EASIER trial (Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room): a single-centre open-label cohort-based randomised controlled trial analysing the efficacy of the ultrasound-guided erector-spinae plane block compared with intravenous morphine in the treatment of acute hepatopancreaticobiliary pain in the emergency department

Abstract

Background: Ultrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED.

Methods: This open-label randomised controlled trial was conducted in the ED of a tertiary-care hospital between March and August 2023. All adult patients with severe HPB pain were recruited during times that a primary investigator was present. Unconsenting patients, numeric rating scale (NRS) ≤6, age ≤18 and ≥80 years, pregnant, unstable or with allergies to local anaesthetics or opioids were excluded. Patients in the intervention arm received bilateral USG ESPB with 0.2% ropivacaine at T7 level, by a trained ED consultant, and those in the control arm received 0.1 mg/kg intravenous morphine. Pain on a 10-point NRS was assessed by the investigators at presentation and at 1, 3, 5 and 10 hours after intervention by the treatment team, along with rescue analgesia requirements and patient satisfaction. Difference in NRS was analysed using analysis of co-variance (ANCOVA) and t-tests.

Results: 70 participants were enrolled, 35 in each arm. Mean age was 40.4±13.2 years, mean NRS at presentation in the intervention arm was 8.0±0.9 and 7.6±0.6 in the control arm. NRS at 1 hour was significantly lower in the ESPB group (ANCOVA p<0.001). At 1, 3, 5 and 10 hours, reduction of NRS in the intervention arm (7±1.6, 6.7±1.9, 6.6±1.8, 6.1±1.9) was significantly greater than the control arm (4.4±2, 4.6±1.8, 3.7±2.2, 3.8±1.8) (t-test, p<0.001). Fewer patients receiving ESPB required rescue analgesia at 5 (t-test, p=0.031) and 10 hours (t-test, p=0.04). More patients were 'very satisfied' with ESPB compared with receiving only morphine at each time period (p<0.001).

Conclusion: ESPB is a promising alternative to morphine in those with HPB pain.

Trial registration number: CTRI/2023/03/050595.

Keywords: analgesia; emergency department; pain management; randomized controlled trial; ultrasonography.

Figure 1. Consolidated Standards of Reporting Trials flow chart of the Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room trial. ESPB, erector-spinae plane block.

Figure 2. Mean reduction in numeric rating scale (NRS) between the patients who received ESPB against those who received intravenous morphine. ESPB, erector-spinae plane block.

Figure 3. Graphical representation of patient satisfaction rates from both study groups across the study period. The majority of patients in the block arm reported being very satisfied with the erector-spinae plane block as compared with morphine.

Figure 4. (A) Bedside erector-spinae plane block (ESPB) using the Single-operAtor Nerve block under Direct ultrasound visualisation in emergencY technique. (B) Sonoanatomy of the ESPB. The needle path is marked by red arrows contacting the transverse process (TP) of T7 with spread of local anaesthetic below the erector-spinae muscle complex (ESMC).