Ultrasound-guided erector spine plane block (ESPB) utilization in managing refractory renal colic pain in the emergency department
Corresponding authors: Mehdi Torabi, Email:me_torabi@kmu.ac.ir
Received: 2022-03-10
Cite this article
Mehdi Torabi, Javad Darijani, Moghaddameh Mirzaee, Amin Honarmand.
Due to the acute and terrible pain that patients with renal colic experience, the most essential therapeutic priority for these patients in the emergency department (ED) is to reduce pain.[1] Although numerous medications are utilized to reduce pain in patients with acute renal colic, no therapy has yet been developed to totally and quickly relieve pain.[2,3] Intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly administered intravenously to control pain in these patients in the ED; however, the need for frequent monitoring for possible complications and relatively slow-acting features render these strategies undesirable.[4]
Erector spine plane block (ESPB) is one of the newest types of intra-fascial plane block in which an anesthetic substance is injected between the erector spine muscle and the transverse vertebral process under ultrasound guidance to block the dorsal and ventral branches of the thoracolumbar spinal nerve. ESPB block can be used to deliver regional analgesia, and is used to reduce chronic pain and acute pain in the ED.[5⇓⇓-8]
The present study was to compare the effectiveness of ultrasound-guided ESPB, as a complementary pain-controlling method, with that of intravenous fentanyl administration in patients with treatment-refractory renal colic. Moreover, complications and patient satisfaction levels were compared between the two methods.
METHODS
Study environment
This was a single-blinded clinical trial conducted on patients with renal colic refractory to ketorolac plus intravenous morphine sulfate administration (i.e., a pain score—numeric rating scale [NRS] above 8 despite receiving treatment).[9] The study was performed in the Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran. These two EDs accept more than 135,000 patients each year.[10] Renal colic is treated with a mix of ketorolac and opioids at both sites, and the pain management approach is the same. The block randomization procedure was used to divide the patients into two groups after they had given their informed consent. Patients were randomly assigned to the fentanyl and ESPB groups using four blocks (each with two patients). This research employed a total of 10 blocks of four patients.
Ethical approval
This study was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.AH.REC.1400.226.) and registered at the Iranian Registry of Clinical Trials (IRCT20220113053709N1).
Study population
All patients over 18 years of age with a diagnosis of treatment-refractory renal colic (after ruling out other causes of acute abdominal pain) referred during a one-year period (from December 1, 2020, to December 1, 2021) were included in the study. Individuals refusing to participate in the trial, those with a history of addiction, infection at the site of the block, a history of coagulopathy, sensitivity to lidocaine, NSAIDS, or narcotics, those with an acute abdomen, patients less than 18 years of age, or pregnant women were excluded.
Study protocols and procedures
A total of 40 patients with renal refractory colic who had an NRS score above 8 despite receiving 60 mg ketorolac (30 mg/mL, Iran Hormone Co., Iran) plus 0.2 mg/kg intravenous morphine sulfate (10 mg/mL, Darou Pakhsh, Iran) were enrolled in the study. In the outpatient operating room, standard patient monitoring was performed, including continuous electrocardiogram (ECG) monitoring, pulse oximetry, and blood pressure measurement at least every 5 min. Access to an intravenous line was established, and resuscitation equipment, including vasopressors, drugs for local anesthetic toxicity, and intubating equipment, was maintained accessible. The first group of patients (n=20) was treated with fentanyl (50 µg/mL, Darou Pakhsh, Iran) at a starting dose of 1.5 μg/kg via slow intravenous injections. The second group of patients (n=20) received ESPB. After preparation, the patients were placed in the prone position. An ultrasound 7.5 MHz linear probe (DC-7 Mindray Ultrasound Machine, China) was placed at the longitudinal parasagittal orientation to the T8 vertebral level. The probe was then progressively pushed laterally toward the paravertebral area (3 cm from the midline) until the transverse process became apparent. The erector spine muscle should have been found superficial to the transverse process during verification of the transverse process. A 22G needle was inserted in the cephalad to caudal direction superior to the ultrasound probe using an in-plane technique. When the needle tip was below the erector spine muscle and after initial aspiration, to ensure that blood was not withdrawn, 1% lidocaine (4.5 mg/kg) was injected into the site. The erector spine muscle was visualized, separated from the transverse process.[11]
Pain intensity (the range of 0 to 10) was measured before the treatment and 30 and 60 min after the start of the treatment using the NRS. After 20 min of treatment, if minimally acceptable pain reduction was not achieved in either group (i.e., 2-point reduction compared to the baseline NRS score), the patient was infused with intravenous fentanyl (1 µg/kg) and then excluded from the study.[10] The block was completed under the direct supervision of an emergency medicine expert with the support of a resident in emergency medicine (PGY 3). The doctor completed a training course in ultrasound-guided nerve blocking at the Tehran University of Medical Sciences in 2014 and occasionally used this method for eight years. The data collection tool was a questionnaire into which all variables and outcomes were recorded.
Study variables and outcomes
The study variables included age, sex, pain level (baseline and 30 and 60 min after treatment), patient satisfaction, and treatment complications. As the primary outcomes of the study, NRS scores were recorded at 30- and 60-min post-blocking and compared between the two groups. Furthermore, treatment complications and patient satisfaction, as secondary outcomes, were compared between the two groups. Patient satisfaction was assessed using the standard Iowa questionnaire.
Sample size
According to the formula designed to compare two ratios, considering α=0.05 and β=0.2 (power=80%), and based on previous studies, the sample size was determined to be 20 per group.[12]
Statistical analysis
Qualitative indices were described by frequency percentages, and quantitative indices, which had normal distributions, were described by the mean±standard deviation. Analyses regarding sex and age were performed by the Chi-square test and Mann-Whitney U-test, respectively. The repeated measures ANOVA test was used to compare the NRS score between the two groups. The analysis of the interaction between the study group and time rendered a statistically significant outcome, indicating that the difference between the two groups in terms of the NRS score was time dependent. Thus, between-group and within-group comparisons of the NRS score at each time point (i.e., 30- and 60-min post-treatment) were made using Bonferroni correction. The Fisher’s exact test was utilized to compare patient satisfaction and treatment complications between the two groups. A P-value <0.05 was regarded as statistically significant. SPSS 23 software (SPSS Inc., USA) was used for data analysis.
RESULTS
Out of 66 patients enrolled in the study, 26 were excluded. Finally, the data of a total of 40 patients were finally analyzed (Figure 1).
Figure 1.
Figure 1.
Consolidated standards of reporting trials flow diagram. ESPB: erector spine plane block.
The mean age was 34.75±6.21 years in the fentanyl group and 38.20±6.85 years in the ESPB group. The mean NRS score was 8.55±1.27 in the fentanyl group and 8.60±1.09 in the ESPB group. There was no significant difference between the two groups in terms of age, gender, or NRS score at the beginning of the study (Table 1). However, the NRS score was significantly different between the fentanyl and ESPB groups after 30 and 60 min of treatment (P<0.01, Table 1). Moreover, comparisons within each group revealed a significant reduction in pain severity over time (P<0.01, Table 2). There was no significant difference between the two groups in terms of treatment complications (P=0.48). Only two cases of respiratory depression (10%) were observed in the fentanyl group. Finally, there was no significant difference between the two groups in terms of patient satisfaction (P=0.69).
Table 1. Comparison of basic characteristics and pain intensity changes in different time between ESPB and fentanyl groups
Variables | Fentanyl group | ESPB group | P-value |
---|---|---|---|
Age, years, mean±SD | 34.75±6.21 | 38.20±6.85 | 0.92 |
Gender, n (%) | |||
Male | 12 (60) | 14 (70) | 0.70 |
Female | 8 (40) | 6 (30) | |
NRS, mean±SD | |||
Initial | 8.55±1.27 | 8.60±1.09 | 0.59 |
NRS 30th min | 3.25±1.60 | 1.30±1.03 | <0.01 |
NRS 60th min | 4.55±0.88 | 2.20±0.83 | <0.01 |
ESPB: erector spine plane block; NRS: numeric rating scale.
Table 2. Pain intensity changes compared to prior time in ESPB and fentanyl groups
Groups | Comparison of NRS between time 1 and 2 (P-value) | Comparison of NRS between time 2 and 3 (P-value) | Comparison of NRS between time 1 and 3 (P-value) |
---|---|---|---|
Fentanyl group | <0.01 | <0.01 | <0.01 |
ESPB group | <0.01 | <0.01 | <0.01 |
ESPB: erector spine plane block; NRS: numeric rating scale.
DISCUSSION
Our research found that ESPB may significantly reduce discomfort in patients with refractory renal colic. This approach may be regarded as an alternative pain-relieving treatment in patients with refractory renal colic in the ED due to the absence of complications and probable patient satisfaction. As one of the newest local anesthetic blocks, ESPB was reported to be beneficial in the management of acute and chronic pain. Although its exact mechanism of action is unclear, it seems that ESPB can promote neural blockade and central inhibition from the direct spread of local anesthetic to the paravertebral space. Analgesia may also be induced by increasing the plasma concentrations of local anesthetics owing to systemic absorption, immunomodulation of local anesthetics, and activation of the mechanosensory characteristics of the thoracolumbar fascia. After being thoroughly distributed into neuronal spaces in the fascial plane to the erector spine muscles and neighboring tissues, ESPB may most likely produce local anesthesia principally and directly.[13,14] In EDs, ESPB is increasingly employed as a pain-relieving technique in patients with severe pain. Several studies have been conducted in this field; however, most of these studies are case reports and case series. Aydin et al[4] evaluated three patients with renal colic: the first patient with an NRS score of 10/10 was initially treated with fentanyl, but due to persistent pain, ESPB was performed, leading to a drop in the NRS score to zero; the second and third patients had NRS scores of 8/10 and 10/10, respectively, which both reduced to 2 after blocking. The findings of this research suggested that ESPB might be a good alternative to analgesics in individuals suffering from renal colic pain. Despite receiving high-dose acetaminophen, morphine sulfate, and fentanyl after 15 h of admission, a man with acute pancreatitis referred to the ED maintained an 8/10 pain level, according to Mantuani et al.[14] The patient subsequently underwent ESPB, which resulted in a pain score of zero after half an hour and a modest increase to 2/10 after 5 h. The analgesic effects of ESPB have also been reported in patients with traumatic back pain[15] and cancer-related abdominal pain[16] referred to the ED. In a 2020 clinical review by Abdelhamid et al,[17] ESPB was reported to be highly efficient in controlling the pain caused by rib-vertebrae fractures, burns, pancreatitis, herpes zoster infection, and renal colic in patients admitted to the ED. In conclusion, this technique seems to be a safe and easily applicable method for managing pain in EDs. Consistently, our findings revealed that ESPB could significantly relieve the pain associated with refractory renal colic.
To date, there have been no reports of ESPB causing any apparent side effects. Because the injection site is distant from the pleura, major blood arteries, and spinal cord, complications are uncommon. Complications included infections at the needle insertion site, local anesthetic toxicity, vascular puncture, pneumothorax, and failure block.[18] Hence, we observed no side effects for this procedure, which is in agreement with the meta-analysis conducted by Ma et al.[19]
ESPB was associated with desirable patient satisfaction, which was in line with a previous study comparing this method with other therapeutic procedures.[20] All of our patients were satisfied with the effectiveness of this method in controlling the pain. Meanwhile, there was no significant difference between the fentanyl and ESPB groups in terms of patient satisfaction.
Limitations
The current study has certain limitations, such as the exclusion of some patients who refused to participate and the lack of an experienced emergency medicine expert on our research team. It was also a single-blinded study since a double-blinded experiment was not viable to construct. Finally, the patients were not followed up on for any potential long-term consequences; thus, our findings cannot be applied to other age groups.
CONCLUSIONS
Considering the effectiveness and safety of ESPB and the satisfactory levels of patient satisfaction, this method may be considered an alternative or complementary therapy to control pain in patients with refractory renal colic admitted to the ED.
Funding: This study was supported by Kerman University of Medical Sciences.
Ethical approval: The study was approved by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.AH.REC.1400.226.) and Iranian Registry of Clinical Trials (IRCT20220113053709N1).
Conflicts of interest: No potential conflict of interest was reported by the authors.
Contributors: MT proposed and wrote the paper. All authors read and approved the final version.
Reference
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Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. However, the fear of NSAID adverse effects and the uncertainty about superior analgesic effect have maintained the practice of advocating intravenous opioids as the initial analgesia.The objective of this systematic review and meta-analysis was to compare the safety and efficacy of NSAIDs with opioids and paracetamol (acetaminophen) for the management of acute renal colic.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and the reference list of retrieved articles were searched up to December 2016 without language restrictions. Two reviewers independently assessed eligible studies using the Cochrane Collaboration tool for assessing and reporting the risk of bias and abstracted data using predefined data fields.From 468 potentially relevant studies, 36 randomized controlled trials (RCTs) including 4887 patients, published between 1982 and 2016, were included in this systematic review. The treatment effect observed indicated marginal benefit of NSAIDs over opioids in initial pain reduction at 30min (11 RCTs, n=1985, mean difference [MD] -5.58, 95% confidence interval [CI] -10.22 to -0.95; heterogeneity I=81%). In the subgroup analyses by the route of administration, NSAIDs required fewer rescue treatments (seven RCTs, n=541, number needed to treat [NNT] 11, 95% CI 6-75) and had lower vomiting rates compared with opioids (five RCTs, n=531, NNT 5, 95% CI 4-8). Comparisons of NSAIDs with paracetamol showed no difference for both drugs at 30min (four RCTs, n=1325, MD -5.67, 95% CI -17.52 to 6.18, p=0.35; I=89%). Patients treated with NSAIDs required fewer rescue treatments (two trials, n=1145, risk ratio 0.56, 95% CI 0.42-0.74, p<0.001; I=0%).NSAIDs were equivalent to opioids or paracetamol in the relief of acute renal colic pain at 30min. There was less vomiting and fewer requirements for rescue analgesia with NSAIDs compared with opioids. Patients treated with NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of a lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of ease of delivery, suggest that NSAIDs should be the preferred analgesic option for patients presenting to the emergency department with renal colic.In kidney stone-related acute pain episodes in patients with adequate renal function, treatment with nonsteroidal anti-inflammatory drugs offers effective and most sustained pain relief, with fewer side effects, when compared with opioids or paracetamol.Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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Evaluate opioid prescribing before and after emergency department (ED) renal colic guideline implementation focused on multi-modal pain management.Retrospective study of ED patients who received analgesia for urolithiasis before and after guideline implementation. The guideline recommends oral acetaminophen, intravenous (IV) ketorolac, and a fluid bolus as first line, IV lidocaine as second line, and opioids as refractory therapy to control pain. Opioid exposure, adverse effects, length of stay (LOS), and ED representation were evaluated. Comparisons were made with univariate analyses. Backwards stepwise binomial multivariate logistic regression to identify factors related to opioid use was performed.Overall, 962 patients were included (451 pre- and 511 post-implementation). ED and discharge opioid use decreased; 65% vs. 58% and 71% vs. 63% in pre- and post-implementation groups, respectively. More post-implementation patients received non-opioid analgesia (65% vs. 56%) and non-opioid analgesia prior to opioids (50% vs. 38%). A longer ED LOS and higher initial pain score were associated with ED opioid administration. Guideline implementation, receiving non-opioid therapy first, and first renal colic episode were associated with decreased ED opioid administration. Seventeen adverse events (1.8%) were reported. There was no difference in change in ED pain score between groups, but patients in the post-implementation group were admitted more and had a higher 7-day ED representation (11% vs. 7%).A multimodal analgesia protocol for renal colic was associated with decreased opioid prescribing, higher rates of admission to the hospital, and a higher 7-day ED representation rate.Copyright © 2019 Elsevier Inc. All rights reserved.
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The erector spinae plane block (ESPB) was first described in 2016 as a regional block for thoracic neuropathic pain. Given its short history, there are a paucity of controlled clinical trials, yet an abundance of case reports. The primary aim of this review is to examine pooled clinical data from published literature to gain an understanding of ESPB characteristics.A PubMed search was conducted to identify all ESPB related publications. Inclusion criteria included reports of ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. Only publications obtained in English were included. Measures included type of publication, year and country of publication, journal of publication, block technique, anatomic location, age, opioid and adjunct pain medication use, sensory and motor changes, side effects and adverse events. Qualitative statistics were used.The initial search yielded 201 publications. After application of inclusion and exclusion criteria, 85 publications from 21 journals were included in the pooled review which yielded 242 reported cases between 2016 and 2018. The majority of publications reported single shot techniques (80.2%), followed by intermittent boluses (12.0%) and continuous infusions (7.9%). 90.9% reported use of multimodal analgesia in addition to the ESPB and 34.7% reported sensory changes from ESPB. A reduction in opioid use was reported in 34.7% of cases. One adverse event involving a pneumothorax was reported.To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.Copyright © 2018 Elsevier Inc. All rights reserved.
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Renal colic is one of the most common painful disorders in patients referred to the emergency department. The main purpose of this study was to compare the efficiency of two methods of intravenous (IVF) and intranasal (INF) fentanyl administration in pain management in patients with severe renal colic.This was a single-blind randomized clinical trial performed on patients with severe renal colic. The severity of pain was ≥8 based on the Numerical Rating Scale (NRS). The efficacy of pain management was compared within and between the IVF (intramuscular Ketorolac + intravenous fentanyl) and INF (intramuscular Ketorolac + intranasal fentanyl) groups at different times points. Oral consent was obtained from all the patients.Of 220 individuals, 96 (43.60%) were women and 124 (56.40%) were men. There were no significant differences between the two groups regarding the baseline pain severity, age, sex, history of urolithiasis and body mass index (BMI). The pain severity showed a significant reducing trend in both groups (p < 0.0001). There was also a significant difference comparing the mean pain severity between groups at different times (p < 0.0001). In each group, the severity of pain showed significant reduction compared with its prior measurement (P < 0.0001).Fentanyl is highly effective in controlling pain in patients with severe renal colic referring to the emergency department. Intranasal administration of fentanyl combination with ketorolac can be an appropriate, non-invasive, easy-to-use and fast alternative to the intravenous method to manage pain in these patients.Copyright © 2019 Elsevier Inc. All rights reserved.
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Acute pain represents one of the most common reasons for emergency department (ED) visits. In the opioid epidemic that North America faces, there is a significant demand for novel effective pain control modalities, especially in the acute setting.The goal of this study was to review all the indications and summarize the efficacy of the Erector Spinae Plane Block (ESPB) in the ED.PubMed, EMBASE, and MEDLINE, as well as CINAHL databases were searched according to the PRISMA guidelines to find any study reporting on the use of ESPB in the ED.Ten studies were published reporting on seven different indications for the use of ESPB in the ED. It was most commonly used for rib and spine fractures. Other indications included: mechanical pain, burn injuries, herpes zoster, renal colic, and acute pancreatitis. All the studies demonstrated a significant reduction in pain after administration of ESPB. Furthermore, it has been reported to improve respiratory function and was not associated with any complications after administration.ESPB is an easy-to-administer interfascial plane block that has several indications and promising potential for acute pain management in the ED. The easily identified landmarks coupled with its low complication rate makes it an appealing technique to be used by emergency physicians in the context of acute pain management. Further studies should investigate any other possible indications and compare its efficacy with other techniques, such as epidurals and serratus anterior blocks.Copyright © 2020 Elsevier Inc. All rights reserved.
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