Evaluating the Effectiveness of Bilateral ESPB in Addition to Standard Analgesia at Reducing Opioid Consumption
Condition: Anesthesia; Block
Study type: Interventional

Summary: 
      Study the benefits of a Erector Spinae nerve block for pain control and decrease narcotics
      usage after mammoplasty in an ambulatory setting
    

Detailed description: 
      Breast surgery is among the most common procedures performed at ambulatory surgery centers.
      Whether for cosmetic or cancer indications, mastectomy and reduction mammoplasty are being
      performed under general anesthesia with standard multimodal pharmacologic analgesia. Regional
      anesthetic techniques have become increasingly prevalent in the management of postoperative
      analgesia. In oncologic surgery, regional anesthetic techniques have demonstrated a lower
      incidence of recurrence or metastasis of breast cancer compared to opioid analgesia. The
      breast has complex innervation, receiving innervation from C5-T7, thus posing a challenge to
      the regional anesthesiologist.

      Current regional techniques for breast and other thoracic surgeries, such as open heart
      surgery, include the PEC I, PEC II, serratus anterior block as well as the paravertebral
      block. Of these options, the paravertebral block is heralded as the gold standard for
      multimodal analgesia in breast surgery. Unfortunately, the paravertebral block carries with
      it the risk of pneumothorax due to its proximity to the pleura. This risk is also increased
      when an inexperienced provider is performing the block, which is common on an academic
      institution. As a result, the PEC I, PEC II and serratus anterior blocks have gained
      traction, is that they carry less risk of adverse events. One drawback of the PEC blocks and
      serratus anterior block is that they may not achieve adequate anterior spread and complete
      coverage of the surgical field, making them less effective at providing adequate
      post-operative analgesia. Due to these drawbacks, the erector spinae plane block (ESPB) has
      begun to gain traction as the regional technique of choice for breast surgery. The ESPB is a
      myofascial block alternative to the paravertebral block. [1] It is performed by injecting
      local anesthetic in the plane between the erector spinae muscle and the spinal transverse
      process. The ESPB is thought to be safer than the paravertebral block because the transverse
      process acts as a barrier to the pleura. It has been postulated that local anesthetic spread
      reaches the paravertebral space and in fact, cadaveric studies have shown dye spreading to
      involve the ventral and dorsal rami of spinal nerves. It is because of this mechanism of
      action that this block has been call the "paravertebral by proxy." The spread of the local
      anesthetic is volume-dependent, and has been seen to anesthetize between 3-8 vertebral levels
      when using local anesthetic volumes of 15-20mL. The ESPB has been used successfully for
      analgesia in open-heart surgery as well as in chronic thoracic neuropathy secondary to
      herpetic neuralgia. Proponents of the erector spinae block prefer it to the paravertebral
      block for its ease to perform and seemingly safer profile.

      The investigators seek to explore the proposed benefits of the erector spinae plane block in
      our patients undergoing bilateral breast reduction mammoplasty. Reducing overall opioid use
      and enhancing recovery after surgery are areas of great importance in the ambulatory,
      outpatient setting. The investigators hope to show the positive impact of ESPB on both of
      important perioperative factors.
    

Intervention name(s): Erecto Spinae nerve block; Multimodal Analgesia
Intervention type(s): Procedure; Procedure
Intervention description(s): The ESPB is a myofascial block alternative to the paravertebral block. It is performed by injecting local anesthetic in the plane between the erector spinae muscle and the spinal transverse process. The ESPB is thought to be safer than the paravertebral block because the transverse process acts as a barrier to the pleura. It has been postulated that local anesthetic spread reaches the paravertebral space and in fact, cadaveric studies have shown dye spreading to involve the ventral and dorsal rami of spinal nerves.; Patients in the control group will receive standard 100mg pregabalin PO, midazolam 2mg IV, fentanyl 100mcg IV.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: erector spinae plane block; multimodal anesthesia