Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series

1 Introduction

Open radical nephrectomy and inferior vena cava (IVC) exploration is the current treatment of choice for renal cancer with cavo-atrial IVC tumour extension [1]. The complex surgery usually involves a trans-abdominal subcostal rooftop incision with extensive visceral dissection and a high risk of intraoperative blood loss. Open upper abdominal surgery is known to be associated with significant degree of acute postoperative pain [1]. Thoracic epidural analgesia (TEA) is cited as the gold standard in upper abdominal surgery [2], [3], [4]. However, TEA may be a relative contraindication in this subset, as patients with cavo-atrial venous tumour extension often require perioperative anticoagulation and risk developing coagulopathy secondary to massive intraoperative haemorrhage. Alternative analgesic techniques have evolved in recent times and include continuous wound catheter analgesia, transversus abdominis plane analgesia and erector spinae plane analgesia [5], [6], [7]. These techniques are ineffective in providing adequate visceral analgesia and often require patient controlled analgesia (PCA) with morphine [8].

We have previously reported on an alternative technique for providing peri-operative analgesia that avoids the use of both TEA as well as PCA with morphine. The novel technique (ESPITO) combines continuous erector spinae plane (ESP) analgesia with intrathecal opioid (ITO) [8]. We have embedded this technique in our enhanced recovery programme and have reported on its use in patients undergoing open radical cystectomy through a sub umbilical midline incision [8], [9]. We present a report on our experience with the novel analgesic regimen in major open upper abdominal surgery.

2 Case reports

Adult patients scheduled to undergo open radical nephrectomy and inferior vena cava exploration through a rooftop incision is included in this report. Patients who refused epidural analgesia were offered ESPITO analgesia. The aim was to obtain pilot data for designing a clinical trial. Patients provided written consent for their de-identified data to be used for analysis and for publication in a peer reviewed journal. Insertion of erector spinae plane catheters was approved by the New Interventional Procedures Authorising Group (NIPAG), University Hospitals of Leicester NHS Trust.

Prior to induction of general anesthesia, bilateral ESP catheters were inserted under real time ultrasound guidance at the level of thoracic T7 spinous process [7]. The ESP catheters were inserted with the patient awake. The patient was positioned sitting. Counting down from the spine of seventh cervical vertebrae, the spine of the seventh thoracic vertebrae (T7) was identified. The skin of the upper back was prepared with 2% chlorhexidine solution. A high frequency (5–10 MHz) ultrasound probe (S-Nerve™; SonoSite Inc., Bothell, WA, USA) was placed across the T7 spine and the probe was moved laterally to identify the T7 transverse process. Thereafter, the probe was moved to a vertical alignment and the erector spinae muscle was visualised lying underneath the trapezius muscle. A 16-G, 8-cm Tuohy needle (Portex; Smiths Medical International Ltd, Kent, UK) was then introduced medially in the plane of the ultrasound beam and directed towards the transverse process. Once the needle was underneath the anterior fascial sheath of the erector spinae muscle, 10 mL of saline 0.9% was injected. The injectate was observed spreading underneath the ES muscle lifting the muscle off the transverse process. A catheter (Portex; Smiths Medical International Ltd) was inserted into the newly formed space underneath the ES muscle and secured. The procedure was repeated on the contralateral side. Subcutaneous tunnelling and skin glue was used to secure the catheters leaving 5 cm of the catheter in the ES plane. Thereafter, the patient received 900 μg of diamorphine mixed with 3 mL of 0.75% of levo-bupivacaine into the intrathecal space at lumbar L3-4 interspace. General anesthesia was induced with propofol, maintained with sevoflurane and muscle relaxation was facilitated by atracurium. The ESP catheters were topped up with 40 mL of 0.125% levo-bupivacaine per catheter an hour before the completion of surgery. The two catheters were connected to a Y connector and an infusion of 10 mL/h of 0.25% bupivacaine was commenced for 3–5 days. Intraoperative hypotension induced by intrathecal bupivacaine and general anesthesia was managed with an infusion of metaraminol. Intravenous fluid administration was based on goal directed cardiac output monitoring using calibrated pulse wave analysis method (EV1000™, Edward Lifesciences, Irvine, CA, USA). Cell salvage technique was utilised. Patients received intravenous ondansetron 4 mg and dexamethasone 6.6 mg at induction and prior to extubation of the trachea. They received intravenous ondansetron regularly (4 mg, 8 hourly) for 3 days after surgery. Postoperative analgesia included acetaminophen 1 g 6 hourly. Patients received additional 30 mL of 0.125% levo-bupivacaine into each catheter twice a day for the first 48 h. Rescue analgesia included tramadol 50 mg (intravenous route on day 1 and thereafter per orally).

Outcomes collected included age, gender, American Society of Anesthesiologists (ASA), body mass index, pain score at rest and on coughing 6 hourly for 3 days, rescue analgesia used, analgesia failure (addition of PCA with morphine), length of hospital stay, any complication with ESPITO (including pruritus, nausea) and patient satisfaction with analgesia.

The cases are reported from a major tertiary care regional urological cancer surgery centre based at the University Hospitals of Leicester NHS Trust. Over a period of 9 months, five adult patients received ESPITO analgesia. All five patients received a trans-abdominal subcostal rooftop incision (Fig. 1) [10]. The tumour staging in all five patients was reported as T3bN0M0. This represents a large renal tumour (T3) that has grown into the inferior vena cava (T3b), without any metastasis into the lymph nodes (N0) or distant metastasis (M0).

Fig. 1:

Large roof-top incision extending beyond the anterior axillary line inferiorly.

Demographic characteristics and postoperative outcomes are shown in Table 1. Patient specific characteristics are shown in Table 2. Novick’s criteria defines the extent of renal tumour invasion into the inferior vena cava and or right atrium [11]. All five patients reported adequate dynamic analgesia, mobilised on day 1 and none of the patients required PCA with morphine. All patients had successful placement of ESP catheters. There were no complications with the technique. Patient satisfaction was high with the analgesia provided. The local enhanced recovery protocol (ERP) for radical nephrectomy is shown in Table 3 [9].

3 Discussion

The authors present a case series of five patients who received ESPITO analgesia as an effective alternative for providing perioperative analgesia following open radical nephrectomy and IVC exploration. Upper abdominal surgery through a rooftop incision (Fig. 1) carries significant perioperative morbidity. Traditionally, TEA has been the favoured mode of analgesia for upper abdominal surgery [3]. Although TEA provides excellent analgesia, it has features, which may not be conducive for enhanced recovery [2], [5]. These include postoperative hypotension, motor block, analgesic failure rate of 30% and potential serious risks [2], [5], [12]. In this subset, the need for perioperative anticoagulation and risk of postoperative coagulopathy makes TEA a relative contraindication. The search for effective alternative analgesia has resulted in the development of novel techniques. We have previously reported on the efficacy of continuous subcostal transversus abdominis plane (STAP) analgesia as a viable alternative to TEA in this population [5]. However, STAP analgesia does not provide pre-emptive and intra-operative analgesia as the catheters are placed at the end of the surgery. Occasionally, the surgical incision can encroach on the subcostal fascial plane making the catheter placement difficult. When the lower end of the incision extends beyond the anterior axillary line, STAP is ineffective as the sole analgesic technique and the patients require additional systemic morphine (Fig. 1). Wound infusion analgesia is effective but requires PCA with morphine to supplement analgesia [6].

Chin et al. first described ultrasound guided ESP analgesia for abdominal surgery [12], [13]. Current understanding is that ESP infusion provides analgesia by blocking the thoracic somatic and sympathetic nerves (paravertebral by proxy) [14], [15]. We have previously reported on efficacy of continuous ESP analgesia in patients undergoing a roof top incision [7]. However, ESP infusion does not provide adequate visceral analgesia thereby necessitating the need for systemic morphine. Combining ESP analgesia with intrathecal opioid (ESPITO) ensures adequate somatic and visceral analgesia thereby removing the need for PCA with morphine. We have reported on ESPITO analgesia in open radical cystectomy through a sub umbilical midline incision [8]. ESPITO analgesia provides significant pre-emptive, intraoperative and postoperative analgesia. The technique also enables controlled intraoperative hypotension, thereby reducing intraoperative blood loss. IVC exploration can be associated with significant blood loss and fluid shifts. As a result, epidural induced hypotension in the postoperative period can delay early ambulation. ESPITO analgesia does not cause postoperative hypotension or lower limb motor block, thereby facilitating early ambulation and intravenous fluid restriction. Two patients in this series required therapeutic anticoagulation in the immediate postoperative period. This would have mandated the removal of an epidural catheter and addition of systemic morphine. The patients continued to receive ESP analgesia for 5 days.

In this series, the patients received twice a day bolus dose of high volume low concentration levo-bupivacaine for 48 h to ensure adequate analgesia. The ESP plane is a high volume fascial plane, which extends from the occiput to the sacrum. As a result, a large volume of local anaesthetic is required to cover upper abdominal incisions. We left 5 cm of the catheter in the ES plane. This may have enabled improved analgesia in the upper abdomen. However, it risks catheter displacement. We recommend subcutaneous tunnelling as well as use of skin glue to secure the catheters. Postoperative nausea can be an issue with the high dose of intrathecal opioid used in ESPITO analgesia. We have observed that using two anti-emetic agents at induction and at the end of the surgery significantly reduces the incidence of postoperative nausea and vomiting.

Historically, systemic morphine has been one of the primary analgesic regimens after major abdominal surgery. It is accepted that postoperative pain after open abdominal surgery has two major components, namely, somatic and visceral [16], [17]. Although visceral pain can be intense and opioid responsive, it usually does not last beyond the first 24–36 h after surgery [7]. Somatic pain from the abdominal wall accounts for over 70% of postoperative pain and lasts over 72 h [16]. Interestingly, systemic opioids are ineffective in treating somatic pain. Despite this knowledge, systemic morphine remains the only rescue analgesia of choice when other techniques fail in the postoperative period. However, there is a gradual recognition that avoiding systemic morphine has significant short term as well as long-term benefits especially in patients undergoing major abdominal surgery [18], [19]. Prescribing short course of opioids in opioid naïve patients has been shown to increase the risk of subsequent long-term opioid use [18]. In the midst of an opioid crisis, there is a pressing need to develop analgesic regimens that have a low risk profile, provide dynamic analgesia and are able to completely avoid systemic morphine.

When compared to TEA, a potential drawback with ESPITO could be the large dose of local anaesthetic utilised to maintain dynamic analgesia. In our series, patients received 600–750 mg/day of levo-bupivacine. However, similar large doses of local anaesthetic have been reported in patients undergoing major abdominal surgery receiving either subcostal trasnversus plane analgesia or bilateral paravertebral infusions, without complications [5], [17], [20], [21]. Our cohort was closely monitored in a high dependency unit for 48–72 h after surgery.

There were no complications reported as a result of the novel technique. We are aware of the significant limitations of this case series. Our aim was to highlight the potential of ESPITO analgesia in upper abdominal surgery and collect data for the design of a clinical trial. We have completed a study of ESPITO analgesia in patients undergoing open radical cystectomy (NCT03410186) and are in the process of designing a trial in patients undergoing upper abdominal surgery.