Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery: A Randomized Controlled Clinical Trial

• Published in: Medicina (Kaunas, Lithuania) Vol. 58; no. 10; p. 1462
• Main Authors: Balan, Cosmin, Tomescu, Dana R, Valeanu, Liana, Morosanu, Bianca, Stanculea, Iulia, Coman, Antonia, Stoian, Anca, Bubenek-Turconi, Serban I
• Format: Journal Article
• Language: English
• Published: Switzerland MDPI AG 01-10-2022; MDPI
• Subjects: Acetaminophen - therapeutic use; Adult; Analgesics; Analgesics, Opioid - therapeutic use; Analysis; Asepsis; Blood pressure; cardiac surgery; Cardiac Surgical Procedures - adverse effects; Clinical trials; Dexamethasone - therapeutic use; Disease prevention; erector spinae plane block; fast-tracking; Fentanyl; Fentanyl - therapeutic use; General anesthesia; Heart; Heart block; Heart rate; Heart surgery; Hemodynamics; Hospital utilization; Humans; Length of stay; Local anesthesia; Medical care, Cost of; Morphine - therapeutic use; Narcotics; Nerve Block - methods; Nociception; NOL index; Norepinephrine - therapeutic use; opioid-sparing; Pain; Pain, Postoperative - drug therapy; Pain, Postoperative - etiology; Pain, Postoperative - prevention & control; Patient outcomes; Patients; Prospective Studies; Recovery (Medical); Ropivacaine - therapeutic use; Skin; Surgery; Thoracic surgery; Ultrasonic imaging; Romania; fast-tracking; cardiac surgery; erector spinae plane block; nociception; opioid-sparing; NOL index
• ISSN: 1648-9144; 1010-660X; 1648-9144
• DOI: 10.3390/medicina58101462

Background and Objectives: The erector spinae plane block (ESPB) is a multimodal opioid-sparing component, providing chest-wall analgesia of variable extent, duration, and intensity. The objective was to examine the ESPB effect on perioperative opioid usage and postoperative rehabilitation when used within a Nociception Level (NOL) index-directed anesthetic protocol. Materials and Methods: This prospective, randomized, controlled, open-label study was performed in adult patients undergoing on-pump cardiac surgery in a single tertiary hospital. Eighty-three adult patients who met eligibility criteria were randomly allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 40) and received general anesthesia with NOL index-directed fentanyl dosing. Preoperatively, group 2 also received bilateral single-shot ultrasound-guided ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Postoperatively, both groups received intravenous paracetamol (1 g every 6 h). Morphine (0.03 mg/kg) was administered for numeric rating scale (NRS) scores ≥4. Results: The median (IQR, 25th−75th percentiles) intraoperative fentanyl and 48 h morphine dose in group 2-to-group 1 were 1.2 (1.1−1.5) vs. 4.5 (3.8−5.5) µg·kg−1·h−1 (p < 0.001) and 22.1 (0−40.4) vs. 60.6 (40−95.7) µg/kg (p < 0.001). The median (IQR) time to extubation in group 2-to-group 1 was 90 (60−105) vs. 360 (285−510) min (p < 0.001). Two hours after ICU admission, 87.5% of ESPB patients were extubated compared to 0% of controls (p < 0.001), and 87.5% were weaned off norepinephrine compared to 46.5% of controls (p < 0.001). The median NRS scores at 0, 6, 12, 24, and 48 h after extubation were significantly decreased in group 2. There was no difference in opioid-related adverse events and length of stay. Conclusions: NOL index-directed ESPB reduced intraoperative fentanyl by 73.3% and 48 h morphine by 63.5%. It also hastened the extubation and liberation from vasopressor support and improved postoperative analgesia.