Erector Spinae Plane Block For Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The aim of this study was to assess the efficacy of bilateral ESPB on postoperative analgesia
      in patients undergoing total abdominal hysterectomy under general anesthesia.
    

Detailed description: 
      60 patients Scheduled for elective total abdominal hysterectomy, after obtaining a written
      informed consent for anesthesia from each patient before enrolment in the study after
      explaining to them the nature of study.

      Inclusion criteria included female patients aged 40 - 70 years, Weighted 50 - 90 Kg and with
      American society of anesthesiologists physical status (ASA) class Ι to ΙΙΙ Scheduled for
      elective total abdominal hysterectomy under general anesthesia. Exclusion criteria included
      Local infection at the site of puncture, Patients having history of hematological disorders,
      including coagulation abnormality, Patients with severe hepatic impairment, Patients with
      chronic pain and Patient had a known allergy to study drugs.

      Patients were randomized into two equal groups. An online randomization program was used to
      generate random number list. Patient randomization numbers were concealed in opaque envelops
      which were opened by the study investigator.

      Members of the study group involved in obtaining functional data were blinded to
      randomization for the period of data acquisition and analysis. Patients were randomly
      allocated into two groups:

      Erector spinae plane block Group (ES): ultrasound guided erector spinae plane block at T9
      vertebrae level with 20 ml of bupivacaine 0. 5%. Control Group (c): did not receive block.

      One day before surgery all patients were interviewed to explain visual analogue scale (VAS),
      learned how to use patient controlled analgesia (PCA) pump and routine investigations were
      fulfilled.

      In both groups Patients were monitored with ECG, non-invasive blood pressure monitoring and
      pulse oximetry. IV access was established and IV midazolam 0.01-0.02 mg.kg-1 was given.

      In (ES) group After skin sterilization, ESPB was performed in sitting position at the level
      of T9 linear ultrasound (US) transducer (Phillips-Saronno Italy) was placed vertically 3cm
      lateral to midline to visualize the muscles of the back: the trapezius muscle above, the
      rhomboid major muscle in the middle and the erector-spinae muscle on the bottom, transverse
      process and simmering pleura in between the two transverse processes. After local
      infiltration of needle insertion site with 2-3ml of 2% lidocaine, a 22-gauge Short bevel
      needle (Spinocan, B.Braun Melsungen AG, Germany) was inserted in cranial-caudal direction
      towards transverse process (TP) in-plane to the US transducer until needle touched the TP
      crossing all the muscles. Correct needle placement was confirmed by Visualizing the needle in
      plane along its entire length, when it contacted the transverse process, 1 ml of anesthetic
      solution was injected. Hydrodissection of the interfascial plane between the erector spinae
      muscle and the transverse process was confirmed by visualizing the local anesthetic spreading
      in a linear pattern between the muscle and the bony acoustic shadows of the transverse
      process, ensuring correct localization. Then, up to 20 ml of bupivacaine 0.5% was injected.
      The procedure was repeated following the same steps on the other side of back. Control Group
      (c): the same pervious technique as in ES group but patient did not receive block.

      Block success was tested by reduced cold sensation at planned surgical incision 5 minutes
      after block completion.

      General anesthesia was induced with fentanyl 2 mcg.kg-1, propofol 2 mg.kg-1 followed by
      atracium 0.5 mg.kg-1 and after intubation Anesthesia was maintained with isoflurane (1 MAC)
      and atracium 0.1mg.kg-1 as a maintenance dose every 30 minutes till the end of the procedure;
      After emerging from anesthesia, the patients were transferred to the post aesthesia care unit
      (PACU) for a 2 hours observation period. The patients were discharged from the PACU after
      fulfilling the discharge criteria based on Aldrete score. Postoperative analgesia was
      provided in both groups immediately after surgery by PCA fentanyl pump then regular oral
      acetaminophen 1 g four times a day.

      The criteria to stop fentanyl titration protocol were satisfactory pain control, Patient
      became sedated (Ramsay sedation scale >2), Respiratory rate < 12 / min, Oxygen saturation <
      95% or development of serious adverse effects (allergy, severe vomiting, hypotension).

      Visual analogue pain score (VAS) for pain (ranging from 0 to 10, where 0 no pain and 10
      maximum pain) was measured postoperatively at 30 min and 2, 4, 6, 12, and 24 hour
      postoperative.

      Any side effects were recorded as nausea or vomiting, pneumothorax, or any other
      complications. Also Duration of hospital stays, from the first day postoperative until
      discharge.

      The primary outcome of this study was Total fentanyl consumption in the first 24 hours And
      The secondary outcome was VAS for pain (ranging from 0 to 10, where 0 no pain and 10 maximum
      pain) was evaluated postoperatively at 30 min and 2, 4, 6, 12, and 24 hour postoperative,
      Duration of hospital stays and any complications.
    

Intervention name(s): Erector Spinae Plane Block; control
Intervention type(s): Procedure; Procedure
Intervention description(s): In (ES) group After skin sterilization, ESPB was performed in sitting position at the level of T9 linear ultrasound (US) transducer (Phillips-Saronno Italy) was placed vertically 3cm lateral to midline to visualize the muscles of the back, transverse process and simmering pleura in between the two transverse processes. After local infiltration of needle insertion site with 2-3ml of 2% lidocaine, a 22-gauge Short bevel needle (Spinocan, B.Braun Melsungen AG, Germany) was inserted in cranial-caudal direction towards transverse process (TP) in-plane to the US transducer until needle touched the TP crossing all the muscles. Then, up to 20 ml of bupivacaine 0.5% was injected. The procedure was repeated following the same steps on the other side of back.; in control group, Erector Spinae Plane Block will not be done
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Prevention
Keywords: Erector Spinae Plane Block; Postoperative Analgesia; Total Abdominal Hysterectomy; fentanyl consumption