Continuous Local Infusion Research Articles

Successful Management of Opioid-refractory Pelvic Cancer Pain Using Continuous Local Anesthetic Infusion via a Tunneled Epidural

Opioid refractory pelvic cancer pain is common and difficult to manage, which often results in analgesic polypharmacy and escalating opioid doses, alongside the use of interventional techniques. However, up-titration of opioids often results in systemic side effects, and interventional procedures have limitations in their duration of action, efficacy, and risk of nerve damage. Therefore, intrathecal pumps have been utilized as a more permanent option for pain management. Their ability to deliver localized therapy using a variety of pharmacological agents makes it an attractive option for cancer pain management. However, they are limited by a need for careful titration, pump volume constraints, and risks of severe side effects. These limitations can be mitigated by targeting the epidural space instead, and we propose the use of a tunneled epidural catheter technique for continuous local anesthetic infusion in opioid-refractory pelvic and abdominal cancer pain. In this case report, we describe a patient with pelvic and abdominal cancer pain due to stage IV sigmoid adenocarcinoma with widespread metastases, who received adequate pain management from a continuous local anesthetic infusion through a tunneled lumbar epidural catheter. Throughout this patient’s hospital admission, their opioid requirements remained the same, and their pain remained well controlled on review in the community one month after discharge. This case demonstrated that epidural catheters with local anesthetic as the sole neuraxial analgesic agent over a short duration could potentially provide preventive analgesia. This case highlights that a local anesthetic tunneled epidural, without addition of neuraxial opioids, is an effective alternative to intrathecal pumps in managing complex cancer pain and has potential for preventive analgesia.

Continuous flow local anesthetic wound infusion for post-operative analgesia following kidney transplantation.

Some patients with end stage renal disease are or will become narcotic-dependent. Chronic narcotic use is associated with increased graft loss and mortality following kidney transplantation. We aimed to compare the efficacy of continuous flow local anesthetic wound infusion pumps (CFLAP) with patient controlled analgesia pumps (PCA) in reducing inpatient narcotic consumption in patients undergoing kidney transplantation. In this single-center, retrospective analysis of patients undergoing kidney transplantation, we collected demographic and operative data, peri-operative outcomes, complications, and inpatient oral morphine milligram equivalent (OME) consumption. Four hundred and ninety-eight patients underwent kidney transplantation from 2020 to 2022. 296 (59%) historical control patients received a PCA for postoperative pain control and the next 202 (41%) patients received a CFLAP. Median age [53.5vs. 56.0 years, p=.08] and BMI [29.5vs. 28.9kg/m2, p=.17] were similar. Total OME requirement was lower in the CFLAP group [2.5vs. 34 mg, p<.001]. Wound-related complications were higher in the CFLAP group [5.9%vs. 2.7%, p=.03]. Two (.9%) patients in the CFLAP group experienced cardiac arrhythmia due to local anesthetic toxicity and required lipid infusion. Compared to PCA, CFLAP provided a 93% reduction in OME consumption with a small increase in the wound-related complication rate. The utility of local anesthetic pumps may also be applicable to patients undergoing any unilateral abdominal or pelvic incision.

Effectiveness of Postoperative Single-shot and Continuous Transverse Abdominis Plane Block Compared to Conventional Analgesia in Hand-assisted Laparoscopic Live-donor Nephrectomy.

Few studies have evaluated the efficacy of transverse abdominis plane (TAP) block in patients undergoing hand-assisted laparoscopic live-donor nephrectomy (HALN). We aimed to evaluate the analgesic effectiveness of TAP block as part of a multimodal pain management regimen in patients undergoing HALN. We retrospectively reviewed the medical records of living kidney donors at our center between June 2016 and February 2020. HALNs were performed via a transperitoneal approach through a suprapubic incision. Additional laparoscopic ports were used in the upper midabdomen. In consenting donors, TAP block was performed postoperatively under ultrasound guidance with either a single-shot or continuous infusion of long-acting local anesthetic (0.2%-0.5% ropivacaine). All the patients received postoperative around-the-clock ketorolac and acetaminophen. Overall, 72 donors received the block (block group, 38 single-shot, 34 continuous), whereas 86 donors did not receive the block (control group). Baseline characteristics were comparable between the groups except for body weight (control: 71.8 ± 13.3 versus block: 77.8 ± 17.3 kg; P = 0.01) and intraoperative opioid dose (32.1 ± 9.6 versus 26.6 ± 10.7 morphine milligram equivalents; P < 0.001). After adjusting for baseline differences, postoperative opioid requirements were similar between the groups. When the baseline pain scale was adjusted for, there was no difference in the overall pain scale scores between the groups (P = 0.242). Subgroup analyses comparing single-shot or continuous TAP versus control did not show any differences. With the caveat of the retrospective nature of the study, the adjunctive effect of TAP block after transabdominal HALN was limited when other multimodal analgesia was used.

Comparison of continuous popliteal nerve blocks using lidocaine vs. bupivacaine infusions for ambulatory foot surgery: a randomized, double-blind, noninferiority trial

Background and objectivesContinuous sciatic popliteal nerve block effectively manages pain after ankle and foot surgery. Most studies on continuous infusion of local anesthetics by perineural catheters have been made with bupivacaine, levobupivacaine, and ropivacaine, but lidocaine has not been used. The main objective of this study was to compare the quality of analgesia, motor function, and side effects between lidocaine and bupivacaine infusions in bilateral continuous popliteal nerve blocks for foot surgery.MethodsThis was a prospective, double-blind, randomized, parallel-group, noninferiority study. We enrolled 70 patients undergoing bilateral foot or ankle surgery that could be performed under general anesthesia and continuous regional analgesia using sciatic popliteal nerve blocks. During their postoperative care, they were randomized into 2 groups: group lidocaine (lidocaine 0.5%, 5 ml/h) or group bupivacaine (bupivacaine 0.1%, 5 ml/h), administered through elastomeric pumps. The primary outcome was pain at 24 h after surgery, assessed by a verbal numeric rating scale (ranging from 0 to 10). A pre-specified non-inferiority margin of 1.5 was defined. Secondary outcomes were the degree of motor and sensitive block, total opioid use, and difficulties with pump or catheter management.ResultsThe mean postoperative pain at 24 h of surgery was 2.06 (95% bootstrap confidence interval bCI 1.29, 2.83) and 1.82 (95% bCI 1.02, 2.62) in the lidocaine and bupivacaine group, respectively. The upper limit of the 95% bCI for the mean difference between lidocaine and bupivacaine was 0.82, declaring non-inferiority. No differences in the postoperative rescue analgesia use and satisfaction with care were found. No differences in postoperative NRS, sensory block and motor block were seen between groups.ConclusionsLidocaine 0.5% and bupivacaine 0.1% provide similar postoperative analgesia through a sciatic popliteal catheter in ambulatory bilateral foot surgery patients.Clinical Trial Registrationhttps://clinicaltrials.gov/, identifier: NCT02121119

Continuous Erector Spinae Plane Block in Patients with Failed Epidural

Pain following thoracotomy is severe and requires adequate analgesia for better postoperative recovery. Epidural analgesia is considered the gold standard for thoracotomy pain. A newer ultrasound-guided analgesic technique, erector spinae plane block, has multidermatomal sensory block. We report two cases, for which an ultrasound-guided continuous erector spinae plane block was given using an 18G catheter. Both the patients received a continuous local anesthetic infusion for 48 hours and were pain-free. Erector spinae plane block can be a suitable alternative for analgesia in patients with failed epidural or contraindication to epidural analgesia.

Continuous Tunneled Infraclavicular Nerve Catheter for Palliative Management of Critical Limb Ischemia: A Case Report.

Critical limb ischemia (CLI) is limb pain occurring at rest or impending limb loss as a result of lack of blood flow to the affected extremity. CLI pain is challenging to control despite multimodal pharmacologic analgesia and surgical intervention. We describe the successful use of a continuous local anesthetic infusion via an infraclavicular nerve catheter to control severe refractory ischemic upper limb pain in a patient with metastatic lung cancer for whom surgical and pharmacological intervention was unsuccessful. As her opioid requirements increased due to worsening ischemic pain, she subsequently developed opioid toxicity, hence prompting the palliative use of a tunneled infraclavicular nerve catheter under ultrasound guidance to minimize opioid requirements. Her opioid requirements tailed down subsequently with the successful insertion of the infraclavicular nerve catheter and she remained pain free till her death. Palliative use of nerve catheters is a safe and an effective alternative in patients with refractory cancer pain, and we describe our methods to prolong its use and minimizing its associated long-term complications.

A randomized comparative study of patient-controlled epidural analgesia with manual standard intermittent bolus for labor analgesia

Background: Patient-controlled epidural analgesia (PCEA) pump has proven to reduce the incidence of unscheduled clinician interventions and total dose of local anesthetic administered for labor pain. Aims and Objectives: The aim of the study was to compare the quality of analgesia, maternal satisfaction, amount of rescue analgesia needed, and neonatal outcome between clinician delivered manual bolus doses and PCEA pumps for epidural labor analgesia. Materials and Methods: 60 parturients of the American Society of Anesthesiologists II scheduled for normal vaginal delivery were randomly divided into two groups, Group A (PCEA) and Group B (Manual bolus). Both groups received an initial epidural bolus of 10 mL of 0.125% Inj. Bupivacaine+20 mcg injection fentanyl. Group A (PCEA) patients received a basal infusion of 5 mL/h with self-administered bolus of 2 mL with a lockout interval of 15 min. Group B patients were provided with a bolus of 10 mL of the same solution manually after every hour. Patients of both groups were given manual rescue boluses for distressing pain (visual analog scale [VAS] &gt;5). Results: Mean VAS score in Group A was 2.97±0.73; and in Group B, it was 3.03±0.56 (P&gt;0.05). Total bupivacaine use and mean duration of second stage of labor in both groups was found comparable. Mean top-up requirement of local anesthetics was significantly high in Group B. Maternal satisfaction was also higher in PCEA group. Conclusion: As PCEA pump provides continuous infusion of local anesthetics, there was lesser requirement of top ups of bupivacaine and higher maternal satisfaction score in PCEA group than manual bolus group.

Pemberian Analgetik Epidural Lumbal Kontinu sebagai Tatalaksana Nyeri Kanker dengan Metastasis

Pain is the most common symptom of cancer patients. Pain in cancer patients is mainly caused by cancerprogressivity and tissue necrosis. Management of chronic pain needs considerable high socioeconomic costs. As an alternative for chronic pain management, a continuous infusion of local anesthetics via epidural catheter is recommended to alleviate chronic pain which caused by cancer pain in certain concentration that can relieve pain. We report 3 cases of patients with cancer pain related to metastatic process. All three patients had previously prescribed with oral opioids and fentanyl patches, which were inadequate in eliminating pain. In all these three patients, lumbal epidural catheter was placed and continuous local anesthetic drugs were administered in 1-2 ml/hour rate. The local anesthetics solution contains levobupivacaine 0.1%, morphine 0.08 mg/ml and klonidin 1.2 mg/ml.

Peripheral Nerve Block and Peri-operative Neurocognitive Disorders in Older Patients With Hip Fractures: A Systematic Review With Meta-analysis.

Poor pain control and opioid use are risk factors for perioperative neurocognitive disorders (PND). The peripheral nerve block (PNB) can reduce pain and opioid consumption. This systematic review aimed to investigate the effects of PNB on PND in older patients with hip fractures. The PubMed, Cochrane Central Registers of Controlled Trial, Embase and ClinicalTrials.gov databases were searched from inception until November 19, 2021 for all randomized controlled trials (RCTs) comparing PNB with analgesics. The quality of the selected studies was assessed according to Version 2 of the Cochrane tool for assessing the risk of bias in RCTs. The primary outcome was the incidence of PND. Secondary outcomes included pain intensity and the incidence of postoperative nausea and vomiting. Subgroup analyses were based on population characteristics, type and infusion method of local anesthetics, and type of PNB. Eight RCTs comprising 1015 older patients with hip fractures were included. Compared with analgesics, PNB did not reduce the incidence of PND in the elderly hip fracture population comprising patients with intact cognition and those with pre-existing dementia or cognitive impairment (risk ratio [RR] = .67; 95% confidence interval [CI] = .42 to 1.08; P = .10; I2 = 64%). However, PNB reduced the incidence of PND in older patients with intact cognition (RR = .61; 95% CI = .41 to .91; P = .02; I2 = 0%). Fascia iliaca compartment block, bupivacaine, and continuous infusion of local anesthetics were found to reduce the incidence of PND. PNB effectively reduced PND in older patients with hip fractures and intact cognition. When the study population included patients with intact cognition and those with pre-existing dementia or cognitive impairment, PNB showed no reduction in the incidence of PND. These conclusions should be confirmed with larger, higher-quality RCTs.

A service evaluation of the newly introduced sciatic nerve local anaesthetic infusion catheters for acute pain management of major lower limb amputations

Background: Patients who undergo lower limb amputations experience severe acute postoperative pain. Despite having no strong evidence for the efficacy of peripheral nerve blocks in reducing phantom limb pain, the reduction in acute postoperative pain and opioid-sparing effect1 make these techniques important to consider. Acute pain management has been identified as a key priority in the management of patients undergoing amputation.2 An initial audit, in October 2021, found that postoperative pain scores and opiate use were high. In April 2022, postoperative local anaesthetic nerve catheters for major lower limb amputations were introduced at our institution. The aim of this service evaluation was to ascertain the postoperative pain scores and analgesic consumption for patients having undergone a lower limb amputation and who subsequently received a continuous postoperative local anaesthetic infusion (levobupivacaine 0.125%, at 6–10 ml h−1 for up to 5 days) via a sciatic nerve catheter. Methods: A retrospective audit was undertaken between July and September 2022 at Birmingham Heartlands Hospital. We included patients having undergone a lower limb amputation with a sciatic nerve catheter placed intraoperatively by surgeons under direct vision and left along the nerve in the cut nerve sheath. Data collected included patient characteristics, postoperative pain scores days 1–5, postoperative opioid use including opioid side-effects, postoperative neuropathic pain, and block related complications. Results: We collected data for 24 patients. Compared with the period before the introduction of sciatic nerve catheters, we observed that the mean pain scores on the numeric rating scale (NRS) decreased. This was particularly evident on day 1 postoperatively when the mean pain scores decreased from the moderate to mild range. On days 1–5 of the postoperative period, the mean immediate-release opioid consumption was 16.1 mg day−1 and mean prolonged-release opioid consumption was 11.6 mg day−1. This was in comparison to the audit in October 2021 that found mean opioid use of 24.1 mg day−1 and 21 mg day−1, respectively. Opioid side-effects reported were sedation (18%), constipation (13%), and nausea or vomiting (8%). Fifty percent of patients reported neuropathic pain. Conclusion: The postoperative pain scores improved and the postoperative opioid consumption reduced slightly with the addition of a sciatic nerve catheter. Opioid side-effects and acute neuropathic pain remain an issue for this group of patients postoperatively. Overall, the introduction of a continuous local anaesthetic infusion via a sciatic nerve catheter after major lower limb amputations in our hospital has been a success and the technique is likely to play a significant future role as part of our multi-modal analgesia regimen for these patients. The Acute Pain Team at University Hospitals Birmingham NHS Foundation Trust. 1.Ilfeld BM. Anesth Analg 2011; 113: 904–252.Gough MJ, Juniper M, Freeth H, Butt A, Mason M. Lower limb amputation: Working together. A report by the National Confidential Enquiry into Patient Outcome and Death, 2014. https://www.hqip.org.uk/wp-content/uploads/2018/02/lower-limb-amputation-report.pdf (accessed 20/03/23)

Continuous Erector Spinae Plane Analgesia in Kidney Transplant Recipients: A Quality Improvement Project.

Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited.Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid managementand optimal haemodynamics to maintain graft function.Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy ofcontinuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesicsgiven were noted.Following satisfactory results from the initial audit, we implemented erector spinae planecatheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit.The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids.During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the nextyear.The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.

PO-04-185 SAFETY AND EFFICACY OF BEDSIDE ULTRASOUND-GUIDED SYMPATHETIC BLOCKADE BY PROXIMAL INTERCOSTAL BLOCK IN PATIENTS WITH ELECTRICAL STORM

Electrical storm (ES) patients (pts) who fail standard therapies have a high mortality rate. Previous studies report effective management of ES with bedside, ultrasound-guided percutaneous stellate ganglion block (SGB) as single injection or continuous infusion of local anesthetics. SGB can be technically challenging by the presence of other catheters and support devices in the anatomical area. We report our experience with sympathetic blockade administered by the regional anesthesiology team via the alternative proximal intercostal block (PICB) (Figure 1A-C). This technique targets an area typically free of catheters and support devices, and may pose less strict requirements for anticoagulation interruption, along with lower risk of focal neurologic side effects. To describe safety and efficacy of PICB in patients with refractory ES. We reviewed our institutional data on ES pts who underwent PICB between 1/2019-10/2022 to analyze procedural safety, short and long-term outcome. Total of 12 pts with ES underwent PICB during this period (Table 1). Five pts initially had left SGB, but 2/5 required PICB due to need for prolonged infusion and rotating site of infusion catheter. Three pts underwent PICB due to lack of efficacy of SGB alone. Sympathetic blockade efficacy appeared higher when left SGB was combined with PICB with response rate of 71.4%. Among ten pts who presented with recurrent ICD shocks (Figure 1D), nine had no further ICD shock after PICB until discharge, heart transplant, or death (P=0.01). There was no procedure-related complication or focal neurologic symptoms. Overall, 8 (66.7%) pts had VT ablation, 9 (75%) pts survived to discharge, 2 (16.7%) pts underwent heart transplantation, 1 (8.4%) patient had ventricular assist device implanted as a bridge to transplant, and 2 (16.7%) pts died. During median of 168 +/- 148.5 days follow up on those pts who survived to discharge without heart transplant, 71.4% remain free of any VT recurrence. In patients with refractory ES, continuous PICB provided safe and effective sympathetic block with no incidence of block-related focal neurologic symptoms. In our series, overall PICB efficacy was 66.7% and the combination of PICB and left SGB appeared complementary. The potential benefits of bilateral sympathetic blocks or block combinations should be carefully weighed against patient- and technique-specific risks and side effects. Larger studies are needed to compare these treatment techniques.

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement Over Conventional Labor Epidural Analgesia?

(Anesthesiology. 2022;136:667–669) Continued innovations of the standard epidural technique have allowed for improvement of the quality of analgesia experienced by laboring women. The introduction of conventional neuraxial analgesia offered effective and safe pain relief to parturients, with relatively infrequent adverse outcomes, and is utilized in &gt;73% of contemporary births in the United States. Procedural refinements over time have offered improvement in analgesia quality, including continuous local anesthetic infusions, optimizations of volume and concentrations of medications delivered, the addition of opioids to the injectate, timed bolus injections, and patient-controlled epidural analgesia. As protocol variations, both combined spinal-epidural and dural puncture epidural utilize a smaller spinal needle that is passed through the epidural needle. In combined spinal-epidural, small doses of opioid and local anesthetic are injected into the intrathecal (IT) space. With dural puncture epidural, the spinal needle is used to intentionally puncture the dura, but no drugs are injected. Initial evidence suggested improved analgesia with this technique over standard epidural and combined spinal-epidural, but the literature has produced mixed results since. In the same issue of this journal, Tan et al deliver results from a randomized clinical trial of obese parturients receiving dural puncture epidural vs conventional epidural to determine if analgesia quality is enhanced by dural puncture in this population at higher risk for epidural failure.

Eight-Kilogramme Giant Mesenteric Cyst of Mullerian Origin: Case Report and Review of Literature

Mesenteric cysts are a rare occurrence in clinical practice, and even fewer are found to be of Mullerian origin. Diagnosis of mesenteric cysts is typically based on clinical assessment and radiological imaging. Surgical excision remains the primary treatment option. We report a case of a middle-aged lady presenting with a giant mesenteric cyst weighing 8-kilogrammes that was managed with laparotomy. Current literature of this rare clinical entity was also reviewed, including differential diagnoses of cystic lesions within the abdomen and role of imaging in guiding pre-operative diagnosis and management strategies. The giant mesenteric cyst was successfully excised en bloc without spillage via a laparotomy. Analgesia optimisation was achieved with a continuous local anaesthetic infusion. Pre-operative radiology can assist in diagnosis of the mesenteric cyst and guide management. Should an open surgical approach be selected, analgesia can be optimised with a continuous local anaesthetic infusion which decreases need for opioid medications.

Continuous local anesthetic wound infusion: Impact on pain score and opioid use in patients undergoing elective mastectomy.

Opioids are commonly used to control acute postoperative pain but their usage is associated with significant complications and the potential of addiction. This study was designed to assess the effect of a Continuous Local Anesthetic Wound Infusion Catheter (CLAWIC) on pain score and as an opioid-sparing agent in patients undergoing elective mastectomy. The search was done using all patients' record from February 2013 to February 2018. The data were collected through the acute pain service database, operation room lists, surgical site infection database, acute pain service sheet, and anesthesia sheet. The patients inclusion criteria were adults who underwent elective mastectomy surgery at King Fahad Specialist Hospital. Patient age, sex, weight, and height were also recorded. The opioid use intraoperatively and postoperatively was significantly lower in the CLAWIC than in the control group. Also, accumulative opioid use was significantly lower in the CLAWIC group. From transfer to the PACU until 48 hours postoperatively, the percentage of patients requiring opioids was significantly lower in the CLAWIC group. After 48 hours, there was no difference in opioid use between the two groups. Visual Analog Scale (VAS) pain scores were significantly lower in the CLAWIC than in the control group. CLWIC showed opioid-sparing effects following mastectomy, as shown by a significantly lower mean opioid dose and a lower percentage of subjects needing opioid analgesia. The procedure is easy to perform and relatively safe. CLWIC could reduce opioid consumption while maintaining good postoperative pain control.

Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery—comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial

BackgroundMinimally invasive thoracic surgery (MITS) has been shown to reduce postoperative pain and contribute to better postoperative quality of life as compared to open thoracic surgery (Bendixen et al., Lancet Oncol 17:836–44, 2016). However, it still causes significant post-operative pain. Regional anaesthesia techniques including fascial plane blocks such as the erector spinae plane block (ESP) have been shown to contribute to post-operative pain control after MITS (Finnerty et al., Br J Anaesth 125:802–10, 2020). Case reports relating to ESP catheters have described improved quality of pain relief using programmed intermittent boluses (PIB) instead of continuous infusion (Bendixen et al., Lancet Oncol 17:836–44, 2016). It is suggested that larger, repeated bolus dose may provide superior pain relief, possibly because of improved spread of the local anaesthetic medications (Ilfeld and Gabriel, Reg Anesth Pain Med 44:285–86, 2019). Evidence for improved spread of local anaesthetic may be found in one study which demonstrated that PIB increased the spread of local anaesthetic medication compared to continuous infusions for continuous paravertebral blocks, which are another type of regional anaesthesia technique for the chest wall (Hida et al., Reg Anesth Pain Med 44:326–32, 2019). Similarly, regarding labour epidural analgesia, the weight of evidence is in favour of PIB providing better pain relief compared with continuous infusion (Onuoha, Anesthesiol Clin 35:1–14, 2017).Since fascial plane blocks, such as ESP, rely on the spread of local anaesthetic medication between muscle layers of the chest wall, intermittent boluses may be particularly useful for this group of blocks. However, until recently, pumps capable of providing automated boluses in addition to patient-controlled boluses were not widely available. To best of our knowledge, there are no randomised controlled trials comparing continuous infusion versus intermittent bolus strategies for erector spinae plane block for MITS in terms of patient centred outcomes such as quality of recovery.MethodsThis trial will be a prospective, double-blinded, randomised controlled superiority trial. A total of 60 eligible patients will be randomly assigned to receive an intermittent bolus regime of local anaesthetic vs a continuous infusion of local anaesthetic. The medication will be delivered via an ultrasound-guided erector spinae plane block catheter which will be inserted by an anaesthesiologist while the patient is under general anaesthetic before their MITS surgery begins. The primary outcome being measured is the Quality of Recovery (QoR-15) score between the two groups 24 h after surgery. Secondary outcomes include respiratory testing of maximal inspiratory volume measured with a calibrated incentive spirometer, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 score at 48 h and time to first mobilisation.DiscussionDespite surgical advancements in thoracic surgery, severe acute post-operative pain following MITS is still prevalent. This study will provide new knowledge and possible recommendations about the efficacy of programmed intermittent bolus regimen of local anaesthetic vs a continuous infusion of local anaesthetic via an ultrasound-guided erector spinae plane catheter for patients undergoing MITS.Trial registrationThis trial was pre-registered on ClinicalTrials.gov Identifier: NCT05181371. Registered on 6 January 2022. All item from the World Health Organization Trial Registration Data set have been included.

Continuous local anaesthetic wound infusion of bupivacaine for postoperative analgesia in neonates: a randomised control trial (CANWIN Study)

ObjectiveTo determine the effect of continuous wound infusion of local anaesthetic drug (bupivacaine) on total amount of systemic opioid use in the first 72 hours in newborn infants undergoing laparotomy.DesignA...

Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS)

PurposePostoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DesignOur primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. MethodsFollowing Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FindingsNinety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). ConclusionsThere was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

This Month in Anesthesiology

This Month in Anesthesiology

Erector spinae plane block for minimally invasive thoracic surgery: a local audit and quality improvement project

Significant postoperative pain is common after minimally invasive thoracic surgery (MITS). This can be mitigated with regional anaesthesia in conjunction with systemic multimodal analgesia. The erector spinae plane block (ESPB), a recently established interfascial block, has demonstrated effective postoperative analgesia after thoracic surgery,1 with fewer risks compared with paravertebral block (PVB). The introduction of ESP catheters for continuous infusion or intermittent bolus administration of local anaesthetic can provide further analgesia in the postoperative period,2 however, sufficient data are lacking.