Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: a randomized, double-blind, placebo-controlled trial

Nociception level index-directed superficial parasternal intercostal plane block vs erector spinae plane block in open-heart surgery: a propensity matched non-inferiority clinical trial

This single-center study explored the efficacy of superficial parasternal intercostal plane block (SPIPB) versus erector spinae plane block (ESPB) in opioid-sparing within Nociception Level (NOL) index-directed anesthesia for elective open-heart surgery. After targeted propensity matching, 19 adult patients given general anesthesia with preincisional SPIPB were compared to 33 with preincisional ESPB. We hypothesized that SPIPB is non-inferior to ESPB in reducing total intraoperative fentanyl consumption, with a non-inferiority margin (δ) set at 0.1 mg. Intraoperative fentanyl dosing targeted a NOL index ≤ 25. Postoperatively, paracetamol 1 g 6-hourly and morphine for numeric rating scale (NRS) ≥ 4 were administered. This study could not demonstrate that SPIPB was inferior to ESPB for total intraoperative fentanyl consumption, as the confidence interval for the median difference of 0.1 mg (95% CI 0.05-0.15) crossed the predefined δ, with the lower bound falling below and the upper bound exceeding δ, p = 0.558. SPIPB led to higher postoperative morphine use at 24 and 48 h: 0 (0-40.6) vs. 59.5 (28.5-96.1) µg kg-1, p < 0.001 and 22.2 (0-42.6) vs. 63.5 (28.5-96.1) µg kg-1, p = 0.001. Four times fewer SPIPB patients remained morphine-free at 48 h, p < 0.001, and their time to first morphine dose was three times shorter compared to ESPB patients, p = 0.001. SPIPB led to higher time-weighted average NRS scores at rest, 1 (0-1) vs. 1 (1-2), p = 0.004, and with movement, 2 (1-2) vs. 3 (2-3), p = 0.002, calculated over the 48-h period post-extubation. The SPIPB group had a significantly higher average NOL index, p = 0.003, and greater NOL index variability, p = 0.027. This study could not demonstrate that SPIPB was inferior to ESPB for intraoperative fentanyl consumption. Significant differences were observed in secondary outcomes, with SPIPB leading to higher postoperative morphine use, higher pain scores, and reduced nociception control.

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.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy

BACKGROUND

Ultrasound (US) guided erector spinae plane block (ESPB) is a safe and effective technique in providing perioperative pain management in pediatrics with a high success rate.

THE AIM OF THIS STUDY

Was to compare the efficacy of bilateral ultrasound-guided erector spinae plane block for management of acute postoperative surgical pain after pediatric cardiac surgeries through a midline sternotomy.

METHODS

One hundred patients aged 4-12 years were randomly assigned into two groups, both groups received general anesthesia followed by bilateral sham erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg normal saline on each side in the control group (group C) or bilateral ultrasound-guided erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg ropivacaine 0.2% with a maximum dose of 2 mg/kg mixed with adrenaline 2 mcg/ml in erector spinae plane block group (group E). The postoperative pain scores were evaluated immediately post-extubation, at 1 hour, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hours after extubation, total consumption of intraoperative fentanyl and time to first rescue analgesic administration were also recorded.

RESULTS

There was a statistically high significant delay in the group E (314.72 ± 45.94) compared with the group C (36.7 ± 7.22) as regards to the mean (SD) of the time of the rescue analgesia (P < 0.001) (with 95% CI), moreover; the number of rescue analgesic was significantly higher in the group C compared with the group E (P < 0.001) (with 95% CI) and the mean (SD) of total intraoperative and postoperative levels fentanyl requirements in the group C were significantly higher compared with the group E (6.47 ± 0.98 and 5.09 ± 0.83) (with 95% CI) in group C versus (4.69 ± 0.71 and 2.31 ± 0.66) (with 95% CI) in group E respectively (P < 0.001) (with 95% CI).

CONCLUSION

Ultrasound-guided bilateral ESPB with ropivacaine and adrenaline delays the postoperative need of analgesia and reduces postoperative fentanyl consumption at 24 h in pediatric patients undergoing cardiac surgery through midline sternotomy.

Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVE

This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy.

DESIGN

A double-blind, prospective, randomized, placebo-controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy.

INTERVENTIONS

The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone.

MEASUREMENTS

The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented.

MAIN RESULTS

Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016).

CONCLUSIONS

Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.

The effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain control in idiopathic scoliosis patients undergoing posterior spine fusion surgery: study protocol of a randomized controlled trial

BACKGROUND

Posterior spinal fusion (PSF) for the correction of idiopathic scoliosis is associated with severe postoperative pain. Erector spinae plane block (ESPB) has been proposed to provide analgesia and reduce opioid consumption. We aimed to investigate the effect of bilateral ultrasound-guided single-shot ESPB on postoperative analgesia in pediatric patients undergoing PSF.

METHODS

This double-blinded, randomized controlled trial will enroll 74 AIS patients undergoing elective PSF. Participants will be assigned to the ESPB group or control group at a 1:1 ratio. Patients in the ESPB group will receive ultrasound-guided bilateral ESPB preoperatively, and patients in the control group received sham ESPB using normal saline. The primary joint endpoints are the area under the curve (AUC) of numerical rating scale (NRS) score and opioid consumption in postoperative 24 h. The secondary endpoints are numerical rating scale (NRS) score and opioid consumption at postoperative 0.5, 3, 6, 9, 12, 24, 36, and 48 h, rescue analgesia, recovery outcomes, and adverse events.

DISCUSSION

At present, studies investigating the effect of ESPB on pediatric patients are still needed. This study focuses on the effect of ESPB on pediatric patients undergoing PSF on postoperative pain control and intends to provide a new strategy of multimodal analgesia management for major spine surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300074505. Registered on August 8, 2023.

Updates From the Other Side of the Drape: Recent Advances in Multimodal Pain Management and Opioid Reduction Among Pediatric Surgical Patients

As the management of acute pain for children undergoing surgical procedures as well as recognition of the short and long term risks of exposure to opioids has evolved, multimodal and multidisciplinary approaches using organized pathways has resulted in improved perioperative outcomes and patient satisfaction. In this 2023 symposium held at the American Academy of Pediatrics on Surgery meeting, a multidisciplinary discussion on current enhanced recovery after surgery pathways, alternate methods of effective pain control and education and advocacy efforts for opioid reduction were discussed, and highlights are included in this article.

Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac Surgery: A Meta-Analysis

INTRODUCTION

It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic.

METHODS

PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05).

RESULTS

In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95).

CONCLUSION

MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.

Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study

BACKGROUND

Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours.

METHODS

A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy).

RESULTS

Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001).

CONCLUSION

Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.

Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial

OBJECTIVES

The primary objective was to compare the analgesic efficacy of ultrasound-guided erector spinae plane block (ESPB) with a sham procedure in adult patients presenting with rib fractures to the emergency department (ED).

METHODS

A randomized controlled trial was conducted at an academic ED over a 17-month period. Forty-six adults with confirmed rib fractures and numeric rating score (NRS) greater than 4 were randomized to one of two treatment arms: ultrasound-guided ESPB group or placebo (sham procedure). Intravenous opioids were prescribed as rescue analgesia when self-reported pain scores were ≥4. The primary outcome measure, pain intensity reduction, was derived using the 11-point NRS at six time points over 12 h. Secondary outcome measures included the amount of rescue analgesia, in morphine equivalents, and the occurrence of adverse events. Two-way repeated-measures ANOVA was used to compare the trend in NRSs across the two arms. The association between the complications and intervention was explored using the Fisher's exact test.

RESULTS

Forty-six patients (23 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, vital signs, preenrollment analgesia, or baseline pain intensity. In comparing pain intensity during the study period, NRS scores at 30, 60, and 120 min were significantly lower in the ESPB group (p < 0.001) during rest and deep inspiration. Moreover, patients in the ESPB group received lesser rescue analgesia than those in the sham group (10 mg, IQR 2.5 vs. 20 mg, IQR 5 mg; p ≤ 0.01). There was no difference in adverse events between groups.

CONCLUSIONS

Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period and reduced amount of rescue analgesia and had no discernible difference in adverse events when compared with a sham.

Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

Fascial plane blocks for cardiothoracic surgery: a narrative review

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Comparative evaluation of continuous infusion versus programmed intermittent bolus techniques in erector spinae plane block in modified radical mastectomy - A preliminary randomised controlled trial

Background and Aims

Single-shot erector spinae plane block (ESPB) provides excellent analgesia in mastectomy in the immediate post-operative period but is not sufficient to maintain for prolonged duration. This study compares the efficacy of programmed intermittent bolus (PIB) versus continuous infusion (CI) techniques after ESPB by placing a catheter for mastectomy.

Methods

After ethical approval and patient consent, ESPB was performed at the T4 level in 50 patients with an initial bolus of 20 mL 0.375% ropivacaine and a catheter placed 30 min before surgery. In the postoperative period, they were randomised to Group I - intermittent bolus of 20 mL 0.2% ropivacaine every 4 h for 24 h and Group C - continuous infusion of 0.2% ropivacaine at 5 mL/h for 24 h. The primary outcome was the 24-h fentanyl consumption by patient-controlled analgesia device. Data was analysed using Stata 14.0.

Results

Group I patients had reduced post-operative fentanyl consumption {mean [standard deviation (SD)]: 166 (139.17) µg vs 332 (247.96) µg, P = 0.002} and lower median NRS scores (1 h: 3 vs 5), (2 h: 3 vs 5), (4 h: 3 vs 5), (6 h: 4 vs 5) with a higher mean (SD) Quality of Recovery-15 score {134.4 (8.53) vs 127 (12.89), P = 0.020} compared to Group C, respectively. The 24-h dermatomal sensory coverage was more comprehensive in Group I compared to Group C.

Conclusion

The PIB technique after ESPB provides decreased postoperative opioid consumption, better post-operative analgesia and quality of recovery compared to the CI technique in patients undergoing mastectomy.

Erector spinae plane blocks: A narrative update

The erector spinae plane block (ESPB) is perhaps one of the most interesting of the tissue plane blocks described recently. There has been an exponential increase in the number of publications for both adults and children over the past 5 years. Single-shot, intermittent bolus, and continuous infusion techniques have been used effectively. Both the efficacy and safety of the procedure are widely accepted, but the exact mechanism by which the local anesthetic spreads from the tip of the transverse process to block the dorsal and ventral rami of the spinal nerves is controversial and needs clarification. Anatomical differences in children, particularly in neonates and infants, may explain the spread in this age group. In most pediatric studies, erector spinae plane block was opioid sparing, and noninferiority was observed when compared with other regional techniques.

Continuous Erector Spinae Plane Block for Pain Management in a Pediatric Kidney Transplant Recipient: A Case Report and Review of the Current Literature

Pain management in patients undergoing kidney transplantation requires careful consideration due to their altered physiology, and potential risks associated with certain analgesic options. In recent years, personalized and multimodal approaches have proven to be pivotal in perioperative pain management, as well as in children. Implementing regional analgesia methods offers a valuable solution in many pediatric surgical settings and the erector spinae plane block (ESPB) could represent a possible analgesic strategy in pediatric patients undergoing renal transplantation. Here, we report the case of a 13-year-old child who underwent living-donor kidney transplantation (LDKx) and received continuous erector spinae plane block (ESPB) for perioperative pain management. This multimodal approach with continuous ESPB resulted in optimal pain control without the need for opioids, allowing for early mobilization and for an optimal postoperative course.

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery.

DESIGN

A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation).

SETTING

Randomized controlled trials (RCTs).

PARTICIPANTS

Adults and children undergoing heart surgery.

INTERVENTIONS

Any kind of PRA compared to no RA or placebo or neuraxial anesthesia.

MEASUREMENTS AND MAIN RESULTS

In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials.

CONCLUSIONS

Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.

Efficacy of ultrasound-guided erector spinae plane block on analgesia and quality of recovery after minimally invasive direct coronary artery bypass surgery: protocol for a randomized controlled trial

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery.

METHODS

The study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People's Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated.

DISCUSSION

This is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population.

TRIAL REGISTRATION

The study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.

Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy

Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.

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.

Population pharmacokinetic and safety analysis of ropivacaine used for erector spinae plane blocks

INTRODUCTION

Erector spinae plane blocks have become popular for thoracic surgery. Despite a theoretically favorable safety profile, intercostal spread occurs and systemic toxicity is possible. Pharmacokinetic data are needed to guide safe dosing.

METHODS

Fifteen patients undergoing thoracic surgery received continuous erector spinae plane blocks with ropivacaine 150 mg followed by subsequent boluses of 40 mg every 6 hours and infusion of 2 mg/hour. Arterial blood samples were obtained over 12 hours and analyzed using non-linear mixed effects modeling, which allowed for conducting simulations of clinically relevant dosing scenarios. The primary outcome was the Cmax of ropivacaine in erector spinae plane blocks.

RESULTS

The mean age was 66 years, mean weight was 77.5 kg, and mean ideal body weight was 60 kg. The mean Cmax was 2.5 ±1.1 mg/L, which occurred at a median time of 10 (7-47) min after initial injection. Five patients developed potentially toxic ropivacaine levels but did not experience neurological symptoms. Another patient reported transient neurological toxicity symptoms. Our data suggested that using a maximum ropivacaine dose of 2.5 mg/kg based on ideal body weight would have prevented all toxicity events. Simulation predicted that reducing the initial dose to 75 mg with the same subsequent intermittent bolus dosing would decrease the risk of toxic levels to <1%.

CONCLUSION

Local anesthetic systemic toxicity can occur with erector spinae plane blocks and administration of large, fixed doses of ropivacaine should be avoided, especially in patients with low ideal body weights. Weight-based ropivacaine dosing could reduce toxicity risk.

TRIAL REGISTRATION NUMBER

NCT04807504; clinicaltrials.gov.

Bilateral Bi-Level Erector Spinae Plane Blocks as a Part of Opioid-Sparing Multimodal Analgesia in Scoliosis Surgery: A Case Series of Six Pediatric Patients

Background and Aim: Postoperative pain after scoliosis surgery is severe and usually requires long-term intravenous opioid therapy. Local anesthetic options, such as wound infiltration, are limited and include neuraxial analgesia. However, they are rarely used due to side effects and inconsistent efficacy. We report an opioid-sparing multimodal analgesia regimen with bilateral erector spinae plane blocks. This case series evaluated the analgesic effect of the bilateral bi-level erector spinae plane blocks (ESP) in congenital and neurogenic scoliosis surgery. Patients and Methods: Six pediatric patients with congenital or neurogenic scoliosis underwent posterior spinal fusion involving 5 to 12 vertebral levels. Bilateral single-injection ESPB was performed at one or two levels before incision. Preoperatively, patients received intravenous dexamethasone. General anesthesia with endotracheal intubation and volume-controlled ventilation was performed via TIVA with remifentanil and propofol. During and after the procedure, the basic hemodynamic parameters, opioid consumption, pain scores (numerical rating scale/NRS), and possible block complications were monitored. Results: All the patients experienced minimal postoperative pain levels. In addition, on the first day after surgery, they had low opioid requirements with no side effects. Conclusions: ESPB in patients undergoing congenital and neurogenic scoliosis correction surgery seems to be an essential analgesic technique that may reduce both severities of pain and opioid consumption.

Erector spinae plane block for postoperative analgesia in cardiac surgeries- A systematic review and meta-analysis

Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of ESPB in cardiac surgeries. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar to identify the studies in which ESPB was compared with the control group/sham block in patients undergoing cardiac surgeries. The primary outcomes were postoperative opioid consumption and postoperative pain scores. The secondary outcomes were intraoperative opioid consumption, ventilation time, time to the first mobilization, length of ICU and hospital stay, and adverse events. Out of 607 studies identified, 16 studies (n = 1110 patients) fulfilled inclusion criteria and were used for qualitative and quantitative analysis. Although, 24-hr opioid consumption were comparable in both groups group (MD, -18.74; 95% CI, -46.85 to 9.36, P = 0.16), the 48-hr opioid consumption was significantly less in ESPB group than control ((MD, -11.01; 95% CI, -19.98 to --2.04, P = 0.02). The pain scores at various time intervals and intraoperative opioid consumption were significantly less in ESPB group. Moreover, duration of ventilation, time to the first mobilization, and length of ICU and hospital were also less in ESPB group (P < 0.00001, P < 0.00001, P < 0.00001, and P < 0.0001, respectively). This systematic review and meta-analysis demonstrated that ESPB provides opioid-sparing perioperative analgesia, facilitates early extubation and mobilization, leads to early discharge from ICU and hospital, and has lesser pruritus when compared to control in patients undergoing cardiac surgeries.

Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching

Objective

To retrospectively analyze the effect of applying an ultrasound-guided bilateral erector spine plane block (ESPB) after the Nuss procedure for surgical repair of pectus excavatum (PE) in children.

Methods

The subjects of the study were patients with severe PE who received the Nuss procedure in our hospital between 1 January 2019 and 30 November 2021. According to different methods for postoperative pain management, the enrolled patients were divided into two groups, the ultrasound-guided ESPB group and the thoracic epidural analgesia (TEA) group. The primary outcome of this study was analgesic drug dosage and the secondary outcome was numerical rating scales (NRSs) between the two groups.

Results

There was no significant difference between the two groups in terms of demographic, preoperative clinical evaluation, or surgical characteristics (P > 0.05). The catheter duration in the TEA group was significantly shorter than that in the ESPB group (P < 0.05), while the hospitalization time in the ESPB group was significantly shorter than that in the TEA group (P < 0.05). In terms of oral morphine equivalent comparison, the required dose of the TEA group was lower than that of the ESPB group on the 1st and 2nd day after the operation (P < 0.05), and there was no statistical difference between the two groups on the 3rd and 4th day after the operation (P > 0.05). The number of patients with an S-NRS ≥ 7 and D-NRS ≥ 7 in the TEA group at day 1 was lower than that in the ESPB group (P < 0.05). There was no significant difference between the two groups at other time points (P > 0.05).

Conclusion

An ultrasound-guided ESPB used in Nuss surgery for children with funnel chest can provide good analgesia for surgery and shorten the postoperative rehabilitation and hospitalization time of patients. It is a safe and effective alternative to TEA.

The effect of erector spinae plane block on arterial grafts in coronary artery bypass grafting

Background

This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries.

Methods

This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries.

Results

The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05).

Conclusion

The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.

An Expert Review of Chest Wall Fascial Plane Blocks for Cardiac Surgery

The recent integration of regional anesthesia techniques into the cardiac surgical patient population has become a component of enhanced recovery after cardiac surgery pathways. Fascial planes of the chest wall enable single-injection or catheter-based infusions to spread local anesthetic over multiple levels of innervation. Although median sternotomy remains a common approach to cardiac surgery, minimally invasive techniques have integrated additional methods of performing cardiac surgery. Understanding the surgical approach and chest wall innervation is crucial to success in choosing the appropriate chest wall block. Parasternal intercostal plane techniques (previously termed "pectointercostal fascial plane" and "transversus thoracic muscle plane") provide anterior chest and ipsilateral sternal coverage. Anterolateral chest wall coverage is feasible with the interpectoral plane and pectoserratus plane blocks (previously termed "pectoralis") and superficial and deep serratus anterior plane blocks. The erector spinae plane block provides extensive coverage of the ipsilateral chest wall. Any of these techniques has the potential to provide bilateral chest wall analgesia. The relative novelty of these techniques requires ongoing research to be strategic, thoughtful, and focused on clinically meaningful outcomes to enable widespread evidence-based implementation. This review article discusses the key perspectives for performing and assessing chest wall blocks in a cardiac surgical population.

Nociception Control of Bilateral Single-Shot Erector Spinae Plane Block Compared to No Block in Open Heart Surgery-A Post Hoc Analysis of the NESP Randomized Controlled Clinical Trial

Background and Objectives: The erector spinae plane block (ESPB) is an analgesic adjunct demonstrated to reduce intraoperative opioid consumption within a Nociception Level (NOL) index-directed anesthetic protocol. We aimed to examine the ESPB effect on the quality of intraoperative nociception control evaluated with the NOL index. Materials and Methods: This is a post hoc analysis of the NESP (Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery) randomized controlled trial. Eighty-five adult patients undergoing on-pump cardiac surgery were allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 42). Both groups received general anesthesia. Preoperatively, group 2 received bilateral single-shot ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Until cardiopulmonary bypass (CPB) was initiated, fentanyl administration was individualized using the NOL index. The NOL index was compared at five time points: pre-incision (T1), post-incision (T2), pre-sternotomy (T3), post-sternotomy (T4), and pre-CPB (T5). On a scale from 0 (no nociception) to 100 (extreme nociception), a NOL index > 25 was considered an inadequate response to noxious stimuli. Results: The average NOL index across the five time points in group 2 to group 1 was 12.78 ± 0.8 vs. 24.18 ± 0.79 (p < 0.001). The NOL index was significantly lower in the ESPB-to-Control group at T2 (12.95 ± 1.49 vs. 35.97 ± 1.47), T3 (13.28 ± 1.49 vs. 24.44 ± 1.47), and T4 (15.52 ± 1.49 vs. 34.39 ± 1.47) (p < 0.001) but not at T1 and T5. Compared to controls, significantly fewer ESPB patients reached a NOL index > 25 at T2 (4.7% vs. 79%), T3 (0% vs. 37.2%), and T4 (7.1% vs. 79%) (p < 0.001). Conclusions: The addition of bilateral single-shot ESPB to general anesthesia during cardiac surgery improved the quality of intraoperative nociception control according to a NOL index-based evaluation.

Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration.

DESIGN

A retrospective cohort study.

SETTING

At a single pediatric tertiary care center.

PARTICIPANTS

Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022.

INTERVENTIONS

The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube.

MEASUREMENTS AND MAIN RESULTS

Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p = 0.001) and 18 minutes (95% CI -34 to -2; p = 0.03), respectively.

CONCLUSIONS

Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.

Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery: A Randomized Controlled Clinical Trial

Background and Objectives: The erector spinae plane block (ESPB) is a multimodal opioid-sparing component, providing chest-wall analgesia of variable extent, duration, and intensity. The objective was to examine the ESPB effect on perioperative opioid usage and postoperative rehabilitation when used within a Nociception Level (NOL) index-directed anesthetic protocol. Materials and Methods: This prospective, randomized, controlled, open-label study was performed in adult patients undergoing on-pump cardiac surgery in a single tertiary hospital. Eighty-three adult patients who met eligibility criteria were randomly allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 40) and received general anesthesia with NOL index-directed fentanyl dosing. Preoperatively, group 2 also received bilateral single-shot ultrasound-guided ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Postoperatively, both groups received intravenous paracetamol (1 g every 6 h). Morphine (0.03 mg/kg) was administered for numeric rating scale (NRS) scores ≥4. Results: The median (IQR, 25th−75th percentiles) intraoperative fentanyl and 48 h morphine dose in group 2-to-group 1 were 1.2 (1.1−1.5) vs. 4.5 (3.8−5.5) µg·kg−1·h−1 (p < 0.001) and 22.1 (0−40.4) vs. 60.6 (40−95.7) µg/kg (p < 0.001). The median (IQR) time to extubation in group 2-to-group 1 was 90 (60−105) vs. 360 (285−510) min (p < 0.001). Two hours after ICU admission, 87.5% of ESPB patients were extubated compared to 0% of controls (p < 0.001), and 87.5% were weaned off norepinephrine compared to 46.5% of controls (p < 0.001). The median NRS scores at 0, 6, 12, 24, and 48 h after extubation were significantly decreased in group 2. There was no difference in opioid-related adverse events and length of stay. Conclusions: NOL index-directed ESPB reduced intraoperative fentanyl by 73.3% and 48 h morphine by 63.5%. It also hastened the extubation and liberation from vasopressor support and improved postoperative analgesia.

Erector Spinae Plane Blocks for the Early Analgesia of Rib Fractures in Trauma (ESPEAR): protocol for a multicentre pilot randomised controlled trial with feasibility and embedded qualitative assessment

INTRODUCTION

Patients with rib fractures commonly experience significant acute pain and are at risk of hypoxia, retained secretions, respiratory failure and death. Effective analgesia improves these outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous and epidural routes of administration. Erector spinae plane (ESP) blockade, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking.

METHODS AND ANALYSIS

To determine if a definitive trial of ESP blockade in rib fractures is possible, we are conducting a multicentre, randomised controlled pilot study with feasibility and qualitative assessment. Fifty adult patients with rib fractures will be randomised in a 1:1 ratio to ESP blockade with multimodal analgesia or placebo ESP blockade with multimodal analgesia. Participants and outcome assessors will be blinded. The primary feasibility outcomes are recruitment rate, retention rate and trial acceptability assessed by interview.

ETHICS AND DISSEMINATION

The study was approved by the Oxford B Research Ethics Committee on 22 February 2022 (REC reference: 22/SC/0005). All participants will provide written consent. Trial results will be reported via peer review and to grant funders.

TRIAL REGISTRATION NUMBER

ISRCTN49307616.

The Year in Review: Anesthesia for Congenital Heart Disease 2021

This review focuses on the literature published during the calendar year 2021 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Four major themes are discussed, including cardiovascular disease in children with COVID-19, aortic valve repair and replacement, bleeding and coagulation, and enhanced recovery after surgery (ERAS).

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study

STUDY OBJECTIVE

We aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.

DESIGN

A prospective, blinded, randomized, controlled study.

SETTING

A tertiary university hospital, operating room and intensive care unit.

PATIENTS

Forty children aged 2-10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).

INTERVENTIONS

Group B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.

MEASUREMENTS

The MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.

MAIN RESULTS

Bilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.

CONCLUSION

Ultrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.

Erector Spinae Plane Block for Children Undergoing Cardiac Surgeries via Sternotomy: A Randomized Controlled Trial

Background

Ineffective management of postoperative pain following pediatric cardiac surgeries adversely affects a patient’s postoperative course. The erector spinae plane (ESP) block has been described in the literature regarding perioperative pain management. We hypothesized that bilateral ESP blocks in pediatric patients would decrease intraoperative fentanyl consumption, reduce the need for postoperative morphine consumption, and improve pain scores.

Objectives

The aim of this double-blinded randomized controlled trial was to assess the efficacy and safety of bilateral ESP blocks in pediatric patients undergoing cardiac surgeries through a median sternotomy.

Methods

The study involved 98 children aged 6 months to 7 years who were American Society of Anesthesiologists (ASA) II and III and scheduled for cardiac surgery through a median sternotomy. Patients were divided randomly into 2 groups: the ES group (n = 50) who received bilateral ultrasound-guided ESP blocks, and the N group (n = 48) who received no block. The primary outcome was the total dose of administered fentanyl intraoperatively. Secondary outcomes included morphine consumption in the first 24 hours postoperatively; the length of time before the first need for postoperative analgesia; and FLACC (face, legs, activity, consolability, and cry) scores at the first and second hours postoperatively and every 4 hours, with readings taken for a period of 24 hours.

Results

There were statistically significantly higher levels of administered fentanyl intraoperatively (6.7 ± 3 vs 4.3 ± 1.9 µg.kg^-1) and postoperative morphine consumption (0.5 ± 0.2 vs 0.4 ± 0.2 mg.kg^-1) in the N group compared with the ES group (P < 0.001). Moreover, the timing of the first rescue analgesia was significantly delayed in the ES group compared with the N group (231.6 ± 104.5 vs 108.8 ± 47.8 minutes).

Conclusions

Bilateral ultrasound-guided ESP blocks can be used to reduce perioperative opioid consumption in pediatric patients undergoing cardiac surgery through a sternotomy. It also can be used to decrease postoperative pain scores.

Comparison of erector spinae plane and paravertebral nerve blocks for postoperative analgesia in children after the Nuss procedure: study protocol for a randomized controlled non-inferiority clinical trial

Background

Thoracic paravertebral block (TPVB) is a widely advocated regional technique for alleviating postoperative pain in children undergoing elective pectus excavatum repair. However, this technique is associated with some undesirable adverse events. Recently, the erector spinae plane block (ESPB) has been introduced as a practical alternative to the TPVB in thoracic surgery. This interfascial regional anesthesia technique interrupts pain sensation by injecting local anesthetics between the muscular layers of the thoracic wall. Several case series described it as an effective pain management technique following pectus excavatum repair. Therefore, this trial is designed to test the hypothesis that ESPB is non-inferior to TPVB in postoperative pain control after pectus excavatum repair.

Methods

This is a prospective randomized double-blind non-inferiority trial. A total of 40 patients aged 4 to 18 years undergoing Nuss surgery will be randomly assigned to receive pain treatment with either ESPB or TPVB. All patients will receive additional systemic multimodal analgesia with an intravenous patient-controlled analgesia pump and acetaminophen. The primary outcome is the pain intensity at rest, 24 h postoperatively. Secondary outcomes include accumulated morphine-equivalent consumption, postoperative pain scores, emergence agitation incidence, time of the first mobilization, time to first rescue analgesia, complications related to pain treatment, and morphine-related adverse events.

Discussion

This will the first randomized controlled trial to compare ESPB with TPVB for analgesia after pectus excavatum repair. This trial aims to provide important clinical evidence to elaborate on the analgesic mechanism of ESPB in children.

Trial registration

ClinicalTrials.govNCT05034601. This trial was prospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06044-y.

The effect of ultrasound-guided bilateral thoracic retrolaminar block on analgesia after pediatric open cardiac surgery: a randomized controlled double-blind study

Background

The thoracic retrolaminar block (TRLB) is a relatively new regional analgesia technique that can be used as an alternative to the thoracic paravertebral block. This study aimed to evaluate the postoperative analgesia effects of ultrasound-guided TRLB in children undergoing open cardiac surgery via median sternotomy incision.

Methods

Sixty-six patients aged 2–8 years were recruited. In the TRLB group, 0.25% bupivacaine 0.4 ml/kg was injected into the retrolaminar space on both sides at the level of the T4 lamina. Patients in the control group were injected with 0.9% saline. The primary outcome measure was fentanyl consumption in the first 24 h post-extubation. The secondary outcome measures were the total intraoperative fentanyl consumption, postoperative modified objective pain score (MOPS), and time to extubation.

Results

The total intraoperative fentanyl requirements and fentanyl consumption in the first 24 h post-extubation were significantly lower (P < 0.001) in the TRLB group (9.3 ± 1.2; 6.9 ± 2.1 μg/kg, respectively) than in the control group (12.5 ± 1.4; 16.6 ± 2.8, respectively). The median (Q1, Q3) time to extubation was significantly shorter (P < 0.001) in the TRLB group (2 [1, 3] h) than in the control group (6 [4.5, 6] h). The MOPS was significantly lower (P < 0.05) in the TRLB group than in the control group at 0, 2, 4, 8, 12 and 16 h post-extubation.

Conclusions

Bilateral ultrasound-guided TRLB is effective in providing postoperative analgesia in children undergoing open cardiac surgery via median sternotomy incision.

Enhancing Recovery in Congenital Cardiac Surgery

BACKGROUND

The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery.

METHODS

Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression.

RESULTS

Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods.

CONCLUSIONS

An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.

Effects of erector spinae plane block on postoperative pain in children undergoing surgery: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The erector spinae plane block is a novel regional anesthetic technique that is gaining popularity in pediatrics. However, the efficacy of erector spinae plane block in children is unclear. The aim of the systematic review and meta-analysis was to investigate effects of erector spinae plane block on postoperative pain relief in children.

METHODS

We searched MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure, and Wan fang databases for randomized controlled trials that compared erector spinae plane block with no block or other types of block in pediatric patients undergoing surgeries. The primary outcomes were pain intensity at rest within 24 h postoperatively and the number of patients requiring rescue analgesics. Data were analyzed using the fixed- or random-effects model, depending on whether the heterogeneity tested by the I²  statistic was >30%. We assessed the quality of evidence for the outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation method.

RESULTS

Seven randomized controlled trials involving 379 patients were reviewed. Compared with no block, erector spinae plane block slightly reduced the pain scores at 0 h (standardized mean difference [SMD]: -1.07; 95% confidence interval [CI]: -1.60 to -0.54; I²  = 52%), 6 h (SMD: -0.82; 95% CI: -1.39 to -0.25; I²  = 79%) postoperatively at rest and significantly reduced the need for rescue analgesics (odds ratio 0.09; 95% CI: 0.04 to 0.21; I²  = 16%). One trial demonstrated the analgesic effect of erector spinae plane block was similar to a quadratus lumborum block, while another trial demonstrated the analgesic effect of ESPB was superior to an ilioinguinal nerve block.

CONCLUSIONS

This review provides low-quality evidence that erector spinae plane block exhibits superior analgesia compared to no block in children. Due to the limited data, evidence regarding the comparison with other regional blocks remains unclear. Future large-sized and well-designed randomized controlled trials are needed.

Erector spinae plane block for minimally invasive mitral valve surgery: a double-blind, prospective, randomised placebo-controlled trial-a study protocol

INTRODUCTION

In the context of enhanced recovery after cardiac surgery, surgical techniques for mitral valve surgery have witnessed substantial modifications, from approaching the heart using open approaches with traditional sternotomy to thoracoscopic access via minithoracotomy. After cardiac surgery, acute postoperative pain is frequent and caused by surgical incision and retraction. Perioperative analgesia in cardiac surgery still relies mainly on opioids. Although neuraxial techniques could be a valuable non-opioid-based analgesia regimen, they can be associated with devastating complications in situations with (iatrogenic) coagulation abnormalities. Only two randomised clinical trials describe the erector spinae plane (ESP) block to provide sufficient postoperative analgesia following cardiac surgery with median sternotomy. Regarding postoperative analgesia after cardiac surgery with a minithoracotomy approach, adequately designed trials are still lacking. We, therefore, designed a double-blind, placebo-controlled trial to prove the hypothesis that the ESP block reduces opioid consumption in patients undergoing minimally invasive mitral valve surgery (MIMVS).

METHODS AND ANALYSIS

Sixty-four patients undergoing MIMVS will be included in this double-blind, prospective, placebo-controlled trial. Patients will be randomised to receive an ESP block with a catheter with either intermittent ropivacaine 0.5% (ropi group) or normal saline 0.9% (placebo group). Both groups will receive patient-controlled intravenous analgesia with morphine following extubation. Primary endpoint is the 24-hour cumulative morphine consumption after extubation. Multiple secondary endpoints will be evaluated.

ETHICS AND DISSEMINATION

The study is approved by the ethics committee of the University Hospitals Leuven, the Clinical Trials Centre of the University Hospitals Leuven and the 'Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten'. Dissemination of the study results will be via scientific papers.

TRIAL REGISTRATION NUMBER

EudraCT identifier: 2019-001125-27.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery

We describe the use of liposomal bupivacaine (Exparel) in erector spinae plane blocks for two patients undergoing pediatric cardiac surgery with cardiopulmonary bypass and one undergoing division of the compressive vascular ring. The perioperative course of all patients was remarkable for low pain and sedation scores, especially after chest tube removal. Erector spinae plane blocks are an expanding pain-control technique in both adult and pediatric cardiac surgery for postoperative analgesia. Liposomal bupivacaine offers prolonged analgesia and may be an attractive option for this indication.

New peripheral nerve blocks: are they worth the hype?

The advent of portable ultrasound technology has revolutionised our ability to place peripheral nerve blocks within tissue planes. Ultrasound guidance has facilitated the introduction of new innovative approaches to deeper nerves not previously attempted using landmark-based techniques. The majority of these truncal blocks involve the branches of the spinal nerves.