ESP Block in Pediatric Patients for Postoperative Analgesia
Condition: Opioid Use; Pain, Postoperative; Quality of Life
MeSH terms: Pain, Postoperative
Study type: Interventional
Phase: Phase 4

Summary: 
      Pediatric cardiac surgery is associated with moderate to severe postoperative pain that is
      related to median sternotomy. In a fast-track protocol, used in modern-day cardiac surgical
      care, early extubation may be facilitated by effective postoperative pain control, which also
      helps in maintaining hemodynamic stability This prospective, randomized, and double-blind
      study is designed to examine the efficacy and safety of the ESP block on the postoperative
      analgesia in pediatric patients after cardiac surgery.

      40 pediatric patients aged 2-10 years, undergoing cardiac surgery with median sternotomy will
      be enrolled. Children received oral premedication of midazolam 0.5 mg/kg. After i.v. access
      will be obtained, fentanyl 5 µg/kg will be given. Anesthesia will be induced with 2-3 mg/kg
      propofol and all children will receive rocuronium 0,6 mg/kg for tracheal
      intubation.Subsequently, fentanyl 5 µg/kg will be administered prior to incision and an
      additional 5 microg/kg of fentanyl given prior to CPB. Anesthesia will be maintained with
      %2-3 sevoflurane. Fentanyl 1 µg/kg will be given before skin closure at the end of surgery.
      Patients were randomly assigned to a study group by the computer generated number table.
      Children in group B were administered bilateral ESPB with 0.25% bupivacaine, while children
      in group C did not receive any intervention. Following inhalational induction and
      endotracheal tube placement, the patient will be turned into a left lateral decubitus
      position and bilateral ESP block will be performed under aseptic conditions.

      ESP block at bilateral side will be performed in the lateral decubitis position and at T5
      transverse process level by using 10-MHz liner ultrasound probe. The probe will be located 1
      cm lateral to T5 spinous process in longitudinal parasagittal orientation. Simplex A 50mm
      (B.Braun, Germany) will be inserted by using out of plane technique. The ESP blocks proceed
      with 0,5 ml/kg of 0,25% bupivacaine (Group B).

      Postoperative care: All the patients then will be shifted to the intensive care unit (ICU)
      after the surgery and managed with the institution's ICU protocol for postoperative pain
      management and ventilation.The postoperative analgesia will be provided with rescue
      intravenous (IV) morphine 0.05 mg/kg. Both the groups will receive IV paracetamol 15 mg/kg
      every 6 hours as a component of multimodal analgesia.

      Postoperative sternal wound pain will be judged by the Modified Objectice Pain Scale.

      Postoperative sedation levels will be evaluated with Ramsya sedation score.
    

Detailed description: 
      Reducing the pain from surgical procedures performed early in life psychologically reduces
      the pain experienced by children in subsequent procedures. Pediatric cardiac surgery is
      associated with moderate to severe postoperative pain that is related to median sternotomy.
      Pediatric cardiac surgical patients usually undergo multiple surgical interventions and
      hospital admissions and will benefit from effective pain relief during their initial surgery.
      In a fast-track protocol, used in modern-day cardiac surgical care, early extubation may be
      facilitated by executive postoperative pain control, which also helps in maintaining
      hemodynamic stability.

      Neuraxial analgesia techniques are eﬀective for sternotomy pain. However cardiac surgery
      procedures potentially require cardiopulmonary bypass (CPB) and systemic anticoagulation,
      thus increasing the epidural hematoma risk. Erector spinae plane (ESP) block appears to
      provide adequate regional analgesia for multiple dermatomal levels covering the sternum
      without increasing the risks associated with neuraxial blocks.

      This prospective, randomized, and double-blind study is designed to examine the efficacy and
      safety of the ESP block on the postoperative analgesia in pediatric patients after cardiac
      surgery. We hypothesized that the ESP block significantly improves pain control, as evidenced
      by the reduced need for systemic postoperative analgesics.

      METHOD After obtaining approval from the Institutional Review Boards at Çukurova University
      Medical Faculty, 40 pediatric patients aged 2-10 years, undergoing cardiac surgery with
      median sternotomy will be enrolled. Parental consent and patient assent from patients of an
      appropriate age will be obtained. Children with a preoperative ejection fraction<35%, a
      ventricular arrhythmia/dysrhythmia, a low cardiac output syndrome, a redo or an emergency
      surgery, a scoliosis or other anatomic contraindication to ESPB, a history of bleeding
      diathesis, an anticoagulant drug use at the time of the block and with known allergies to any
      of the study drugs will be excluded from the study.

      Anesthesia Children received oral premedication of midazolam 0.5 mg/kg. After i.v. access
      will be obtained, fentanyl 5 µg/kg will be given. Anesthesia will be induced with 2-3 mg/kg
      propofol and all children will receive rocuronium 0,6 mg/kg for tracheal intubation. After
      tracheal intubation, an arterial line, central venous catheter, and urinary catheter will be
      inserted. Subsequently, fentanyl 5 µg/kg will be administered prior to incision and an
      additional 5 microg/kg of fentanyl given prior to CPB. Anesthesia will be maintained with
      %2-3 sevoflurane. Fentanyl 1 µg/kg will be given before skin closure at the end of surgery.

      Intervention Patients were randomly assigned to a study group by the computer generated
      number table. Children in group B will be administered bilateral ESPB with 0.25% bupivacaine,
      while children in group C did not receive any intervention. The anesthesia resident observing
      the patient in the postperative period and the intensive care unit staff giving postoperative
      care will be blind to the study protocol.

      Following anesthesia induction and endotracheal tube placement, the patient will be turned
      into a left lateral decubitus position and bilateral ESP block will be performed under
      aseptic conditions.

      ESP block at bilateral side will be performed in the lateral decubitis position and at T5
      transverse process level by using 10-MHz liner ultrasound probe. The probe will be located 1
      cm lateral to T5 spinous process in longitudinal parasagittal orientation. Simplex A 50mm
      (B.Braun, Germany) will be inserted by using out of plane technique. The ESP blocks proceed
      with 0,5 ml/kg of 0,25% bupivacaine (Group B). The injection will be applied after the
      confirmation of location by hydrodissection developed anterior to erector spinae muscle with
      1-2 ml of local anesthetic solution.

      Postoperative care All the patients then will be shifted to the intensive care unit (ICU)
      after the surgery and managed with the institution's ICU protocol for postoperative pain
      management and ventilation.The postoperative analgesia will be provided with rescue
      intravenous (IV) morphine 0.05 mg/kg. Both the groups will receive IV paracetamol 15 mg/kg
      every 6 hours as a component of multimodal analgesia.

      Postoperative sternal wound pain will be judged by the Modified Objectice Pain Scale.

      Postoperative sedation levels will be evaluated with Ramsay sedation score.
    

Intervention name(s): Bupivacain; saline
Intervention type(s): Drug; Drug
Intervention description(s): The erector spinae plane blocks proceed with 0,5 ml/kg of 0,25% bupivacain (Group B).; No drugs or interventions were administered to the control group.
Intervention MeSH terms: Bupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment