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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 271-275

Comparison of thoracic epidural and ultrasound guided erector spinae plane block in pediatric thoracic surgeries


1 Department of Anaesthesiology, Rainbow Children Hospital, Bangalore, Karnataka, India
2 Department of Community Medicine, AFMS, New Delhi, India
3 Department of Community Medicine, Koppal Institute of Medical Sciences, New Delhi, India
4 Department of Aviation Medicine, AFMS, New Delhi, India

Date of Submission31-Jan-2022
Date of Decision15-Mar-2022
Date of Acceptance25-Mar-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Sandhya Ghodke
Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_20_22

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  Abstract 


OBJECTIVE: The objective of this study was to compare the efficacy of thoracic epidural and ultrasound-guided (USG) erector spinae plane block in pediatric thoracic surgeries.
MATERIALS AND METHODS: Eight patients undergoing elective thoracic surgeries – videoscopic-assisted thoracic surgeries were divided into two groups, Group A – who received single-shot thoracic epidural using 0.125% bupivacaine in a dose of 0.5 ml/kg and Group B – who received USG erector spinae block (ESP block) using 0.125% bupivacaine in a dose of 0.5 ml/kg. Postprocedure visual analog scale (VAS) score was used to assess pain for the first 24 h. Pain assessment was done 6th hourly. Time of the first requirement of analgesics was noted and injection paracetamol 15 mg/kg intravenously was given as rescue analgesic.
RESULTS: In Group A, VAS scores were higher compared to Group B. The duration of analgesia with single-shot epidural lasted for about 4–6 h postoperative whereas that with ESP block lasted for 8 or 10 h postoperatively. The time of the first requirement of analgesics was earlier in Group A compared to Group B.
CONCLUSION: USG ESP block provides better analgesia compared to thoracic epidural.

Keywords: Erector spinae block, pediatric thoracic surgeries, rescue analgesia, ultrasound


How to cite this article:
Reddy N V, Ghodke S, Hiremath RN, Nimbannavar SM, Kulkarni MK. Comparison of thoracic epidural and ultrasound guided erector spinae plane block in pediatric thoracic surgeries. BLDE Univ J Health Sci 2022;7:271-5

How to cite this URL:
Reddy N V, Ghodke S, Hiremath RN, Nimbannavar SM, Kulkarni MK. Comparison of thoracic epidural and ultrasound guided erector spinae plane block in pediatric thoracic surgeries. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Jan 28];7:271-5. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/271/355847



Regional anesthesia in pediatrics has become an area of interest nowadays because of its effective pain relief with improved patient satisfaction and comfort. This is a part of pediatric enhanced recovery after surgery protocol.[1] Thoracic epidurals were a routinely used regional anesthesia technique for thoracic procedures. Nowadays, fascial plane blocks are widely used to manage pain in the perioperative period. Erector spinae block (ESP block) is one such technique which is gaining importance in recent days.[2],[3] This was first described by Forero et al.[4] In this, local anesthetic is deposited deep to erector spinae muscle and superficial to transverse process.[4] In this block, spread occurs both cranially and caudally. Its main advantage is that it is easy to perform, provides good analgesia, and has high efficacy and decreased risk of complications. In this study, we compared the efficacy of thoracic epidural and ultrasound-guided (USG) ESP block.

Recently, the focus shifting toward myofascial plane blocks for postoperative analgesia for open abdominothoracic procedures, ESP block is evolving as a novel and beneficial technique for managing both acute and chronic pain postsurgery.[2],[4] Muñoz and Cubillo had given 14 ml of 0.5% bupivacaine for tumor resection of right rib. Patient complained of only mild pain till 32 h after surgery.[5] Adhikary et al. had given 20 ml of 0.5% ropivacaine and a catheter was placed for postoperative infusion. They concluded that decreased opioid requirement, earlier ambulation, and decreased hospital stay may be achieved with ESP block.[6] Gaio-Lima et al. described continuous ESP block with 0.2% ropivacaine in a 15-month-old boy for a paracardiac tumor excision. They concluded that this was a good alternative to thoracic epidural and paravertebral block with greater safety of technique.[7] Hernandez et al. described single-shot ESP block in a 3-year- old scheduled for paraspinal lipoma excision. They observed pain score of 0 on FLACC (Face, Legs, Activity, Cry, Consolability) scale. This was maintained till discharge, and the first rescue analgesia was given after 18 h.[8] Nardiello and Herlitz described this block for reconstructive surgery of pectus carinatum and excavatum. They gave it bilaterally using 0.25% bupivacaine preemptively and observed a postoperative visual analog scale (VAS) score <4.[9]


  Materials and Methods Top


An interventional study was carried out in pediatric multispecialty hospital in South India where in children between 4 and 9 years age of the American Society of Anesthesiologists (ASA) 1 and ASA 2 electively posted for thoracic procedures were included in the study. Eight patients undergoing elective thoracoscopic procedures were included in the study. Simple randomization method was used, and random numbers were generated using a computer-generated random sequence number. The patients were randomly assigned to one of the two groups as mentioned below.

Group A was administered 0.125% bupivacaine using a single-shot epidural technique at T7-T8 with 0.5 ml/kg of bupivacaine. Group B was administered 10 ml of 0.125% bupivacaine using USG ESP block at T7-T8.

Written informed consent was taken from parents before enrolment into the study. Detailed clinical history was taken, and investigations accordingly required were asked for the procedure. All patients were explained about VAS scale in the preoperative period to facilitate pain assessment in the postoperative period.

Standard nil per oral guidelines was explained and followed.

In the operation theater (OT), the anesthesia workstation was checked and drugs according to body weight were loaded and kept in both groups. Patients were premedicated with injection midazolam 0.05 mg/kg intravenous (IV) before shifting inside OT.

Standard multiparameter monitoring was attached to all patients. In both the groups, induction was done with IV propofol 2 mg/kg and IV fentanyl 2 mcg/kg. After check ventilation, IV atracurium 0.5 mg/kg was given and an appropriate size endotracheal tube was placed. For maintenance, 50% oxygen air mixture with sevoflurane was used. The child was turned in lateral position.

In Group A–Under aseptic precautions using 19 G Tuohy needle and loss of resistance to saline (LOS) technique, single-shot epidural was given at T7-T8 level using 0.5 ml/kg of 0.125% bupivacaine after negative aspiration of blood and cerebrospinal fluid.

Group B was administered 10 ml of 0.125% bupivacaine using USG ESP block at T7-T8 [Figure 1]. Ultrasound image showing the spread of local anesthetic post injection in erector spinae plane is shown in [Figure 2].
Figure 1: Ultrasound image of the paraspinal muscles. ESM = Erector spinae muscle, RM = Rhomboidus major, TR = Trapezius, T7 = Transverse process of T7 vertebra

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Figure 2: Ultrasound image showing the spread of local anesthetic postinjection in erector spinae plane

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After the procedure, children were transferred to PACU (Post Anesthesia Care Unit) for continuous monitoring and further management. VAS scale was used to assess pain during the first 24 h. Pain assessment was done every 6th hourly. The time of the first requirement of analgesics was noted. IV paracetamol 15 mg/kg was used as rescue analgesic and was administered to patients with VAS score of >4. Pain scores were recorded by nurses blinded to the study. An anesthesiologist not involved in the study recorded the time of the first requirement of analgesics.


  Results Top


The time of the first requirement of analgesics was 8 to 10 h postprocedure in Group B. Distribution of groups age wise and analysis of age-wise distribution are shown in [Table 1] and [Table 2]. Distribution of group wise duration of surgery is as shown in [Figure 3] and analysis of duration of surgery is as shown in [Table 3]. Distribution of Group A and Group B visual analog scale score are shown in [Figure 4] and [Figure 5] respectively.
Figure 3: Distribution of group-wise duration of surgery

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Figure 4: Distribution of Group A visual analog scale score

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Figure 5: Distribution of Group B visual analog scale score

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Table 1: Distribution of groups age wise

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Table 2: Analysis of age-wise distribution

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Table 3: Analysis of duration of surgery

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  Discussion Top


The current study was performed to compare the efficacy of pediatric thoracic epidural and USG ESP block. Although thoracic epidural technique and paravertebral block are the commonly used modalities for analgesia in thoracic surgeries, minimally invasive surgeries such as videoscopic-assisted thoracic surgeries (VATS) might have more benefits with less-invasive modalities of analgesia such as ESP blocks by avoiding most of the adverse effects which are encountered in epidural technique.[10],[11] Erector spinae plane block is a comparatively newer technique of regional anesthesia but is increasingly gaining popularity among anesthetists because of its ease of administration and better efficacy.[12] However, reports of its use in pediatric surgeries are still restricted up to the level of case reports only except by Aksu et al.[13] Although thoracic epidurals have been in practice since long, it is still a difficult procedure in pediatrics as it is a blind technique and also chances of dural puncture are very high in pediatrics as all the structures are in proximity to each other. Furthermore, because of soft elastic tissues, chances of false loss of resistance are there before ligamentum flavum is pierced. Hence, chances of failure or higher requirement of rescue analgesia are approximately 32% more with thoracic epidurals.[14] Moreover, USG-guided ESP block is a paraspinal technique and as it is given under vision with real-time sonography, it is a safer procedure compared to epidural block. It is a proven technique of regional anesthesia known for safe and enhanced recovery, early ambulation

The epidural zone is a very small limited area surrounded by the spinal column as compared to the erector spinae in which the local anesthetic medication is instilled in the myofascial plane deep to the erector spinae muscle and superficial to the transverse process and hence provides the sensory blockade at multi-dermatome levels.[4] Visser et al. studied the factors affecting the distribution of neural blockade by LA in epidural anesthesia according to which the volume and the site of injection of drug are pivotal in determining the spread of an epidural.[15] As per the study done by Forero et al. on a cadaveric model, a single injection at T5 level in the erector spinae plane could spread from C7 to T8. A higher spread from T2 to T10 with partial blockade of C7-C8 has been reported in many of the studies done on adult surgical patients including VATS.[4],[16],[17]

As per most of the studies which were mainly case reports using ESP block in pediatric patients, the postoperative pain scores and the requirement of rescue analgesic were less in initial hours postsurgery.[6],[8] In our study, we observed that patients who received ESP block had lower VAS scores as compared to the patients who were given epidural block. Furthermore, patients in ESP group required lesser rescue analgesics. In patients who were given epidural block, both the time of requirement of rescue analgesic was earlier and required higher analgesic doses in 24 h.

Furthermore, patients in ESP block had fewer medication side effects as they had lesser requirement of opioids in perioperative period, had achieved early ambulation because of low VAS scores, and had early discharge to home.

Our study reveals that ESP block is a safer and better alternative than thoracic epidural for perioperative analgesia for thoracic procedures in pediatric patients. It also lessens the requirement of opioids and rescue analgesic leading to early recovery and early ambulation of the patients.


  Conclusion Top


From the above study, we conclude that USG-guided ESP block provides better analgesia compared to thoracic epidural in pediatric thoracic surgeries. Our study being a case series, further studies will help in confirming that erector spinae plane block is a better, safer, and viable alternative of thoracic epidural in thoracic surgeries in pediatrics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tsui B, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: A review of current literature and its application in the practice of extremity and trunk blocks. Anesthesiology 2010;112:473-92.  Back to cited text no. 1
    
2.
Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia 2017;72:452-60.  Back to cited text no. 2
    
3.
Ueshima H, Otake H. RETRACTED: Clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery. J Clin Anesth 2017;38:137.  Back to cited text no. 3
    
4.
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 4
    
5.
Muñoz F, Cubillos J, Bonilla AJ, Chin KJ. Erector spinae plane block for postoperative analgesia in pediatric oncological thoracic surgery. Can J Anaesth 2017;64:880-2.  Back to cited text no. 5
    
6.
Adhikary SD, Pruett A, Forero M, Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth 2018;62:75-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Gaio-Lima C, Costa CC, Moreira JB, Lemos TS, Trindade HL. Continuous erector spinae plane block for analgesia in pediatric thoracic surgery: A case report. Rev Esp Anestesiol Reanim (Engl Ed) 2018;65:287-90.  Back to cited text no. 7
    
8.
Hernandez MA, Palazzi L, Lapalma J, Forero M, Chin KJ. Erector spinae plane block for surgery of the posterior thoracic wall in a pediatric patient. Reg Anesth Pain Med 2018;43:217-9.  Back to cited text no. 8
    
9.
Nardiello MA, Herlitz M. Bilateral single shot erector spinae plane block for pectus excavatum and pectus carinatum surgery in 2 pediatric patients. Rev Esp Anestesiol Reanim (Engl Ed) 2018;65:530-3.  Back to cited text no. 9
    
10.
Rawal N. Epidural technique for postoperative pain: Gold standard no more? Reg Anesth Pain Med 2012;37:310-7.  Back to cited text no. 10
    
11.
Kamiyoshihara M, Nagashima T, Ibe T, Atsumi J, Shimizu K, Takeyoshi I. Is epidural analgesia necessary after video-assisted thoracoscopic lobectomy? Asian Cardiovasc Thorac Ann 2010;18:464-8.  Back to cited text no. 11
    
12.
Aksu C, Gurkan Y. Defining the indications and levels of erector spinae plane block in pediatric patients: A retrospective study of our current experience. Cureus 2019;11:e5348.  Back to cited text no. 12
    
13.
Aksu C, Şen MC, Akay MA, Baydemir C, Gürkan Y. Erector spinae plane block vs. quadratus lumborum block for pediatric lower abdominal surgery: A double blinded, prospective, and randomized trial. J Clin Anesth 2019;57:24-8.  Back to cited text no. 13
    
14.
Ready LB. Acute pain: Lessons learned from 25,000 patients. Reg Anesth Pain Med 1999;24:499-505.  Back to cited text no. 14
    
15.
Visser WA, Lee RA, Gielen MJ. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Anesth Analg 2008;107:708-21.  Back to cited text no. 15
    
16.
Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth 2017;118:474-5.  Back to cited text no. 16
    
17.
Scimia P, Basso Ricci E, Droghetti A, Fusco P. The ultrasound-guided continuous erector spinae plane block for postoperative analgesia in video-assisted thoracoscopic lobectomy. Reg Anesth Pain Med 2017;42:537.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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