Efficacy of the erector spinae plane (ESP) block for quality of recovery in posterior thoraco-lumbar spinal decompression surgery: study protocol for a randomised controlled trial.

BACKGROUND: Spinal surgery can be associated with significant postoperative pain. Erector spinae plane (ESP) block is a new regional anaesthesia technique, which promises effective postoperative analgesia compared with systemically administered opioids, but has never been evaluated in terms of patient-centred outcomes such as quality of recovery and overall morbidity after major thoraco-lumbar spinal surgery. METHODS: We are conducting a prospective, randomised, double-blind trial in two hospitals in the Republic of Ireland. The sample size will be 50 patients (25 in the intervention group and 25 in the control group). Randomisation will be done using computer-generated concealed envelopes. Both patients and investigators collecting outcome data will be masked to group allocation. Participants will be male or female, aged 18 years and over, capable of providing informed consent and ASA grade I-IV. Patients scheduled to undergo posterior approach thoraco-lumbar decompression surgery involving 2 or more levels will be recruited to the study. Participants randomised to the intervention arm of the study will receive bilateral ultrasound-guided ESP block totalling 40 ml 0.25% levo-bupivcaine (20 ml each side), post induction of general anaesthesia and before surgical incision. The control group will not receive an ESP block. Both groups will receive the same standardised analgesic protocol both intra- and postoperatively. The primary outcome will be the quality of recovery at 24 h postoperatively as determined by the QoR-15 score. This score is determined by a questionnaire which measures patient responses to 15 subjective parameters, each response graded on a scale from 0 to 10. The maximum score achievable is 150 with a potential minimum score of 0. Higher scores indicate a higher quality of recovery experience. Secondary outcomes will include area under the curve (AUC) of VRS pain versus time at rest and on movement up to 24 h postoperatively, 24 h opioid consumption, time to first analgesia in recovery, length of stay (LOS), incidence and severity of postoperative complications as measured by the Comprehensive Complication Index (CCI) score. DISCUSSION: To the best of our knowledge, this will be the first randomised control trial to examine the efficacy and safety of the ESP block in terms of patient-centred outcomes in the setting of major spinal surgery. The QoR-15 is a validated means of assessing the quality of recovery after surgery and gives a more holistic assessment of the recovery experience from the patient's point of view. TRIAL REGISTRATION: This trial is pre-registered on ClinicalTrials.gov reference number NCT04370951 . Registered on 30 April 2020. All items from the World Health Organisation Trial Registration Data Set have been included.

Recent Developments in Cardiology Procedures for Adult Congenital Heart Disease: The Anesthesiologist's Perspective.

Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care have significantly increased the number of survivors. Unfortunately, as these patients progress through life they frequently require further interventions. Although surgical intervention may be required frequently, these patients can be managed in the cardiac catheterization or electrophysiology laboratory. Surgical correction of tetralogy of Fallot can leave patients with pulmonary valve dysfunction later in life. A percutaneous approach is now available for these patients, which can obviate the need for resternotomy. During deployment of the valve, anesthesiologists should be aware that compression of coronary arteries can occur. Adult congenital heart disease (ACHD) patients often require pacemaker/implantable cardioverter- defibrillator (ICD) insertion or ablation therapy. These patients may have altered cardiac anatomy, which can make endovascular procedures extremely challenging. Recent developments have made these procedures safer and more efficient. A number of congenital cardiac conditions can also be associated with orofacial abnormalities. ACHD patients, as a result, can present with challenging airways. The catheterization laboratory may not be the optimum environment for the anesthesiologist to manage a difficult airway. The requirement of transesophageal echocardiography for some cath eterization procedures needs to be considered when deciding on an airway management plan. Knowledge of the underlying cardiac anatomy and the planned procedure is advised when providing anesthesia for this complex patient group outside the theater setting.

Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial.

BACKGROUND: Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery. METHODS: Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay. RESULTS: The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h-1vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h-1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25-75% range): 4 (2-4) vs 5 (3-6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25-75%) CCI in ESP and SAP was 1 (0-2) vs 4 (0-26) (P=0.03), whereas hospital stay was 3 (2-6) vs 6 (3-9) days (P=0.17), respectively. CONCLUSION: Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery. CLINICAL TRIAL REGISTRATION: NCT03862612.