|Year : 2022 | Volume
| Issue : 2 | Page : 192-196
Effectiveness of erector spinae plane block in patients with percutaneous nephrolithotomy
SS Pehlivan1, OO Gergin1, N Baydilli2, A Ulgey1, I Erkan1, A Bayram1
1 Department of Anaesthesiology and Reanimation, Erciyes University, Medical Faculty, Kayseri, Turkey
2 Department of Urology Surgery, Erciyes University, Medical Faculty, Kayseri, Turkey
|Date of Submission||23-Jul-2020|
|Date of Acceptance||27-Nov-2021|
|Date of Web Publication||16-Feb-2022|
Dr. S S Pehlivan
Köşk Mahallesi, Obalar Sokak, Kat: 13, No: 26 Melikgazi, Kayseri
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Percutaneous nephrolithotomy operation is a minimally invasive surgical procedure for the treatment of kidney stones. Aim: This study aimed to evaluate the effectiveness of ultrasound-guided erector spinae plane block (ESPB) on analgesic consumption in patients who underwent percutaneous nephrolithotomy. Subjects and Methods: The data of 60 cases who underwent percutaneous nephrolithotomy operation between 01.01.2020 January and 12.01.2020 were retrospectively analyzed. Hemodynamic parameters, verbal analogue scale adjectives, total morphine consumption, additional analgesic and antiemetic need, duration of hospitalization, and patient satisfaction score were compared in patients who had ESPB and did not have block. Results: Demographic data and hemodynamic parameters were similar between the two groups. Verbal rating scale values were lower for Group I at 2, 6, 12, and 24 h (P < 0.05). Patient satisfaction score was significantly higher in Group I over 24 h (P = 0.039). Total morphine consumption at postoperative 2nd, 6th, and 24th h was less than that of Group II (P < 0.05). Analgesia consumption in postoperative 24 h of group I was less than that of Group II (P = 0.001). The amount of fentanyl given intraoperatively was significantly higher in Group II (P = 0.001). Nausea and vomiting rates were significantly lower for Group I (P = 0.002). Conclusion: Ultrasound-guided ESPB reduced postoperative morphine consumption and the rate of nausea and vomiting.
Keywords: Erector spinae plane block, percutaneous nephrolithotomy, postoperative analgesia, ultrasound, verbal analogue scale
|How to cite this article:|
Pehlivan S S, Gergin O O, Baydilli N, Ulgey A, Erkan I, Bayram A. Effectiveness of erector spinae plane block in patients with percutaneous nephrolithotomy. Niger J Clin Pract 2022;25:192-6
|How to cite this URL:|
Pehlivan S S, Gergin O O, Baydilli N, Ulgey A, Erkan I, Bayram A. Effectiveness of erector spinae plane block in patients with percutaneous nephrolithotomy. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 2];25:192-6. Available from: https://www.njcponline.com/text.asp?2022/25/2/192/337761
| Introduction|| |
Percutaneous nephrolithotomy (PCNL) is a minimally invasive technique in the surgical treatment of kidney stones. The nephrostomy tube insertion technique for providing patients urinary drainage and homeostasis is a treatment causing pain, prolonged hospitalization, and anxiety.
In order to provide postoperative analgesia for PNCL patients, certain methods are adopted, such as injecting opioids, local anesthetic infiltration, or peripheral nerve blockages. Morphine is an occasionally preferred agent as an opioid. However, its side effects, such as respiratory depression, nausea, vomiting, and itching, restrict its usage at high doses. Regional techniques such as intercostal nerve blocks, paravertebral block, and erector spinae plane block (ESPB) are quite effective techniques in postoperative analgesia.
ESPB is a block defined by Ferora et al. in 2016 for the management of thoracic neuropathic pain. Unilateral somatosensorial and sympathetic block show its efficacy through spreading in the erector spinal region after local anesthetic injection. The most significant advantage of ESPB is its simplicity and safety. The transverse process can be discerned via Ultrasound (USG) and used as a barrier. It is far from significant structures that can be easily damaged by a needle such as pleura, vessels, and nerves. When there is a need to maintain analgesia, it can be done by implanting a catheter. Thus, it has broad spectrum use. It was found to be effective in postoperative analgesia for thoracotomy, breast surgery, abdominal surgery, and hip surgery. Nevertheless there are not enough studies to prove its efficacy in PNCL operations.
Our primary aim was to assess the effect of ESPB on analgesic efficacy and morphine consumption in patients who underwent ultrasound-guided PCNL.
| Methods|| |
Study population and design
This study was conducted retrospective cohort by examining the data of 60 PNCL cases that underwent operation between January and December 2019. The Local Ethics Committee approved the study (Approval number = 2019-881). Files of 41 patients who underwent PCNL between January and December 2019, aged between 18-65 and whose America Society of Anesthesia (ASA) Classifications were I and II, and 45 patients who did not undergo ESPB were investigated. Two groups, both including 30 patients, were created after identifying the files that had no missing data, including the usage of a patient-controlled analgesia (PCA) device for postoperative analgesia and a Verbal Analogue Scale (VAS) (0: no pain, 10: severe pain). Group I consisted of patients who underwent ESPB and Group II, those who did not. The study design is summarized in the flow chart.
General anesthesia was conducted with 2.5 milligrams/kilogram (mg/kg) propofol, 1 microgram/kg (μg/kg) fentanyl and 0.6 mg/kg rocuronium in all patients. All the patients were operated with endotracheal intubation. 1-3% Sevoflurane and 50%/50% oxygen/nitrous oxide were used to maintain anesthesia. Bispectral index (BIS) was held between 40-60. Whenever hypertension or tachycardia was observed, it was considered as inadequate analgesia, and 1 mg/kg fentanyl was added, while BIS was between 40-60. 0.9% NaCl (5-10 ml/kg) infusion was given to patients during the operation. In the lithotomy position, an open-endedureter catheter (5 French) was inserted retrogradely into the renal pelvis under fluoroscopic guidance by urologist. The patient was then turned into a prone position. Surgical area sterilization was provided in the prone position for patients who underwent ESPB. ESPB was performed on the surgery side at the 10th vertebrate transverse process level, which is on the line of dermatomes innervating the kidney by counting from the 7th vertebrae with the guidance of an ultrasound device (MyLabTMFive, Esaote, Genoa, Italy) (USG) whose transducer was linearly adjusted to 6–13 MHz. Thirty milliliters (mL) of 0.25% bupivacaine was injected through a Block 22, Gauge 80 mL needle (Braun, Stimuplex Ultra 360, Germany). A standard PNCL procedure was performed.
Morphine (0.05 mg/kg) was injected into all patients 15 min before the end of the operation. In total, 40 μg/kg mg of neostigmine and 20 μg/kg atropine were injected to antagonize muscle relaxation after the operation. Patients who gained their muscle power were transferred to the postoperative awakening unit. A PCA device (WYM PCA pump, Anesmed Medical, Korea) was set to 10 min of lock duration, 10 mg with a 4 h limit, and attached to all patients after 1 mg of morphine injection. Patients whose VAS score was 4 or more were given an additional 1000 mg of paracetamol. Metoclopramide, as an antiemetic, was given to patients with nausea or vomiting. Patients whose Aldrete score was ≥9 were sent to the urology service. All PCNL operations were performed by the same team with the same surgical technique. VAS score, morphine consumption, additional analgesic need, and satisfaction rate (1 = very bad, 2 = bad, 3 = good, 4 = very good, 5 = perfect) of patients at the 2nd, 4th, 6th, 12th, and 24th h were noted.
Demographic and operation-specific data were found from anesthesia and postoperative forms. The data obtained from those forms included age, gender, ASA score, SpO2, heart rate, MAP, ETCO2, operation duration, stone weight, 24 h morphine consumption, additional antiemetic, analgesic need, if performed, pain and patient satisfaction score, and hospitalization duration.
Shapiro–Wilk test, histogram, and Q–Q plots were applied to assess data normality. Variance homogeneity was assessed using Levene's test. Abnormally distributed data was compared with Mann–Whitney U test. Normally distributed data were compared with t-test. The Pearson Chi-square analysis was employed for categorical variables. Data are given as median (percentiles 25–75%) and frequencies as percentages. Analyses were conducted using the SPSS statistical package software (version 20.0; SPSS, Inc., Chicago, IL, USA), software. The sample size of the study was calculated based on the postoperatif overall the morphine consumption. The mean morphine consumption was 15.03 ± 5.29 mg in the ESP group and 25.70 ± 3.67 mg in the control group. Power of the performed test was found as 1.00 for alpha level 0.05. Analyses were conducted using TURCOSA (Turcosa Analytics Ltd Co, Turkey, www.turcosa.com.tr).
| Results|| |
Intraoperative and postoperative 24 h anesthesia data of 60 patients were examined. Differences in gender, age, ASA score, operation duration, hospitalization duration, needle diameter, and stone burden were statistically insignificant between the two groups (P = 0.791, P = 0.037, P = 0.584, P = 0.431, P = 0.741, P = 0.158, P = 0.109, respectively) [Table 1]. Differences in mean arterial pressure and pulse were statistically insignificant between the groups. The amount of fentanyl injected during the operation was significantly higher in the nonblockage group (P = 0.001). Additionally, the patient satisfaction score was significantly higher in Group I at 24 h than Group II (P = 0.039) [Table 2].
|Table 2: Intraoperative and postoperative variables and satisfaction scores|
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VAS scores at the 2nd, 6th, 12th, and 24th h were lower in Group I compared to Group II (P = 0.001, P = 0.002, P = 0.006, P = 0.007) [Figure 1]. Mean morphine consumption in the postoperative 24 h was significantly lower in group I (15.03 ± 5.29 and 25.70 ± 3.67 mg, respectively; P < 0.001)). Also, morphine consumption at the 2nd and 6th h was lower in group I than Group II (P = 0.001, P = 0.008) [Table 3].
|Figure 1: Verbal analogue scales cores of the groups over postoperative time. Group I, Erector spinae plane block group; Group II nonblock group. P < 0.05, significant difference|
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The rates of nausea, vomiting, and metoclopramide use were significantly higher in Group II (P = 0.002). Any complications observed in both groups. The total need for analgesic (paracetamol 1000 mg) was lower in group I in the 24 h period (P = 0.001) [Table 3].
| Discussion|| |
In this study, we observed that USG-guided ESPB significantly reduced the consumption of morphine in the postoperative 24 h for PCNL operations and increased patient satisfaction scores.
Various analgesia methods are preferred in PCNL operations. Intercostal nerve blocks, paravertebral blocks, and ESPB are some of the regional blockage methods. The paravertebral block was a frequently preferred method before ESPB arose. However, complications such as intravascular injections, epidural or intrathecal spread, and pneumothorax can occur during paravertebral block application.
ESPB has been reported as a successful anesthesia technique to provide postoperative analgesia for various surgical procedures. The application technique is easier and safer than a paravertebral block. Although it is in its infancy in terms of application history, it has been preferred for a wide range of surgical procedures and has been continuously supported by studies, yet there are still not enough studies to show its advantages with a PCNL operation.
Ibrahim et al. conducted ESPB with 30 mL of 0.25% bupivacaine at the T11 level before general anesthesia induction in PCNL operation. The analgesic effects of ESPB and morphine consumption were similar to our study. However, the application duration of the block procedure and analgesia assessment scores were different. The block is applied after general anesthesia in the prone position in our clinic. It is applied as a short procedure within the operation time. Therefore, applying ESPB before the induction of general anesthesia in their study could be the reason for the shortened postoperative analgesia duration. The mean analgesia period of bupivacaine is 6–12 h. It was argued that the anesthesia duration is related to the postoperative duration of sympathectomy supported by local anesthesia.
Compared to the study of Ibrahim et al. study, both morphine consumption and VAS scores were found lower during the postoperative 24 h in group I. There was not any significant difference between the control group and the blockage group at the initiation and at the 4th, 6th, and 24th h's periods in their study. Only the VAS score at the seconnd hour was significantly different. The reason why there was no difference for the VAS score at the initiation and at the 4th hour could not be explained. Only total morphine consumption in 24 h in the blockage group was found lower in their study, but differences every 2 h were not taken into consideration. In our study, the total morphine consumption in the ESPB group was 34% less.
Chin et al. and Adhikary et al. studied the spreading of local anesthetic to the paravertebral space. According to these cadaver studies, the medicine given bilaterally at the T7 level spreads on the right side craniocaudally from T2 to T10, on the left side from C5 to L2, and on the lateral side from T10 to T12 level. They reported that local anesthesia given through ESPB could be effective in the mentioned regions.
While kidney innervations are between T10 and L1 levels, ureter innervation is between T10 and L2. Sufficient analgesia can be maintained by applying regional blockage unilaterally between T10 and L2 levels in the PCNL operation with the help of this anatomical information. We applied the block at the T10 level considering nerve innervations and medication spreading. Thus, local anesthetic can spread its efficacy to a wider area. The postoperative analgesic effect was adequate, especially for the first 2 h after the operation, since the block was applied just before the operation.
Kim et al. conducted another study examining the analgesic efficacy of ESPB in PCNL operations. ESPB was applied at the level of T8 with 10 mL of 0.75% ropivacaine, 10 mL of saline, and epinephrine (1:200,000). The local anesthesia combination was applied through the catheter twice a day for 5 days after the operation, and zaltoprofen was given as an additional analgesic. Patients did not need any other analgesics. This study showed the eligibility of analgesic medicine infusion through a catheter and ESPB efficacy in a case report. However, the hospitalization period of PCNL patients varies, so in the case of an increase in patient numbers, costs would be higher. Catheterization in the postoperative period can lead to infection. It can be applied in some cases, but the surgeon should consider the application in case series. In our study, ESPB was applied once, and at one dose, then morphine infusion was maintained by PCA. Therefore, the cost did not change too much, and the risk of infection was not high.
Gultekin et al. applied ESPB to 30 patients at the T8 level. They used 20 mL of 0.5% bupivacaine as a local anesthetic and used tramadol and paracetamol injections after the operation when needed. Bupivacaine is a frequently used local anesthetic for ESPB. It is advised not to exceed the limit of 2.5 mg/kg bupivacaine to prevent local anesthetic-dependent toxicity. Therefore, local anesthetics should be applied at the lowest and the most effective dose to decrease the risk of toxicity. We applied 30 mLof 0.25% bupivacaine, thus establish adequate analgesia at a low dose.
USG-guided ESPB has become a popular blockage technique. Only two complications, which are pneumothorax and motor muscle deficiency, were reported., Pneumothorax can occur when the visual depth cannot be controlled clearly by USG. Motor muscle deficiency can be seen as a result of lumbar plexus damage due to the application points at lower thoracic or lumbar levels. In our study, since all blocks were applied by USG guidance and after the transverse process was seen, no complications occurred.
Recently, maintaining analgesia and reducing opioid consumption in the perioperative period are the most important targets. The one-time application of ESPB reduced morphine consumption.
Another positive effect of ESPB is reducing the incidence of opioid-dependent side effects, especially nausea and vomiting. Nausea and vomiting were significantly lower in the blockage group in our study. Antiemetic treatment was not needed.
There are a few limitations for the study. Only 60 patients in the 12-month period whose data had no missing information were included in the study. The number of patients was limited for a retrospective study. A sense test that could determine the blockage region was not applied. It is thought that the analgesic effect was limited to the injection area.
The reason for reduced analgesic consumption was not clear. It could be a result of the systemic effect of the local anesthetic or could be caused by the blockage. This study showed that ESPB usage could be clinically beneficial for PNCL. Further studies should be conducted to support its efficacy and safety. We believe that further studies will resolve these limitations.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]