DISCUSSION
This study shows that ESPB may be applied for postoperative pain
management of the PCNL, improves outcomes such as reducing the incidence
of emergence agitation and preventing PEFR reduction comparing to
preoperative values in recovery room. ESPB provided low VAS and DVAS
values within the first 24 hours, and the mean SPO2values of the patients were found to be higher at the 24th hour compared
to the control group.
Regional analgesia is an important element of successful postoperative
pain-management since they reduce the consumption of opioids which have
a high profile of side effects such as respiratory depression, nausea,
vomiting, and slowing bowel movements 16. Trend in
postoperative pain management has turned from epidural analgesia to the
paravertebral, truncal and recently erector spinae plane block since it
can be applied easily and has fewer complications17,18.
ESPB was defined by Forero et al. for the treatment of neuropathic chest
pain in 2016 and has become popular as a postoperative pain treatment in
many surgical procedures. It is a good alternative because of its
relatively easy application compared to paravertebral blocks and it does
not have complications such as pneumothorax, subarachnoid injection,
urinary retention and hypotension.
There is a rapidly expanding literature on the efficacy of the ESPB in
postoperative pain management of the PCNL 9-14. Our
study may contribute to the relevant literature in several points. We
ruled out potential confusion in the subjective evaluation of the
patients by questioning the pain caused by the urinary catheter. We
comprehensively investigated the pain using serial PEFR measurements and
DVAS in association with its features that may be related to cough,
respiration and mobilization in addition to the subjective and
one-dimensional VAS scale. Additionaly we investigated the positive
outcomes of the pain management with serial PEFR-SpO2measurements, assesing recovery agitation, mobilization, oral intake and
discharge time.
After thoracic and upper abdominal surgeries, it has been shown that
pain affects respiratory muscles and impairs respiratory functions. Pain
can reduce vital capacity, may cause development of atelectasis and
postoperative hypoxemia 19.
PEFR is an inexpensive, easily accessible respiratory function test that
reflects vital capacity. PEFR value may decrease in the early
postoperative period due to pain 19. In PNL surgery,
Hosseini et al.4 investigated the effectiveness of
peritubal ketamine infiltration and Imani et al.20also investigated the analgesic efficacy of ropivacaine infiltration and
its effects on PEFR values. In these studies, it was shown that PEFR
values decreased significantly in the early postoperative period after
PNL, but pain management with peritubal infiltration did not affect PEFR
values positively 4,20.
Although there are many predisposing factors in the pathogenesis of
recovery agitation after urological surgery, a high level of
relationship between pain and postoperative agitation has been
reported7.
Our study showed that ESPB provides effective pain management and
improves patient outcomes by preventing agitation and negative effects
on early pulmonary functions.
For all that there are several limitations of our study. Patient
controlled analgesia methods may be preferred instead of intermittent
intravenous rescue tramadol analgesia. It can be assumed that this can
reduce adverse outcomes of the intermittent bolus intravenous opioids.
The exclusion of patients with ASA> II and the small sample
size may have caused not to measure the effect of ESPB on length of
hospital stay and mobilization time.