Outcomes in pediatric liver transplant recipients receiving bilateral continuous erector spinae plane blocks.

BACKGROUND: Regional anesthesia allows for opioid-sparing and enhanced recovery after many major surgeries. Erector spinae blockade, with reduced bleeding risk and the option for continuous infusion, offers an opportunity to promote this principle in pediatric liver transplant patients. Our goal was to evaluate pain scores, opioid use, and return of bowel function following continuous ESP blockade in pediatric liver transplant recipients. METHODS: This retrospective cohort study included extubated patients who received a liver transplant at St. Louis Children's Hospital from July 2016 to July 2021. The control group, which did not meet the criteria for ESP blockade and received standard analgesia regimens, was compared to the group receiving continuous ESP blockade. Measured outcomes included pain scores, opioid consumption through postoperative day two, date of first bowel movement, and length of stay in the ICU and the hospital. RESULTS: Patient demographics between control and ESP groups showed no significant differences. Pain scores between control and ESP groups also showed no significant differences. Intraoperative and postoperative opioid requirements, studied in oral morphine equivalents per kilogram (OME/kg), were significantly lower for patients with ESP blockade. Time to first bowel movement was also significantly earlier for the ESP group. No significant differences were found in length of ICU or hospital stay. There were no safety concerns or complications related to ESP blockade. CONCLUSIONS: Use of continuous ESP blockade resulted in reduced opioid consumption through postoperative day two and earlier return of bowel function.

Postoperative pain treatment with erector spinae plane block and pectoralis nerve blocks in patients undergoing mitral/tricuspid valve repair - a randomized controlled trial.

BACKGROUND: Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks. METHODS: This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry. RESULTS: Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6-16] mg vs. 20 [IQR: 18-29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry. CONCLUSIONS: The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy. TRIAL REGISTRATION: The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.

Efficacy of Erector Spinae Plane (ESP) Block for Non-cardiac Thoracic and Upper Abdominal Surgery: A Single Institute Comparative Retrospective Case Series.

Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022. All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD) 1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and required significantly more antiemetic pharmacotherapy (mean 1.4 antiemetics administered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24 hours (95% CI -9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral block techniques in thoracic and upper abdominal surgeries for perioperative pain management.

Ultrasound-Guided Regional Anesthesia Using a Mixture of Dexamethasone, Dexmedetomidine, and 0.2% Levobupivacaine for Bilateral Breast Cancer Surgery Under a Spontaneous Breathing Opioid-Free Anesthesia: A Case Report.

Breast cancer is unfortunately the most common cancer in women, although survival rates have greatly increased in recent years. Breast surgery can be very aggressive and therefore highly painful, leading to high rates of acute postsurgical pain and chronic pain. In addition to general anesthesia (GA), ultrasound-guided regional anesthesia (RA) is sometimes performed to help reduce acute postoperative pain and consumption of opioids. Although effective, the main limitation of fascial plane blocks is that they require high volumes of local anesthetics, carrying the risk of local anesthetic systemic toxicity. In this article, we present the case of a 41-year-old woman, who refused GA and was successfully operated on for bilateral breast cancer, under a spontaneous breathing opioid-free sedation and ultrasound-guided RA, based on only 0.2% levobupivacaine with the addition of dexamethasone and dexmedetomidine as adjuvants. Despite this, postoperative analgesia lasted for more than 48 hours, and the patient did not require additional analgesia or opioids.

Continuous Erector Spinae and Serratus-Intercostal Block With Ketamine-Dexmedetomidine Sedation for Quadrantectomy and Axillary Dissection in a Multimorbid Patient.

Multimorbidity is a clinical presentation that poses an increased risk of perioperative and postoperative complications. Tailored anaesthetic management could potentially minimise the risk of negative outcomes. Peripheral nerve and fasciae blocks are valid strategies for perioperative and postoperative pain management, which avoid complications related to general anaesthesia and reduce the risk of intensive care unit admission as well as the hospital length of stay. We describe the case of a 56-old patient with multimorbidity, including obesity with a BMI of 45.7, unstable angina, predicted difficult airway management and obstructive sleep apnoea syndrome (OSAS) scheduled for left mastectomy with sentinel lymph node biopsy, managed with a left continuous thoracic erector spinae plane (ESP) block plus serratus-intercostal plane block (BRanches of Intercostal nerves at the Level of Mid-Axillary line (BRILMA)), and sedation with combined ketamine-dexmedetomidine. Fascial blocks combined with opioid-free anaesthesia (OFA) proved to be effective for the multimorbid patient, ensuring successful perioperative management and a proper recovery after surgery.

Successful Management of a Patient With a History of Postoperative Delirium Undergoing Cardiac Surgery With an Erector Spinae Plane Block and Multimodal Analgesia: A Case Report.

Perioperative delirium is an acute confusional state with fluctuating levels of consciousness, which can be precipitated by opioid-based anesthetics and inadequate pain control, especially in patients undergoing cardiac surgery. We seek to minimize opioid usage to avoid postoperative delirium in a patient with multiple risk factors undergoing aortic valve replacement. We used cardiac enhanced recovery after surgery protocols (ERAS-C), which include multimodal analgesia and regional anesthesia via bilateral erector spinae plane (ESP) blocks. Our observations suggest that bilateral ESP blocks and cardiac ERAS protocols offer a potential option to manage pain and control risk factors in patients at high risk of postoperative delirium undergoing cardiac surgery.

Simulation-Based Medical Education and Training Enhance Anesthesia Residents' Proficiency in Erector Spinae Plane Block.

Background: Advances in regional anesthesia and pain management led to the advent of ultrasound-guided fascial plane blocks, which represent a new and promising route for the administration of local anesthetics. Both practical and theoretical knowledge of locoregional anesthesia are therefore becoming fundamental, requiring specific training programs for residents. Simulation-based medical education and training (SBET) has been recently applied to ultrasound-guided regional anesthesia (UGRA) with remarkable results. With this in mind, the anesthesia and intensive care residency program of the University of Milano-Bicocca organized a 4-h regional anesthesia training workshop with the BlockSim® (Accurate Srl, Cesena) simulator. Our study aimed to measure the residents' improvement in terms of reduction in time required to achieve an erector spinae plane (ESP) block. Methods: Fifty-two first-year anesthesia residents were exposed to a 4-h training workshop focused on peripheral blocks. The course included an introductory theoretical session held by a locoregional anesthetist expert, a practical training on human models and mannequins using Onvision® (B. Braun, Milano) technologies, and two test performances on the BlockSim simulator. Residents were asked to perform two ESP blocks on the BlockSim: the first without previous practice on the simulator, the second at the end of the course. Trainees were also also asked to complete a self-assessment questionnaire. Results: The time needed to achieve the block during the second attempt was significantly shorter (131 [83, 198] vs. 68 [27, 91] s, p < 0.001). We also observed a reduction in the number of needle insertions from 3 [2, 7] to 2 [1, 4] (p = 0.002), and an improvement aiming correctly at the ESP from 30 (58%) to 46 (88%) (p < 0.001). Forty-nine (94%) of the residents reported to have improved their regional anesthesia knowledge, 38 (73%) perceived an improvement in their technical skills and 46 (88%) of the trainees declared to be "satisfied/very satisfied" with the course. Conclusions: A 4-h hands-on course based on SBET may enhance first-year residents' UGRA ability, decrease the number of punctures and time needed to perform the ESP block, and improve the correct aim of the fascia.

Fascial Plane Blocks Combination for Breast Surgery in Obese Patients With Difficult Airway Management: Insidious or a Valid Alternative.

Obesity poses several challenges for anesthetists. The several comorbidities associated with obesity can result in very complex management, which requires a multimodal and reasoned approach. The possible difficult airways are, certainly, the obstacle that most can put the anesthetist to the test. From this point of view, regional anesthesia (RA) can be a valid alternative to general anesthesia (GA) in selected patients. The possibility of performing an anesthetic block allows the fulfilment of the surgical act. We present the case of a 56-year-old woman, with a BMI of 43. In her medical history, she has obstructive sleep apnea syndrome (OSAS) on home-oxygen therapy without continuous positive airway pressure (CPAP) therapy. The patient reported probable airway difficulties in previous breast surgery, and the preoperative evaluation highlighted and confirmed the high risk. For this reason, in agreement with the surgeons and the patient, we decided to perform RA. Forty minutes before the start of the surgery, a deep anesthetic ultrasound-guided serratus anterior plane (US-SAP; branches of the intercostal nerves in the middle axillary line [BRILMA]) was performed, followed by a right ultrasound-guided erector spinae plane (US-ESP) block. Mild sedation with propofol 1 mg/kg/h was administered and SpO2 always remained above 97% with nasal oxygen at 3 l/min. The surgery was completed in 35 minutes, the patient complained of no pain, and received opioid rescue therapy during the post-operative period. This case presents clinical evidence that RA can help in avoiding some dreadful complications that can occur during GA in obese patients. In any case, the anesthetic management choice must be carefully reasoned, considering the patient's clinical conditions, surgical needs, and, not least, the skills of the anesthetist.