ESP block
Bradycardia, ESPB, nausea and vomiting, pain, PONV, NRS
CHRONIC PAIN, THORACIC, COLD, LOCAL INFILTRATION
Ultrasound guided ESP Block was performed, after local infiltration with 2.0 mL of 2% lignocaine at the site of puncture, on two thoracic (T) levels (T2 and T5) using the transverse process, visualized as a hyperechoic structure with acoustic shadowing below, as main ultrasound landmark.When the needle came in contact with the transverse process 12 mL of 0.5% ropivacaine was injected for each level (120 mg of Ropivacaine), not exceeding the toxic dose (Fig. Erector spinae muscle before (Thirty minutes after performing the blocks, the sensory level of the block was assessed by a cold sensation with an alcohol–soaked sponge and a pin prick testing using a 22-G short bevel needle, in each dermatomal distribution from T1 to T8 by an anesthesiologist who was not aware of the study group.All patients had dermatomal coverage from T1 to T8.All patients in Thoracic Paraverterbal block group (Group TPVB) and Erector Spinae Plane Block group (Group ESPB) received GA with intravenous (IV) bolus of propofol 2 mg kgIV dexamethasone 8 mg was administered before induction of anesthesia.Anesthesia was maintained by continuous IV infusion of propofol (6–9 mg kgFentanyl 100 mcg in bolus was administered intravenously if the mean blood pressure or heart rate exceeded 20% of the pre-operative value. The total intraoperative fentanyl consumption was recorded.In patients requiring an axillary lymph node dissection, top-up local infiltration analgesia into the surgical field, to allow the enlargement of the operative field, was performed by the surgeon using 6 mL lignocaine (20 mg mLHypotension (mean arterial pressure < 60 mmHg) was treated with boluses of fluid and, if required, ephedrine in doses of 25–50 mg. Bradycardia (HR < 40 beats min or < 20% of baseline) was managed with 0.5 mg atropine.All patients were administered 2 gr of Cefazolin half an hour before the start of surgery.No prophylactic antiemetics were administered.Acetaminophen 1gr IV was administered 30 min before the end of surgery, and then every eight hours.The pain assessment, at rest and related to movement, was carried out, using the NRS scale, at the awakening of the patients (time 0) and 2, 6, 12, 24 and 36 post-operative hours. The assessment was done by an anesthesiologist who had no role in giving the block and in the intraoperative management of the patient but aware of the type of block performed.Wherever pain exceeded 3 according to the NRS scale, or at the explicit request of the patient, 30 mg of Ketorolac was administered IV for a maximum of three times a day.We used morphine 2 mg if, thirty minutes after the administration of Ketorolac, pain persists with NRS > 3.A total of 492 NRS and dose rescue request measurements were performed.The first-line treatment of PONV consisted of IV ondansetron 4 mg twice a day as needed and, if this proved ineffective, second-line therapy consisted of IV metoclopramide 10 mg as needed.The quantity of opioids (morphine) administered post-operatively, requests for rescue doses of NSAIDs, and the presence and number of nausea and vomiting episodes, were all assessed.Patients’ satisfaction was evaluated and recorded 36 h after surgery on a 7‐point Likert scale. (1‐ Extremely dissatisfied, 2‐ Very dissatisfied, 3‐ Dissatisfied, 4‐ Neither satisfied nor dissatisfied, 5‐ Satisfied, 6‐ Very satisfied, 7‐ Extremely satisfied).The patients were then discharged when deemed safe according to the Italian version of the Post Anesthesia Discharge Scoring System (PADS). Lastly, the total number of days of hospitalization were also recorded.After six months, patients received a telephone call to ascertain the presence of chronic pain during rest and in motion assessed using the NRS. Patients were also asked to evaluate the pain interference with sleep, work activity, mood tone, and possibility of entertainment.The sample size of the study was calculated based on a retrospective pilot study designed to measure NRS pain score 12 h after surgery in the two groups TPVB vs ESPB (10 patients in each group). We observed a mean NRS of 2.7 vs.0.9 (s.d. = 2.9). Setting the power to 80% and the alpha to 0.05%, the sample size required was 82 patients.