What is the protocol for conscious sedation with Erector Spinae Plane (ESP) block in endoscopic surgery?

Protocol for Conscious Sedation with ESP Block in Endoscopic Surgery

While ESP block shows promise for reducing sedation requirements in certain endoscopic procedures, traditional conscious sedation protocols using benzodiazepines with opioids or propofol remain the standard approach for gastrointestinal endoscopy, as established guidelines do not specifically address ESP block integration. 1

Pre-Procedure Assessment

Essential Medical History Elements

• Cardiac or pulmonary disease (heart attack, heart failure, stroke, asthma, emphysema) 1, 2
• Neurologic disorders or seizure history 1, 2
• Airway concerns including stridor, snoring, or sleep apnea 1
• Previous adverse reactions to sedation or anesthesia 1, 2
• Current medications including all prescription drugs, over-the-counter medications, aspirin, and oral contraceptives 1, 2
• Drug and food allergies 1, 2
• Alcohol or substance abuse history 1
• Time of last oral intake (minimum 8-hour fast for upper endoscopy) 1, 2

ASA Classification and Risk Stratification

• ASA Class I-III patients are appropriate candidates for endoscopist-administered sedation 1
• ASA Class IV-V patients require anesthesia specialist involvement 1
• Consider anesthesia consultation for emergency procedures, complex procedures (ERCP, EUS), history of inadequate response to moderate sedation, or substance abuse 1

Standard Conscious Sedation Protocol

Traditional Sedation Regimens

• Benzodiazepines with opioids remain the most common regimen for conscious sedation in gastrointestinal endoscopy 3, 4
• Midazolam is the benzodiazepine of choice due to shorter duration of action and better pharmacokinetic profile compared to diazepam 4
• Opioid options include pethidine and fentanyl as the most popular choices 4
• Propofol use has increased significantly in the past decade, showing advantages including faster recovery time compared to traditional regimens 3, 4

Monitoring Requirements

• Practitioners must possess resuscitation skills to rescue patients who become more deeply sedated than intended 1
• Continuous monitoring during the procedure is mandatory, as complication rates increase with sedation use 3
• Properly trained staff and emergency equipment must be available 3

ESP Block Integration (Emerging Evidence)

Evidence for ESP Block in Endoscopic Procedures

• ESP block combined with sedation reduced intraoperative fentanyl and propofol requirements in transforaminal percutaneous endoscopic discectomy compared to local infiltration anesthesia plus sedation 5
• No adverse events occurred with ESP block versus multiple adverse sedation events (minimal, minor, and sentinel risk descriptors requiring rescue ventilation) in the local anesthesia group 5
• Pain intensity, patient satisfaction, and mechanical pain threshold were equivalent between ESP block and local infiltration groups 5
• Postoperative sedation levels were significantly lower with ESP block 5

ESP Block Technical Considerations

• Bilateral ESP block technique has been described for various surgical procedures including laparoscopic hepatectomy and lumbar surgery 6, 7
• Ultrasound guidance is essential for proper ESP block placement 6, 7
• Typical dosing includes ropivacaine 0.5%, 15 ml on each side for bilateral blocks 6
• ESP blocks the dorsal and ventral rami of spinal nerves and sympathetic nerve fibers 7

Important Caveat

ESP block is not mentioned in established endoscopy sedation guidelines 1, and the only endoscopic evidence comes from a single 2023 trial in percutaneous endoscopic discectomy 5, which differs substantially from standard gastrointestinal endoscopy. The technique remains investigational for routine endoscopic procedures.

Post-Procedure Care

Immediate Recovery (0-2 Hours)

• Position patient on their side and allow sleep for up to two hours 1, 2
• Test swallowing with water after initial recovery period; if tolerated without pain or coughing, advance to normal fluids 1, 2
• Report any pain or distress immediately to the medical team 1, 2

Discharge Instructions

• Patient must be accompanied home by a responsible adult if discharged within 24 hours 1, 2
• No driving, operating machinery, or alcohol consumption for 24 hours after endoscopy 1, 2
• Sore throat for 24-48 hours is normal 1, 2
• Severe pain in neck, chest, or abdomen requires immediate medical attention 1, 2

Clinical Algorithm

For standard gastrointestinal endoscopy: Use traditional conscious sedation with midazolam plus fentanyl or propofol-based sedation, following established ASA risk stratification 1, 4

For percutaneous endoscopic spine procedures: Consider bilateral ESP block with reduced sedation based on emerging evidence showing equivalent analgesia with fewer sedation-related adverse events 5

For complex or high-risk patients: Involve anesthesia specialists regardless of technique chosen 1