1. 2024;27;425-433Erector Spinae Plane Block Provided Comparable Analgesia as Thoracic Paravertebral Block Post Pediatric Nuss Procedure for Pectus Excavatum: A Randomized Controlled Trial
   Randomized Controlled Trial
   Min Xu, MD, Guangchao Zhang, MBBS, Rui Wang, MD, Yong Liu, MBBS, Bin Du, MD, and Jing Yang, MD.

BACKGROUND: Thoracic paravertebral block (TPVB) is frequently used to treat pain following a pediatric Nuss procedure but is associated with various undesirable risks. The erector spinae plane block (ESPB) also provides postoperative analgesia, which is purported to be easier to administer and has a favorable safety profile. However, it remains unknown whether ESPB provides analgesia comparable to the TPVB technique post  pediatric Nuss procedure.

OBJECTIVE: This study aimed to compare the analgesic effects of ultrasound-guided ESPB and TPVB in children undergoing the Nuss procedure.

STUDY DESIGN: A prospective, randomized, noninferiority trial.

SETTING: A university hospital in the People’s Republic of China.

METHODS: A total of 68 children aged 4 to 18 scheduled for the Nuss procedure were enrolled in the study. They were randomly assigned to receive a single-injection ultrasound-guided bilateral T5-level ESPB or TPVB with 0.5 mL/kg of 0.25% ropivacaine post anesthesia induction. All patients received postprocedure multimodal analgesia. The primary outcomes were pain scores at rest and 24 hours postprocedure. The secondary outcomes included total rescue morphine milligram equivalents, emergence agitation, chronic postprocedure pain, and side effects.

RESULTS: The median difference in pain scores at rest 24 hours postprocedure  was 0 (95% CI, 0 to 1), demonstrating the noninferiority of ESPB to TPVB. In addition, the difference in oral morphine milligram equivalents at 24 hours postprocedure was -4.9 (95% CI, -16.7 to 7.9) with the ESPB group consuming median (interquartile range) 37.7 mg (12–53.2) vs 36.9 mg (23.9–58.1) for the TPVB group. We concluded that the non-inferiority of ESPB with regard to opioid consumption as the 95% CI upper limit of 7.9, which was within the predefined margin of 10. We found no significant differences in pain scores at rest or during coughing, incidences of chronic postoperative pain, emergence agitation, or side effects.

LIMITATIONS: We did not evaluate the effect of analgesic protocols on patient-centric outcomes, such as resuming functional status and emotional wellbeing. Also, the sample size is small to some extent.

CONCLUSIONS: Preoperative ESPB, when combined with multimodal analgesia, was noninferior in analgesic effect compared with TPVB in terms of pain scores and opioid consumption in pediatric patients undergoing the Nuss procedure.

KEY WORDS: Erector spinae plane block, thoracic paravertebral block, pectus excavatum, pain management