Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind, randomized controlled trial.

PURPOSE: The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery. METHODS: A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10-15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded. RESULTS: The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred. CONCLUSION: The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

A randomized double-blind controlled study comparing erector spinae plane block and thoracic paravertebral block for postoperative analgesia after breast surgery.

BACKGROUND: Thoracic paravertebral block (PVB) is an effective regional block for pain control after breast surgery. However, accidentally puncturing adjacent vital structures may cause undesirable complications. Erector spinae plane block (ESPB) has been considered a safer proxy of PVB for beginners. This study aimed to evaluate the analgesic effects of ultrasound-guidance PVB and ESPB after breast surgery. METHODS: This randomized control trial was conducted in patients who underwent mastectomy. Forty-four females were randomly allocated into PVB group or ESPB group. All patients received a block with 20 ml of 0.5% levobupivacaine before general anesthesia. The primary outcome was the 24-h postoperative morphine requirements. The other outcomes of interest were postoperative pain scores, time to first analgesic request, dermatome of sensory blockade, block-related complications, and opioid adverse events. RESULTS: The 24-h morphine requirements were significantly lower in PVB compared to the ESPB group (3.5 ± 3.3 vs. 8.6 ± 3.8 mg, P < 0.001). The overall pain scores were also lower in the PVB group (P < 0.001). Only 14 patients in the PVB group requested additional morphine, whereas all patients in the ESPB group requested it (P = 0.004). The dermatome of sensory blockade was wider in the PVB group (7 vs. 4 levels, P = 0.019). No serious complications occurred in either group. CONCLUSIONS: Compared to ESPB, PVB provided lower postoperative opioid requirements, lower pain scores, and wider sensory blockade after mastectomy.

Erector Spinae Plane Block and Paravertebral Block for Breast Surgery: A Retrospective Propensity-Matched Noninferiority Trial.

PURPOSE: Thoracic paravertebral block (TPVB) is an established analgesic technique for breast surgery although it is technically challenging. Erector spinae plane block (ESPB) requires less technical expertise and may be an alternative to TPVB. However, whether ESPB has similar analgesic effects to TPVB for breast surgery is still inconclusive. Moreover, information on sensory blockade of ESPB is scarce. Accordingly, we conducted this retrospective propensity-matched study to see if ESPB could provide comparable analgesic effects to TPVB in patients undergoing breast surgery. We also compared cutaneous sensory block levels after the two techniques. PATIENTS AND METHODS: In this retrospective cohort study, we analyzed data saved in our database and compared the two techniques using a propensity matching method. The data of patients who underwent unilateral breast surgery under general anesthesia with the addition of either TPVB or ESPB were identified. We considered that the analgesic efficacy of ESPB was noninferior to TPVB if both postoperative fentanyl consumption and area under the curve (AUC) for pain scores within 24 h were within 50 µg and 240 mmï½¥h margins, respectively. Cutaneous sensory block levels, additional analgesic requirements, and complications were also compared between the two groups. RESULTS: Among 93 patients, 30 patients for each group were matched. Both postoperative fentanyl consumption and AUC for pain scores after ESPB were noninferior to those after TPVB. ESPB did not produce sensory blockade consistently, and the number of dermatomes was smaller after ESPB [1 (0-3)] [median (interquartile range)] than after TPVB [4 (2-5)] (P=0.002). No serious complications related to blocks were observed. CONCLUSION: ESPB and TPVB provided comparable postoperative analgesia for 24 h in patients undergoing breast surgery. Dermatomal sensory blockade was, however, less apparent and narrower after ESPB than after TPVB.

Distribution of injectate administered through a catheter inserted by three different approaches to ultrasound-guided thoracic paravertebral block: a prospective observational study.

BACKGROUND: Despite the popularity of continuous thoracic paravertebral block (TPVB), there is a paucity of information on catheter tip position and distribution of injectate through the catheter. We observed, in real time, the spread of dye, the catheter tip position and sensory block levels produced with three different (intercostal (IC), transverse process sagittal (TS) and paralaminar (PL)) approaches to ultrasound-guided TPVB in patients undergoing video-assisted thoracoscopic surgery. METHODS: After the induction of general anesthesia, ultrasound-guided TPVB was conducted with a patient in the lateral decubitus position. During surgery, 10 mL of dye was injected through a catheter to observe the catheter tip and the dye distribution under thoracoscopy. Dermatomal sensory block levels were measured postoperatively. RESULTS: Ten patients for each of three different approaches completed the study. There were a variety of dye spreading patterns. The median (range) number of segmental levels stained with dye was 1.5 (1-4), 3 (1-4) and 3 (1-5) with the IC, TS and PL approaches, respectively. We observed that a catheter tip was present at the same segmental paravertebral space as intended in 50%-90% of patients using these approaches. The median (range) number of dermatomes with sensory blockade at 6 hours after block was 2.5 (1-4), 3 (2-8) and 3 (1-8) with the IC, TS and PL approaches, respectively. CONCLUSIONS: Although a bolus injection through a catheter for ultrasound-guided TPVB produced multiple levels of spread and sensory blockade in more than half the patients, considerable differences existed in the spread regardless of approach.

Continuous basal infusion versus programmed intermittent bolus for quadratus lumborum block after laparoscopic colorectal surgery: a randomized-controlled, double-blind study.

BACKGROUND: Quadratus lumborum block (QLB) has recently attracted attention as a part of multimodal analgesia after abdominal surgery. It has been shown that programmed intermittent boluses of local anesthetic can produce better analgesia and wider sensory blockade compared with continuous basal infusion with some peripheral nerve blocks. The present study was conducted to see if this theory holds true for QLB in patients undergoing laparoscopic colorectal surgery. METHODS: Fifty patients undergoing laparoscopic colorectal surgery were divided into 2 groups to receive continuous basal infusion (group C) or programmed intermittent boluses (group PIB) of local anesthetic. After surgery, patients received the posterior approach to QLB and a catheter was introduced bilaterally. Patients in group C received a continuous infusion of 0.15% levobupivacaine at 3 ml/h, and those in group PIB received a bolus of 12 ml every 4 h. All patients received intravenous patient-controlled analgesia using fentanyl. Measurements were taken for cumulative fentanyl consumption, pain scores, cutaneous sensory blockade, analgesic requirements, and adverse events for 46 h. RESULTS: The primary outcome of cumulative fentanyl consumption at 22 h showed no significant difference between the groups [group C: 11.9 (11.2-15.5) µg/kg (median (interquartile range)) and group PIB: 12.3 (11.6-15.3), p = 0.473]. Pain scores, demands for rescue analgesics, and spread of cutaneous sensory blockade were similar for the two groups. CONCLUSION: Programmed intermittent boluses of local anesthetic for continuous QLB did not produce better analgesia or wider sensory blockade compared with continuous basal infusion in patients undergoing laparoscopic colorectal surgery.

Effect of intermediate dose dexamethasone on post-operative pain in lumbar spine surgery: A randomized, triple-blind, placebo-controlled trial.

OBJECTIVES: Dexamethasone has demonstrated analgesic properties and is used as an adjunctive pain agent for many procedures. We evaluated the efficacy of a single, intermediate dose of dexamethasone on post-operative analgesic consumption, and pain scores for lumbar spine surgery. METHODS: Eighty patients aged between 18 and 70 scheduled for lumbar decompressive laminectomy were randomly allocated into two groups to receive either intravenous 0.2 mg/kg dexamethasone (group D = 40) or normal saline (group P = 40) before anesthetic induction. Post-operative total morphine consumption and the respective pain score at the PACU, 4, 6, 12, 24 and 48 h were evaluated. In addition, any adverse events were recorded. RESULTS: Total post-operative morphine consumption within 48 h was significantly lower in group D (34.5 vs. 42.5 mg, p = 0.031); however, the respective morphine consumption at each assessment was similar between groups. The respective NRS pain score at rest and upon movement in both groups was not significantly different for any time comparison. The average NRS pain score at rest and upon movement within 48 h was similar in both groups (i.e., NRS at rest Group D 3.6 vs. Group P 3.8, p = 0.936, and NRS for movement Group D 6.2 vs. Group P 6.3, p = 0.791). The adverse events within 48 h were also similar and serious complications (i.e., respiratory depression or surgical infection) were not found in either group. CONCLUSION: A single, intermediate dose of dexamethasone before anesthetic induction could minimally decrease post-operative morphine consumption within 48 h after lumbar decompressive laminectomy without any effect on the pain score.

Outcome of anesthetic management for children with craniofacial deformities.

BACKGROUND: The challenge for anesthetic management for children with craniofacial deformities is to develop comprehensive anesthetic care. The purposes of this study were to review the authors' experience with airway management and ventilator support and evaluate outcome during the perioperative period among these patients at the Tawanchai Center, Srinagarind Hospital. METHODS: A retrospective (2005-2009), descriptive study was conducted to analyze the anesthetic management and perioperative outcomes among children with craniofacial deformities at the Tawanchai Center. Techniques for airway management included direct laryngoscope (DL), DL with stylet, fiber-optic bronchoscope (FOB), laryngeal mask airway, retrograde intubation, a combination of these techniques and more than one anesthesiologist. RESULTS: Forty-five children with craniofacial deformities were classified as having the following: craniosynostosis; craniofacial microsomia; Treacher-Collins syndrome (TCS); coloboma of the eye, heart defects, atresia choanae, retarded growth and/or development, genital and/or urinary abnormalities, ear abnormalities and deafness (CHARGE) syndrome; frontoethmoidal encephalomeningocele; Pierre Robin sequence; and craniofacial cleft. Most of the patients underwent induction of anesthesia by inhalation of an anesthetic agent. The children with TCS were the most difficult group with regard to airway management with DL view (13%), and multiple airway accessories and intubation techniques were needed. The two most common methods for management of difficult airway obstructions were the use of stylet and FOB. No complications occurred during intubation and minor complications were observed during the perioperative period. CONCLUSION: A successful outcome depended on the provision of interdisciplinary craniofacial team management, comprehensive anesthetic evaluation and management, well-informed and cooperative children and supportive family members.