Analgesic efficacy and safety of erector spinae plane block in pediatric patients undergoing elective surgery
A systematic review and Meta-analysis of randomized controlled trials
Journal of Clinical Anesthesia
Submitted March 2025 by Dr Matt Hart
Read by 67 Journal Watch subscribers
Summary
This systematic review and meta-analysis compared analgesic efficacy and safety between erector spinae plane block (ESPB) and controls in paediatric surgical patients. The primary outcome analysed was cumulative opioid consumption. Secondary outcomes analysed were pain score, intra-operative opioid consumption, parental satisfaction, time to extubation, post-operative nausea and vomiting, and the incidence of itch and hypotension.
The authors utilised a comprehensive search strategy and identified 17 randomised controlled trials, comprising 919 participants. The participants underwent a variety of thoracic, abdominal, and hip surgical procedures. Control groups included those who received no blocks or sham blocks, as well as those receiving blocks other than ESPB.
The study demonstrated a statistically significant difference favouring ESPB when comparing cumulative opioid consumption after surgery (their primary outcome). A statistically significant difference favouring ESPB was also demonstrated for the time to first request for post-operative analgesia, the need for rescue analgesia, pooled pain scores, and intraoperative opioid consumption.
Additional subgroup analyses were performed, separating the control group into those who received no blocks, or those who received blocks other than ESPB. In these analyses statistically significant differences favouring ESPB against no block were also demonstrated for pain scores at specific time points up to 24 hours post-op, parental satisfaction, and incidence of PONV.
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Commentary
The erector spinae plane block, first described in 2016, has seen a rapid adoption in adult practice, where the literature supports its analgesic efficacy in a range of thoracic and abdominal surgeries. In addition, compared with conventional neuraxial blockade, it is a regional technique that is technically easier to perform and with a lower risk of major adverse events. However, the evidence for its use in the paediatric surgical population remains sparse, and so studies such as this one interrogating the utility of this block in children are useful.
There are several limitations apparent in this study. Firstly, there is no quantification of the degree of reduction in cumulative opioid consumption; instead the standardised mean difference (SMD) is used. The authors report that this was due to heterogeneity in how included studies reported opioid consumption. Without absolute values, it remains unclear whether the opioid-sparing effect is large enough to be clinically meaningful or merely statistically significant. This also applies to the authors' findings related to pain scores.
A second limitation is that there is limited data analysed relating to safety outcomes relevant to ESPB. While the authors investigated PONV, itch, and hypotension, they do not discuss more serious complications that could influence the risk-benefit assessment of ESPB in paediatrics, for example infection, haematoma, pneumothorax, and local anaesthetic toxicity.
Thirdly, there are a range of other established regional anaesthetic techniques that can be performed for the paediatric surgical procedures included in this study, such as caudal or thoracic epidural analgesia. Indeed, the authors report that when subgroup analyses were performed comparing ESPB to other blocks, then all of the statistical differences were no longer apparent, or in the case of time to first analgesic request actually favoured the group receiving other blocks. This suggests that ESPB may not offer a distinct advantage over other well-established techniques in paediatric anaesthesia, and further direct comparative trials are warranted.
Overall, whilst this meta-analysis suggests that ESPB is a promising alternative for paediatric patients undergoing trunk and hip surgery, it does not yet provide sufficient evidence to justify routine adoption over established techniques. Future studies should first focus on quantifying the clinical impact and safety profile more comprehensively, as well as determining whether ESPB is superior to existing regional techniques.
