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Table of Content - Volume 19 Issue 3 - September 2021
Study of efficacy of ultrasonography guided erector spinae plane block for abdominothoracic surgeries
Amol B Sasane1, Rahul D Kore2*, Pushpa I Agrawal3
1Senior Resident, 2Associate Professor, 3Professor and HOD, Department of Anaesthesiology, Dr. V M Government Medical College and SCSMSR, Solapur, Maharashtra, INDIA. Email: Rahuldkorefb@yahoo.com
Abstract Background: Erector spinae block (ESPB) provides analgesia by targeting the dorsal and ventral rami of the spinal nerves, performed in the lumbar region for postoperative analgesia of abdomino-thoracic surgeries. This study was aimed to assess the efficacy of Erector spinae block (ESPB) on postoperative analgesia in patients undergoing abdominothoracic surgeries under general anesthesia. Material and Methods: Present study was prospective, randomized, comparative study, conducted in patients with 18-70 years age, ASA grade- I/II, posted for abdominothoracic surgeries, Mallampatti scores - I and II, consented for participation. 120 patients were randomly assigned into two groups of 60 each, to either Erector spine block group (Group 1) or conventional pain killers (Group 2). Results: General characteristics such as age, height, weight, BMI were comparable in both groups and difference was not statistically significant. The postoperative systolic blood pressure, diastolic blood pressure, heart rate and Mean post-operative VAS score difference was statistically significant, from 30 minutes post-operative to 480 mins (8 hours). Group 1 have significantly less amount opioid requirement as none of the patients required inj tramadol more than 100 mg and only 5 (8.33%) cases required 100 mg whereas in the Group 2 73.33% required inj tramadol more than 100 mg and 8.55% required 175 mg. Group 1 have significantly long period of opioid free time as during first 2 hours none of the patients required inj tramadol whereas in the Group 2 83.33% required inj tramadol in the first 2 hours. Conclusion: In our study we concluded that the analgesic efficacy of Ultrasound guided Erector spinae block is an effective procedure over systemic analgesics and provide better patient satisfaction and compliance Keywords: Erector spinae block.
INTRODUCTION Erector spinae block (ESPB) provides analgesia by targeting the dorsal and ventral rami of the spinal nerves, performed in the lumbar region for postoperative analgesia of abdomino-thoracic surgeries.1 Adequate postoperative analgesia is essential to prevent complications such as systemic hypertension, myocardial ischemia or infarction, cardiac arrhythmias, respiratory compromise, pneumonia, postoperative ileus and delayed wound healing.2 Moreover, the severity of acute pain may lead on to distressing postsurgical chronic pain.3 Erector spinae block (ESPB) gained wide attention as it is a faster procedure that carries a lower risk of hypotension, can be used in patients with coagulopathy, is easy to perform, and requires less training.1 Erector spinae block performed at low thoracic levels was recently shown to provide satisfactory analgesia for gynecologic and abdominal surgery in case reports and series describing lower segment cesarean section, ventral hernia repair, and abdominoplasty.4 This study was aimed to assess the efficacy of Erector spinae block (ESPB) on postoperative analgesia in patients undergoing abdominothoracic surgeries under general anesthesia.
MATERIAL AND METHODS Present study was prospective, randomized, comparative study, conducted in Department of Anaesthesiology, Dr. V M Government. Medical College, Solapur, India. Study duration was of 2 years (Dec 2018 to Oct 2020). The study was conducted after obtaining Ethics committee approval. Inclusion criteria: Age - 18-70 years, ASA grade- I/II, posted for abdominothoracic surgeries, Mallampatti scores - I and II, consented for participation Exclusion criteria: BMI >35 kg/m. Skin infection at the puncture site, Patients posted for emergency surgery, Patients with difficult airway, Severe coagulopathy, Chronic hepatic or renal failure, Preoperative opioid or non-steroidal anti-inflammatory drugs for chronic pain treatment. Patients who satisfied the inclusion criteria were explained about the nature of the study and the anesthetic procedure and written informed consent was taken. The patients were familiarized with 10 cm visual analogue scale (VAS) for pain during preanesthetic visit. 120 patients were randomly assigned into two groups of 60 each. Randomization done by alternating patients to either Erector spine block group (Group 1) or conventional pain killers (Group 2) Group 1: - Postoperative ultrasound guided erector spine block with 0.25 % bupivacaine 20 cc. Group 2: - Postoperative No Block given, Conventional drug-based pain management In the operating room, all basic monitors were connected to the patient (ECG, SPO2, EtCO2, non-invasive BP). Baseline vitals were recorded. Postoperative as per randomization, anaesthesia was given accordingly. Primary Outcome was Post-operative visual analogue scale pain score and Post-operative hemodynamic characteristics. Secondary Outcome was Post-operative opioid requirement. Descriptive statistics was done for all data and suitable statistical tests of comparison were done. Continuous variables were analysed with the T test and categorical variables were analysed with the Chi-Square Test and Fisher Exact Test. Statistical significance was taken as P < 0.05. The data was analysed using SPSS version 26 software and Microsoft Excel 2010
RESULTS General characteristics such as age, height, weight, BMI were comparable in both groups and difference was not statistically significant. Table 1: General characteristics of study population
The postoperative systolic blood pressure ranged from 126 to 172 mm of Hg the Group 2 have higher mean systolic blood pressure than the Group 1, the effect on systolic blood pressure is considered to be statistically significant since p < 0.05, from 30 minutes post-operative to 480 mins (8 hours)
Table 2: Systolic Blood Pressure distribution
The postoperative diastolic blood pressure ranged from 82 to 114 mm of Hg the Group 2 have higher mean diastolic blood pressure than the Group 1, the effect on diastolic blood pressure is considered to be not statistically significant since p > 0.05. from 30 minutes post-operative to 480 mins (8 hours).
Table 3: Diastolic Blood Pressure distribution in study population
The postoperative heart rate ranged from 61 to 94 per minute, the Group 2 have higher mean heart rate than the Group 1, the effect on heart rate is considered to be not statistically significant since p > 0.05, from 30 minutes post-operative to 480 mins (8 hours) Table 4: Heart rate distribution in study population
Mean post-operative VAS score at 0 mins, 30mins 1,2,3,4,5,6,7,8 9 and 12 hrs. (Group 1 vs Group 2s) was considered to be statistically significant since p < 0.05
Table 5: VAS Score distribution in study population
Group 1 have significantly less amount opioid requirement as none of the patients required in j tramadol more than 100 mg and only 5 (8.33%) cases required 100 mg whereas in the Group 2 73.33% required in j tramadol more than 100 mg and 8.55% required 175 mg. the mean dose of opioid in group 1 is 63.3333 ± 16.25190 mg whereas in Group 2 127.0833 ± 25.33323mg. By conventional criteria the association between the treatment groups, first dose of Injection Tramadol is considered to be statistically significant since p < 0.05. Table 6: Use of Injection Tramadol
Group 1 have significantly long period of opioid free time as during first 2 hours none of the patients required inj tramadol whereas in the Group 2 83.33% required inj tramadol in the first 2 hours. the mean time of first dose of opioid in Group 1 is 4.0500 ± 1.12634 hours whereas in Group 2 1.6167 ± 0.80447 hours. By conventional criteria the association between the treatment groups, first dose of Injection Tramadol is considered to be statistically significant since p < 0.05. Table 7: First dose of Injection Tramadol
DISCUSSION Ultrasound guided erector spinae (ESP) block is a regional anesthesia technique, recently described by Forero et al.,1 for use in thoracic neuropathic pain. ESP block is reported to lead to analgesic effect on somatic and visceral pain by effecting the ventral rami and rami communicants that include sympathetic nerve fibers, as LA spreads through the paravertebral space.1,4 When performed bilaterally it has been reported to be as effective as thoracic epidural analgesia.4 In present study, mean age in case group was 37.05 ± 15.00 years, in control group the mean age was 43.25 ± 14.22 years, similar findings were seen by Peker et al.,5 in his study the case and control group have age 48 ±15.91 and 48.44 ± 14.32 respectively , Krishna et al.,6 found the case and control group have age 48.321±1.7 and 49.62 ± 1.51 years respectively and Aksu et al.,7 found the case and control group have age 49.26±14.18 and 47.26±13.461 years respectively, Systolic Blood Pressure distribution in study population ranged from 126 to 172 mm of Hg the control group have higher mean systolic blood pressure than the cases group,. Ciftci et al.,8 reported similar results. Effect on systolic blood pressure was considered to be statistically significant from 30 minutes post-operative to 480 mins (8 hours) similar findings were also seen by S. Tulgar et al.,9 Aksu et al.,7 and Krishna et al.,6 Postoperative diastolic blood pressure ranged from 82 to 114 mm of Hg the control group have higher mean diastolic blood pressure than the cases group, Elyazed et al.,10 and Krishna et al.,7 reported similar results. Effect on diastolic blood pressure is considered to be not statistically significant. from 30 minutes post-operative to 480 mins (8 hours) like S. Tulgar et al.,9 Aksu et al.,7 and Elyazed et al.,10 also reported similar results. Post operative heart rate ranged from 61 to 94 per minute, the control group have higher mean heart rate than the cases group, the effect on heart rate was considered to be statistically significant from 30 minutes post-operative to 480 mins (8 hours) similar findings were also seen by S. Tulgar et al.,9 Aksu et al.,7 and Krishna et al.,6 For VAS Score the post-operative analgesia was considered to be better in study group and difference was statistically significant, similar reports are given by almost all the studies like S. Tulgar et al.,9 Aksu et al.,6, Elyazed et al.,10 and Krishna et al.,6 Total dose of Inj Tramadol given to the patients post op, cases group have significantly less amount opioid requirement as none of the patients required inj tramadol more than 100 mg and only 5 (8.33%) cases required 100 mg whereas in the control group 73.33% required inj tramadol more than 100 mg and 8.55% required 175 mg. Similar findings are reported by Aksu et al.,7 Elyazed et al.,10 Krishna et al.,6 and Altiparmak et al.,11 Total dose of Injection Tramadol was more in control group as compared to cases and difference was statistically significant, similar findings are shown with systemic pain killers by Koo et al.,12 Singh et al.,13 and a systemic review of RCT conducted by Mostafa et al.,14 In distribution of time of 1st dose of Inj Tramadol, cases group have significantly long period of opioid free time as during first 2 hours none of the patients required inj tramadol whereas in the control group 83.33% required inj tramadol in the first 2 hours, similar findings were reported by Aksu et al.,7 Elyazed et al.,10 Krishna et al.,6 and Altiparmak et al.,11 First dose of Injection Tramadol was earlier required in control group as compared to cases and difference was statistically significant, similar findings are reported by Koo et al.,12 Singh et al.,13 Aksu et al.,7 and Elyazed et al.,10Erector spinae block (ESPB) provides extensive, potent unilateral analgesia, is performed by local anesthetic injection in the plane between the erector spinae muscle and the Transverse process. The local anesthetic diffuses into the paravertebral space through spaces between adjacent vertebrae and blocks both the dorsal and ventral branches of the thoracic spinal nerves.3,4In our study, the analgesic efficacy of Ultrasound guided Erector spinae block in patients undergoing abdominothoracic surgeries is highly improved than with systemic analgesics.
CONCLUSION In our study we concluded that the analgesic efficacy of Ultrasound guided Erector spinae block is an effective procedure over systemic analgesics and provide better patient satisfaction and compliance
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