Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients. DESIGN: A prospective, randomized, double-blind, comparative study. SETTING: At a single institution tertiary referral cardiac center. PARTICIPANTS: A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups. CONCLUSION: Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients.

Ultrasound-guided multiple-injection costotransverse block for mastectomy and primary reconstructive surgery. A study protocol.

BACKGROUND: Post-operative pain amelioration following breast cancer surgery is inconsistent. The novel multiple-injection costotransverse block (MICB) mimics the thoracic paravertebral block by possible anaesthetising the ventral rami of the thoracic spinal nerves and the sympathetic trunk. Proof of concept has been determined in a cadaveric study and needs further clinical testing. METHODS: This double-blinded, randomised and placebo-controlled study investigates the efficacy of the ultrasound-guided MICB versus placebo in 36 patients undergoing unilateral mastectomy and primary subpectoral reconstruction surgery. Oral pre-operative medicine is standardised for all patients. Active group is pre-operatively administered MICB with three injections of each 10 ml of ropivacaine (5 mg/ml). The placebo group is pre-operatively administered three injections of each 10 ml of saline (0.9%). Standard general anaesthesia is induced and 30 min before emergence 0.2 µg/kg total body weight sufentanil IV, 1 g of paracetamol IV and 4 mg of ondansetron IV (post-operative nausea and vomiting, PONV, prophylaxis) will be administered. All patients are provided with a patient-controlled analgesia pump with morphine. The primary aim is total morphine consumption in the first 24 post-operative hours. Secondary aims are pain intensity, duration of the block, patient satisfaction, side effects, time to ambulation, time to discharge, and quality of recovery. DISCUSSION: Recruitment began in November 2019 and is expected to finish ultimo 2021. Results are expected to be published in an international peer-reviewed medical journal. The results will hopefully provide a substantial contribution to the knowledge of these new 'intertransverse process blocks' providing regional anaesthesia of the thoracic wall.

Are single-injection erector spinae plane block and multiple-injection costotransverse block equivalent to thoracic paravertebral block?

BACKGROUND: Thoracic paravertebral block (TPVB) is considered the gold standard for hemithoracic regional anaesthesia. Erector spinae plane block (ESPB) is a new posterior thoracic wall block. Multiple-injection costotransverse block (MICB) mimics TPVB but with injection points within the thoracic intertransverse tissue complex and posterior to the superior costotransverse ligament. We aimed to compare the spread of injectate into the thoracic paravertebral space (TPVS) resulting from single-injection ESPB and MICB, respectively, with TPVB. METHODS: Ten soft-embalmed cadavers were utilised. In five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided single-injection ESPB or single-injection TPVB; vice versa on the other side. In another five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided MICB or multiple-injection TPVB. About 20 mL of dye was injected in each hemithorax with all techniques. RESULTS: With TPVB, the dye was consistently present in the TPVS with concomitant epidural spread in the majority of cases. The injectate spread into the TPVS with ESPB (60%) and MICB (100%). MICB consistently stained the ventral rami (T1-7), communicating rami and thoracic sympathetic trunk without epidural spread. Dissection after MICB revealed dye spread into the TPVS via the costotransverse foramina and along the dorsal branches of the posterior intercostal veins. CONCLUSIONS: Consistent spread of dye into the TPVS colouring the ventral rami, the communicating rami, and the sympathetic trunk was observed with MICB; in this respect equivalent to TPVB. ESPB exhibited only partial success and was not equivalent to TPVB. No epidural spread was found with neither MICB nor ESPB.