Daily Anesthesiology Research Analysis
Top perioperative anesthesia research today centers on optimizing regional blocks, pediatric premedication, and local anesthetic formulation choices. A large meta-analysis finds erector spinae plane block (ESPB) outperforms quadratus lumborum block (QLB), a pediatric RCT shows intranasal esketamine reduces sevoflurane needs and emergence delirium, and a thoracic surgery RCT reports only limited benefits of liposomal bupivacaine over plain bupivacaine for paravertebral blockade.
Summary
Top perioperative anesthesia research today centers on optimizing regional blocks, pediatric premedication, and local anesthetic formulation choices. A large meta-analysis finds erector spinae plane block (ESPB) outperforms quadratus lumborum block (QLB), a pediatric RCT shows intranasal esketamine reduces sevoflurane needs and emergence delirium, and a thoracic surgery RCT reports only limited benefits of liposomal bupivacaine over plain bupivacaine for paravertebral blockade.
Research Themes
- Regional anesthesia block selection (ESPB vs QLB)
- Pediatric premedication with intranasal esketamine
- Value of liposomal bupivacaine in paravertebral block
Selected Articles
1. Comparison of the analgesic effects of ultrasound-guided erector spinae plane block and quadratus lumborum block: a systematic review and meta-analysis.
This PROSPERO-registered meta-analysis of 27 RCTs (n=1,942) found ESPB provides superior postoperative analgesia to QLB across surgeries, with lower 24-hour analgesic consumption, faster block performance, and reduced PONV. Evidence quality was appraised with GRADE and supported by subgroup and sensitivity analyses.
Impact: Directly informs block selection for perioperative analgesia by synthesizing randomized evidence with GRADE appraisal. Likely to influence ERAS pathways and regional anesthesia practice.
Clinical Implications: Consider ESPB as the preferred truncal block over QLB for postoperative analgesia, anticipating less opioid use, faster placement, and lower PONV. Tailor by surgery type and patient factors while maintaining ultrasound-guided best practices.
Key Findings
- Across 27 RCTs (n=1,942), ESPB reduced 24-hour postoperative analgesic consumption versus QLB (WMD −4.03; 95% CI −6.25 to −1.82).
- ESPB had faster block performance times than QLB.
- ESPB was associated with a lower incidence of postoperative nausea and vomiting compared with QLB.
- GRADE assessment indicated moderate-to-high quality evidence; subgroup and sensitivity analyses supported robustness.
Methodological Strengths
- PROSPERO-registered protocol and comprehensive multi-database search
- Use of GRADE with subgroup and sensitivity analyses to assess robustness
Limitations
- Heterogeneity across surgical procedures and analgesic regimens
- Potential publication bias and variability in opioid conversion metrics
Future Directions: Head-to-head, surgery-specific RCTs with standardized outcome definitions and cost-effectiveness analyses to refine block selection algorithms.
BACKGROUND: Erector spinae plane block (ESPB) and quadratus lumborum block (QLB) are commonly used for perioperative analgesia in various surgeries. An increasing number of randomized controlled trials (RCTs) have compared the analgesic effect and safety of ESPB with those of QLB, but the conclusions are controversial. This study was designed to identify whether ultrasound-guided ESPB was better than the QLB for postoperative analgesia. METHODS: To identify RCTs comparing ESPB with QLB for postoperative analgesia, we searched PubMed, Embase, the Cochrane Library, and Web of Science. The primary outcome was postoperative analgesic consumption over 24 h. The secondary outcomes included the time to the first analgesic request, postoperative resting pain scores, block performance time, postoperative rescue analgesia rate, incidence of complications, and postoperative satisfaction. RevMan 5.4 software was used in the analysis. Subgroup analysis and sensitivity analysis were performed to explore the source of heterogeneity and test the reliability of the pooled results. The quality of evidence was systematically assessed via the GRADE evaluation. RESULTS: Twenty-seven studies involving 1942 patients were included. Compared with QLB, ESPB consumed fewer 24-h postoperative analgesics (WMD, -4.03; 95% CI, -6.25 to -1.82; CONCLUSION: Moderate-to high-quality evidence indicates that ESPB is superior to QLB for postoperative analgesia because of less postoperative analgesic consumption, faster block performance and a lower incidence of postoperative nausea and vomiting. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024607988.
2. Intranasal Esketamine Premedication Reduces Sevoflurane Requirements During Laryngeal Mask Airway Insertion in Pediatric Patients: A Randomized Controlled Trial.
In a double-blind RCT of 90 children (2–5 years), intranasal esketamine reduced sevoflurane MAC for LMA insertion in a dose-dependent manner (−13.4% with 0.5 mg/kg; −30.6% with 1.0 mg/kg). The 1.0 mg/kg dose improved induction quality, reduced emergence delirium and negative postoperative behaviors, without prolonging emergence or increasing adverse events.
Impact: Provides high-quality pediatric evidence supporting a practical premedication that reduces volatile exposure and perioperative neurobehavioral complications.
Clinical Implications: Intranasal esketamine 1.0 mg/kg can be considered for premedication to facilitate LMA insertion, reduce volatile anesthetic requirements, and lower emergence delirium risk in preschool children undergoing brief procedures.
Key Findings
- Sevoflurane MAC for LMA insertion decreased from 2.16% (control) to 1.87% (0.5 mg/kg) and 1.50% (1.0 mg/kg), indicating a dose-dependent effect.
- Esketamine 1.0 mg/kg improved induction quality and reduced emergence delirium (13.8% vs 46.4%) and negative behavioral changes at day 3.
- Emergence time and adverse events were similar across groups, suggesting maintained safety.
Methodological Strengths
- Randomized, double-blind, placebo-controlled design with three arms
- Use of Dixon’s up-and-down method to estimate MAC and assessment of neurobehavioral outcomes
Limitations
- Single-center study focused on strabismus surgery; generalizability to other procedures is uncertain
- Short follow-up limited to early postoperative period and day-3 behavior
Future Directions: Multicenter trials across varied pediatric surgeries, comparisons with alternative premedications, and longer-term neurodevelopmental follow-up.
PURPOSE: This study evaluated whether intranasal esketamine premedication reduces sevoflurane requirements for laryngeal mask airway (LMA) insertion in young children. PATIENTS AND METHODS: This randomized, double-blind, placebo-controlled trial enrolled 90 children (2-5 years) undergoing elective strabismus surgery. Participants received intranasal premedication with either saline (control), esketamine 0.5 mg/kg, or esketamine 1.0 mg/kg. The primary outcome was the minimum alveolar concentration of sevoflurane needed for successful LMA placement, determined using Dixon's up-and-down method. Secondary outcomes included anesthesia induction quality (4-point cooperation scale), emergence delirium (Pediatric Anesthesia Emergence Delirium scale), emergence time (from sevoflurane discontinuation to purposeful response), behavioral changes at day 3 (Post-Hospitalization Behavior Questionnaire), and adverse events. RESULTS: Intranasal esketamine produced dose-dependent reductions in sevoflurane requirements: 2.16 ± 0.18% (control), 1.87 ± 0.17% (0.5 mg/kg), and 1.50 ± 0.19% (1.0 mg/kg), representing decreases of 13.4% and 30.6%, respectively. The higher esketamine dose significantly improved induction quality (p=0.002), reduced emergence delirium (13.8% versus 46.4%, p=0.007), and decreased negative postoperative behavioral changes on day 3 (20.7% versus 53.6%, p=0.010). Emergence time and adverse event rates remained similar across groups. CONCLUSION: Intranasal esketamine premedication effectively reduces sevoflurane requirements for LMA placement in children in a dose-dependent manner. The 1.0 mg/kg dose provides optimal clinical benefits without prolonging recovery or increasing complications. This approach offers pediatric anesthesiologists a practical method to reduce volatile anesthetic exposure while improving patient outcomes and potentially minimizing anesthetic-related risks.
3. Thoracic Paravertebral Block with Liposomal Bupivacaine Versus Plain Bupivacaine in Patients Undergoing Thoracoscopic Lung Resection: A Randomized Controlled Study.
In 114 VATS patients randomized to thoracic paravertebral block with liposomal versus plain bupivacaine, 48-hour opioid consumption (primary endpoint) was unchanged. Liposomal bupivacaine modestly improved 24-hour QoR-15, prolonged time to first analgesia, and reduced cumulative rest pain, without differences in cough pain or 3-month CPSP.
Impact: Provides comparative RCT evidence questioning routine use of costly liposomal bupivacaine for paravertebral block in thoracic surgery by showing limited clinical gains without opioid-sparing.
Clinical Implications: Routine substitution of plain bupivacaine with liposomal bupivacaine for TPVB in VATS may not be justified solely for opioid reduction. Consider LB selectively for early recovery metrics if cost and availability permit.
Key Findings
- 48-hour postoperative opioid consumption did not differ between liposomal and plain bupivacaine groups (primary endpoint).
- LB increased QoR-15 at 24 hours (120.2 vs 116.5) and prolonged time to first analgesia (≈586 vs 315 minutes).
- LB reduced the AUC of rest NRS pain; cough pain and 3-month CPSP rates were similar between groups.
Methodological Strengths
- Randomized controlled design with clearly defined primary and secondary endpoints
- Standardized TPVB levels and comprehensive pain/recovery assessments including QoR-15
Limitations
- Single-trial context without explicit cost-effectiveness analysis
- Potential differences in pharmacokinetics and dosing equivalence between formulations
Future Directions: Cost-effectiveness trials and head-to-head comparisons within multimodal ERAS pathways to identify subgroups benefitting from liposomal formulations.
BACKGROUND: The effectiveness of a thoracic paravertebral blockade with liposomal bupivacaine for thoracic surgery pain management is not well examined. This study compared the effects of liposomal bupivacaine and plain bupivacaine on a thoracic paravertebral blockade in adult patients undergoing video-assisted thoracoscopic surgery (VATS). METHODS: Consenting participants (114) scheduled for VATS were randomly assigned to thoracic paravertebral blockade at T4-5 and T7-8 levels with 20 mL (266 mg) liposomal bupivacaine (LB) or 20 mL (37.5 mg) plain bupivacaine (PB) groups. The primary endpoint was opioid consumption at 48 hours postoperatively. Additional main outcomes included the opioid consumption 24 and 72 hours postoperatively; the pain score at rest and coughing 24, 48, and 72 hours postoperatively; Quality of Recovery-15 (QoR-15) scores 24 hours postoperatively, the time to the first analgesia request. RESULTS: Opioid consumption did not differ between the groups at 48 hours postoperatively. The QoR-15 scores 24 hours after surgery were higher in the LB group than in the PB group (mean [SD], 120.2 [7.1] vs 116.5 [7.8]; P = 0.009). The time to the first analgesia request was longer in the LB group than in the PB group (mean [SD], 585.8min [211.7] vs 315.3min [101.7]; P <0.001). The areas under the curve for the NRS score at rest were 21.2 and 35.8 for the LB and PB groups, respectively (P = 0.002). The NRS scores during coughing did not differ between the two groups, nor did the CPSP three months postoperatively. CONCLUSION: Liposomal bupivacaine offers limited but measurable clinical benefits when used for thoracic paravertebral blockade in patients undergoing VATS. REGISTRATION: Chinese Clinical Trial Registry; Registration number: ChiCTR2400081544, URL: https://www.chictr.org.cn/showproj.html?proj=221025.