What is the recommended approach for erector spinae plane (ESP) block coverage for Video-Assisted Thoracic Surgery (VATS)?

Recommended Approach for Erector Spinae Plane Block Coverage for VATS

Single-shot erector spinae plane (ESP) block with 20 ml bupivacaine 5 mg/ml is recommended for video-assisted thoracoscopic surgery (VATS) as it provides effective analgesia with reduced pain scores and opioid consumption during the first 24 hours postoperatively. 1

Efficacy of ESP Block for VATS

• ESP block significantly reduces pain scores at rest and during coughing for the first 6-8 hours after VATS surgery compared to placebo or no block 1
• Patients receiving ESP blocks demonstrate lower opioid consumption during the first 24 hours postoperatively 1, 2
• ESP blocks are associated with reduced postoperative nausea and vomiting, which improves patient comfort 1, 3
• Single preoperative injection of ESP block improves acute postoperative analgesia and reduces emergence agitation in VATS patients 2

Technical Considerations

• A single injection at T4-T6 level is recommended rather than multiple injections, as multiple injections (T4-T8) have not demonstrated superior analgesia but increase procedural time and patient discomfort 1
• The recommended volume is 20 ml of bupivacaine 5 mg/ml for single-shot ESP block 1
• For continuous ESP block, an infusion of ropivacaine 0.15% at 10-15 ml/h for 48 hours provides effective analgesia 4

ESP Block vs. Other Regional Techniques

• ESP block and paravertebral block show comparable efficacy in terms of pain scores and opioid consumption during the first 48 hours postoperatively 1
• Some studies suggest paravertebral block may provide superior analgesia compared to ESP block in the first 8 hours after surgery 1
• ESP block demonstrates better safety profile with lower incidence of complications such as hematoma compared to other regional techniques 5
• ESP block provides better Quality of Recovery (QoR) scores at 24 and 48 hours compared to video-assisted paravertebral block 4, 3

Adjuvants to ESP Block

• Adding dexmedetomidine to ropivacaine in ESP block results in reduced pain scores, lower rescue analgesia requirements, and shorter hospital stays compared to plain ropivacaine or ropivacaine with dexamethasone 1
• The addition of adjuvants should be considered when prolonged analgesia is required 1

Timing of Block

• Preoperative administration of ESP block is recommended as it provides immediate postoperative analgesia 2, 3
• No significant difference has been found between blocks performed after incision or at the end of the procedure in terms of pain score and opioid consumption 1

Patient Outcomes with ESP Block

• ESP block improves Quality of Recovery (QoR) scores at 24 and 48 hours postoperatively 4, 3
• Patients receiving ESP block demonstrate faster postoperative out-of-bed activity 1
• ESP block is associated with shorter post-anesthesia care unit (PACU) stay and higher patient satisfaction 2, 3
• ESP block may be considered as a safer alternative to thoracic epidural analgesia for VATS procedures 6, 5

Potential Pitfalls and Caveats

• The analgesic effect of single-shot ESP block may diminish after 6-8 hours, requiring supplemental analgesia 1
• Basic analgesia with NSAIDs and paracetamol should be administered concurrently with ESP block to optimize pain management 1
• ESP block may provide less consistent analgesia compared to paravertebral block in some patients, requiring careful assessment of individual pain control 1
• Despite improvements in acute pain management, ESP block has not demonstrated significant reduction in chronic postsurgical pain at 3 months compared to paravertebral block 4