Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery-comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial

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

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

Latest Advances in Regional Anaesthesia

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

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.