Korean J Pain.  2019 Jul;32(3):206-214. 10.3344/kjp.2019.32.3.206.

Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study

• Hong B
• Bang S
• Chung W
• Yoo S
• Chung J
• Kim S

• KMID: 2455616
• DOI: http://doi.org/10.3344/kjp.2019.32.3.206

Abstract

BACKGROUND
Although case reports have suggested that the erector spinae plane block (ESPB) may help analgesia for patients after breast surgery, no study to date has assessed its effectiveness. This retrospective observational study analyzed the analgesic effects of the ESPB after total mastectomy.
METHODS
Forty-eight patients were divided into an ESPB group (n = 20) and a control group (n = 28). Twenty patients in the control group were selected by their propensity score matching the twenty patients in the ESPB group. Patients in the ESPB group were injected with 30 mL 0.375% ropivacaine, followed by catheter insertion for further injections of local anesthetics every 12 hours. Primarily, total fentanyl consumption was compared between the two groups during the first 24 hours postoperatively. Secondary outcomes included pain intensity levels (visual analogue scale) and incidence of postoperative nausea and vomiting (PONV).
RESULTS
Median cumulative fentanyl consumption during the first 24 hours was significantly lower in the ESPB (33.0 μg; interquartile range [IQR], 27.0-69.5 μg) than in the control group (92.8 μg; IQR, 40.0-155.0 μg) (P = 0.004). Pain level in the early postoperative stage (<3 hr) and incidence of PONV (0% vs. 55%) were also significantly lower in the ESPB group compared to the control (P = 0.001).
CONCLUSIONS
Intermittent ESPB after total mastectomy reduces fentanyl consumption and early postoperative pain. ESPB is a good option for multimodal analgesia after breast surgery.

Keyword

Acute Pain; Analgesia; Anesthesia, Conduction; Breast; Mastectomy; Nerve Block; Pain, Postoperative; Ropivacaine; Ultrasonography

MeSH Terms

Acute Pain
Analgesia*
Anesthesia, Conduction
Anesthetics, Local
Breast
Catheters*
Fentanyl
Humans
Incidence
Mastectomy
Mastectomy, Simple*
Nerve Block
Observational Study*
Pain, Postoperative
Postoperative Nausea and Vomiting
Propensity Score
Retrospective Studies*
Ultrasonography
Anesthetics, Local
Fentanyl

Figure

• 

  Fig. 1 The erector spinae plane block. (A) The level of the T5 rib and transverse process was located using a counting-down approach from the first rib; this was marked on the skin at the lateral position. (B) After placing a linear probe parallel to the vertebral axis, a needle was inserted toward the transverse process. (C) After confirming proper position of needle tip, we injected the local anesthetic. The catheter was inserted using real-time ultrasound guidance. (D) The catheter was secured by suture to the skin. ESM: erector spinae muscle, RMM: rhomboid major muscle, TM: trapezius muscle, TP: transverse process, SP: spinous process of vertebra. Data from the article of Kwon et al. (J Korean Med Sci. 2018; 33: e291) [32].

• 

  Fig. 2 Flow chart of patient selection and propensity score matching. PCA: patient-controlled analgesia, ESPB: erector spinae plane block, IV: intravenous.

• 

  Fig. 3 Cumulative fentanyl consumption over time in the erector spinae plane block (ESPB) and control groups. Cumulative fentanyl consumption at all postoperative time points was lower in the ESPB than in the control group. Data are expressed as median (interquartile range). *P < 0.01.

• 

  Fig. 4 Pain visual analogue scales over time in the erector spinae plane block (ESPB) and control groups. Pain intensity at an early postoperative stage was significantly lower in the ESPB than in the control group. Data are expressed as median (interquartile range). PACU: post-anesthesia care unit. *P < 0.008.

Reference

1. Woodworth GE, Ivie RMJ, Nelson SM, Walker CM, Maniker RB. Perioperative breast analgesia: a qualitative review of anatomy and regional techniques. Reg Anesth Pain Med. 2017; 42:609–31. DOI: 10.1097/AAP.0000000000000641. PMID: 28820803.

2. Wildsmith JA. Continuous thoracic epidural block for surgery: gold standard or debased currency? Br J Anaesth. 2012; 109:9–12. DOI: 10.1093/bja/aes177. PMID: 22696554.

3. Choe WJ, Kim JY, Yeo HJ, Kim JH, Lee SI, Kim KT, et al. Postpartum spinal subdural hematoma: irrelevant epidural blood patch: a case report. Korean J Anesthesiol. 2016; 69:189–92. DOI: 10.4097/kjae.2016.69.2.189. PMID: 27066211. PMCID: 4823418.

4. Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev. 2016; 2:CD009121. PMID: 26897642.

5. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012; 37:310–7. DOI: 10.1097/AAP.0b013e31825735c6. PMID: 22531384.

6. Marhofer D, Marhofer P, Kettner SC, Fleischmann E, Prayer D, Schernthaner M, et al. Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paravertebral blockade: a volunteer study. Anesthesiology. 2013; 118:1106–12. DOI: 10.1097/ALN.0b013e318289465f. PMID: 23442752.

7. Sherwin A, Buggy DJ. Anaesthesia for breast surgery. BJA Educ. 2018; 18:342–8. DOI: 10.1016/j.bjae.2018.08.002.

8. Pace MM, Sharma B, Anderson-Dam J, Fleischmann K, Warren L, Stefanovich P. Ultrasound-guided thoracic paravertebral blockade: a retrospective study of the incidence of complications. Anesth Analg. 2016; 122:1186–91. DOI: 10.1213/ANE.0000000000001117. PMID: 26756911.

9. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia. 1995; 50:813–5. DOI: 10.1111/j.1365-2044.1995.tb06148.x. PMID: 7573876.

10. Bonvicini D, Giacomazzi A, Pizzirani E. Use of the ultrasound-guided erector spinae plane block in breast surgery. Minerva Anestesiol. 2017; 83:1111–2. PMID: 28492298.

11. Finneran JJ 4th, Gabriel RA, Khatibi B. Erector spinae plane blocks provide analgesia for breast and axillary surgery: a series of 3 cases. Reg Anesth Pain Med. 2018; 43:101–2. DOI: 10.1097/AAP.0000000000000695. PMID: 29261601.

12. 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. DOI: 10.1097/AAP.0000000000000451. PMID: 27501016.

13. 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. DOI: 10.1097/AAP.0000000000000616. PMID: 28632673.

14. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: a case series. Scand J Pain. 2017; 17:325–9. DOI: 10.1016/j.sjpain.2017.08.013. PMID: 28919152.

15. 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. DOI: 10.1111/anae.13814. PMID: 28188621.

16. Kline J, Chin KJ. Modified dual-injection lumbar erector spine plane (ESP) block for opioid-free anesthesia in multilevel lumbar laminectomy. Korean J Anesthesiol. 2019; 72:188–90. DOI: 10.4097/kja.d.18.00289. PMID: 30392347. PMCID: PMC6458518.

17. Kim E, Kwon W, Oh S, Bang S. The erector spinae plane block for postoperative analgesia after percutaneous nephrolithotomy. Chin Med J (Engl). 2018; 131:1877–8. DOI: 10.4103/0366-6999.237408. PMID: 30058589. PMCID: PMC6071450.

18. Bang S. Erector spinae plane block: an innovation or a delusion? Korean J Anesthesiol. 2019; 72:1–3. DOI: 10.4097/kja.d.18.00359. PMID: 30732436. PMCID: 6369339.

19. Ramos J, Peng P, Forero M. Long-term continuous erector spinae plane block for palliative pain control in a patient with pleural mesothelioma. Can J Anaesth. 2018; 65:852–3. DOI: 10.1007/s12630-018-1097-z. PMID: 29488178.

20. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017; 42:372–6. DOI: 10.1097/AAP.0000000000000581. PMID: 28272292.

21. Masaracchia MM, Herrick MD, Seiffert EA, Sites BD. Nerve blocks under general anesthesia: time to liberalize indications? Reg Anesth Pain Med. 2017; 42:299–301. DOI: 10.1097/AAP.0000000000000579. PMID: 28257389.

22. Ho D, Imai K, King G, Stuart EA. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011; 42:1–28. DOI: 10.18637/jss.v042.i08.

23. In J, Lee S. Statistical data presentation. Korean J Anesthesiol. 2017; 70:267–76. DOI: 10.4097/kjae.2017.70.3.267. PMID: 28580077. PMCID: 5453888.

24. Kumar A, Hulsey A, Martinez-Wilson H, Kim J, Gadsden J. The use of liposomal bupivacaine in erector spinae plane block to minimize opioid consumption for breast surgery: a case report. A A Pract. 2018; 10:239–41. DOI: 10.1213/XAA.0000000000000674. PMID: 29708919.

25. Tanaka N, Ueshima H, Otake H. Erector spinae plane block for combined lovectomy and radical mastectomys. J Clin Anesth. 2018; 45:27–8. DOI: 10.1016/j.jclinane.2017.12.012. PMID: 29274543.

26. Gürkan Y, Aksu C, Kuş A, Yörükoğlu UH, Kılıç CT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: a randomized controlled study. J Clin Anesth. 2018; 50:65–8. DOI: 10.1016/j.jclinane.2018.06.033. PMID: 29980005.

27. Yoshizaki M, Murata H, Ogami-Takamura K, Hara T. Bilateral erector spinae plane block using a programmed intermittent bolus technique for pain management after Nuss procedure. J Clin Anesth. 2019; DOI: 10.1016/j.jclinane.2019.03.014. PMID: 30852328.

28. Tiburzi C, Cerotto V, Gargaglia E, Carli L, Gori F. Pectoral nerve block II with programmed intermittent bolus of local anesthetic and postoperative pain relief in breast surgery. Minerva Anestesiol. 2019; 85:201–2. DOI: 10.23736/S0375-9393.18.13027-6. PMID: 30207137.

29. Öbrink E, Jildenstål P, Oddby E, Jakobsson JG. Postoperative nausea and vomiting: update on predicting the probability and ways to minimize its occurrence, with focus on ambulatory surgery. Int J Surg. 2015; 15:100–6. DOI: 10.1016/j.ijsu.2015.01.024. PMID: 25638733.

30. Porreca F, Ossipov MH. Nausea and vomiting side effects with opioid analgesics during treatment of chronic pain: mechanisms, implications, and management options. Pain Med. 2009; 10:654–62. DOI: 10.1111/j.1526-4637.2009.00583.x. PMID: 19302436.

31. Ohgoshi Y, Ikeda T, Kurahashi K. Continuous erector spinae plane block provides effective perioperative analgesia for breast reconstruction using tissue expanders: a report of two cases. J Clin Anesth. 2018; 44:1–2. DOI: 10.1016/j.jclinane.2017.10.007. PMID: 29065334.

32. Kwon WJ, Bang SU, Sun WY. Erector spinae plane block for effective analgesia after total mastectomy with sentinel or axillary lymph node dissection: a report of three cases. J Korean Med Sci. 2018; 33:e291. DOI: 10.3346/jkms.2018.33.e291. PMID: 31044575. PMCID: PMC6209766.

33. Kim D, Bang S, Sun WY. Erector spinae plane block with sedation for surgical anesthesia in breast conserving surgery. J Clin Anesth. 2019; DOI: 10.1016/j.jclinane.2019.03.003. PMID: 30852327.

34. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Reg Anesth Pain Med. 2018; 43:756–62. PMID: 29794943.

35. Costache I, de Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, et al. The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anaesthesia. 2017; 72:1230–6. DOI: 10.1111/anae.14004. PMID: 28762464.

36. Luyet C, Eichenberger U, Greif R, Vogt A, Szücs Farkas Z, Moriggl B. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth. 2009; 102:534–9. DOI: 10.1093/bja/aep015. PMID: 19244265.

37. Damjanovska M, Stopar Pintaric T, Cvetko E, Vlassakov K. The ultrasound-guided retrolaminar block: volume-dependent injectate distribution. J Pain Res. 2018; 11:293–9. DOI: 10.2147/JPR.S153660. PMID: 29445296. PMCID: 5808708.

38. El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018; 11:35–44. DOI: 10.2147/LRA.S154512. PMID: 30122981. PMCID: 6087022.

39. De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: a systematic qualitative review. Minerva Anestesiol. 2019; 85:308–19. DOI: 10.23736/S0375-9393.18.13341-4. PMID: 30621377.