Erector Spinae Plane vs. Paravertebral Nerve Block for Thoracic Surgery
Condition: Thoracic Surgical Procedures
Intervention: Paravertebral nerve block; Erector Spinae nerve block
Intervention description: The patient will be placed in a sitting position and the level of needle insertion will be marked corresponding to the level of surgical incision. With sterile technique an ultrasound Paravertebral Nerve Block will be performed.; The patient will be placed in a sitting position and the level of needle insertion will be marked corresponding to the level of surgical incision. With sterile technique an ultrasound erector spinae nerve block will be performed.
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 2 groups of patients will be studied simultaneously. One group will have the intervention of the nerve block in the erector spinae approach and the other group will have the nerve block in the traditional paravertebral approach.
Masking: None (Open Label)
Enrollment: 35.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: Accepts Healthy Volunteers
Keywords: VATS; Regional Anesthesia; Paravertebral nerve block; Erector Spinae nerve block; Video assisted thoracoscopic surgery

Summary:

      Continuous paravertebral analgesia and erector spinae plane blockade (ESP) are accepted
      techniques at University of Pittsburgh Medical Center (UPMC) for the management of thoracic
      pain following surgery and trauma. Recently, an increasing number of erector spinae plane
      nerve blocks are being performed as it has been demonstrated in our institution, and via case
      reports that the blocks provide clinical effectiveness, but may have a better side-effect
      profile than the paravertebral nerve block. However, the relative efficacy of ESP compared to
      paravertebral nerve block remains to be established for video assisted thoracoscopic surgery
      (VATS). This is a prospective randomized study intended to assess the efficacy, safety and
      side-effect profile of continuous erector spinae plane analgesia versus continuous
      paravertebral analgesia for VATS procedures. It will include 60 patients presenting to UPMC
      Passavant for a VATS procedure. Patients will be randomized 1:1 to receive either a nerve
      block via continuous paravertebral infusion or via erector spinae plane infusion. In
      addition, to treat breakthrough pain, the patients in both arms will receive multimodal
      adjunctive therapy per routine. Bupivacaine and ropivacaine are FDA approved for use in nerve
      block catheters. The primary outcome will be to compare analgesic efficacy between the two
      nerve blocks as defined by total opioid consumption and pain scores on the numeric pain
      rating scale. Secondary outcomes include incentive spirometer amounts (baseline vs daily
      score postoperatively), length of stay, duration of catheter and report of adverse events or
      complications. Other data points include number of chest tubes and location and level of
      catheter and nerve block placement as well as number of blocks per case.
    

Eligibility criteria:

        Inclusion criteria:

          -  Patients undergoing VATS agreeable to have a nerve block as analgesic technique

          -  Age: 18 years old and older.

          -  ASA (American Society of Anesthesiologists Class) I-IV

        Exclusion criteria:

          -  Cognitive impairment that would not allow effective nerve block placement or gathering
             information related to the study (ex. pain score).

          -  Contraindications for nerve block placement such as coagulopathy, use of clopidogrel
             in the past 48hs, patients on dual antiplatelet therapy, infection at the site of
             puncture, patient refusal, allergy to local anesthetics.

          -  Chronic opiate consumption

          -  Patient expected to be on therapeutic anticoagulation post procedure.

          -  Pregnancy

          -  Comorbid conditions: Any comorbid condition that in the judgment of the
             anesthesiologist would preclude the patient from any aspect of the study (ex. sepsis,
             possibly abnormalities of the thoracic spine or paravertebral anatomy such as
             neoplastic mass occupying the space, empyema, increased intracranial pressure)