Complications Rate Estimation After Thoracic Erector Spinae Plane Block

Abstract

Thoracic erector spinae plane (ESP) block is an interfascial block used to provide analgesia in cardiac surgery.1De Cassai A Bonvicini D Correale C et al.Erector spinae plane block: A systematic qualitative review.Minerva Anestesiol. 2019; 85: 308-319Crossref PubMed Scopus (74) Google Scholar, 2Song K Xu Q Knott VH et al.Liposomal bupivacaine–based erector spinae block for cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (Accessed 10 March 2021)https://doi.org/10.1053/j.jvca.2020.09.115Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 3Krishna SN Chauhan S Bhoi D et al.Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: A randomized controlled trial.J Cardiothorac Vasc Anesth. 2019; 33: 368-375Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 4Zullino V Bonvicini D Alfonsi L et al.Bilateral continuous erector spinae plane block in open abdominal aortic aneurysm repair.J Cardiothorac Vasc Anesth. 2020; 34: 1588-1590Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Anecdotal complications have been described in patients undergoing ESP block, such as pneumothorax5Hamilton DL. Pneumothorax following erector spinae plane block.J Clin Anesth. 2019; 52: 17Crossref PubMed Scopus (19) Google Scholar and motor block,6De Cassai A Fasolo A Geraldini F et al.Motor block following bilateral ESP block.J Clin Anesth. 2020; 60: 23Crossref PubMed Scopus (10) Google Scholar and recent evidence demonstrated a rapid absorption from the ESP plane, possibly leading to local anesthetic systemic toxicity (LAST).7De Cassai A Bonanno C Padrini R et al.Pharmacokinetics of lidocaine after bilateral ESP block.Reg Anesth Pain Med. 2021; 46: 86-89Crossref PubMed Scopus (15) Google Scholar However, the true incidence of these complications still is unknown. The aim of the present study was to attempt to estimate of the incidence of these complications in adult patients undergoing a thoracic ESP block. We performed a systematic review of the literature indexed by MEDLINE using the following PICOS criteria: >18 years old patients (P); thoracic ESP block (I); any comparator (C); pneumothorax, motor block, LAST (O); and randomized controlled trials (RCTs) (S). We used the same search strategy of a previous systematic review1De Cassai A Bonvicini D Correale C et al.Erector spinae plane block: A systematic qualitative review.Minerva Anestesiol. 2019; 85: 308-319Crossref PubMed Scopus (74) Google Scholar without any restrictions on publication type, status, language, or publication period. The search was performed on January 2, 2021. We identified 602 articles; of these, 420 were excluded after reading the abstract, whereas 182 full-text manuscripts were retrieved and examined. Finally, 45 RCTs were included in the analysis. Sixteen studies performed a bilateral ESP block, whereas the remaining studies performed ESP block on a single side, leading to a total of 1,386 patients and 1,904 ESP blocks. None of the included studies reported complications. Even though the evidence of zero adverse events is encouraging, we cannot infer a zero risk on the basis of the relatively small sample size and given the anecdotal case reports reporting such complications.5Hamilton DL. Pneumothorax following erector spinae plane block.J Clin Anesth. 2019; 52: 17Crossref PubMed Scopus (19) Google Scholar,6De Cassai A Fasolo A Geraldini F et al.Motor block following bilateral ESP block.J Clin Anesth. 2020; 60: 23Crossref PubMed Scopus (10) Google Scholar Using the Quigley et al. method,8Quigley J Revie M Dawson J. Estimating risk when zero events have been observed.BMJ Qual Saf. 2013; 22: 1042-1043Crossref PubMed Scopus (7) Google Scholar which consists of minimizing the maximum expected error, we determined the upper confidence bound on event risk of each of the aforementioned complications to be no greater than two cases every 10,000 patients. This observation was consistent with those described for other thoracic fascial plane blocks9Urits I Ostling PS Novitch MB et al.Truncal regional nerve blocks in clinical anesthesia practice.Best Pract Res Clin Anaesthesiol. 2019; 33: 559-571Crossref PubMed Scopus (12) Google Scholar; however, to our knowledge, this was the first study trying to provide an estimate of the complication rate. This study had some limitations. We included only RCTs, which was done in order to avoid an underestimation of the risk given by a report bias. Furthermore, only thoracic ESP blocks in adults were examined, making our results specific for this application but reducing its generalizability. Future studies are deemed necessary to accurately establish the incidence of these complications; however, state-of-the-art suggests ESP block as a safe technique burdened with only minimal risk of complications. None