Daily Anesthesiology Research Analysis
A multicenter RCT found thoracic paravertebral block superior to erector spinae plane block for major breast surgery analgesia, challenging the use of ESPB as a primary technique. A meta-analysis of 58 RCTs confirmed opioid-sparing strategies reduce morphine consumption, pain scores, and PONV. An RCT of esophageal pressure–guided individualized ventilation in severe pancreatitis–associated ARDS improved mechanics, oxygenation, and reduced 28-day mortality, supporting precision ventilation at the
Summary
A multicenter RCT found thoracic paravertebral block superior to erector spinae plane block for major breast surgery analgesia, challenging the use of ESPB as a primary technique. A meta-analysis of 58 RCTs confirmed opioid-sparing strategies reduce morphine consumption, pain scores, and PONV. An RCT of esophageal pressure–guided individualized ventilation in severe pancreatitis–associated ARDS improved mechanics, oxygenation, and reduced 28-day mortality, supporting precision ventilation at the bedside.
Research Themes
- Comparative effectiveness of regional anesthesia for breast surgery
- Opioid-sparing multimodal analgesia in postoperative pain
- Personalized mechanical ventilation using esophageal pressure monitoring
Selected Articles
1. Erector spinae plane block versus paravertebral block for major oncological breast surgery: a multicentre randomised controlled trial.
In a multicenter double-blind RCT (n=292), ESPB failed noninferiority to PVB for early morphine rescue after major breast surgery, showed higher pain scores (notably on mobilization), and less reliable dermatomal coverage. No major complications occurred; patient satisfaction was high in both arms.
Impact: This high-quality comparative RCT directly informs regional anesthesia choices for breast cancer surgery and challenges routine use of ESPB as a primary technique.
Clinical Implications: For major oncological breast surgery, PVB should remain the preferred regional technique when feasible, while ESPB may be considered when PVB is contraindicated or expertise is limited, with counseling on potentially higher pain and incomplete coverage.
Key Findings
- ESPB group had a higher percentage requiring morphine within 2 hours postoperatively (75.2% vs 50.3%), failing noninferiority.
- Pain scores were higher with ESPB, particularly during mobilization.
- Dermatomal coverage was incomplete more often with ESPB (55.9% not covering required area vs 20.4% with PVB).
- Morphine consumption and patient satisfaction were similar; no major complications were observed.
Methodological Strengths
- Prospective multicenter randomised double-blind design
- Clear primary endpoint with clinically meaningful rescue morphine requirement
Limitations
- Focus on early postoperative period; chronic pain outcomes not assessed
- Block performance and spread may vary by operator and anatomy, affecting generalizability
Future Directions: Evaluate long-term pain, opioid use, and chronic pain syndromes; define subgroups where ESPB may be noninferior; standardize ESPB techniques to improve dermatomal coverage.
2. Individualized Lung-Protective Ventilation Strategy Based on Esophageal Pressure Monitoring in Patients With ARDS Associated With Severe Acute Pancreatitis-A Randomized Controlled Trial.
In SAP-related ARDS (n=124), esophageal pressure–guided individualized lung-protective ventilation reduced transpulmonary driving pressure, improved compliance and oxygenation, shortened ventilation and ICU stay, lowered VAP, and reduced 28-day mortality versus conventional lung-protective ventilation. ΔPL at 72 h independently predicted mortality.
Impact: Provides randomized evidence that precision ventilation using esophageal pressure monitoring can improve hard clinical outcomes, including mortality, in a high-risk ARDS subgroup.
Clinical Implications: Consider implementing esophageal pressure monitoring to guide individualized PEEP and tidal strategies in SAP-related ARDS; monitor ΔPL (72 h) as a prognostic marker and target to optimize.
Key Findings
- EPM-guided ventilation lowered transpulmonary pressure and transpulmonary driving pressure compared with conventional lung-protective ventilation.
- Static compliance and PaO2/FiO2 were significantly higher in the EPM group.
- EPM-guided strategy reduced duration of mechanical ventilation and ICU length of stay, decreased VAP incidence, and lowered 28-day mortality (19.35% vs 32.26%).
- ΔPL at 72 h was an independent predictor of 28-day mortality (AUC 0.832).
Methodological Strengths
- Randomized controlled design with pragmatic clinical outcomes including mortality
- Comprehensive physiologic measurements linking mechanism (ΔPL) to outcomes
Limitations
- Single-center trial; blinding not reported and may be impractical for EPM
- Results specific to SAP-related ARDS; external validity to other ARDS etiologies requires testing
Future Directions: Multicenter RCTs to validate mortality benefit; assess protocolized ΔPL targets; evaluate cost-effectiveness and training requirements for broader implementation.
3. The Impact of Opioid-Sparing Analgesia on Postoperative Pain and Recovery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Across 58 RCTs (n=5614), opioid-sparing strategies reduced 24-hour morphine use (MD -9.47 mg), lowered 24-hour pain scores, decreased PONV and pruritus, and improved patient satisfaction, without changes in length of stay or overall recovery quality.
Impact: Provides broad, aggregated evidence supporting multimodal, opioid-sparing perioperative analgesia with tangible benefits in pain, opioid exposure, and PONV.
Clinical Implications: Adopt opioid-sparing multimodal regimens (e.g., NSAIDs, acetaminophen, regional techniques, adjuncts) as standard postoperative analgesia to reduce opioid exposure and PONV while maintaining recovery metrics.
Key Findings
- Opioid-sparing strategies reduced 24-hour morphine consumption (MD -9.47 mg; 95% CI -13 to -5.95).
- 24-hour pain scores decreased (MD -0.72) and patient satisfaction improved (MD 0.88).
- PONV (OR 0.73) and pruritus (OR 0.64) were reduced; no differences in length of stay or quality of recovery.
Methodological Strengths
- Systematic review and meta-analysis of randomized controlled trials with PROSPERO registration
- Comprehensive assessment of efficacy and adverse effects across multiple outcomes
Limitations
- Heterogeneity in surgical procedures, analgesic protocols, and outcome definitions
- Potential publication bias and limited data on long-term outcomes
Future Directions: Head-to-head RCTs of specific multimodal bundles, standardized outcome reporting, and evaluation of long-term opioid use and chronic pain.