Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

Abstract Introduction Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations. Materials and methods This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups. Results There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011). Discussion In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Effects of bilateral erector spinae plane block for posterior lumbar spine surgery in elderly patients / 中南大学学报(医学版)

OBJECTIVES@#With the rapid development of aging population, the number of elderly patients undergoing posterior lumbar spine surgery continues to increase. Lumbar spine surgery could cause moderate to severe postoperative pain, and the conventional opioid-based analgesia techniques have many side effects, which are barriers to the recovery after surgery of the elderly. Previous studies have demonstrated that erector spinae plane block (ESPB) could bring about favorable analgesia in spinal surgery. As far as the elderly are concerned, the analgesic and recovery effects of ESPB on posterior lumbar spine surgery are not completely clear. This study aims to observe the effects of bilateral ESPB on elderly patients undergoing posterior lumbar spine surgery, and to improve the anesthesia techniques.@*METHODS@#A total of 70 elderly patients of both sex, who were selected from May 2020 to November 2021, scheduled for elective posterior lumbar spine surgery, and in the age of 60-79 years, with American Society of Anesthesiologists class Ⅱ-Ⅲ, were divided into a ESPB group and a control (C) group using a random number table method, with 35 patients each. Before general anesthesia induction, 20 mL 0.4% ropivacaine was injected to the transverse process of L3 or L4 bilaterally in the ESPB group and only saline in the C group. The score of Numerical Rating Scale (NRS) indicating pain at rest and on movement within 48 h after operation, time of first patient control analgesia (PCA), cumulative consumptions of sufentanil within 48 hours, Leeds Sleep Evaluation Questionnaire (LSEQ) scores on the morning of day 1 and day 2 after operation, Quality of Recovery-15 (QoR-15) scores at 24 and 48 h after operation, full diet intake times, perioperative adverse reactions such as intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation were compared between the 2 groups.@*RESULTS@#A total of 70 patients were enrolled and 62 subjects completed the study, including 32 in the ESPB group and 30 in the C group. Compared with the C group, the postoperative NRS scores at rest at 2, 4, 6, and 12 h and on movementat at 2, 4, and 6 h were lower, time of first PCA was later, sufentanil consumptions were significantly decreased during 0-12 h and 12-24 h after operation, LSEQ scores on the morning of day 1 and QoR-15 scores at 24 and 48 h after operation were higher, full diet intakes achieved earlier in the ESPB group (all P<0.05). There were no significant differences in the incidences of intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation between the 2 groups (all P>0.05).@*CONCLUSIONS@#Providing favorable analgesic effects with reduced opioids consumption, bilateral ESPB for posterior lumbar spine surgery in the elderly patients could also improve postoperative sleep quality, promote gastrointestinal functional restoration, and enhance recovery with few adverse reactions.

Bilateral continuous erector spinae plane block for cardiac surgery: case series / Bloqueo bilateral continúo del plano erector de la espina para cirugía cardiaca: serie de casos

Abstract Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain. The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses. This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution. All patients reported pain according to the numeric rating scale (NRS) ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively. Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.

Resumen En cirugía cardiaca mediante esternotomía, la analgesia multimodal incluye el bloqueo bilateral continuo del plano erector de la espina (BBC-ESP). Sin embargo, existe incertidumbre sobre la efectividad de los esquemas de dosificación del anestésico local. Se busca evaluar el control del dolor proporcionado por un esquema de analgesia multimodal que incluye el BBC-ESP a la altura de T5 con ACP de bupivacaína 0,125 % en infusión y bolos de rescate. Se trata de un estudio descriptivo, serie de casos. Se reclutaron 11 pacientes adultos sometidos a cirugía cardiaca mediante esternotomía en quienes se usó analgesia multimodal que incluía BBC-ESP entre febrero y abril del 2021, en una institución de cuarto nivel. Todos los pacientes refirieron dolor, según la escala numérica (EN) ≤ 3 tanto en reposo como en movimiento, a la extubación, a las 4 y a las 12 horas. A las 24 horas el dolor fue EN ≤ 3 en el 100 % de los pacientes en reposo y en el 63,6 % en movimiento. A las 48 h el 81 % de los pacientes refirieron dolor EN ≤ 3 en reposo y en movimiento. A las 72 h todos los pacientes presentaron dolor EN ≤ 3 en reposo y 82 % en movimiento. El consumo intraoperatorio promedio de fentanilo fue de 2,35 ug/kg y de hidromorfona posoperatoria de 5,3, 4,1 y 3,3 mg a las 24, 48 y 72 horas. Así, el BBC-ESP en infusión continua más bolos de rescate permiten el control del dolor agudo intra y posoperatorio.

A prospective comparative randomized controlled study of erector spinae plane block using local anesthetics versus general anesthesia for the perioperative control of pain in patients undergoing thoracoscopic procedures

Background: Patients posted for video-assisted thoracoscopic surgeries (VATS) are nowadays managed intraoperatively by general anesthesia (GA) with the use of oral and parenteral analgesics in the post-operative period. Ongoing research points out that the erector spinae plane block (ESP Block) with local anesthetics is a safe technique for the perioperative management of pain in thoracoscopic procedures. Aims and Objectives: Our study aimed at comparing ultrasound guided ESP block using local anesthetics versus GA for perioperative pain management in patients who underwent thoracoscopic procedures. The objectives of this research were to assess the hemodynamic changes in patients undergoing the procedure, to calculate the total amount of analgesics required by patients in the next 24 h, to assess the overall patient satisfaction and complications in the post-operative period. Materials and Methods: In this prospective comparative randomized controlled trial, 40 patients aged 18–65 years planned to undergo VATS were enrolled and randomized to either group G or group E in equal numbers depending on the anesthetic technique employed. Group G patients received GA and Group E patients received ultrasound guided ESP block. Both the groups were compared for hemodynamic stability, pain in postoperative period using visual analog scale (VAS), time to first rescue analgesia requested since induction, total amount of rescue analgesia requested, overall patient satisfaction, and post-operative complications. Results: Better control of hemodynamic parameters, less post-operative pain, prolonged duration of analgesia (P < 0.05), and requirement of lesser amount of rescue analgesics were observed in patients of Group E in comparison with patients of Group G. Side effects such as post-operative nausea and vomiting were more in patients of Group G in the first 24 h (P < 0.05). Conclusion: ESP block with local anesthetics can be used as an effective sole anesthetic technique for VATS <60 min providing a longer pain free post-operative period, lesser rescue analgesic requirement, better patient satisfaction, and lesser post-operative complications.

Anesthetic and surgical considerations for staged bilateral nephrectomies in a pediatric patient: A case report / Consideraciones anestésicas y quirúrgicas en nefrectomía bilateral en dos tiempos en un paciente pediátrico: Reporte de caso

Abstract We present a 9-year-old patient with end-stage renal disease, on peritoneal dialysis, who underwent a staged prone retroperitoneoscopic bilateral nephrectomy. Bilateral nephrectomy was indicated in preparation for renal transplant in the context of genetic predisposition malignancy when immunosuppressed. The two mirror-image surgeries enable the comparison of the anesthetic management and outcomes in a single patient. Features of interest to anesthesiologists include approach to a child with chronic kidney disease, different requirements for intraoperative antihypertensives; pain management strategies, including a comparison of erector spinae plane block with and without adjunct dexmedetomidine; anesthetic management of retroperitoneoscopic pediatric surgery and the first description of using a Foley bag attached to a peritoneal dialysis catheter to aid in diagnosis and repair of posterior peritoneal cavity entry.

Resumen Se presenta un paciente de 9 años de edad con enfermedad renal terminal, en diálisis peritoneal, quien se sometió a nefrectomía bilateral retroperitoneoscópica estadificada en posición prona. Se indicó la nefrectomía bilateral en preparación para trasplante renal en el contexto de predisposición genética hacia desarrollar una patología maligna al estar inmunosuprimido. Las dos cirugías en espejo permiten hacer una comparación del manejo anestésico y de los desenlaces en un mismo paciente. Las características de interés para los anestesiólogos incluyen el abordaje de un niño con enfermedad renal crónica, con requisitos diferentes de antihipertensivos intraoperatorios; estrategias para el manejo del dolor, incluyendo una comparación de bloqueo del plano del erector espinal con y sin dexmedetomidina adyuvante; manejo anestésico de cirugía pediátrica retroperitoneoscópica y la primera descripción del uso de una bolsa Foley conectada a un catéter de diálisis peritoneal para ayudar en el diagnóstico y la reparación de la entrada de la cavidad peritoneal posterior.

Is Continuous Erector Spinae Plane Block (ESPB) Better than Continuous Serratus Anterior Plane Block (SAPB) for Mitral Valve Surgery via Mini?Thoracotomy? Results from a Prospective Observational Study

Aims:Chest wall blocks are effective alternatives for postoperative pain control inmitral valve surgery in rightmini?thoracotomy (mini?MVS).We compared the efficacy of Serratus Anterior plane block (SAPB) and Erector Spinae plane block (ESPB) on postoperative pain relief aftermini?MVS. Settings and Design: It is a prospective, observational study. Material and Methods: A total of 85 consecutive patients undergoing continuous SAPB and continuous ESPB for mini?MVS from March 2019 to October 2020 were included. The primary outcome was the assessment of postoperative pain evaluated as absolute value of NRS at 12, 24 and 48 h. Secondary outcomes were assessment of salvage analgesia (both opioids and NSAIDs), incidence of mild adverse effects (i.e. nausea, vomiting, and incorrect catheter placement) and timing of postoperative course (ICU and hospital length of stay, duration of mechanical ventilation, ventilator?free days). Results: The median NRS was 0.00 (0.00–3.00) at 12 h and 0.00 (0.00–2.00) at 24 and 48 h. No significant differences were observed between groups. Postoperative morphine consumption in the first 24 h was similar in both groups (P = 0.76), whereas between 24 and 48 h was significantly less in the ESPB group compared with SAPB group, P = 0.013. NSAIDs median consumption and Metoclopramide consumption were significantly lower in the ESPB group compared to SAPB group (P = 0.002 and P = 0.048, respectively). Conclusions: ESPB, even more than SAPB, appears to be a feasible and effective strategy for the management of postoperative pain, allowing good quality analgesia with low consumption of opioids, NSAIDs and antiemetic drugs.

Comparison of Epidural Analgesia with Ultrasound?Guided Bilateral Erector Spinae Plane Block in Aorto?Femoral Arterial Bypass Surgery

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

Investigation of the effect of ultrasonography-guided bilateral erector spinae plane block on postoperative opioid consumption and pain scores in patients undergoing hepatectomy: a prospective, randomized, controlled study

ABSTRACT BACKGROUND: There is still a debate about what constitutes effective and safe postoperative analgesia in hepatectomy surgery. Erector spinae plane (ESP) block may be an important part of multimodal analgesia application in hepatectomy surgery. OBJECTIVES: To compare the effects of ultrasound-guided bilateral erector spinae plane block combined with intravenous (iv) patient-controlled analgesia (iv PCA), in comparison with iv PCA alone, in hepatectomy surgery. DESIGN AND SETTINGS: Randomized prospective single-blinded study in a tertiary university hospital. METHODS: Fifty patients scheduled for elective hepatectomy surgery were included in the study. Patients were randomized into the ESP group or the control group. In the ESP group, bilateral ESP block was performed preoperatively and iv PCA was used. In the control group, only iv PCA was used. Numerical rating scale (NRS) scores at rest and coughing, analgesic requirements and occurrences of nausea and vomiting were recorded. RESULTS: Intraoperative and postoperative opioid consumption, rescue analgesia requirement and resting and dynamic NRS scores were significantly lower in the ESP group (P < 0.05). There was no significant difference between two groups in terms of the presence of dynamic pain after the first postoperative hour. While all patients in the control group had nausea and vomiting, 24% of the patients in the ESP group did not have nausea and vomiting. CONCLUSION: This study showed that ESP block can be used as a part of multimodal analgesia, with the benefit of reducing opioid consumption and postoperative nausea and vomiting in hepatectomy surgery. CLINICAL TRIAL REGISTRATION: ACTRN12620000466943.

Continuous erector spinae plane block at lumbar level for relief of severe pain due to hip fracture: case series / Bloqueo continuo del plano erector de la espina lumbar para manejo del dolor severo por fractura de cadera: serie de casos

Abstract Introduction Hip fracture pain is frequently acute and disabling and increases perioperative complications in the patient; hence it requires a multimodal analgesia approach. This case series describes the continuous erector spinae plane block at the lumbar level for hip fracture analgesia. Methods A search was conducted of patients with hip fracture referred to the pain service of Hospital Universitario San Vicente Fundación (HUSVF) from August 2019 to March 2020, who had undergone continuous erector spinae plane block as part of their analgesic regimen. Results A total of 6 patients, 4 females and 2 males with an average age of 75 years were identified. A reduction in pain intensity from acute to mild or absent was observed in every case, up to 24 hours after the initial injection. 66 % experienced a relapse of severe pain after 24 hours and 2 patients the catheter functionality failed after 24 hours. One patient underwent dermatome pinprick assessment. Conclusions The continuous erector spinae plane block with a single injection provided analgesic efficacy similar to other single injection peripheral blocks, although continuous analgesia for more than 24 hours was not achieved. Some variations in the block technique described may improve the analgesic effectiveness in patients with hip fracture pain.

Resumen Introducción El dolor de la fractura de cadera suele ser fuerte e incapacitante y aumenta las complicaciones perioperatorias en el paciente, lo que hace indispensable el enfoque de analgesia multimodal. En esta serie de casos se describe la experiencia del bloqueo continuo del plano erector de la espina a nivel lumbar para analgesia en fractura de cadera. Métodos Se realizó una búsqueda de los pacientes con fractura de cadera remitidos al servicio de dolor del Hospital Universitario San Vicente fundación (HUSVF) desde agosto de 2019 hasta marzo de 2020, a quienes se les realizó bloqueo continuo del plano erector de la espina como parte de su esquema analgésico. Resultados Se encontraron 6 pacientes, 4 mujeres y 2 hombres, con una edad promedio de 75 años. Se observó reducción de la intensidad del dolor de fuerte a leve o ausente en todos los casos hasta las 24 horas posteriores a la inyección inicial. El 66 % tuvo recaída del dolor fuerte posterior a las 24 horas y en 2 pacientes no se logró funcionalidad del catéter por más de 24 horas. En un paciente se hizo evaluación dermatómica por pinprick (prueba de pinchazo). Conclusiones El bloqueo continuo del plano erector de la espina con inyección única ofreció eficacia analgésica similar a otros bloqueos periféricos en inyección única, aunque no se logró analgesia continua con el catéter por más de 24 horas. Ciertas variaciones en la técnica del bloqueo descrita podrían mejorar la efectividad analgésica en pacientes con dolor por fractura de cadera.

Case report: Patient controlled analgesia after pediatric scoliosis surgery through erector spinal plane catheter / Analgesia controlada por paciente a través de catéter en plano erector espinal poscirugía escoliosis pediátrica

INTRODUCTION: Erector spinae plane block (ESPB) is a recently described technique (2016); its use as continuous analgesia with an intrafascial catheter in anterior scoliosis surgery for pediatric patients in intensive care unit (ICU) has not been reported in the literature. OBJECTIVE: To describe the use of an intrafascial catheter in the erector spinae for continuous infusion and patient-controlled analgesia as a postoperative analgesic technique in anterior scoliosis surgery. CLINICAL CASE: 15-year-old patient weighing 34 kg, diagnosed with scoliosis with 110° Cobb angle in the context of neurofibromatosis, subjected to anterior corrective surgery with continuous analgesia and patient-controlled analgesia through an intrafascial catheter in the erector spinae. CONCLUSIONS: The use of continuous intrafascial analgesia and patient-controlled analgesia in the erector spinae provided adequate analgesic control in the postoperative period of corrective anterior scoliosis surgery in a pediatric patient in ICU.

INTRODUCCIÓN: El bloqueo del plano del erector de la espina (ESPB) es una técnica de reciente descripción (2016). Su uso como analgesia continua con catéter intrafascial en cirugía de escoliosis por vía anterior para pacientes pediátricos en unidad de cuidados intensivos (UCI) no ha sido reportado en la literatura. OBJETIVO: Describir el uso del catéter intrafascial del erector de la espina como técnica analgésica posoperatoria en cirugía de escoliosis vía anterior con analgesia en infusión continua y controlada por el paciente. CASO CLÍNICO: Paciente de 15 años, peso 34 kg, con diagnóstico de escoliosis con ángulo de Cobb 110° en el contexto de neurofibromatosis, sometido a cirugía correctiva vía anterior con analgesia continua y controlada por el paciente mediante catéter intrafascial en erector de la espina en UCI. CONCLUSIONES: El uso de analgesia intrafascial continua y controlada por el paciente por catéter en el erector de la espina resulta en un adecuado control analgésico posoperatorio de cirugía correctiva de escoliosis via anterior en un paciente pediátrico en UCI.

Optimized strategy of anesthesia for thoracoscopic pulmonary surgery: erector spinae plane block with high volume of ropivacaine combined with general anesthesia / 中华麻醉学杂志

Objective:To evaluate the optimized efficacy of erector spinae plane block (ESPB) with high volume of ropivacaine combined with general anesthesia for patients undergoing thoracoscopic pulmonary surgery.Methods:Sixty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 18-64 yr, with body mass index of 18-24 kg/m 2, scheduled for elective thoracoscopic pulmonary surgery, were divided into 2 groups ( n=30 each) using a random number table method: ESPB with high volume (40 ml) of 0.4% ropivacaine combined with general anesthesia group (E40 group) and ESPB with conventional volume (20 ml) of 0.4% ropivacaine combined with general anesthesia group (E20 group). Ultrasound-guided ESPB was performed on the operated side before general anesthesia induction in both groups.In E40 group, 0.4% ropivacaine 40 ml was injected.In E20 group, 0.4% ropivacaine 20 ml was injected.Total intravenous anesthesia was applied in both groups.Sufentanil was used for patient-controlled intravenous anesthesia (PCIA) after the end of operation.The PCIA pump was set up with a 2 ml bolus dose (0.04 μg/kg), a 10 min lockout interval and background infusion at a rate of 0.05 μg·kg -1·h -1.The analgesia lasted for 48 h after operation, and the numeric rating scale (NRS) score was maintained ≤ 3.When NRS score ≥ 4, morphine 5 mg was intravenously injected for rescue analgesia.The onset time of block, intraoperative consumption of propofol and remifentanil, time to first pressing the analgesia pump, the first requirement for morphine and the ratio of patients using morphine within 48 h after surgery were recorded.The cumulative consumption of requirement for opioids (effective pressing dose of analgesic pump+ consumption of requirement for morphine) within 12, 24, 36 and 48 h after surgery and satisfaction with analgesia were recorded.The extubation time, length of ICU stay, the first postoperative off-bed time, the chest tube removal time and duration of stay in hospital were recorded.The incidence of intraoperative adverse events (hypertension and hypotension) and postoperative adverse events (dizziness, nausea and vomiting) were recorded. Results:Compared with E20 group, the onset time of block was significantly shortened, the cumulative consumption of requirement for opioids within 24, 36 and 48 h after surgery was decreased, the ratio of paitents using morphine within 48 h after surgery was decreased, time to first pressing the analgesia pump and the first requirement for morphine were prolonged, satisfaction with analgesia score was increased, and the first postoperative off-bed time and the chest tube removal time were shortened in group E40 ( P<0.05). There was no significant difference in the incidence of adverse events between the 2 groups ( P>0.05). Conclusion:Compared with ESPB with the conventional volume of ropivacaine combined with general anesthesia, ESPB with the high volume of ropivacaine combined with general anesthesia can reduce the postoperative consumption of opioids, and prolong the duration of effective analgesia, which are helpful for postoperative rapid recovery without increasing the development of adverse events in patients undergoing thoracoscopic pulmonary surgery.

Continuous erector spinae plane block for pain management in laparoscopic liver resection: case report / Bloqueo continuo del elevador de la espina para el manejo del dolor en una reseccion hepática laparoscopica: reporte de caso

Abstract Pain after liver resection can be difficult to manage. Epidural anesthesia (EA) is an effective technique in pain control in this surgery. However, postoperative coagulopathy and hypotension due to autonomic nervous system block in high-risk patients, may result that the EA is an inadequate analgesic technique in according to enhanced recovery after surgery (ERAS) recommendations for liver surgery. Regional block techniques have been recommended for liver surgery in ERAS guidelines. Erector spinae plane (ESP) block is a recent block described for thoracic and abdominal surgeries and provides both somatic and visceral analgesia. We describe a high-risk patient with cardiac dysfunction and Parkinson's disease who underwent laparoscopic right liver resection for hepatocellular carcinoma. Satisfactory intra and postoperative analgesia was achieved by a combined continuous ESP block, transversus abdominis plane (TAP), and oblique subcostal TAP blocks. Surgery and postoperative period was uneventful. No opioids were administered during hospitalization. A combined of thoracic and abdominal wall blocks can be an effective approach for intra and postoperative analgesia in high-risk patients undergoing laparoscopic liver resection. Further clinical research is recommended to establish the effectiveness of the ESP block as an analgesic technique in this surgery.

Resumen El dolor posterior a una resección hepática puede ser difícil de manejar. La anestesia epidural (AE) es una técnica efectiva para el control del dolor en esta cirugía. Sin embargo, la coagulopatía y la hipotensión postoperatorias debido al bloqueo del sistema nervioso autónomo en pacientes de alto riesgo, puede hacer que la AE sea una técnica analgésica inadecuada, de acuerdo con las recomendaciones de la recuperación mejorada después de cirugía (ERAS, por las iniciales en inglés de Enhanced Recovery After Surgery) para cirugía hepática. Se han recomendado las técnicas de bloqueo regional para cirugía hepática en las guías ERAS. El bloqueo del plano erector de la espina (BEE) (ESP, por las iniciales en inglés de erector spinae plan block) es una técnica reciente, para cirugías torácicas y abdominales, que brinda analgesia tanto somática como visceral. Se describe aquí un paciente de alto riesgo con disfunción cardiaca y enfermedad de Parkinson que se sometió a resección la paroscópica del lóbulo derecho del hígado por carcinoma hepatocelular. Se logró analgesia intra y postoperatoria eficaz mediante una combinación de bloqueo continuo ESP, y bloqueos del plano transverso abdominal (PTA) y del plano transverso abdominal subcostal oblicuo. La cirugía y el periodo postoperatorio transcurrieron sin novedad y no se administraron opioides durante la hospitalización. La combinación de bloqueos combinados torácicos y de la pared abdominal pueden ser un abordaje efectivo para la analgesia intra y postoperatoria en pacientes de alto riesgo que se someten a resección hepática laparoscópica. Se recomienda continuar con la investigación clínica a finde establecer la efectividad del bloqueo ESP como técnica anestésica para esta cirugía.

Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series / Bloqueio bilateral do plano eretor da espinha torácica inferior em cirurgia oncológica ginecológica aberta por via abdominal: série de casos

Abstract Objective and background: Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients. Method: Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded. Results: Pain scores ranged from 0 to 4 among the three patients and 48 h opioid consumption in oral morphine equivalents of 4, 6 and 18 mg. No adverse events were recorded up to patient discharge from the hospital. Conclusions: Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Resumo Justificativa e objetivo: O bloqueio do plano do músculo eretor da espinha é um novo bloqueio troncular analgésico popularizado devido à sua facilidade de aplicação e segurança percebida. O bloqueio do plano do músculo eretor da espinha foi postulado para atingir os ramos ventrais e os ramos comunicantes dos nervos espinhais, proporcionando analgesia somática e visceral. Nesta casuística, descrevemos nossa experiência com o bloqueio do plano do músculo eretor da espinha bilateral depositado no nível torácico inferior em cirurgia oncológica ginecológica aberta em três pacientes. Método: Os bloqueios do plano do músculo eretor da espinha guiados por ultrassom foram administrados no pré-operatório, entre o 8° e o 10° processo transverso do tórax bilateralmente. Os valores de uma escala de classificação numérica para dor e consumo de opioides nas primeiras 48 horas de pós-operatório foram registrados. Resultados: Os escores de dor variaram de 0-4 entre as três pacientes e o consumo de opioide em 48 horas equivaleu à morfina oral (4, 6 e 18 mg). Nenhum evento adverso foi registrado até a alta hospitalar das pacientes. Conclusões: O bloqueio do plano do músculo eretor da espinha proporcionou analgesia efetiva em nossa casuística. Embora o mecanismo de ação verdadeiro permaneça obscuro, os relatos de casos disponíveis mostram resultados analgésicos encorajadores, sem eventos adversos registrados. Ensaios prospectivos randômicos formais estão em andamento para fornecer mais evidências sobre sua eficácia, taxa de falha e segurança.

Do we still need central blocks while we have erector spinae plane block? Case of 2. 5 month old infant / Ainda precisamos de bloqueios centrais enquanto temos o bloqueio do eretor da espinha? Caso de criança de 2, 5 meses de idade

Abstract Erector spinae plane block is gaining popularity both for its ease of application and as its comparable effect on postoperative analgesia with central regional techniques like paravertebral block or epidural anesthesia. Its use for many indications has been reported in the literature for pediatric patients. We would like to share our experiences in a 2.5-month infant scheduled for thoracotomy for a giant congenital cyst. Single shot erector spinae plane block was done at T4 level before the start of the surgery for both surgical and postoperative analgesia. No complication was seen during both surgery and follow up period. Erector spinae plane block with the combination of paracetamol was adequate for pain relief.

Resumo O bloqueio do plano do músculo eretor da espinha tem ganhado popularidade, tanto pela facilidade de aplicação quanto pelo efeito comparável em analgesia pós-operatória com técnicas regionais centrais, como o bloqueio paravertebral ou a anestesia peridural. Seu uso tem sido relatado na literatura para muitas indicações em pacientes pediátricos. Gostaríamos de compartilhar nossas experiências no caso de um bebê de 2,5 meses de idade programado para toracotomia para excisão de um cisto congênito gigante. O bloqueio do plano do eretor da espinha dorsal com injeção única foi realizado no nível de T4 antes do início da cirurgia para analgesia cirúrgica e pós-operatória. Nenhuma complicação foi observada durante a cirurgia e o período de acompanhamento. O bloqueio do plano do eretor da espinha com a combinação de paracetamol foi adequado para o alívio da dor.

Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report / Bloqueio contínuo do plano do eretor da espinha lombar para o controle da dor pós-operatória em procedimento de revisão de cirurgia do quadril: relato de caso

Abstract The number of total hip arthroplasty cases performed each year continues to increase; accordingly, so does the number of revision total hip arthroplasty procedures. While our traditional method of analgesia for these patients has involved multimodal medications and a continuous lumbar plexus block, we report two cases of patients who received continuous lumbar erector spinae plane blocks. Both patients exhibited excellent pain control postoperatively and were able to discharge home on postoperative day one. This case report illustrates the possible utility of continuous erector spinae plane blocks for postoperative analgesia in the more frequently occurring revision total hip arthroplasty surgeries.

Resumo O número de artroplastias totais de quadril feitas a cada ano continua a aumentar; consequentemente, o mesmo acontece com o número de procedimentos de revisão de artroplastia total de quadril. Embora nosso método tradicional de analgesia para esses pacientes tenha envolvido medicações multimodais e um bloqueio contínuo do plexo lombar, relatamos dois casos de pacientes que receberam bloqueios contínuos do músculo eretor da coluna lombar. Ambos apresentaram excelente controle da dor pós-operatória e obtiveram alta hospitalar no primeiro dia de pós-operatório. Este relato de caso ilustra a possível utilidade do bloqueio contínuo do plano do eretor da espinha para analgesia pós-operatória nas cirurgias, cada vez mais frequentes, de revisão de artroplastia total do quadril.

Ultrasound guided erector spinae plane block for postoperative analgesia after augmentation mammoplasty: case series / Bloqueio do plano eretor da espinha guiado por ultrassom para analgesia pós-operatória em mamoplastia de aumento: série de casos

Abstract Augmentation mammoplasty is the third most frequently performed esthetic surgical procedure worldwide. Breast augmentation with prosthetic implants requires the insertion of an implant under breast tissue, which causes severe pain due to tissue extension and surgical trauma to separated tissues. In this case series, we present the successful pain management of six patients with ultrasound-guided Erector Spinae Plane block after augmentation mammoplasty. In the operating room, all patients received standard monitoring. While the patients were sitting, the anesthesiologist performed bilateral ultrasound-guided erector spinae plane block at the level of T5. Bupivacaine (0.25%, 20 mL) was injected deep to the erector spinae muscle. Then, induction of anesthesia was performed with propofol, fentanyl, and rocuronium bromide. All patients received intravenous dexketoprofen trometamol for analgesia. The mean operation time was 72.5±6 min and none of the patients received additional fentanyl. The mean pain scores of the patients were 1, 2, 2, and 2 at the postoperative 5th, 30th, 60th and 120th minutes, respectively. At the postoperative 24th hour, the mean Numerical Rating Scale score was 1. The mean intravenous tramadol consumption was 70.8±15.3 mg in the first 24 h. None of the patients had any complications related to erector spinae plane block.

Resumo A mamoplastia de aumento é o terceiro procedimento cirúrgico estético mais feito em todo o mundo. A cirurgia com implantes protéticos requer a inserção de um implante sob o tecido mamário, o que causa dor intensa devido à extensão do tecido e trauma cirúrgico aos tecidos separados. Nesta série de casos, apresentamos o manejo bem-sucedido da dor em seis pacientes com bloqueio do plano eretor da espinha guiado por ultrassom (US-ESP) após mamoplastia de aumento. Na sala de cirurgia, todas as pacientes receberam monitoramento padrão. Enquanto as pacientes estavam sentadas, o anestesiologista fez o bloqueio US-ESP bilateral no nível de T5. Bupivacaína (0,25%, 20 mL) foi injetada entre os músculos romboide maior e eretor da espinha. Em seguida, a indução anestésica foi feita com propofol, fentanil e rocurônio. Todas as pacientes receberam dexcetoprofeno trometamol por via venosa para analgesia. O tempo médio de operação foi de 72,5 ± 6 minutos e nenhuma das pacientes recebeu fentanil adicional. Os escores médios de dor das pacientes foram 1, 2, 2 e 2 no 5°, 30°, 60° e 120° minutos de pós-operatório, respectivamente. No 24° dia de pós-operatório, o escore médio da Escala de Avaliação Numérica (NRS) foi 1. O consumo médio de tramadol foi de 40 ± 33,4 mg nas primeiras 24 horas. Nenhuma das pacientes apresentou complicações relacionadas ao bloqueio US-ESP.

Erector spinae plane block as a multiple catheter technique for open esophagectomy: a case report / Bloqueio do plano do eretor da espinha com técnica de múltiplos cateteres para esofagectomia aberta: relato de caso

Abstract Background and objective: Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery. Case report: A patient underwent open esophagectomy followed by reconstructive esophagogastroplasty but refused thoracic epidural analgesia; a multi-modal analgesia with a multiple erector spinae plane block was then planned. Three erector spinae plane catheters (T5 and T10 on the right side and T9 on the left side) for continuous analgesia were placed before surgery. During the first 48 h pain was never reported in the thoracic area but the patient reported multiple times to feel a pain well localized in epigastrium, but never localized in any other abdominal quadrant. Discussion: Erector spinae plane block is a valid technique to provide analgesia simultaneously for combined thoracic and abdominal surgery and could be a valid alternative strategy if the use of epidural analgesia is contraindicated.

Resumo Justificativa e objetivo: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia em cirurgias combinadas, torácica e abdominal, de modo simultâneo. Relato de caso: Um paciente foi submetido à esofagectomia aberta seguida de esofagogastroplastia reconstrutiva, mas recusou analgesia peridural torácica; uma analgesia multimodal com o bloqueio dos múltiplos segmentos do eretor da espinha foi então planejada. Três cateteres foram colocados no plano do eretor da espinha (T5 e T10 no lado direito e T9 no lado esquerdo) para analgesia contínua antes da cirurgia. Durante as primeiras 48 horas, não houve queixa de dor na área torácica, mas várias vezes o paciente relatou sentir uma dor bem localizada no epigástrio, mas nunca localizada em qualquer outro quadrante abdominal. Discussão: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia de modo simultâneo em cirurgias combinadas - torácica e abdominal - e pode ser uma estratégia opcional também válida nos casos em que o uso de analgesia peridural for contraindicado.

Continuous erector spinae plane block for postoperative analgesia of multiple rib fracture surgery: case report / Bloqueio do plano do eretor da espinha para analgesia pós-operatória de cirurgia de fratura de múltiplas costelas: relato de caso

Abstract Introduction: The erector spinae plane block is a newly described and effective interfascial plane block for thoracic and abdominal surgery. This case report describes a patient with multiple rib fractures undergoing ultrasound-guided continuous erector spinae plane block for analgesia. Case report: A 37-year-old male patient was taken for surgical fixation of multiple rib fractures. At the end of the surgery, using ultrasound-guided longitudinal parasagittal orientation 3 cm to the lateral aspect of the T5 spinous process and an in-plane technique, 20 mL 0.25% bupivacaine was administered between the erector spinae muscle and the transverse process, and a catheter was then inserted in the same plane. Before the end of surgery, 1 g paracetamol and 50 mg dexketoprofen were administered. Postoperative analgesia was applied with patient controlled analgesia method using 0.25% bupivacaine via the catheter. The patient's Visual Analogue Scale score at rest in the first 24 h was 0. The patient was monitored for 3 days with Visual Analogue Scale < 4, and the catheter was removed on postoperative day 4. No opioid requirement other than paracetamol and dexketoprofen occurred during this time. No postoperative complications were recorded. Discussion: The erector spinae plane block is an alternative to paravertebral, intercostal, epidural or other regional techniques. It may be a suitable technique in anesthesia and algology practice due to providing analgesia in the postoperative period with a catheter in the erector spinae plane.

Resumo Introdução: O bloqueio do plano do eretor da espinha é um bloqueio do plano interfacial recentemente descrito e eficaz para cirurgia torácica e abdominal. Neste relato descrevemos o caso de um paciente com fratura de múltiplas costelas, submetido ao bloqueio contínuo do plano do eretor da espinha guiado por ultrassom para analgesia. Relato de caso: Paciente do sexo masculino, 37 anos, encaminhado para fixação cirúrgica de fratura de múltiplas costelas. Ao final da cirurgia, usando a orientação parassagital longitudinal guiada por ultrassom 3 cm em relação à face lateral do processo espinhoso T5 e a técnica no plano, 20 ml de bupivacaína a 0,25% foram administrados entre o músculo eretor da espinha e o processo transverso, e um cateter foi então inserido no mesmo plano. Antes do final da cirurgia, 1 g de paracetamol e 50 mg de dexcetoprofeno foram administrados. A analgesia pós-operatória foi aplicada com o método de analgesia controlada pelo paciente, com bupivacaína a 0,25% via cateter. Na Escala Visual Analógica, o escore do paciente em repouso nas primeiras 24 h foi zero. O paciente foi monitorado por três dias com a Escala Visual Analógica < 4, e o cateter foi removido no quarto dia de pós-operatório. Exceto por paracetamol e dexcetoprofeno, não houve necessidade de outro agente opioide durante esse tempo. Não houve registro de complicação pós-operatória. Discussão: O bloqueio do plano do eretor da espinha é uma alternativa às técnicas paravertebrais, intercostais, epidurais ou outras técnicas regionais. Pode ser uma técnica adequada na prática de anestesia e algologia devido ao fornecimento de analgesia no período pós-operatório mediante um cateter no plano do eretor da espinha.

Bloqueo del erector de la espina en cirugía torácica pediátrica / Erector spinae plane block in thoracic pediatric surgery

Thoracotomy is associated with intense pain. In the pediatric population, the pain affects the ventilatory mechanics, which is also strongly influenced by the characteristics of the respiratory tract and chest according to the age. Therefore, regional techniques are strongly recommended. In 2016, ESP is described for the first time, which generates extensive sensory block in the chest wall, without approaching the pleura and the neuroaxial space from the technical point of view. At present, there is increasing experience in different surgical settings, but it is still scarce in pediatric patients. We present the successful application of the technique in 2 pediatric cases of thoracic surgery and various outcomes are described.

La toracotomía está asociada con intenso dolor. En la población pediátrica, el dolor afecta la mecánica ventilatoria, que además se ve fuertemente influida por las características propias de las vías respiratorias y del tórax según la edad. Por lo anterior, las técnicas regionales están fuertemente recomendadas. En 2016 se describe por primera vez el ESP, que genera bloqueo sensitivo extenso en la pared torácica, sin aproximarse desde el punto de vista técnico a la pleura y al espacio neuroaxial. En la actualidad, existe experiencia en aumento en diversos settings quirúrgicos, pero es aún escasa en pacientes pediátricos. Presentamos la aplicación exitosa de la técnica en 2 casos pediátricos de cirugía torácica, así como la descripción de diferentes resultados posoperatorios.

Efficacy of erector spinae block versus retrolaminar block for postoperative analgesia following posterior lumbar surgery / 南方医科大学学报

OBJECTIVE@#To compare the effect of erector spinae plane block and retrolaminar block for relieving acute pain after posterior lumbar surgery.@*METHODS@#Eighty-nine patients undergoing selective posterior lumbar surgery under general anesthesia in our hospital between January and December, 2018, were recruited. Of these patients, 30 received total intravenous general anesthesia to serve as the control group, 28 received total intravenous general anesthesia (TIVA) combined with erector spinae plane block (ESPB), and 31 had TIVA combined with retrolaminar block (RLB). All the patients received patient-controlled intravenous analgesia (PCIA) for postoperative analgesia, and their heart rate, blood pressure, and pulse oximetry were routinely monitored during the anesthesia. VAS scores were evaluated before and at 2, 8, 12, 24, and 48 h after the surgery. Sufentanil consumption during the operation and PCIA were also recorded. The postoperative complications such as nausea and vomiting, urinary retention, itching and respiratory depression within 48 h after the surgery were also recorded.@*RESULTS@#At 2, 8 and 12 h postoperatively, VAS scores in the ESPB group and RLB group were significantly lower than those in the control group; the scores were significantly lower in RLB group than in ESPB group ( < 0.05). Compared with that in the control group, sufentanil consumption during the operation and PCIA were significantly decreased in both ESPB and RLB groups, particularly in the latter group ( < 0.05). Two patients experienced nausea and vomiting and 1 patient complained of pruritus in control group; 1 patient had over sedation and 1 had urinary retention in ESPB group; 1 patient had urinary retention in RLB group.@*CONCLUSIONS@#Ultrasound-guided RLB has better analgesic effect than ESPB for management of perioperative pain following posterior lumbar surgery.