Paravertebral block versus thoracic epidural for patients undergoing thoracotomy

Pain Management in Minimally Invasive Cardiac Surgery: A Review of Current Clinical Evidence

Compared with conventional sternotomy, minimally invasive cardiac surgery (MICS) is associated with significant advantages such as reduced tissue trauma, faster recovery, and shorter hospital stay. However, the management of postoperative pain caused by intercostal nerve injury, pleural irritation, and tissue retraction remains a major challenge. Despite the less invasive nature of MICS, patients often report experiencing pain similar to that experienced following conventional cardiac surgery, particularly during the acute postoperative period. Effective pain management is essential for optimizing recovery, reducing the consumption of opioids, and preventing the transition to chronic postsurgical pain. Regional anesthesia techniques play a key role in multimodal analgesia for MICS. Thoracic epidural analgesia exhibits strong analgesic efficacy; nevertheless, it remains underutilized owing to concerns regarding anticoagulation-related complications and hemodynamic instability. The thoracic paravertebral block is a safer alternative that provides comparable pain relief with fewer side effects. Similarly, ultrasound-guided fascial plane blocks, such as serratus anterior, parasternal intercostal, interpectoral + pectoserratus, and erector spinae plane blocks, have gained popularity owing to their safety and feasibility; however, the effectiveness of these blocks varies according to the surgical approach and type of incision. Systemic analgesia is an integral component of multimodal pain management in MICS. Despite the efficacy of opioids, a shift toward opioid-sparing strategies has been observed given the significant adverse effects associated with the use of opioids. Intravenous adjuncts such as dexmedetomidine, ketamine, and non-steroidal anti-inflammatory drugs can reduce opioid consumption and improve postoperative pain control. Despite advances in pain management, a single approach that can provide comprehensive analgesia for MICS remains to be established. A multimodal strategy that combines systemic and regional techniques must be developed to optimize pain management and long-term outcomes.

Effect of Thoracic Paravertebral Block on Postoperative Pulmonary Complications After Video-Assisted Thoracoscopic Surgery: A Dual-Center Randomized Clinical Trial

Purpose

TPVB can provide effective postoperative analgesia in lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS), which may enhance respiratory mechanics and postoperative expectoration, as well as relieve inflammation and stress. These mechanisms may reduce the incidence of postoperative pulmonary complications (PPCs). This study explored whether TPVB reduces the risk of PPCs in patients undergoing VATS for lung cancer.

Patients and Methods

In this dual-center trial, patients who underwent VATS for lung cancer were randomly divided into the PV group (n = 151, general anesthesia [GA] and TPVB) and the C group (n = 151, GA only). The primary outcome was the incidence of a composite of PPCs within seven days postoperatively.

Results

The incidence of PPCs within seven days postoperatively was lower in the PV group (37.7%, 57/151) compared to the C group (49.0%, 74/151), with a risk ratio of 1.59 (95% CI: 1.00 to 2.50, P=0.048). And within 8-30 days postoperatively, compared with that in the C group (33.1%, 50/151), the incidence of PPCs was lower in patients in the PV group (22.5%, 34/151), with a risk ratio of 1.70 (95% CI, 1.02 to 2.84, P=0.040). There was a significant difference in the incidence of pneumonia between the PV group (11/151, 7.3%) and the C group (35/151, 23.3%; P < 0.001), and the incidence of pneumothorax between the PV group (27/151, 17.9%) and the C group (45/151, 29.8%; P = 0.015).

Conclusion

Compared to GA alone, TPVB combined with GA reduces the incidence of PPCs within seven days postoperatively in patients undergoing VATS for lung cancer, and this beneficial effect can last up to 30 days after surgery. A possible mechanism is that TPVB reduces acute postoperative pain in patients.

Single versus multisite intercostal nerve block for post-thoracoscopic pain: a prospective observational study

Background

The analgesic efficacy of intercostal nerve block (ICNB) in adults undergoing thoracic surgery and the optimal extent of nerve block remain unclear. To evaluate the analgesic efficacy of ICNB and the optimal extent of nerve block in adults undergoing thoracoscopic surgery, we conducted a prospective cohort study of post-thoracoscopic pain.

Methods

We conducted a prospective observational cohort study to assess the postoperative pain intensity scores and other relevant factors associated with different ICNB techniques for pain management in thoracoscopic surgery in a tertiary hospital in Beijing, China. Postoperative pain management was categorized into three groups: the ICNB single-site injection (ICNB SI) group, in which the third to fifth intercostal nerves were blocked with 1 mL of 0.5% ropivacaine at each costal level; the ICNB incision-specific multi-site injection (ICNB ISMSI) group, in which the third to eighth intercostal nerves were blocked with 1 mL of 0.5% ropivacaine at each costal level; and the non-ICNB anesthesia group, which did not undergo any block.

Results

Pain intensity scores (visual analog scale, VAS) in the ICNB SI group were significantly lower than those in the ICNB ISMSI group within 24 hours after surgery (4.9±2.4 vs. 6.2±2.0). Within 24 hours after surgery (day 0), no significant difference in pain intensity scores was observed between the ICNB ISMSI group and the non-ICNB group (6.2±2.0 vs. 6.3±2.1). Additionally, ICNB was effective in reducing pain following thoracoscopic surgery, with analgesic effects lasting up to 4 days postoperatively. Long-term follow-up showed lower incidence of chronic chest pain and better quality of life (QL-Index) in the ICNB groups compared to the non-ICNB group (QL-Index scores: 9.18±0.7 at 3 months in the ICNB group vs. 8.67±0.5 in the non-ICNB group).

Conclusions

Thoracic incision-specific multi-site injections were not superior to single injections of ICNB in terms of post-thoracoscopic analgesia. The single-injection approach (ICNB SI) maintained analgesia for 4 days after thoracoscopic surgery, while the multisite injection (ICNB ISMSI) did not demonstrate this prolonged effect. Further research is needed to elucidate the exact mechanisms underlying these differential analgesic effects in clinical practice.

Advances in the use of non-intubated spontaneous-ventilation video-assisted thoracoscopic surgery

With the advancement of Enhanced Recovery After Surgery (ERAS), minimally invasive thoracoscopic surgery has gained widespread clinical adoption owing to its reduced trauma and faster recovery compared to traditional open chest procedures. Thoracoscopic surgery has evolved from initial three-port and two-port techniques to single-port non-intubated approaches, which preserve spontaneous breathing while minimizing trauma and accelerating recovery. NIVATS represents a groundbreaking advancement in thoracic surgery and anesthesia by innovatively avoiding endotracheal intubation and mechanical ventilation, thereby challenging conventional surgical approaches. This paper reviews the research progress on the anesthesia techniques, indications, and contraindications of Non-Intubated Spontaneous-Ventilation Video-Assisted Thoracoscopic Surgery (NIVATS), discussing its advantages compared to traditional surgical methods, its application in thoracic diseases, as well as the risks and management of NIVATS.

A Comparison of Intercostal Nerve Block and Thoracic Epidural Anesthesia in Patients Undergoing Video-Assisted Thoracic Surgery: A Propensity Score-Matched Retrospective Study

BACKGROUND

Intercostal nerve block (ICNB) plus intravenous (IV) patient-controlled analgesia (PCA) could be an alternative method of perioperative pain management in patients undergoing video-assisted thoracic surgery (VATS). However, the efficacy of this strategy has not been established.

METHODS

A retrospective observational study was conducted at an acute care hospital in Japan. Among patients who underwent VATS under general anesthesia from January 1, 2012, to December 31, 2022, we included those who received ICNB or thoracic epidural anesthesia (TEA). The ICNB group had postoperative IV PCA, and the TEA group had postoperative epidural PCA. VATS indicated for pneumothorax or biopsy was excluded. The primary outcome was the maximum pain score measured by the numerical rating scale on postoperative day 1. Secondary outcomes included the times rescue analgesics were used and the use of antiemetics. Propensity score matching was performed to minimize bias from nonrandomized assignment of anesthesia methods.

RESULTS

Among 1,641 patients who met the criteria, 590 underwent ICNB and IV PCA, while 1,051 received TEA. After 1:1 propensity score-matching, 456 were in each group. The median (interquartile range) pain score on postoperative day 1 was higher in the ICNB group than in the TEA group, with values of 5 (4-7) vs. 3 (2-5) (p < 0.0001). Patients in the ICNB group more frequently used rescue analgesics on postoperative day 0, with values of 2 (1-2) vs. 1 (1-2) (p < 0.0001), and had a higher proportion of receiving antiemetics on postoperative day 1 (13.4% vs. 6.1%, p = 0.0004), compared to the patients in the TEA group.

CONCLUSIONS

ICNB plus IV PCA was inferior to TEA for postoperative pain management of VATS in the study population. Protocol-based prospective studies are needed to determine the efficacy of this strategy.

Subserratus Anterior Plane Block vs Thoracic Paravertebral Block for Postoperative Analgesia in Laparoscopic Radical Nephrectomy: Protocol for a Randomized Controlled, Double-Blind, Non-Inferiority Clinical Trial

Introduction

Thoracic paravertebral nerve block (TPVB) is a widely used regional anesthesia technique employed in opioid-sparing anesthesia for abdominal surgery. Although the subserratus anterior plane block (SSAPB) has shown effectiveness in providing analgesia in upper abdominal surgery, it remains unclear whether the SSAPB offers comparable analgesic effects to the TPVB for retroperitoneal laparoscopic nephrectomy.

Methods and Analysis

This study is designed as a prospective, randomized controlled, double-blind, single-center, non-inferiority trial involving a total of 106 patients undergoing retroperitoneal laparoscopic nephrectomy. Participants will be randomly assigned to either the SSAPB group or the TPVB group in a 1:1 ratio. Both ultrasound-guided SSAPB and TPVB will involve the administration of 0.375% ropivacaine at a dose of 0.4 mL/kg prior to anesthesia induction. Subsequently, opioid-sparing anesthesia will be utilized during surgery. Each patient will receive standardized patient-controlled intravenous analgesia (PCIA) without a background infusion. The primary outcome measure will be the 24-hour postoperative consumption of rescue opioids. Secondary outcomes will include pain visual analogue scale (VAS) scores at various predefined time points within 48 hours post-surgery, analgesic consumption during and after surgery, time to first administration of rescue analgesics, incidence of perioperative cardiopulmonary adverse events, assessment of block characteristics, quality of recovery, time to ambulation and initiation of an oral diet, and length of stay in both the postoperative anesthesia care unit (PACU) and the hospital. Additionally, levels of inflammatory markers, including interleukin-6 (IL-6) and C-reactive protein (CRP), will be assessed at predefined time points.

Discussion

This protocol outlines the first prospective, randomized controlled, double-blinded, non-inferiority clinical trial comparing perioperative analgesic efficacy and safety of SSAPB versus TPVB in patients undergoing retroperitoneal laparoscopic nephrectomy under opioid-sparing anesthesia. The study is designed to generate preliminary insights into optimizing regional anesthesia strategies for perioperative pain management in this surgical cohort.

Paravertebral block analgesia during surgical stabilization for rib fractures patients under conscious state: a single-arm, pilot study and post-hoc analysis

BACKGROUND

Paravertebral block (PVB) is commonly used for analgesia postoperatively while rarely as anesthesia during surgical stabilization for rib fractures. This study aimed to explore the feasibility and safety of PVB analgesia alone during surgical stabilization for patients with multiple rib fractures (MRF) under conscious state.

METHODS

This prospective single-arm pilot study was conducted in patients with MRF who schedule for surgical stabilization using PVB analgesia in Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine between September 2019 and September 2020. The outcomes were the vital signs, postoperative pain and nausea and vomiting (PONV). Those who underwent general anesthesia (GA) during the same period were included for post hoc analysis.

RESULTS

Eighteen patients (aged 62 ± 10.64 years; 8 males) were enrolled. The vital signs, including SpO2, systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, of the patients at baseline, perioperative, intraoperative, and postoperative day 1 were kept normal. The postoperative numerical rating scale (NRS) pain scores at 6, 12, and 24 h were 2.67 ± 1.36, 2.44 ± 0.80, and 2.33 ± 0.86, respectively, which were improved compared with baseline (5.78 ± 1.00). No PONV, postoperative morbidity, pulmonary infections, or incision infections were observed. Additionally, post-hoc analysis for the comparison of patients who underwent GA with PVB (in the pilot study) showed a similar number of rib fracture fixation (P = 0.06) and analgesic effect (P = 0.06) after operation, while a significantly shorter total length of hospital stay (P < 0.01), postoperative hospital stay (P < 0.01), lower dose of sufentanil citrate use (P < 0.01),and total costs(P < 0.03)in patients who underwent PVB.

CONCLUSIONS

PVB analgesia during surgical stabilization for MRF under a conscious state might be feasible and safe. Compared with GA, PVB analgesia might reduce the dose of narcotics, shorten the length of hospital stay, and reduce the cost of hospitalization.

CLINICAL REGISTRATION

www.

CLINICALTRIALS

gov (#NCT04536311).

Analgesic Efficacy of Thoracoscopic Direct-View Versus Ultrasound-Guided Thoracic Paravertebral Block in Multi-Port Video-Assisted Thoracoscopic Lung Surgery: A Randomized Controlled Non-Inferiority Study

Purpose

This study compares the analgesic effects of the Thoracoscopic Direct-view Thoracic Paravertebral Nerve Block (DTPVB) with those of the Ultrasound-guided Thoracic Paravertebral Nerve Block (UTPVB), providing a clinical reference.

Patients and Methods

Sixty-eight patients undergoing three-port video-assisted thoracic surgery (VATS) with general anesthesia were randomly assigned to either the DTPVB group (Group D, n = 34) or the UTPVB group (Group U, n = 34). Both groups received a 10 mL injection of 0.75% ropivacaine at the T4 and T7 interspaces. Primary outcomes were cumulative sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively, with group differences assessed against a non-inferiority margin of 5 μg (Δ). Secondary outcomes include postoperative pain scores, analgesic consumption, patient satisfaction, adverse effects, and other related indicators.

Results

The cumulative use of sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively was 35.0 ± 6.1 μg in Group D and 33.2 ± 5.6 μg in Group U, with no significant difference (P = 0.217). The difference in cumulative sufentanil equivalents (Group D minus Group U) was 1.8 (95% CI -1.07, 4.65), within the non-inferiority margin of 5 (Δ). Postoperative pain scores, analgesic consumption, adverse effects, and complications were similar were similar between groups. However, DTPVB was associated with lower anxiety and higher satisfaction (P<0.001). At 15 minutes post-block, ropivacaine plasma concentrations were higher in Group D (P=0.024).

Conclusion

DTPVB, via transmural pleural puncture, was non-inferior to UTPVB in analgesic efficacy from the beginning of the manipulation of the lungs in operation to 24h postoperatively. DTPVB provides a good alternative, especially for patients who are anxious before surgery, have difficulty cooperating with UTPVB, or in cases where UTPVB puncture fails. However, when using high concentrations of ropivacaine, greater vigilance for toxicity is required.

Comparison of midazolam and dexmedetomidine combined with thoracic paravertebral block in hemodynamics, inflammation and stress response, and cognitive function in elderly lung cancer patients

OBJECTIVE

This study aimed to compare the clinical outcomes of midazolam and dexmedetomidine combined with ropivacaine-induced thoracic paravertebral nerve block (TPVB) in radical lung cancer surgery.

METHODS

To retrospectively analyze the clinical data of elderly patients who underwent thoracoscopic radical lung cancer surgery from March 2020 to February 2023 in our hospital. All patients underwent a single two-site method of TPVB at the levels of T4 and T7 under ultrasound guidance. The patients were divided into midazolam group (0.25 % ropivacaine + 0.1 mg/kg midazolam) and dexmedetomidine group (0.25 % ropivacaine + 0.8 μg/kg dexmedetomidine) according to the application of sedative drugs, with 78 cases in each group. Ramsay sedation score, mean arterial pressure (MAP), heart rate (HR), electroencephalographic bispectral index (BIS), and blood oxygen saturation (SpO2), as well as the serum levels of C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), epinephrine (E), cortisol (Cor), and norepinephrine (NE) were recorded at 6, 12, 24, 36 and 48 h postoperatively, respectively. The patients' cognitive function was assessed using the Brief Mental State Evaluation Scale (MMSE) at 1 d preoperatively, 1 d postoperatively, and 7 d postoperatively.

RESULTS

The amount of intraoperative sufentanil in the dexmedetomidine group was lower than that in the midazolam group (P < 0.05). The rate of atropine use was higher in the dexmedetomidine group than that in the midazolam group (P < 0.05). There was no significant difference in the occurrence of overall intraoperative adverse reactions (P > 0.05), but the incidence of respiratory depression in the dexmedetomidine group was significantly lower than that in the midazolam group, and the incidence of bradycardia in the dexmedetomidine group was significantly higher than that in the midazolam group (P < 0.05). At T0 ∼ T4, BIS and MAP showed a decreasing trend in both groups. 12, 24, 36 and 48 h postoperatively, the Ramsay sedation score was higher in the dexmedetomidine group than in the midazolam group (P < 0.05). At 36 and 48 h postoperatively, the serum Cor, E, NE, CRP, TNF-α, and IL-6 levels were lower in the dexmedetomidine group than in the midazolam group (P < 0.05). Compared with the preoperative 1d, the MMSE scores were significantly lower in both groups on one day postoperative, while the MMSE scores were significantly higher at postoperative day 7 than on postoperative day 1 (P < 0.05). At postoperative day 1, the MMSE score was significantly higher in the dexmedetomidine group than in the midazolam group (P < 0.05). The difference in the incidence of adverse events within 72 h postoperatively between the two groups was not statistically significant (3.95 % vs. 1.28 %, χ2 = 0.284, P = 0.594).

CONCLUSION

Dexmedetomidine compounded with ropivacaine-induced ultrasound-guided thoracic paravertebral nerve block is superior to midazolam for sedation, anti-inflammation, and anti-stress in elderly lung cancer patients.

Ultrasound Identification of an Atypical Course of the Posterior Intercostal Artery During Paravertebral Block

The thoracic paravertebral block (TPVB), while relatively safe, can be associated with significant complications, including inadvertent vascular injury. We describe an ultrasound-guided TPVB where a pulsatile artery was identified between the two transverse processes and in close proximity to the T7-8 paravertebral space, likely the dorsal branch of the posterior intercostal artery. A similar artery was also noted one intercostal space cephalad and caudal of this area. The use of ultrasound allowed for real-time visualization of the needle, minimizing the risk of arterial puncture.

Comparison of Intercostal Nerve Block and Serratus Anterior Plane Block for Perioperative Pain Management and Impact on Chronic Pain in Thoracoscopic Surgery: A Randomized Controlled Trial

OBJECTIVES

The intent of this study was to compare the analgesic efficacy of intercostal nerve block (ICNB) under direct thoracoscopic visualization and serratus anterior plane block (SAPB) with ultrasound guidance during thoracoscopic surgery's perioperative period. Furthermore, it examined their impact on chronic pain and identifies potential risk factors associated with its development.

MATERIALS AND METHODS

In this prospective randomized controlled study, 74 thoracoscopic surgery patients were randomly assigned to ICNB or SAPB groups. Attending surgeons administered ICNB, while anesthesiologists performed SAPB, both using 20 mL of 0.5% ropivacaine. Primary outcomes included Visual Analog Scale (VAS) scores for resting and coughing pain at 6, 12, 24, and 48 hours postoperatively, perioperative opioid and NSAID consumption, and chronic pain incidence at 3 months postoperatively. Secondary outcomes aimed to identify independent risk factors for chronic pain.

RESULTS

The primary results reveal that the SAPB group exhibited significantly lower VAS scores than the ICNB group for postoperative coughing at 24 hours ( P <0.001, 95% CI=0.5, 1) and for resting pain at 48 hours ( P =0.001, 95% CI=0.2, 1). Conversely, the ICNB group demonstrated a reduced VAS score for resting pain at 6 hours compared with the SAPB group ( P =0.014, 95% CI=-0.5, 0.5). SAPB group required significantly less intraoperative sulfentanil ( P <0.001, 95% CI=2.5, 5), remifentanil ( P =0.005, 95% CI=-0.4, -0.1), and flurbiprofen ester ( P =0.003, 95% CI=0, 50) than ICNB group. Chronic pain incidence was similar ( P =0.572, 95% CI=0.412, 1.279), with mild pain in both ICNB and SAPB groups. Secondary findings indicate that resting VAS score at 12 hours (OR=7.59, P =0.048, 95% CI=1.02, 56.46), chest tube duration (OR=3.35, P =0.029, 95% CI=1.13, 9.97), and surgical duration (OR=1.02, P =0.049, 95% CI=1.00, 1.03) were significant predictors of chronic pain occurrence.

DISCUSSION

ICNB and SAPB demonstrated comparable analgesic effects, with similar rates of chronic pain occurrence. Chronic pain independent risk factors included resting VAS score at 12 hours, chest tube duration, and surgical duration.

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Association of thoracic epidural analgesia and hospital length of stay for patients undergoing thoracotomy: a retrospective cohort analysis

INTRODUCTION

Regional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional anesthesia with time to hospital discharge for these patients.

METHODS

This was a retrospective cohort study using National Surgical Quality Improvement Program dataset from 2014 to 2020. Propensity-matched cohorts were assembled based on use of regional anesthesia, peripheral regional anesthesia, or epidural. Fine-Gray competing risk regressions were used to explore the association between regional anesthesia use and rate of discharge. The subdistribution hazard ratio (HR) represented relative discharge rates, and in-hospital death was a competing event. A sensitivity analysis was subsequently performed in which patients with American Society of Anesthesiologists score ≥4 were removed.

RESULTS

There were 4350 patients included in this analysis, in which 472 (10.8%) received a peripheral regional anesthesia nerve block and 565 (13.0%) received thoracic epidural analgesia. The subdistribution HR for rate of discharge in the epidural versus non-epidural cohort was 1.09 (95% CI 1.01 to 1.18), thus epidurals were associated with an increased rate of discharge over time. However, this benefit was no longer apparent with the sensitivity analysis. The subdistribution HR for rate of discharge in the peripheral regional anesthesia versus no regional anesthesia cohort was 1.26 (95% CI 1.15 to 1.39), thus peripheral regional anesthesia was associated with an increased rate of discharge over time. This benefit remained even with the sensitivity analysis.

CONCLUSIONS

Thoracic epidural use when compared with no regional anesthesia was associated with decreased length of stay following thoracotomy in our primary analysis. The difference was no longer apparent with the sensitivity analysis. Peripheral regional anesthesia was associated with decreased length of stay even after sensitivity analysis.

Predictors of prolonged hospital stay in patients undergoing lung resection

PURPOSE

To identify potential predictors of prolonged length of hospital stay in patients submitted to lung resection surgery.

MATERIALS AND METHODS

This is a cohort study, carried out in 105 patients with lung cancer, submitted to posterolateral thoracotomy pulmonary resection. Data collection included preoperative assessment of demographic, clinical, pulmonary function, respiratory muscle function, physical fitness, and behavioral habits. After surgery, length of hospital stay was documented, and the sample was divided into two groups according to the length of hospital stay (LOS): the normal hospital stay group (NLOS) until 8 days, and the prolonged hospital stay group (PLOS) with more than 8 days of hospital stay. Multiple linear regressions were performed between length of hospital stay and the studied variables, for the total sample and, specifically, for the PLOS group.

RESULTS

The multiple linear regression for the total sample, the most explanatory power variables were TLC, MIP, PEF, and BMI. When considering only the PLOS, the variables that mostly explained were the MIP%, MEP and TLC%.

CONCLUSION

Besides the classic outcomes used to calculate surgical risk, the body mass index, respiratory muscle strength, peak expiratory flow, and total lung capacity are predictors of the variation on length of hospital stay in patients submitted to lung resection.

Erector spinae plane block for laparoscopic surgeries: a systematic review and meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a novel analgesic technique that can reduce post-operative pain and postoperative opioid consumption in laparoscopic surgeries.

METHODS

We searched PubMed, Scopus, and Web of Science on November 17th, 2023 for clinical trials comparing ESPB with other analgesic techniques or placebo for laparoscopic surgeries. We meta-analyzed post-operative pain at rest, postoperative opioid consumption, time to first rescue analgesic request, and postoperative nausea and vomiting using a random effects model.

RESULTS

ESPB significantly reduced opioid consumption compared to placebo (SMD, (95CI), p-value; -1.837, (-2.331, -1.343), < 0.001) and also compared to transversus abdominis plane block (TAPB) (SMD, (95CI), p-value; -1.351, (-1.815, -0.887), < 0.001) but not quadratus lumborum plane block (QLB) (SMD, (95CI), p-value; 0.022, (-0.241, 0.286), 0.869). ESPB also significantly reduced participant-reported pain scores at rest at 24h post-operation compared to placebo (SMD, (95CI), p-value; -0.612, (-0.797, -0.428), < 0.001) and TAPB (SMD, (95CI), p-value; -0.465, (-0.767, -0.162), < 0.001), however, there was a significant increase in pain score compared to QLB (SMD, (95CI), p-value; 1.025, 0.156, 1.894), 0.021). A statistically significant increase in time to first rescue analgesic in ESPB groups compared to placebo and TAPB groups was observed in our meta-analysis. There was a lower post-operative nausea and vomiting rate in the ESPB groups compared to placebo groups, yet a comparable rate with QLB and TAPB groups was observed in the meta-analysis.

CONCLUSION

ESPB is an effective and safe analgesic technique for managing post-operative pain and opioid consumption in laparoscopic surgeries compared to placebo, reducing postoperative nausea or vomiting as well. Compared to other techniques, ESPB has a similar efficacy to QLB, except for the pain score at 24 h post-operation, but appears to be superior to TAPB as an analgesic technique in laparoscopic surgeries, with a similar safety profile.

TRIAL REGISTRATION

Prospero registration ID: CRD42024508363. Link: https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Analgesic efficacy of ultrasound-guided retrolaminar block in truncal surgeries: A narrative review

Postoperative pain management in patients undergoing thoracoabdominal surgery always remains challenging for the anesthesiologist. As a method of pain management, multimodal analgesia is commonly used. In recent years, interfascial plane blocks like erector spine plane block (ESPB), retrolaminar block (RLB), transverse thoracic plane block, and pectointercostal plane block have been increasingly utilized as important components of acute postoperative pain management in truncal surgeries. Here, we reviewed the analgesic efficacy of ultrasound (US)-guided retrolaminar block in patients undergoing truncal surgeries. The primary objective of this review was total opioid consumption within 24 hours of the postoperative period. The secondary objectives were postoperative pain score, time to first analgesic requirement, and adverse effects. All articles relevant to the retrolaminar block were searched in six major databases (PubMed, Embase, Medline, Ovid, PMC, and Google Scholar). A total of 706 records were identified, out of which only 11 kinds of literature were included in this review article, based on our inclusion criteria. The published literature suggests that retrolaminar (RLB) provides more effective analgesia in comparison to the erector spinae block (ESP), is associated with reduced opioid consumption and numeric rating scale (NRS) score, and is not inferior to paravertebral (PVB). There is an evidence that a retrolaminar block can effectively relieve pain during truncal surgery. RLB had a lower rate of complications, was simpler to perform, and required shorter hospital stays.

Comparison of the postoperative analgesic efficacy of serratus anterior plane block with different types of blocks for video-assisted thoracoscopic surgery: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The study aimed to compare the analgesic efficacy of single-shot serratus anterior plane block (SAPB) for video-assisted thoracoscopic surgery (VATS) with other regional block techniques.

METHODS

In this meta-analysis, randomized controlled trials published in the PubMed, Scopus, Web of Science, ClinicalKey, and PROSPERO electronic databases between March 24, 2014 and March 24, 2024 comparing the analgesic efficacy of SABP with other regional blocks in adult patients undergoing VATS were reviewed.

RESULTS

Nine randomized controlled trials consisting of a total of 537 participants (287 males, 250 females; mean age: 55.2±13.1 years) were included in this meta-analysis. Serratus anterior plane block was compared with erector spinae plane block (ESPB), local infiltration anesthesia (LIA), and thoracic paravertebral block (TPVB). The postoperative 24-h cumulative opioid consumption was statistically significantly higher in SAPB than in ESPB (standardized mean difference [SMD]=1.98; 95% confidence interval [CI], 0.23 to 3.73; Z=2.22; p=0.03; I 2 =97%; random effects model) and TPVB (SMD=0.63; 95% CI, 0.31 to 0.96; Z=3.84; p<0.001; I 2 =0%; fixed effects model) and lower than in LIA (SMD=-1.77; 95% CI, -2.24 to -1.30; Z=7.41; p<0.001; I 2 =0%; fixed effects model). Active pain scores 2 h postoperatively were statistically significantly lower in SAPB than in LIA (SMD=-2.90; 95% CI, -5.29 to -0.50; Z=2.37; p=0.02; I 2 =93%; random-effects model). At 12 h postoperatively, both passive pain scores (SMD=0.37; 95% CI, 0.07 to 0.66; Z=2.41; p=0.02; I 2 =0%; fixed effects model) and active pain scores (SMD=0.55; 95% CI, 0.25 to 0.85; Z=3.60; p<0.001; I 2 =0%; fixed effects model) were statistically significantly lower in ESBP than in SAPB. There was no difference between SAPB and the other groups in terms of the incidence of postoperative nausea and vomiting.

CONCLUSION

After a comprehensive evaluation of postoperative analgesic effects, it appears that ESBP and TPVB may be better than SABP, and SABP may be better than LIA for analgesia of patients undergoing VATS. Further studies are required to determine the optimal regional analgesia technique in VATS.

Efficacy of epidural anesthesia in minimally invasive cardiac surgery

Introduction

The most commonly performed minimally invasive cardiac surgery (MICS) is lateral minithoracotomy, which requires one of the most painful incisions. Adequate postoperative pain management is essential for cardiac surgery to prevent perioperative complications. Thoracic epidural analgesia (TEA) is the gold standard for thoracotomy; however, it is still controversial because of the risk of epidural hematoma following systematic heparinization. The objective of our study was to investigate the safety and efficacy of TEA following MICS.

Methods

The clinical data of patients aged over 18 years who underwent elective MICS and received epidural analgesia along with general anesthesia between January 2014 and March 2019 were reviewed. Data were collected, including patient demographics, operative data, postoperative pain, postoperative course, and complications. Chronic pain was evaluated 6 months after discharge, and we defined it as a NRS score ≧3. Postoperative complications included epidural-related complications.

Results

Seventy patients were included in the analysis. The mean NRS score was below 2. We collected chronic pain data from 52 patients and found that 11 patients had chronic pain. TEA-related complications were not observed.

Conclusion

The current observational study revealed that TEA following lateral thoracotomy was effective for acute pain as well as chronic pain without causing any severe epidural-related complications. Protocols to prevent potential devastating complications, including epidural hematoma, should follow the American Society of Regional Anesthesia and Pain Medicine recommendation. If the rules are strictly followed, TEA can be a safe and effective pain management method for patients who undergo MICS.

Continuous serratus anterior plane block for postoperative analgesia following lung transplantation via anterolateral incision: a pilot study

Background

Unilateral or bilateral anterolateral thoracotomy May lead to severe acute pain in lung transplantation (LTx). Although serratus anterior plane block (SAPB) is apparently effective for pain control after open thoracic surgery, there remains a lack of evidence for the application of SAPB for postoperative analgesia after LTx.

Objective

In this case series pilot study, we describe the feasibility of continuous SAPB after lung transplantation and provide a preliminary investigation of its safety and efficacy.

Methods

After chest incisions closure was complete, all patients underwent ultrasound-guided SAPB with catheter insertion. Numerical rating scale (NRS), additional opioid consumption, time to endotracheal tube removal, ICU length of stay, and catheter-related adverse events were followed up and recorded for each patient within 1 week after the procedure.

Results

A total of 14 patients who received LTx at this center from August 2023 to November 2023 were included. All patients received anterolateral approaches, and 10 (71.4%) of them underwent bilateral LTx. The duration of catheter placement was 2 (2-3) days, and the Resting NRS during catheter placement was equal to or less than 4. A total of 11 patients (78.6%) were supported by extracorporeal membrane oxygenation (ECMO) in LTx, whereas 8 patients (57.1%) removed the tracheal tube on the first day after LTx. Intensive care unit (ICU) stay was 5 (3-6) days, with tracheal intubation retained for 1 (1-2) days, and only one patient was reintubated. The morphine equivalent dose (MED) in the first week after LTx was 11.95 mg, and no catheter-related adverse events were detected.

Limitations

We did not assess the sensory loss plane due to the retrospective design. In addition, differences in catheter placement time May lead to bias in pain assessment.

Conclusion

Although continuous SAPB May be a safe and effective fascial block technique for relieving acute pain after LTx, it should be confirmed by high-quality clinical studies.

Comparison of Postoperative Opioid Consumption of Paravertebral Block and Erector Spinae Plane Block After Thoracotomy: A Randomized Controlled Trial

Background Thoracotomy is associated with severe postoperative pain. Pain developing after thoracotomy causes lung infections, inability to expel secretions, and atelectasis as a result of deep breathing. Effective management of acute pain after thoracotomy may prevent these complications. A multimodal approach to analgesia is widely employed by thoracic anesthetists using a combination of regional anesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anesthesia blockade. Nowadays, regional anesthesia techniques such as thoracic epidural paravertebral block (PVB), erector spinae plane block (ESPB), and serratus plane block are frequently used to prevent pain after thoracotomy. In this study, we compared paravertebral block with erector spinae block for pain relief after thoracotomy. Our primary aim was to determine whether there was a difference between postoperative opioid consumption and pain scores. We also compared the two regional anesthesia techniques in terms of intraoperative hemodynamic data and postoperative complications. Methodology Patients aged between 18 and 75 years with an American Society of Anesthesiology (ASA) physical status I-III and scheduled for elective thoracotomy were included in the study. Using www.randomizer.org, patients were divided into two different groups, namely, ESPB and PVB. All patients were provided with a patient-controlled analgesia device preloaded with morphine. Postoperative 24-hour morphine consumptions were recorded. Results Data from 45 patients were used in the final analyses. Morphine consumption was higher in the ESPB group than in the PVB group at 24 hours postoperatively (19.2 ± 4.26 mg and 16.2 ± 2.64 mg, respectively; p < 0.05). There was no significant difference in numerical rating scale scores both at rest and with coughing (p > 0.05). Intraoperative heart rates were similar between groups. However, mean intraoperative blood pressure was significantly lower in the PVB group at 30 minutes (p < 0.05). Nausea and vomiting were observed in two patients in the ESPB group and one patient in the PVB group. The complication of nausea and vomiting was not statistically significant between the two groups (p > 0.05). Catastrophic complications such as hematoma, pneumothorax, and local anesthetic systemic toxicity were not observed in either group. Conclusions We found that patients who underwent PVB consumed less morphine postoperatively than patients who underwent ESPB. However, we did not observe any difference in pain scores between both groups. We think that ESPB can be considered a reliable method in thoracotomy surgery due to its ease of application and the fact that the place where the block is technically performed is farther from the central structures compared to PVB. In light of the results of our study, ESPB can be used as an alternative to PVB, which has been proven as postoperative analgesia in thoracic surgery.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND

This study was designed to investigate the clinical outcomes of enhanced recovery after surgery (ERAS) in the perioperative period in elderly patients with non-small cell lung cancer (NSCLC).

AIM

To investigate the potential enhancement of video-assisted thoracic surgery (VATS) in postoperative recovery in elderly patients with NSCLC.

METHODS

We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS (the ERAS group) and 327 elderly NSCLC patients who received routine care (the control group) after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017. After propensity score matching of baseline data, we analysed the postoperative stay, total hospital expenses, postoperative 48-h pain score, and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.

RESULTS

After propensity score matching, ERAS significantly reduced the postoperative hospital stay (6.96 ± 4.16 vs 8.48 ± 4.18 d, P = 0.001) and total hospital expenses (48875.27 ± 18437.5 vs 55497.64 ± 21168.63 CNY, P = 0.014) and improved the satisfaction score (79.8 ± 7.55 vs 77.35 ± 7.72, P = 0.029) relative to those for routine care. No significant between-group difference was observed in postoperative 48-h pain score (4.68 ± 1.69 vs 5.28 ± 2.1, P = 0.090) or postoperative complication rate (21.2% vs 27.1%, P = 0.371). Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.

CONCLUSION

ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

S erratus anterior plane block alone, paravertebral block alone and their combination in video-assisted thoracoscopic surgery: the THORACOSOPIC double-blind, randomized trial

OBJECTIVES

Serratus anterior plane block (SAPB) and paravertebral block (PVB) are well known to reduce pain levels after video-assisted thoracoscopic surgery (VATS). However, the relative efficacies of each block and a combination of the 2 have not been fully characterized. The objective of the present study was to assess the efficacy of PVB alone, SAPB alone and the combination of PVB and SAPB with regard to the occurrence and intensity of pain after VATS.

METHODS

We conducted the THORACOSOPIC single-centre, double-blind, randomized trial in adult patients due to undergo elective VATS lung resection. The participants were randomized to PVB only, SAPB only and PVB + SAPB groups. The primary end-point was pain on coughing on admission to the postanaesthesia care unit. The secondary end-points were postoperative pain at rest and on coughing at other time points and the cumulative opioid consumption. Pain was scored on a visual analogue scale.

RESULTS

One-hundred and fifty-six patients (52 in each group) were included. On admission to the postanaesthesia care unit, the 3 groups did not differ significantly with regard to the pain on coughing: the visual analogue scale score was 3 (0-6), 4 (0-8) and 2 (0-6) in the PVB, SAPB and PVB + SAPB groups, respectively (P = 0.204). During postoperative care, the overall pain score was significantly lower in the SABP + PVP group at rest and on cough.

CONCLUSIONS

The combination of SABP + PVB could be beneficial for pain management in VATS in comparison to SABP or PVB alone.

Analgesic Efficacy and Safety of Intrathecal Morphine or Intercostal Levobupivacaine in Lung Cancer Patients after Major Lung Resection Surgery by Videothoracoscopy: A Prospective Randomized Controlled Trial

Background: Lung resection using video-assisted thoracoscopic surgery (VATS) improves surgical accuracy and postoperative recovery. Unfortunately, moderate-to-severe acute postoperative pain is still inherent to the procedure, and a technique of choice has not been established for the appropriate control of pain. In this study, we aimed to compare the efficacy and safety of intrathecal morphine (ITM) with that of intercostal levobupivacaine (ICL). Methods: We conducted a single-center, prospective, randomized, observer-blinded, controlled trial among 181 adult patients undergoing VATS (ISRCTN12771155). Participants were randomized to receive ITM or ICL. Primary outcomes were the intensity of pain, assessed by a numeric rating scale (NRS) over the first 48 h after surgery, and the amount of intravenous morphine used. Secondary outcomes included the incidence of adverse effects, length of hospital stay, mortality, and chronic post-surgical pain at 6 and 12 months after surgery. Results: There are no statistically significant differences between ITM and ICL groups in pain intensity and evolution at rest. In cough-related pain, differences in pain trajectories over time are observed. Upon admission to the PACU, cough-related pain was higher in the ITM group, but the trend reversed after 6 h. There are no significant differences in adverse effects. The rate of chronic pain was low and did not differ significantly between groups. Conclusions: ITM can be considered an adequate and satisfactory regional technique for the control of acute postoperative pain in VATS, compatible with the multimodal rehabilitation and early discharge protocols used in these types of surgeries.

Thoracoscopic Intercostal Nerve Block with Cocktail Analgesics for Pain Control After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study

OBJECTIVE

To evaluate whether using a cocktail of intercostal nerve blocks (TINB) during thoracoscopic surgery results in better clinical outcomes than patient-controlled analgesia (PCIA).

METHODS

Patients in two medical groups undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary nodules in West China Hospital of Sichuan University were collected consecutively between March 2022 and December 2022. The groups were divided into two subgroups based on their analgesic program, which were TINB group and PCIA group. The primary outcome was the visual analogue scale (VAS) of the two groups at different stage after surgery and after discharge. Any analgesic related adverse events (ARAEs) were also recorded.

RESULTS

A total of 230 patients who underwent VATS were enrolled, in which 113 patients (49.1%) received a cocktail TINB after surgery, and 117 patients (50.9%) received a PCIA. After PSM, 62 patients in each group were selected. The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period (p < 0.05, p < 0.05), and the two groups showed no significant differences in RVAS or AVAS during hospitalization (p = 0.271, p = 0.915). However, the rates of dizziness (4.84% vs 25.81%, p = 0.002), nausea and vomiting (0 vs 22.58%, p < 0.05), fatigue (14.52% vs 34.87%, p = 0.012), and insomnia (0 vs 58.06%, p < 0.05) in TINB group were lower than that in PCIA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PCIA group (p < 0.05, p < 0.05).

CONCLUSION

Cocktail TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.

The association of regional block with intraoperative opioid consumption in patients undergoing video-assisted thoracoscopic surgery: a single-center, retrospective study

BACKGROUND

Regional block, such as thoracic epidural analgesia (TEA), thoracic paravertebral block (TPVB), or serratus anterior plane block (SAPB) has been recommended to reduce postoperative opioid use in recent guidelines, but the optimal options for intraoperative opioid minimization remain unclear. The aim of this study was to evaluate the intraoperative opioids-sparing effects of three regional blocks (TEA, TPVB, and SAPB) in patients undergoing video-assisted thoracoscopic surgery (VATs).

METHODS

This was a retrospective study of the adults undergoing VATs at a tertiary medical center between January 2020 and February 2022. According to the type of regional block used, patients were classified into 4 groups: GA group (general anesthesia without any regional block), TEA group (general anesthesia combined with TEA), TPVB group (general anesthesia combined with TPVB), and SAPB group (general anesthesia combined with SAPB). Cases were matched with a 1:1:1:1 ratio for analysis by age, sex, ASA physical status, and operation duration. The primary outcome was the total intraoperative opioid consumption standardized to Oral Morphine Equivalents (OME). Multivariable linear regression was used to estimate the association of the three regional blocks with the OME.

RESULTS

A total of 2159 cases met the eligibility criteria. After matching, 168 cases (42 in each group) were included in analysis. Compared with GA without any reginal block, the use of TEA, TPVB, and SAPB reduced the median of intraoperative OME by 78.45 mg (95% confidence interval [CI], -141.34 to -15.56; P = 0.014), 94.92 mg (95% CI, -154.48 to -35.36; P = 0.020), and 11.47 mg (95% CI, -72.07 to 49.14; P = 0.711), respectively.

CONCLUSIONS

The use of TEA or TPVB was associated with an intraoperative opioid-sparing effect in adults undergoing VATs, whereas the intraoperative opioid-sparing effect of SAPB was not yet clear.

Liposomal bupivacaine intercostal block placed under direct vision reduces morphine use in thoracic surgery

Background

Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA vs. LB.

Methods

We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups.

Results

In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18% vs. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2 vs. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS.

Conclusions

Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Safety and effectiveness of opioid-free anaesthesia in thoracoscopic surgery: a preliminary retrospective cohort study

BACKGROUND

This study aimed to observe the effect of opioid-free anaesthesia (OFA) on intraoperative haemodynamic,postoperative analgesia and postoperative nausea and vomiting (PONV) in thoracoscopic surgery in order to provide more evidence for evaluating the safety and effectiveness of OFA technology.

METHODS

This was a single-centre retrospective observational study.Adult patients who underwent thoracoscopic surgery with the preoperative thoracic paravertebral block between January 2017 and June 2020 were included.A cohort of 101 thoracoscopic surgery patients who received the OFA technique were matched with 101 thoracoscopic surgery patients who received standard opioid-containing anaesthesia(SOA). Heart rate (HR) and mean arterial blood pressure (MAP) were measured before anaesthesia induction, immediately after endotracheal intubation, at the beginning of surgery, and 10, 20, and 30 min after surgery began.The total amount of intraoperative infusion, frequency of vasoactive drugs use, morphine ingested via the patient-controlled intravenous analgesia (PCIA) 24 h post-surgery,visual analogue scale (VAS) scores at rest and activity on the first day post-surgery, and frequency of nausea and vomiting within 24 h post-surgery were analysed.

RESULTS

There was no significant difference in intraoperative HR between the two groups (F = 0.889, P = 0.347); however, there was significant difference in intraoperative MAP (F = 16.709, P < 0.001), which was lower in SOA patients than in OFA patients. The frequency of vasoactive drug use and amount of infusion was less in OFA patients (P = 0.001). The consumption of morphine used by the PCIA 24 h post-surgery was significantly lower in OFA patients (OFA, 1.8 [0, 4.8] mg vs. SOA, 3.6 [0.6, 23] mg, P < 0.001). There was no significant difference in VAS scores at rest (P = 0.745) or during activity (P = 0.792) on the first day post-surgery. There was also no statistically significant difference in nausea and vomiting within 24 h post-surgery (P = 0.651).

CONCLUSIONS

This case-control study demonstrated that compared with SOA, OFA can effectively maintain the stability of intraoperative MAP, reduce the incidence of hypotension. Although OFA reduced morphine consumption via the PCIA pump 24 h post-surgery, postoperative pain scores and nausea and vomiting within 24 h post-surgery were similar between the groups.But this study was only a preliminary study and needed to confirm in a larger, more robust trial.

[Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]

In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.

Programmed Intermittent Bolus for Erector Spinae Plane Block Versus Intercostal Nerve Block With Patient-controlled Intravenous Analgesia in Video-assisted Thoracoscopic Surgery: A Randomized Controlled Noninferiority Trial

OBJECTIVE

Postoperative analgesia is crucial after video-assisted thoracoscopic surgery (VATS). This study was designed to investigate whether the analgesic effect of programmed intermittent bolus (PIB) erector spinae plane block (ESPB) is noninferior to that of intercostal nerve block with patient-controlled intravenous analgesia (ICNB-PCIA) for VATS.

METHODS

The study was a single-center, open labeled, randomized noninferiority trial. A total of 80 patients (American Society of Anesthesiologists I to III) undergoing elective video-assisted thoracoscopic lobectomy or bulla resection were randomly allocated to the ICNB-PCIA (n=40) or the ESPB (n=40) group using a PIB injection. The primary outcome was pain intensity at movement at 4 hours postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included pain scores at rest and movement in the recovery room, at 8, 24, and 48 hours postoperatively, perioperative analgesics, adverse effects, hospital stay, and patient satisfaction.

RESULTS

The mean difference in NRS scores at movement at 4 hours postoperatively between the ESPB (n=39) and the ICNB-PCIA (n=37) groups was under the noninferiority margin. NRS scores were significantly higher in the ICNB-PCIA group than the ESPB group at movement postoperatively. At rest, NRS scores were significantly elevated in the ICNB-PCIA at 4, 8, and 24 hours. The postoperative opioids consumption was decreased in the ESPB group. No difference was found in rescue analgesics, hospital stay, and patient satisfaction.

DISCUSSION

ESPB using a PIB injection offers noninferior analgesia to ICNB-PCIA after VATS.

Comparison of analgesic effects of percutaneous and transthoracic intercostal nerve block in video-assisted thoracic surgery: a propensity score-matched study

BACKGROUND

This study aimed to compare the analgesic efficacy of transthoracic intercostal nerve block (TINB) and percutaneous intercostal nerve block (PINB) for video-assisted thoracic surgery (VATS) using a retrospective analysis.

METHODS

A total of 336 patients who underwent VATS between January 2021 and June 2022 were reviewed retrospectively. Of the participants, 194 received TINB and were assigned to the T group, while 142 patients received PINB and were assigned to the P group. Both groups received 25 ml of ropivacaine via TINB or PINB at the end of the surgery. The study measured opioid consumption, pain scores, analgesic satisfaction, and safety. Propensity score matching (PSM) analysis was performed to minimize selection bias due to nonrandom assignment.

RESULTS

After propensity score matching, 86 patients from each group were selected for analysis. The P group had significantly lower cumulative opioid consumption than the T group (p < 0.01). The Visual Analogue Scale (VAS) scores were lower for the P group than the T group at 6 and 12 h post-surgery (p < 0.01); however, there was no significant difference in the scores between the two groups at 3, 24, and 48 h (p > 0.05). The analgesic satisfaction in the P group was higher than in the T group (p < 0.05). The incidence of back pain, nausea or vomiting, pruritus, dizziness, and skin numbness between the two groups was statistically insignificant (p > 0.05).

CONCLUSION

The study suggests that PINB provides superior analgesia for patients undergoing thoracic surgery compared to TINB without any extra adverse effects.

Analgesic efficacy of surgeon placed paravertebral catheters compared with thoracic epidural analgesia after Ivor Lewis esophagectomy: a retrospective non-inferiority study

Background

The Ivor Lewis esophagectomy is an operation that involves a laparotomy and a right thoracotomy, both of which are associated with severe postoperative pain and subsequent impairment of respiratory function. Currently, the accepted "gold standard" for postoperative analgesia for laparotomies and thoracotomies is the thoracic epidural. A systematic review has shown paravertebral blocks to be equivalent to epidural analgesia for post-thoracotomy pain control and have decreased incidence of nausea and vomiting, hypotension and respiratory depression. To our knowledge, the use of the paravertebral catheter (PVC) in open Ivor Lewis esophagectomy has not been formally studied. The primary outcome is the area under the curve (AUC) pain scores in the first 48 hours after surgery.

Methods

We performed a retrospective chart review of the open Ivor Lewis esophagectomy patients at our local institution, with local research ethics board (REB) approval.

Results

A total of 92 patients were included in this study: 43 patients had a PVC and 49 had a thoracic epidural for postoperative pan control. Overall, the PVC group was non-inferior and statistically equivalent to the epidural group. Time to ambulation in the PVC group was non-inferior compared to epidurals. The PVC group was superior when comparing total opioid consumption.

Conclusions

Our retrospective study continues to challenge the role of epidurals as the gold standard of pain control post thoracotomy and laparotomy. Further prospective studies with a larger population are needed to better compare the two modalities.

Paravertebral block's effect on analgesia and inflammation in advanced gastric cancer patients undergoing transarterial chemoembolization and microwave ablation

BACKGROUND

Transarterial chemoembolization (TACE) combined with microwave ablation (MWA) is an effective treatment strategy for patients with advanced gastric cancer and liver metastasis. However, it may cause severe postoperative pain and inflammatory responses. The paravertebral block (PVB) is a regional anesthetic technique that provides analgesia to the thoracic and abdominal regions.

AIM

To evaluate the effect of PVB on postoperative analgesia and inflammatory response in patients undergoing TACE combined with MWA for advanced gastric cancer and liver metastasis.

METHODS

Sixty patients were randomly divided into PVB and control groups. The PVB group received ultrasound-guided PVB with 0.375% ropivacaine preoperatively, whereas the control group received intravenous analgesia with sufentanil. The primary outcome was the visual analog scale (VAS) score for pain at 6 h, 12 h, 24 h, and 48 h after the procedure. Secondary outcomes were the dose of sufentanil used, incidence of adverse events, and levels of inflammatory markers (white blood cell count, neutrophil percentage, C-reactive protein, and procalcitonin) before and after the procedure.

RESULTS

The PVB group had significantly lower VAS scores at 6 h, 12 h, 24 h, and 48 h after the procedure compared with the control group (P < 0.05). The PVB group also had a significantly lower consumption of sufentanil and a lower incidence of nausea, vomiting, and respiratory depression than did the control group (P < 0.05). Compared with the control group, the PVB group had significantly lower levels of inflammatory markers 24 h and 48 h after the procedure (P < 0.05).

CONCLUSION

PVB can effectively reduce postoperative pain and inflammatory responses and improve postoperative comfort and recovery in patients with advanced gastric cancer and liver metastasis treated with TACE combined with MWA.

Thoracic paravertebral block for perioperative lung preservation during VATS pulmonary surgery: study protocol of a randomized clinical trial

BACKGROUND

Postoperative pulmonary complications (PPCs) extend the length of stay of patients and increase the perioperative mortality rate after video-assisted thoracoscopic (VATS) pulmonary surgery. Thoracic paravertebral block (TPVB) provides effective analgesia after VATS surgery; however, little is known about the effect of TPVB on the incidence of PPCs. The aim of this study is to determine whether TPVB combined with GA causes fewer PPCs and provides better perioperative lung protection in patients undergoing VATS pulmonary surgery than simple general anaesthesia.

METHODS

A total of 302 patients undergoing VATS pulmonary surgery will be randomly divided into two groups: the paravertebral block group (PV group) and the control group (C group). Patients in the PV group will receive TPVB: 15 ml of 0.5% ropivacaine will be administered to the T4 and T7 thoracic paravertebral spaces before general anaesthesia induction. Patients in the C group will not undergo the intervention. Both groups of patients will be subjected to a protective ventilation strategy during the operation. Perioperative protective mechanical ventilation and standard fluid management will be applied in both groups. Patient-controlled intravenous analgesia is used for postoperative analgesia. The primary endpoint is a composite outcome of PPCs within 7 days after surgery. Secondary endpoints include blood gas analysis, postoperative lung ultrasound score, NRS score, QoR-15 score, hospitalization-related indicators and long-term prognosis indicators.

DISCUSSION

This study will better evaluate the impact of TPVB on the incidence of PPCs and the long-term prognosis in patients undergoing VATS lobectomy/segmentectomy. The results may provide clinical evidence for optimizing perioperative lung protection strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05922449 . Registered on June 25, 2023.

Thoracotomy Patients Under General Anesthesia: A Comparison on Intra-Operative Anesthetic and Analgesic Requirements, When Combined with Either Epidural Analgesia or Continuous Unilateral Paravertebral Analgesia

BACKGROUND AND OBJECTIVE

Regional analgesia is effective for post-thoracotomy pain. The primary objective of the study is to compare the intraoperative requirement of isoflurane and fentanyl between general anaesthesia (GA) with epidural analgesia and GA with paravertebral analgesia.

METHODS AND MATERIAL

A prospective observational comparative study was conducted on 56 patients undergoing open thoracotomy procedures. The patients were divided into two groups of 28 by assigning the study participants alternatively to each group: Group GAE - received thoracic epidural catheterization with GA, and Group GAP - received ultrasound guided thoracic paravertebral catheterization on the operative side with GA. Intraoperative requirement of isoflurane, fentanyl, postoperative analgesia, stress response, need of rescue analgesics and adverse effects were observed and analysed.

RESULTS

25 patients in each group were included in the data analysis. The intraoperative requirement of isoflurane (32.28 ± 1.88 vs 48.31 ± 4.34 ml; p < 0.0001) and fentanyl (128.87 ± 25.12 vs 157 ± 30.92 μg; p = 0.0009) were significantly less in the GAE group than in the GAP group. VAS scores and need of rescue analgesics and blood glucose levels were not statistically significant during the postoperative period (p > 0.05). The incidence of adverse effects was comparable except for hypotension and urinary retention which were significantly higher in the GAE group.

CONCLUSION

GA with epidural analgesia resulted in significant reduction in the intraoperative consumption of isoflurane and fentanyl in comparison to GA with paravertebral analgesia. However, both the techniques were equally effective in the postoperative period.

Assessment of feasibility of opioid-free anesthesia combined with preoperative thoracic paravertebral block and postoperative intravenous patient-controlled analgesia oxycodone with non-opioid analgesics in the perioperative anesthetic management for video-assisted thoracic surgery

INTRODUCTION

This study, conducted between December 2015 and March 2018 at a single university hospital, explored the feasibility and safety of opioid-free anesthesia combined with preoperative thoracic paravertebral block (ThPVB) for patients undergoing elective video-assisted thoracoscopic surgery (VATS). The aim was to assess the impact of this approach on postoperative pain levels and opioid consumption.

MATERIAL AND METHODS

Sixty-four patients scheduled for elective VATS were randomly assigned to either the intervention group, receiving opioid-free anesthesia with ThPVB, or the control group, managed with standard general anesthesia. Postoperatively, both groups received oxycodone patient-controlled analgesia along with non-opioid analgesics. Pain intensity was measured using the Numeric Pain Rating Scale (NRS) and Prince Henry Hospital Pain Score (PHHPS). The total dose of postoperative oxycodone and the occurrence of opioid-related adverse events were recorded during the 24-hour follow-up period.

RESULTS

Patients in the intervention group showed significantly lower pain levels at 20 and 24 hours post-procedure ( P = 0.015, P = 0.021, respectively) compared to the control group. Notably, oxycodone consumption at 24 hours was significantly higher in the control group ( p < 0.0001). No serious adverse events were observed during the study period.

CONCLUSIONS

This study demonstrates the feasibility and safety of opioid-free anesthesia combined with ThPVB for elective VATS. The approach significantly reduces postoperative pain and the need for opioids, supporting its potential as an effective and balanced perioperative anesthetic strategy.

Effectiveness of Surgeon-Performed Paravertebral Block Analgesia for Minimally Invasive Thoracic Surgery: A Randomized Clinical Trial

Importance

In minimally invasive thoracic surgery, paravertebral block (PVB) using ultrasound (US)-guided technique is an efficient postoperative analgesia. However, it is an operator-dependent process depending on experience and local resources. Because pain-control failure is highly detrimental, surgeons may consider other locoregional analgesic options.

Objective

To demonstrate the noninferiority of PVB performed by surgeons under video-assisted thoracoscopic surgery (VATS), hereafter referred to as PVB-VATS, as the experimental group compared with PVB performed by anesthesiologists using US-guided technique (PVB-US) as the control group.

Design, Setting, and Participants

In this single-center, noninferiority, patient-blinded, randomized clinical trial conducted from September 8, 2020, to December 8, 2021, patients older than 18 years who were undergoing a scheduled minimally invasive thoracic surgery with lung resection including video-assisted or robotic approaches were included. Exclusion criteria included scheduled open surgery, any antalgic World Health Organization level greater than 2 before surgery, or a medical history of homolateral thoracic surgery. Patients were randomly assigned (1:1) to an intervention group after general anesthesia. They received single-injection PVB before the first incision was made in the control group (PVB-US) or after 1 incision was made under thoracoscopic vision in the experimental group (PVB-VATS).

Interventions

PVB-VATS or PVB-US.

Main Outcomes and Measures

The primary end point was mean 48-hour post-PVB opioid consumption considering a noninferiority range of less than 7.5 mg of opioid consumption between groups. Secondary outcomes included time of anesthesia, surgery, and operating room occupancy; 48-hour pain visual analog scale score at rest and while coughing; and 30-day postoperative complications.

Results

A total of 196 patients were randomly assigned to intervention groups: 98 in the PVB-VATS group (mean [SD] age, 64.6 [9.5] years; 53 female [54.1%]) and 98 in the PVB-US group (mean [SD] age, 65.8 [11.5] years; 62 male [63.3%]). The mean (SD) of 48-hour opioid consumption in the PVB-VATS group (33.9 [19.8] mg; 95% CI, 30.0-37.9 mg) was noninferior to that measured in the PVB-US group (28.5 [18.2] mg; 95% CI, 24.8-32.2 mg; difference: -5.4 mg; 95% CI, -∞ to -0.93; noninferiority Welsh test, P ≤ .001). Pain score at rest and while coughing after surgery, overall time, and postoperative complications did not differ between groups.

Conclusions and Relevance

PVB placed by a surgeon during thoracoscopy was noninferior to PVB placed by an anesthesiologist using ultrasonography before incision in terms of opioid consumption during the first 48 hours.

Trial Registration

ClinicalTrials.gov Identifier: NCT04579276.

The comparison of the analgesic efficacy of continuous paravertebral block alone compared with continuous paravertebral and intercostal nerve block for thoracotomy in adults: a randomized controlled trial

PURPOSE

The study aims to compare the analgesic efficacy of two analgesic interventions, continuous paravertebral (PVB) nerve block alone with continuous paravertebral and intercostal nerve block (PVB/ICB) in patients undergoing thoracotomy.

METHODS

A total of 70 patients undergoing thoracotomy were randomly enrolled in either continuous paravertebral nerve block (PVB) group or in continuous paravertebral and intercostal nerve block (PVB/ICB) group and received corresponding blocks. Analgesic efficacy measured by Visual Analog Scale (VAS) pain score, hemodynamic effects, total narcotic consumption, sedation score, patient's length of stay in hospital and patient's satisfaction with the analgesic technique were recorded.

RESULTS

Demographic characteristics of the patients were similar in both groups. The mean VAS pain score was not statistically significant in both groups at 24 h. The mean pulse rate and blood pressures were comparable in both groups for the first 24 h. Nalbuphine consumption was significantly higher in PVB group as compared to PVB/ICB group at 1 h (p = 0.01), 6 h (p = 0.03) and 12 h (p = 0.009) and 24 h (p = 0.03). The mean total nalbuphine consumption in the PVB group was higher (28.29 mg vs. 22.63 mg) and statistically significant then PVB/ICB group (p = 0.03). The total tramadol consumption as a rescue analgesic was higher in the PVB group (131.42 mg) as compared to PVB/ICB group (120 mg) after 24 h but not statistically significant (p = 0.17).

CONCLUSION

Continuous paravertebral nerve block with intercostal nerve block provides effective post-operative pain relief after thoracotomy with reduced narcotic consumption compared to continuous paravertebral nerve block alone.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrails.gov NCT04715880.

Study protocol for a randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: 2 (TOPIC 2)

BACKGROUND

Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain.

METHODS

TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis.

DISCUSSION

Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS.

TRIAL REGISTRATION

NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856 . First patient recruited 8 January 2019.

Erector spinae plane block versus paravertebral block for postoperative pain management in thoracic surgery: a systematic review and meta-analysis

INTRODUCTION

The 2018 guidelines for enhanced recovery in thoracic surgery recommend paravertebral block (PVB) for postoperative pain management. However, recent studies demonstrate that erector spinae plane block (ESPB) achieves similar postoperative pain control with reduced block-related complications.

EVIDENCE ACQUISITION

We conducted a meta-analysis of randomized controlled trials to evaluate the analgesic efficacy and safety of ESPB versus PVB for pain management after thoracic surgery. PubMed, Embase, and Scopus were searched through December 2022 (PROSPERO registration - CRD42023395593). Primary outcomes were postoperative pain scores, resting at 6, 12, 24, and 48 hours, and at movement at 24 and 48 hours. Secondary outcomes included opioid consumption at 24 and 48 hours, and incidence of postoperative nausea and vomiting or block-related complications in the first 48 hours.

EVIDENCE SYNTHESIS

Ten randomized control trials enrolling a total of 624 total patients were included. There were no significant differences in pain scores, resting or at movement, at any time points except reduced resting pain scores at 12 hours with PVB (mean difference [MD]) 0.60, 95% confidence interval [CI] 0.32 to 0.88). Opioid consumption demonstrated no significant differences at 24 hours; PVB reduced opioid consumption at 48 hours (MD 0.40, 95% CI -0.09 to 0.89). There were no significant differences in postoperative nausea or vomiting. ESPB exhibited a nonsignificant trend toward reduced cumulative block-related complications (risk difference [RD] 0.05, 95% CI -0.10 to 0.00).

CONCLUSIONS

Compared with PVB, ESPB is safe and demonstrates no clinically significant differences in pain management after thoracic surgery.

Pain management after thoracic surgery or chest trauma

Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.

Efficacy and safety of thoracoscopic-guided multiple paravertebral block for video-assisted thoracoscopic lobectomy surgery: a randomized blinded controlled study

Background

Paravertebral block (PVB) has been increasingly popular for postoperative analgesia. However, few studies estimated the efficacy and safety of multiple PVB using thoracoscope-assisted technique for intraoperative analgesia and postoperative pain management for video-assisted thoracoscopic lobectomy (VATS LOBECTOMY).

Methods

A total of 120 patients scheduled to undergo VATS LOBECTOMY were randomly assigned into two groups: a placebo group and a PVB group in a ratio of 1:2. Thoracoscopic-guided multi-point PVB was carried out with 0.5% ropivacaine (PVB group) or 0.9% NaCl (placebo group) at the beginning and the end of surgery. The primary endpoint was consumption of intraoperative opioid.

Results

Consumption rate of intraoperative opioids was significantly lower in the PVB group (878.14 ± 98.37 vs. 1,432.20 ± 383.53 for remifentanil; 123.83 ± 17.98 vs. 266.42 ± 41.97 for fentanyl). Postoperatively, significantly longer duration of using patient-controlled intravenous analgesia for the first time, reduced times of analgesic pump pressing, and less rescue analgetic consumption were observed in the PVB group. Visual analog scale scores at rest and during exercising were significantly lower in the PVB group at all time points within the first 48 h after surgery. The PVB group was also associated with significantly higher total QoR-40 scores and lower incidence of analgesia-related adverse events.

Conclusions

Thoracoscopic-guided multiple PVB was a simple and effective technique in controlling pain both intra- and postoperatively for VATS LOBECTOMY. It was also associated with the absence of detrimental effects attributed to opioid overuse and benefits of the early resumption of activity and physical function recovery. Therefore, this regional anesthesia technique should be advocated as part of a multimodal analgesia protocol for VATS LOBECTOMY.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

The safety of thoracic paravertebral block and erector spinae plane block in patients treated with anticoagulant or antiplatelet therapy. A narrative review of the evidence

INTRODUCTION

The management of thoracic paravertebral block (TPVB) and erector spine plane block (ESPB) in patients treated with anticoagulant or antiplatelet therapy is based on limited clinical data, mostly from single case reports. Scientific societies and organizations do not provide strong detailed indications about the limitations of these regional anesthesia techniques in patients receiving antithrombotic therapy. This review summarizes evidence regarding TPVB and ESPB in patients under antithrombotic therapy.

EVIDENCE ACQUSITION

A literature review from PubMed/MEDLINE, EMBASE, Cochrane, Google Scholar and Web of Science databases was conducted from 1999 to 2022 to identify articles concerning TPVB and ESPB for cardio-thoracic surgery or thoracic procedures in patients under anticoagulant or antiplatelet therapy.

EVIDENCE SYNTHESIS

A total of 1704 articles were identified from the initial search. After removing duplicates and not-pertinent articles, 15 articles were analyzed. The results demonstrated a low risk of bleeding for TPVB and minimal or absent risk for ESPB. Ultrasound guidance was extensively used to perform ESPB, but not for TPVB.

CONCLUSIONS

Although the low level of evidence available, TPVB and ESPB are reasonably safe options in patients ineligible for epidural anesthesia due to antithrombotic therapy. The few published studies suggest that ESPB offers a risk profile safer than TPVB and the use of ultrasound guidance minimizes any complication. Since the literature available does not allow us to draw definitive conclusions, future adequately-powered trials are warranted to determine the indications and the safety of TPVB and ESPB in patients receiving anticoagulant or antiplatelet therapy.

Analgesia in esophagectomy: a narrative review

Background and Objective

Optimal pain management for esophagectomy facilitates prevention of postoperative complications such as pneumonia, but also chronic pain. Historically, multimodal intravenous analgesia was employed. In the last decades, regional anesthesia including epidural and paravertebral analgesia is frequently used. In this narrative review, we provide a comprehensive overview of the available evidence for the different analgesia regimens for esophagectomy.

Methods

A search was conducted in the PubMed/MEDLINE database in November 2022. Only reports in English or Dutch were included. Editorials or articles lacking full text were excluded. A review of different analgesia regimens after esophagectomy is provided.

Key Content and Findings

Epidural analgesia (EA) was suggested to reduce postoperative pneumonia and prevent chronic postsurgical pain (CPSP) as compared to opioid-based systemic analgesia and was considered the gold standard of pain management for esophagectomy. In the last decades, the side-effects of EA became more evident. Next to mild or moderate side-effects such as hypotension and urinary retention, several reports emphasized the incidence of serious neurologic complications to be much higher than estimated before. In addition, minimally invasive surgery fostered that other regional analgesia (RA) techniques are potential alternatives for EA. Paravertebral catheter placement can be performed under videoscope view during the thoracic phase of esophagectomy, making it a safe and easily placed block. Evidence on the effectiveness of erector spinae plane block (ESPB) is limited in this context.

Conclusions

Several analgesia regimens after esophagectomy are described. EA is most common, however paravertebral analgesia is a good alternative. Other techniques are also gaining ground but randomized clinical trials are lacking. Future studies should focus on the efficacy of paravertebral and erector spinae blocks for postoperative pain management for esophagectomy.

The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study

BACKGROUND

We aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy.

METHODS

Eighty 18-70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump.

RESULTS

Thirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group.

CONCLUSIONS

Intermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04304274), date: 11/03/2020.

Advances in the Management of Acute Postsurgical Pain: A Review

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.