Can an erector spinae plane (ESP) block be performed with a concentration of ropivacaine higher than 0.25%?

Erector Spinae Plane (ESP) Block with Higher Concentration Ropivacaine

Yes, you can perform an erector spinae plane block with a concentration of ropivacaine higher than 0.25%, though current guidelines primarily recommend 0.2-0.25% concentrations for optimal efficacy and safety. 1

Current Guideline Recommendations

• European Society for Paediatric Anaesthesiology (ESPA) recommends ropivacaine 0.2% for ESP blocks at a volume of 0.2-0.5 ml/kg 1
• For other regional blocks, concentrations of 0.2-0.25% ropivacaine are similarly recommended across multiple block types 1
• American Society of Anesthesiologists recommends standard concentration of 0.25% bupivacaine for peripheral nerve blocks 2

Pharmacological Considerations

• Ropivacaine has a high pKa and low lipid solubility, which allows it to preferentially block pain fibers (Aδ and C fibers) over motor fibers (Aβ fibers) 3
• Ropivacaine has a more favorable safety profile than bupivacaine with reduced CNS and cardiotoxic potential 3, 4
• Higher concentrations of ropivacaine (0.75% or 1.0%) have been studied for lumbar epidural anesthesia when equivalent sensory and motor blockade to bupivacaine 0.5-0.75% is desired 3

ESP Block Efficacy Evidence

• Studies have demonstrated that ESP blocks with 0.2-0.25% ropivacaine provide effective analgesia for thoracic procedures 1
• ESP blocks performed with 20 ml bupivacaine 0.5% (higher concentration) have shown lower pain scores and reduced opioid consumption compared to no block 1
• ESP blocks have shown similar analgesic efficacy to paravertebral blocks in multiple studies 1

Safety Considerations

• When using higher concentrations, careful calculation of total dose in mg/kg is essential to prevent local anesthetic toxicity 5
• The maximum safe dose of ropivacaine should not be exceeded regardless of concentration used 5
• Higher concentrations may increase the risk of motor blockade, which is typically less pronounced with standard ropivacaine concentrations 3, 4

Clinical Application

• If using a higher concentration of ropivacaine (>0.25%), consider reducing the volume proportionally to maintain the same total dose 5
• Higher concentrations may be appropriate when:
  • More dense blockade is required 3
  • Longer duration of action is needed 3, 4
  • Limited volume can be used due to anatomical constraints 6

Common Pitfalls

• Exceeding maximum safe dose when using higher concentrations 5
• Potential for increased motor blockade with higher concentrations 3, 4
• Failure to adjust volume when increasing concentration 5
• Inadequate monitoring for systemic toxicity 5

While most guidelines recommend 0.2-0.25% ropivacaine for ESP blocks, higher concentrations can be used with appropriate dose adjustments and monitoring for systemic toxicity.