Erector Spinae Plane Block Guidelines

Primary Indications

The erector spinae plane block is recommended as a first-line regional analgesia technique for video-assisted thoracoscopic surgery (VATS) and can be used for thoracic, abdominal, and hip surgeries requiring multimodal pain management 1
ESP block is specifically recommended for VATS as part of multimodal analgesia, showing non-inferiority to paravertebral block with comparable efficacy in reducing pain scores and opioid consumption during the first 48 hours postoperatively 1, 2

ESP block provides effective analgesia with reduced pain scores and opioid consumption during the first 24 hours after VATS 2
ESP block is particularly indicated when the parietal pleural leaflet is damaged, which would preclude the efficacy of a paravertebral block with catheter 1

ESP block is an acceptable alternative to thoracic epidural analgesia for cardiac surgery under cardiopulmonary bypass or off-pump procedures, with identical analgesic efficacy but fewer adverse effects 3

For oncological breast surgery, ESP block reduces morphine consumption compared to general anesthesia alone, though PECS blocks demonstrate superior pain control after the first postoperative hour 4, 5

Use ultrasound guidance to identify the erector spinae muscle and transverse process at the target level 1
The recommended volume is 20 ml of bupivacaine 5 mg/ml (0.5%) for single-shot ESP block 2

Adding dexmedetomidine to ropivacaine in ESP block results in reduced pain scores, lower rescue analgesia requirements, and shorter hospital stays compared to plain ropivacaine 2
Consider adjuvants when prolonged analgesia beyond 6-8 hours is required 2

ESP block significantly reduces pain scores at rest and during coughing for the first 6-8 hours after VATS compared to placebo 2
Patients demonstrate lower opioid consumption during the first 24 hours postoperatively 2
Faster postoperative out-of-bed activity occurs with ESP block 2

ESP block avoids the risks of hypotension, urinary retention, and lower limb weakness associated with thoracic epidural 1

The analgesic effect of single-shot ESP block diminishes after 6-8 hours, requiring supplemental analgesia 2
Always administer basic analgesia with NSAIDs and paracetamol concurrently with ESP block to optimize pain management 2
Neither ESP nor PECS blocks reliably provide sufficient analgesia to the axilla (T1 nerve distribution), requiring supplemental local anesthetic wound infiltration for axillary procedures 6
ESP block must be part of a comprehensive multimodal analgesic strategy including paracetamol and NSAIDs or COX-2 selective inhibitors 1, 6
Opioids should be reserved for rescue analgesia only 6

The American Society of Anesthesiologists recommends considering the erector spinae plane (ESP) block for patients on anticoagulation therapy due to its safer profile compared to paravertebral block (PVB), with a lower risk of clinically significant hematoma 7

The European Society of Anaesthesiology notes that PVB involves injection near the paravertebral space where major intercostal vessels and the spinal canal are located, creating a risk for non-compressible bleeding, whereas ESP block is performed in a more superficial plane 7