|Ahead of print publication
Role of Erector Spine Plane Block for Postoperative Analgesia in Patients Undergoing Percutaneous Nephrolithotomy
Rohan Bhatia, Veena Asthana, Rajeev Sarpal, Kriti Bindal
Swami Rama Himalayan University, Dehradun, Uttarakhand, India
|Date of Submission||01-Jun-2021|
|Date of Decision||09-Jun-2021|
|Date of Acceptance||26-Jun-2021|
|Date of Web Publication||11-Oct-2021|
Department of Anaesthesiology, Swami Rama Himalayan University, HIMS, Dehradun, Uttarakhand-248140
Source of Support: None, Conflict of Interest: None
Background and objective: The objective of the present study was to determine the effectiveness of erector spinae plane block (ESPB) for pain relief in patients undergoing percutaneous nephrolithotomy. Methods: Sixty-four patients of either sex, American Society of Anaesthesiology (ASA) Grade I/II for surgery were enrolled. After informed consent, all participants received subarachnoid block with 3 ml of 0.5% injection heavy bupivacaine. Participants in the block group received ultrasound-guided ESPB with 30 ml of 0.5% ropivacaine, whereas participants in the control group received routine analgesia as per our hospital’s protocol for percutaneous nephrolithotomy procedure which is tramadol 100 mg intravenously. This prospective, single-blind, randomized, controlled study was conducted after approval from the institutional ethics committee (SRHU/HIMS/RC/2019/291) and written informed consent was obtained for surgery under spinal anesthesia. Pain score (visual analog scale, VAS) was evaluated by the anesthesiologist who was not involved in the study at 30 minutes and 2, 4, 6, 8, 12, 18, and 24 hours postoperatively and patient was monitored with electrocardiogram, noninvasive blood pressure, heart rate, and pulse oximetry. Unpaired t test was used for comparison between the groups. Results: Both the groups were appropriately matched for age, ASA physical status, weight, and duration of surgery. The total dosing of rescue analgesia, that is, tramadol was considerably more in the control group in comparison with the ESPB group in the first postoperative day (P = 0.000; 218.75 ± 82.06 mg vs. 103.12 ± 47.41 mg, respectively). Similar results were obtained in the VAS pain score. Conclusion: ESPB helped in providing considerable postoperative pain relief in patients undergoing percutaneous nephrolithotomy.
Keywords: Erector spinae plane block, percutaneous nephrolithotomy, postoperative analgesia, tramadol, ultrasound
|How to cite this URL:|
Bhatia R, Asthana V, Sarpal R, Bindal K. Role of Erector Spine Plane Block for Postoperative Analgesia in Patients Undergoing Percutaneous Nephrolithotomy. MAMC J Med Sci [Epub ahead of print] [cited 2021 Dec 3]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=328063
| Introduction|| |
Adequate postoperative analgesia is necessary for enhanced recovery after surgery. Percutaneous nephrolithotomy (PCNL) is a frequently used minimally invasive surgical procedure for treatment of nephrolithiasis in which nephrostomy tube is inserted after the procedure for maintaining enough urinary drainage and achieving hemostasis. However, the procedure itself and the nephrostomy tubes may cause significant discomfort and postoperative pain, resulting in delayed recovery leading to prolonged hospitalization and patient dissatisfaction.
Erector spinae plane block (ESPB) is a unique regional interfascial technique with varied applications. Introduced in the year 2016, the local anesthetic is injected under ultrasound guidance between the transverse process and erector spinae muscle, hence blocking the rami (dorsal and ventral) of both the thoracic and abdominal spinal nerves.,, Cadaveric studies demonstrate that a T5 level block is adequate for unilateral multidermatomal sensory block from T1 to L3, hence behaving as a paravertebral block without the risk of pleural injury.
In our institute, epidural and paravertebral blocks are used very frequently for relieving postoperative pain, resulting from thoracic and abdominal surgeries. ESPB has gained popularity as it has lower risk of complications such as hypotension, has lesser contraindications, and is relatively easier to perform with the help of ultrasound. It has multiple potential benefits such as acute postoperative pain and chronic neuropathic pain., The ESPB can be given as a continuous infusion with the help of a catheter or as a single shot. Another significant advantage of the ESPB is its capability to attain both somatic and visceral analgesia. Its continuous nature, extensive craniocaudal spread, no hindrance to surgical field, and only sensory blockade make ESPB superior to pectoral nerve blocks, transversus abdominis plane block, rectus sheath and quadratus lumborum blocks.
With this background information, we planned a prospective, randomized, single-blind controlled study to evaluate the role of ESPB for postoperative pain relief in patients undergoing PCNL under subarachnoid block.
| Methods|| |
This prospective, interventional, randomized controlled study was conducted over a duration of 3 months December 2019 to February 2020 after approval from the institutional ethics committee (SRHU/HIMS/RC/2019/291) and written informed consent was obtained for surgery under spinal anesthesia. A total of 64 patients as per the sample size of either sex, 18 to 60 years of age, American Society of Anesthesiology (ASA) Grade I/II, who were planned for PCNL under spinal anesthesia and who had informed consent for study were included in the study. The sample size was determined by using the visual analog scale (VAS) to compare the effectiveness. Patient refusal to participate, who were undergoing surgery with an anesthetic technique other than spinal anesthesia, with known local anesthetic allergy, skin infection at the injection site, uncoordinated patients, and surgical intervention longer than 3 hours were excluded from this study.
Randomization of the patients in either of the two groups (group E and group C) was carried out according to computer-generated number sequence.
All patients were kept nil per orally for 6 hours for solid foods and 2 hours for clear liquids. In the operating room, intravenous access was established in nondominant hand and patients were loaded with ringer lactate at the rate of 10 ml/kg. Noninvasive blood pressure, SpO2, and electrocardiogram monitoring were started. Lumbar puncture was performed in sitting position using a midline approach at the third or fourth interspace. A 27-gauge Quincke needle (BD; Madrid, Spain) was inserted and 3 ml of 0.5% heavy bupivacaine was injected over 10 to 15 seconds. The patient was immediately placed supine after the injection. PCNL was performed under spinal anesthesia in the lateral position.
Postoperatively, after nephrostomy tubes were placed, ESPB under ultrasound guidance was performed in lateral position. After identifying the level of the intervertebral space using 2 to 5 MHz curved array C60xi probe (FUJIFILM Sonosite, Inc., Bothell, Washington, USA) by a trained anesthesiologist, the transverse process was traced laterally after identifying the spinous process and lamina approximately 2.5 to 3 cm from midline in longitudinal position. The transverse process was identified as a hyperechoic curvilinear structure with pronounced finger-like acoustic shadowing beneath (trident sign) with lamina (sawtooth pattern) and spinous process medially and costochondral junction laterally. A 100-mm 22-gauge sonoplex (B Braun, Ultra 360, Bbraun, Aesculap, Japan) needle was inserted toward the trapezius and erector spinae and the tip of transverse process (TP) (T8) using the in plane technique in a cephalad-to-caudad orientation. After the needle made contact with the TP, needle placement was confirmed by hydrodissection on injecting 2 to 3ml of distil water. Then, patient received 30 ml of 0.5% ropivacaine under real-time ultrasound guidance.
Pain scores were assessed postoperatively by the anesthesiologist using the VAS score. Self-reported VAS scores were recorded at 30 minutes and 2, 4, 6, 8, 12, 18, and 24 hours postoperatively. Rescue analgesia with intravenous tramadol (100 mg) was prescribed if the patient’s VAS score was more than 4. Side effects (nausea and vomiting) and complications (pneumothorax) were looked for.
In statistical analysis, primary outcome was total drug consumption over 24 hours. Secondary outcome was VAS score and duration of first analgesic use. Statistical analysis was performed by SPSS (Chicago, Illinois), version 17 using the unpaired t test for normally distributed variables and Mann–Whitney U test for other variables.
| Discussion|| |
Postoperative pain following PCNL is a commonly faced troublesome clinical event. The ESPB is a recently described truncal block for postoperative pain relief in these patients.
In comparison with the control group, there was decreased consumption of tramadol in block group on the first postoperative day [Table 1].
In our study, the two groups were comparable with respect to age, weight, vitals, ASA grading, and duration of surgery [Table 2]. There were no significant differences in the vitals of the two groups. Gender comparison was not taken in our study.
Opioids though commonly used have adverse effects such as vomiting, sedation, constipation, retention of urine, ileus, and respiratory depression. These may prolong the duration of stay in hospital and reduce the quality of life after discharge. Moreover, opioid-induced immunosuppression can increase the risk of postoperative sepsis, and may lead to metastasis in patients with underlying malignancies. Hence, multimodal opioid-sparing analgesia is desirable for patients at present. In this study, ESPB considerably helps in decreasing the use of tramadol in postoperative period and hence can be used as one of effective methods to reduce opioid consumption thereby leading to enhanced recovery which is in line with isolated case reports and case series which have concluded about the role ESPB plays in reducing postoperative pain in PCNL surgery.
Postoperative pain relief is a big challenge for both doctors and patients. In this study, the duration of pain relief was >12 hours for the block group [Table 3], with a significantly lower VAS scores [Table 4] after the surgery, conclusively demonstrating effectiveness of ESPB. Similar results were observed when ESPB was used as an alternative for postoperative analgesia in video-assisted thoracic surgery and bariatric surgeries.,
Postoperative pain increases morbidity, decreases quality of life, slows down the recovery process, and increases treatment expenditure. In addition, early postoperative pain leads to persistent pain which can last weeks to months eventually progressing to chronic pain, and based on the results in our study erector spinae block might have a role in preventing chronic pain, as was reported by Forero when ESPB was used in treatment of thoracic neuropathic pain.
Limitations of our study included a shorter follow-up period and less number of clinical studies for comparison. Despite of all those limitations, our findings have successfully demonstrated effectiveness of ultrasound guided erector spinae block.
| Conclusion|| |
The ESPB helped in providing good postoperative pain relief with reduced consumption of tramadol in patients undergoing PCNL ultimately leading to enhanced recovery postsurgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]