cleveland Clinic, United States of America
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, United States of America
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic
| | - Wael Ali Sakr Esa
- Department of Outcomes Research, Cleveland Clinic, United States of America; Department of General Anesthesiology, Cleveland Clinic, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, United States of America
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Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial. Ann Surg 2020; 270:193-199. [PMID: 30676382 DOI: 10.1097/sla.0000000000003209] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery. SUMMARY BACKGROUND DATA The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery. METHODS Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10). RESULTS The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group. CONCLUSIONS IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.
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Tang JZJ, Weinberg L. A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery. Anesth Pain Med 2019; 9:e94441. [PMID: 32280615 PMCID: PMC7118737 DOI: 10.5812/aapm.94441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023] Open
Abstract
CONTEXT The optimal analgesic method for patients undergoing major open hepato-pancreatic-biliary surgery remains controversial. Continuous epidural infusion at the thoracic level remains the standard choice, however concerns have been raised due to associated complications. Single shot intrathecal morphine has emerged as a promising alternative offering similar analgesia with an enhanced safety profile. EVIDENCE ACQUISITION This review aimed to evaluate the literature comparing intrathecal morphine analgesia to other analgesic modalities following major open hepato-pancreatic-biliary surgery. The primary outcome was pain scores at rest and on movement 24 h after surgery. Secondary outcomes were postoperative opioid consumption within 72 postoperative hours, length of stay (LOS), intra-operative fluid administration and post-operative fluid administration within 72 postoperative hours, and overall systemic complication rate within 30 postoperative days. RESULTS Eleven trials matching the inclusion criteria were analysed. Intrathecal morphine resulted in equivalent or lower pain scores when contrasted to alternative techniques, but required higher amounts of postoperative opioid. Intrathecal morphine also offered reduced LOS and reduced fluid administration requirements to epidural analgesia, and there was no difference observed in major complication rate between analgesic modalities. CONCLUSIONS In summary the evidence suggests that intrathecal morphine may be a better first-line analgesic modality than epidural analgesia in the context of major open hepato-pancreatic-biliary surgery, but high-quality evidence supporting this is limited.
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Bang S, Chung K, Chung J, Yoo S, Baek S, Lee SM. The erector spinae plane block for effective analgesia after lung lobectomy: Three cases report. Medicine (Baltimore) 2019; 98:e16262. [PMID: 31335674 PMCID: PMC6708622 DOI: 10.1097/md.0000000000016262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The thoracic epidural block and thoracic paravertebral block are widely used techniques for multimodal analgesia after thoracic surgery. However, they have several adverse effects, and are not technically easy. Recently, the erector spinae plane block (ESPB), an injected local anesthetic deep to the erector spinae muscle, is a relatively simple and safe technique. PATIENT CONCERNS Three patients were scheduled for video assisted thoracoscopic lobectomy with mediastinal lymph node dissection. All the patients denied any past medical history to be noted. DIAGNOSES They were diagnosed with primary adenocarcinoma requiring lobectomy of lung. INTERVENTIONS The continuous ESPB was performed at the level of the T5 transverse process. The patient was received the multimodal analgesia consisted of oral celecoxib 200 mg twice daily, intravenous patient-controlled analgesia (Fentanyl 700 mcg, ketorolac 180 mg, total volume 100 ml), and local anesthetic (0.375% ropivacaine 30 ml with epinephrine 1:200000) injection via indwelling catheter every 12 hours for 5 days. Additionally, we injected a mixture of ropivacaine and contrast through the indwelling catheter for verifying effect of ESPB and performed Computed tomography 30 minutes later. OUTCOMES The pain score was maintained below 3 points for postoperative 5 days, and no additional rescue analgesics were administered during this period. In the computed tomography, the contrast spread laterally from T2-T12 deep to the erector spinae muscle. On coronal view, the contrast spread to the costotransverse ligament connecting the rib and the transverse process. In the 3D reconstruction, the contrast spread from T6-T10 to the costotransverse foramen. LESSONS Our contrast imaging data provides valuable information about mechanism of ESPB from a living patient, and our report shows that ESPB can be a good option as a multimodal analgesia after lung lobectomy.
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Affiliation(s)
- Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyudon Chung
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jihyun Chung
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Subin Yoo
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sujin Baek
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Mook Lee
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Hong B, Bang S, Chung W, Yoo S, Chung J, Kim S. Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study. Korean J Pain 2019; 32:206-214. [PMID: 31257829 PMCID: PMC6615445 DOI: 10.3344/kjp.2019.32.3.206] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although case reports have suggested that the erector spinae plane block (ESPB) may help analgesia for patients after breast surgery, no study to date has assessed its effectiveness. This retrospective observational study analyzed the analgesic effects of the ESPB after total mastectomy. METHODS Forty-eight patients were divided into an ESPB group (n = 20) and a control group (n = 28). Twenty patients in the control group were selected by their propensity score matching the twenty patients in the ESPB group. Patients in the ESPB group were injected with 30 mL 0.375% ropivacaine, followed by catheter insertion for further injections of local anesthetics every 12 hours. Primarily, total fentanyl consumption was compared between the two groups during the first 24 hours postoperatively. Secondary outcomes included pain intensity levels (visual analogue scale) and incidence of postoperative nausea and vomiting (PONV). RESULTS Median cumulative fentanyl consumption during the first 24 hours was significantly lower in the ESPB (33.0µg; interquartile range [IQR], 27.0-69.5µg) than in the control group (92.8µg; IQR, 40.0-155.0µg) (P = 0.004). Pain level in the early postoperative stage (<3 hr) and incidence of PONV (0% vs. 55%) were also significantly lower in the ESPB group compared to the control (P = 0.001). CONCLUSIONS Intermittent ESPB after total mastectomy reduces fentanyl consumption and early postoperative pain. ESPB is a good option for multimodal analgesia after breast surgery.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon,
Korea
| | - Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon,
Korea
| | - Subin Yoo
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jihyun Chung
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Seoyeong Kim
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul,
Korea
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11
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Bang S, Chung J, Kwon W, Yoo S, Soh H, Lee SM. Erector spinae plane block for multimodal analgesia after wide midline laparotomy: A case report. Medicine (Baltimore) 2019; 98:e15654. [PMID: 31096490 PMCID: PMC6531090 DOI: 10.1097/md.0000000000015654] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The most commonly used regional techniques for analgesia following laparotomy thoracic epidural analgesia and paravertebral blocks are technically difficult to perform and carry a risk of severe complications. Recently, the erector spinae plane block (ESPB) has been reported to effectively treat neuropathic pain. The ultrasound-guided ESPB is an easily performed fascial plane block that can provide sensory blockade from T2-4 to T12-L1. Moreover, the ESPB reportedly blocks both the ventral rami of spinal nerves and the rami communicants, which contain sympathetic nerve fibres, through spread into the thoracic paravertebral space. PATIENT CONCERNS We report the case of a 35-year-old female patient who underwent excision of a larger ovarian mass via laparotomy with a wide, midline incision from the xiphoid process to the pubic tubercle. DIAGNOSES They were diagnosed with mucinous cystadenoma originated from the right ovary and fallopian tube, and a right oophorectomy and salpingectomy were performed. INTERVENTIONS The ESPB was performed for postoperative pain control at the level of the T8 transverse process. Postoperative multimodal analgesia was provided according to the acute pain service protocol of our hospital. The patient was prescribed oral acetaminophen 175 mg every 6 hours and intravenous patient-controlled analgesia (PCA) with fentanyl 7 μg/mL. A 1:1 mixture of 0.75% ropivacaine (20 mL) and saline (20 mL) with epinephrine (1: 200,000) was manually injected through the indwelling catheter every 8 hours (20 mL per side). OUTCOMES The first demand dose of fentanyl was administered at 9 hours and 39 minutes after the surgery. There were no reported resting pain scores >4, nor were any rescue analgesics needed during the first 5 postoperative days. LESSONS The ESPB provided highly effective analgesia as a part of multimodal analgesia after laparotomy with a wide midline incision.
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Affiliation(s)
- Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jihyun Chung
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woojin Kwon
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Subin Yoo
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyojung Soh
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Mook Lee
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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12
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Soliz JM, Lipski I, Hancher-Hodges S, Speer BB, Popat K. Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review. Anesth Pain Med 2017; 7:e12923. [PMID: 29696110 PMCID: PMC5903215 DOI: 10.5812/aapm.12923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/09/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022] Open
Abstract
The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.
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Affiliation(s)
- Jose M Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Corresponding author: Jose M Soliz, M.D., Associate Professor, Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd.Houston, TX 77030, E-mail:
| | - Ian Lipski
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon Hancher-Hodges
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbra Bryce Speer
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyuri Popat
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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Kolvekar S, Pilegaard H, Ashley E, Simon N, Grant J. Pain management using patient controlled anaesthesia in adults post Nuss procedure: an analysis with respect to patient satisfaction. J Vis Surg 2016; 2:37. [PMID: 29078465 DOI: 10.21037/jovs.2016.02.33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 02/16/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Nuss procedure for correction of pectus excavatum is commonly associated with severe postoperative pain. The belief that thoracic epidural offers the best pain control has recently come under scrutiny after several studies have shown patient controlled anaesthesia (PCA) to be just as effective. Nevertheless, centres who have shifted to an exclusively PCA regime exist in the minority. We have conducted a retrospective survey of all patients who underwent the Nuss procedure at the Heart Hospital, London, where all patients are managed exclusively using PCA. The study aims to assess the efficacy and validity of our practice. METHODS A retrospective survey was carried out on 149 patients (139 males and 10 females), with an average age of 28, after undergoing a Nuss bar insertion. The study was conducted between August and October, 2014. The PCA technique used a 1 mg bolus dose of morphine sulphate, administered through a 5-minute lockout. There was no background infusion and no maximum dose limit in a 4-hour period. The outcome of the study measured patient satisfaction with postoperative analgesia and medication prescribed for home usage. The pre-operative provision of information with regard to patient expectations of pain was also assessed. The study is approved by the institutional ethical committee and has obtained the informed consent from every patient. RESULTS The majority of patients were either satisfied or extremely satisfied with the pain management received in hospital immediately following surgery. Additionally, a substantial number of patients strongly agreed that they were adequately warned about postoperative pain prior to the operation. None of the cohort specified that they experienced more pain than expected or thought that the medication prescribed for home usage was inadequate. Moreover, a small minority of patients reported postoperative long-term or chronic pain, with only one reporting that it lasted for longer than 6 months. CONCLUSIONS Results obtained from retrospective patient satisfaction surveys indicate high efficacy for PCA as a pain management strategy. The large majority of patients did not seek more medication for pain alleviation and found in-hospital treatment sufficient. Further, all patients agreed that they were adequately informed of pain-risk prior to surgery.
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Affiliation(s)
| | - Hans Pilegaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | | | - Natalie Simon
- King's College London, School of Medicine, London, UK
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14
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Rosero EB, Cheng GS, Khatri KP, Joshi GP. Evaluation of epidural analgesia for open major liver resection surgery from a US inpatient sample. Proc AMIA Symp 2014; 27:305-12. [PMID: 25484494 PMCID: PMC4255849 DOI: 10.1080/08998280.2014.11929141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to assess the nationwide use of epidural analgesia (EA) and the incidence of postoperative complications in patients undergoing major liver resections (MLR) with and without EA in the United States. The 2001 to 2010 Nationwide Inpatient Sample was queried to identify adult patients undergoing MLR. A 1:1 matched cohort of patients having MLR with and without EA was assembled using propensity-score matching techniques. Differences in the rate of postoperative complications were compared between the matched groups. We identified 68,028 MLR. Overall, 5.9% of patients in the database had procedural codes for postoperative EA. A matched cohort of 802 patients per group was derived from the propensity-matching algorithm. Although use of EA was associated with more blood transfusions (relative risk, 1.36; 95% confidence interval, 1.12-1.65; P = 0.001) and longer hospital stay (median [interquartile range], 6 [5-8] vs 6 [4-8] days), the use of coagulation factors and the incidence of postoperative hemorrhage/hematomas or other postoperative complications were not higher in patients receiving EA. In conclusion, the use of EA for MLR is low, and EA does not seem to influence the incidence of postoperative complications. EA, however, was associated with an increased use of blood transfusions and a longer hospital stay.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gloria S Cheng
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kinnari P Khatri
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
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