Title: Non-opioid pain management post major surgery: The use of erector spinae block infusions
St Vincent’s University Hospital, Ireland
Abstract: Erector spinae plane (ESP) block is an interfascial plane block where a local anaesthetic is injected in a plane preferably below the erector spinae muscle. It works at the origin of spinal nerves and has emerged as an effective and safe analgesic regional technique. It has a wide variety of applications ranging from control of acute postoperative pain including breast, thoracic, and abdominal surgeries.
Erector spinae block infusions have emerged as an effective novel regional therapy that is safe, effective and most importantly, requires less opioid post-operatively. For thoracic surgeries or rib fractures, ESP block also helps for better lung expansion, superior analgesia, allows patient to cough, weaning off mechanical ventilation, and early ambulation. It can be used for selective multidermatomal sensory blockade according to surgery or site of pain. For sensory blockade of cervical, thoracic, and lumbar dermatomes, ESP block was administered at level T2, T5, and T7, respectively.
Though ESP and paravertebral blocks have been documented to be efficacious for post-operative pain, there has been no direct comparison between the two approaches. The ESP block is considered to be a safer technique with less theoretical adverse events possible and thus, would become a viable alternative to the more technically challenging paravertebral nerve block. In terms of managing abdominal surgery, ESP is advantageous when compared to Transverse Abdominis Plane (TAP) block. TAP block usually achieves a dermatomal block below T7 whereas the ESP block can cover any level. Likewise, T4 – T5 levels are effective for breast and thoracic surgeries.
ESPs are comparatively simpler, safer with lesser expertise, and do not have the procedural complications associated with epidurals or paravertebral blocks. As ESPs are not in the vicinity of the spinal cord, they do not have the risk of hypotension, vascular puncture or motor blocks associated with epidural infusions, or the epidural spread or pneumothorax as a result of a paravertebral block. The continuous nature, extensive craniocaudad spread, no hindrance to surgical field, and only sensory blockade make ESP block superior to pectoral nerve blocks (single shot), TAP block (four quadrant blocks that required for the entire abdomen), rectus sheath, and quadratus lumborum blocks. The risk-benefit of these latter techniques make for a poor comparison to an ESP block.
Audience Take Away:
- This new therapy has the advantage of minimising the use of opioids in post-operative pain management. This will thereby reduce the incidence of post-operative complications associated with opioids.
- The nurse working in theatre or pain management could present this new therapy to the Department of Anaesthesia in their hospital as a non-opioid pain management therapy.
The use of erector spinae plane infusions result in the following:
- Better pain management
- Less nausea and vomiting
- Minimal light-headedness and hallucinations
- Less paralytic ileus
- Less constipation
- Quicker mobilisation
- Shorter length of stay
Elaine Clear is a candidate Advanced Nurse Practitioner in Pain Management and nurse prescriber in St Vincent’s University Hospital, Dublin, Ireland. Having worked as a clinical nurse specialist in post-operative pain management for 10 years she gained enormous experience in utilizing different analgesic therapies. In 2013, she won a Biomnis Healthcare award for developing an acute pain app called APPease in collaboration with the Department of Anaesthesia and pharmacy.