Continuous erector spinae plane block versus intercostal nerve block in patients undergoing video-assisted thoracoscopic surgery: a pilot randomized controlled trial.

BACKGROUND: The optimal analgesia method in video-assisted thoracoscopic surgery (VATS) remains controversial. Intercostal nerve blockade (ICNB) is limited by its duration of action. The erector spinae plane (ESP) block has the potential to provide satisfactory analgesia for VATS; however, the effectiveness of continuous ESP versus surgeon-performed ICNB has not been investigated. The objectives of this study were to establish feasibility of patient recruitment and follow-up before undertaking a fully powered randomized controlled trial (RCT); and, secondarily, to compare opioid usage, pain control, and sensory blockade. METHODS: This feasibility RCT was undertaken at St Joseph's Hospital, Hamilton, Ontario, Canada, and included 24 patients (>18 years) having elective VATS with at least one overnight stay. Exclusion criteria were patient refusal, body mass index >40 kg/m2, contraindications to neuraxial analgesia techniques as per the American Society of Regional Anesthesia and Pain guidelines, known allergy to local anesthetics, language or comprehension barriers, procedures with a higher chance of open surgery, and regular opioid use for ≥3 months preoperatively. Patients underwent either continuous ESP (n=12) or surgeon-performed ICNB (n=12). All patients received routine intraoperative anesthesia care and multimodal analgesia. Feasibility criteria were recruitment rate of two patients/week and full follow-up in all patients in-hospital. We compared opioid consumption, postoperative pain scores (0-10 numerical rating scale), adverse events, patient satisfaction, and distribution of sensory blockade as clinical outcomes (secondary). RESULTS: Feasibility of primary outcomes was successfully demonstrated. Five patients had an epidural in anticipation of open surgery. Mean opioid consumption as equivalent morphine units was less in the ESP group over the first 24 h (mean difference, 1.63 [95% CI -1.20 to 4.45]) and 48 h (mean difference, 2.34 [95% CI -1.93 to 6.61]). There were no differences in adverse effects. CONCLUSIONS: A fully powered RCT is feasible with modifications. Our results also suggest that continuous ESP is safe and can decrease opioid needs. However, it is important to consider procedures to improve compliance to protocol and adherence to assigned interventions. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03176667 . Registered June 5, 2017.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant).

INTRODUCTION: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. METHODS: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. DISCUSSION: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block. TRIAL REGISTRATION NUMBER: NCT03691922; Recruited Date of registration: October 2, 2018.

Optimizing Pain and Rehabilitation After Knee Arthroplasty: A Two-Center, Randomized Trial.

BACKGROUND: This randomized trial compared (1) continuous femoral nerve block (cFNB), (2) single femoral nerve block (sFNB), and (3) local infiltration analgesia (LIA) with respect to analgesic and functional outcomes after primary tricompartmental knee arthroplasty (TKA). METHODS: One hundred twenty patients undergoing primary tricompartmental knee arthroplasty were randomly assigned to 1 of 3 interventions for postoperative analgesia: (1) cFNB-preoperative bolus of ropivacaine 0.5% 20 mL followed by ropivacaine 0.2% 5 mL per hour for 48 hours; (2) sFNB-preoperative bolus of ropivacaine 0.5% 20 mL with placebo 0.9% saline 5 mL per hour for 48 hours; or (3) LIA-intraoperative tricompartmental injection of ropivacaine 0.2% (150 mL) with epinephrine (10 µg/mL) and ketorolac 30 mg with femoral placebo 0.9% saline 20 mL preoperative bolus and 0.9% saline placebo 5 mL per hour for 48 hours. All participants received an identical, standardized, postoperative multimodal analgesic regimen. Participants, health care providers, data collectors, and analysts were blinded. All participants received identical perineural catheters and perineural/LIA solution (depending on randomized intervention) to maintain blinding. The primary outcome measure was numeric rating scale for pain (NRS) during physiotherapy on postoperative day (POD) 2 at 9:00 AM. Secondary outcomes included opioid consumption, NRS on POD 1 (rest/physiotherapy/worst), functional outcomes, and block complications. RESULTS: For the primary outcome, pain during physiotherapy on POD 2 at 9:00 AM, the overall analysis of covariance (ANCOVA) was significant (P = .049), but pairwise comparisons did not demonstrate any significant differences between treatment arms. NRS was 4.6 (95% confidence interval [CI], 3.3-6.0) for the cFNB group, 4.6 (95% CI, 3.3-6.0) for the sFNB group, and 3.4 (95% CI, 2.2-4.8) for the LIA group. The following is the mean difference in NRS on POD 2 at 9:00 AM among groups: cFNB-LIA (1.2, 95% CI, -0.1 to 2.5; P = .073); sFNB-LIA (1.2, 95% CI, -0.2 to 2.5; P = .097); cFNB-sFNB (0.0, 95% CI, -1.3 to 1.4; P = .996). There were no statistically significant differences between groups in cumulative 48-hour opioid consumption or functional outcomes. cFNB and LIA were superior to sFNB for NRS on POD 1 for worst pain experienced and pain during physiotherapy, respectively. There were no adverse events associated with study procedures reported among participants in the 3 groups. CONCLUSIONS: Our findings suggest no clinically significant differences between cFNB, LIA, and sFNB for pain during physiotherapy on POD 2 after TKA. Secondary analyses suggest that cFNB and LIA are superior to sFNB for early analgesic outcomes (NRS on POD 1) after TKA.