Anaesthesia for video-assisted and robotic thoracic surgery

Combined pectoralis and serratus anterior plane blocks with or without liposomal bupivacaine for minimally invasive thoracic surgery: A randomized clinical trial

BACKGROUND

Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption.

METHODS

Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1-3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model.

RESULTS

We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups.

CONCLUSIONS

Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery.

SUMMARY STATEMENT

For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores.

Impact of Regional Anesthesia on Subjective Quality of Recovery in Patients Undergoing Thoracic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Regional anesthesia can be effective for managing pain after thoracic surgery. This study evaluated whether it can also improve patient-reported quality of recovery (QoR) after such surgery.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Postoperative care.

INTERVENTION

Perioperative regional anesthesia.

PATIENTS

Adults undergoing thoracic surgery.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was total QoR scores 24 hours after surgery. Secondary outcomes were postoperative opioid consumption, pain scores, pulmonary function, respiratory complications, and other adverse effects. Eight studies were identified, of which 6 involving 532 patients receiving video-assisted thoracic surgery were included in the quantitative analysis of QoR. Regional anesthesia significantly improved QoR-40 score (mean difference 9.48; 95% CI 3.53-15.44; I2 = 89%; 4 trials involving 296 patients) and QoR-15 score (mean difference 6.7; 95% CI 2.58-10.82; I2 = 0%; 2 trials involving 236 patients). Regional anesthesia also significantly reduced postoperative opioid consumption and the incidence of nausea and vomiting. Insufficient data were available to meta-analyze the effects of regional anesthesia on postoperative pulmonary function or respiratory complications.

CONCLUSIONS

The available evidence suggests that regional anesthesia can enhance QoR after video-assisted thoracic surgery. Future studies should confirm and extend these findings.

Relative efficacy and safety of several regional analgesic techniques following thoracic surgery: a network meta-analysis of randomized controlled trials

BACKGROUND

This network meta-analysis was performed to assess the relative efficacy and safety of various regional analgesic techniques used in thoracic surgery.

MATERIALSAND METHODS

Randomized controlled trials evaluating different regional analgesic methods were retrieved from databases, including PubMed, Embase, Web of Science, and the Cochrane Library, from inception to March 2021. The surface under the cumulative ranking curve) was estimated to rank the therapies based on the Bayesian theorem. Moreover, sensitivity and subgroup analyses were performed on the primary outcomes to obtain more reliable conclusions.

RESULTS

Fifty-four trials (3360 patients) containing six different methods were included. Thoracic paravertebral block and erector spinae plane block (ESPB) were ranked the highest in reducing postoperative pain. As for total adverse reactions and postoperative nausea and vomiting, postoperative complications, and duration of hospitalization, ESPB was found to be superior to other methods. It should be noted that there were few differences between various methods for all outcomes.

CONCLUSIONS

Available evidence suggests that ESPB might be the most effective and safest method for relieving pain after thoracic surgery, shortening the length of hospital stay and reducing the incidence of postoperative complications.

Performance Comparison of Pulmonary Risk Scoring Systems in Lung Resection

OBJECTIVE

To validate and compare the performance of different pulmonary risk scoring systems to predict postoperative pulmonary complications (PPCs) in lung resection surgery.

DESIGN

Retrospective cohort study SETTING: A historic single-center cohort of lung resection surgeries PARTICIPANTS: Adult patients undergoing lung resection surgery under 1-lung ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The accuracy of the following pulmonary risk scoring systems were used to predict pulmonary complications: the ARISCAT (Assess respiratory RIsk in Surgical patients in CATalonia), the LAS VEGAS (Local Assessment of VEntilatory management during General Anesthesia for Surgery), the SPORC (Score for Prediction of Postoperative Respiratory Complications), and a recent thoracic-specific risk score, named CARDOT. Discrimination and calibration were assessed using the concordance (c) index and the intercept of LOESS (locally estimated scatterplot)-smoothed curves, respectively. Additional models were constructed that incorporated predicted postoperative forced expiratory volume (ppoFEV1) into each scoring system. Of the 2,104 patients undergoing lung surgery, 123 developed postoperative pulmonary complications (PPCs; 5.9%). All scoring systems had poor discriminatory power to predict PPCs (ARISCAT c-index 0.60, 95% confidence interval [CI] 0.55-0.65; LAS VEGAS c-index 0.68, 95% CI 0.63-0.73; SPORC c-index 0.63, 95% CI 0.59-0.68; CARDOT c-index 0.64, 95% CI 0.58-0.70), but the inclusion of ppoFEV1 slightly improved the performance of LAS VEGAS (c-index 0.70, 95% CI 0.66-0.75) and CARDOT (c-index 0.68, 95% CI 0.62-0.73). Analysis of calibration showed a slight overestimation when using ARISCAT (intercept -0.28) and LAS VEGAS (intercept -0.27).

CONCLUSIONS

None of the scoring systems appeared to have adequate discriminatory power to predict PPCs among patients undergoing lung resection. An alternative risk score is necessary to better predict patients at risk of PPCs after thoracic surgery.

Programmed intermittent bolus infusion vs. continuous infusion for erector spinae plane block in video-assisted thoracoscopic surgery: A double-blinded randomised controlled trial

BACKGROUND

The optimal form of administration for erector spinae plane block has not been established.

OBJECTIVE

To compare the efficacy of programmed intermittent bolus infusion (PIB) and continuous infusion for erector spinae plane block.

DESIGN

A prospective, randomised, double-blind study.

SETTING

A single centre between June 2019 and March 2020.

PATIENTS

Included patients had an American Society of Anesthesiologists physical status 1 to 3 and were scheduled for video-assisted thoracic surgery.

INTERVENTIONS

Patients were randomised to receive continuous infusion (0.2% ropivacaine 8 ml h-1; Group C) or PIB (0.2% ropivacaine 8 ml every 2 h; Group P).

MAIN OUTCOME MEASURES

The primary outcome was the number of desensitised dermatomes in the midclavicular line, measured 21 h after first bolus injection.

RESULTS

Fifty patients were randomly assigned to each group; finally, the data of 24 and 25 patients in Group C and P, respectively, were analysed. The mean difference in the number of desensitised dermatomes in the midclavicular line at 5 and 21 h after the initial bolus administration was 1.0 [95% confidence interval (CI) 0.5 to 1.5] and 1.6 (95% CI 1.1 to 2.0), respectively, which was significantly higher in Group P than in Group C (P < 0.001). The median difference in rescue morphine consumption in the early postoperative period (0 to 24 h) was 4 (95% CI 1 to 8) mg, which was significantly lower in Group P (P = 0.035). No significant difference in the postoperative numerical rating scale score was found between the groups.

CONCLUSIONS

PIB for erector spinae plane block in video-assisted thoracic surgery resulted in a larger anaesthetised area and required a lower anaesthetic dose to maintain the analgesic effect. Therefore, it is more suitable for erector spinae plane block than continuous infusion.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN-CTR, ID: UMIN000036574, Principal investigator: Taro Fujitani, 04/22/2019, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041671).

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

A comparison of regional anesthesia techniques in patients undergoing video-assisted thoracic surgery: A network meta-analysis

BACKGROUND

Postoperative pain control remains challenging in patients undergoing video-assisted thoracoscopic surgery (VATS). This study aimed to investigate the relative efficacy of different regional anesthesia interventions for VATS using a Network Meta analysis (NMA).

METHODS

A literature search was conducted for NMA using Pubmed, The Cochrane Library, Embase, and the Web of Science databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of different regional analgesia techniques from inception to February 2022. The primary outcome was opioid consumption during the first 24 h postoperatively. The secondary outcomes were morphine consumption at 48 h postoperatively, pain intensity, postoperative nausea and vomiting, and hospital length of stay. Pain scores at two different intervals from different regional analgesia techniques were measured and investigated in this NMA.

RESULTS

A total of 38 RCTs (2224 patients) were included. Two studies compared three arm interventions of intercostal nerve block (ICNB) vs. thoracic paravertebral block (TPVB) vs. erector spinae plane block (ESPB) in intravenous morphine consumption at 24 h and 48 h postoperatively, and showed patients who received TPVB had less demand for morphine than ICNB and ESPB (P = 0.001, P = 0.001). For resting pain scores at 24 h postoperatively, ESPB was superior to serratus anterior plane block (SAPB) (P = 0.01), and TPVB provided effective analgesia compared to ICNB, retrolaminar block (RLB), and ESPB (P = 0.05, P = 0.01, P = 0.03). Similarly, pain scores at rest at 48 h, SAPB and TPVB showed the best results (P = 0.04, P = 0.001, P = 0.01) compared with local infiltration analgesia (LIA), ICNB, RLB, and ESPB. Additionally, pain scores at coughing at 24 h and 48 h, TPVB showed superior results compared with RLB,ESPB(P = 0.02, P = 0.02, P = 0.03). SAPB was superior to LIA in reducing the incidence of postoperative nausea and vomiting (P = 0.04).

CONCLUSION

In regional anaesthesia, TPVB is a better option than other analgesic methods, and its combination with other methods can be beneficial. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery

Purpose of Review

Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are used for anatomic resection of early stage cancer. These surgical techniques require the use of one-lung ventilation (OLV). During OLV, an obligatory intrapulmonary shunt may produce hypoxemia. One method to correct hypoxemia is with the use of continuous positive airway pressure (CPAP). This review focuses on 1) the lung physiology of OLV; 2) application of CPAP in VATS or RATS during supine and lateral position; and 3) the application of CPAP in COVID-19 patients during OLV.

Recent Findings

Studies have shown the beneficial effects of CPAP to improve oxygenation during OLV while the patient is in the lateral decubitus position. In contrast, studies have shown no benefit on improving oxygenation with CPAP in patients undergoing OLV in supine position.

Summary

The application of CPAP to the non-dependent lung is one of the options to treat hypoxemia during VATS or RATS.

Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial

BACKGROUND

Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery.

METHODS

Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay.

RESULTS

The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h-1vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h-1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25-75% range): 4 (2-4) vs 5 (3-6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25-75%) CCI in ESP and SAP was 1 (0-2) vs 4 (0-26) (P=0.03), whereas hospital stay was 3 (2-6) vs 6 (3-9) days (P=0.17), respectively.

CONCLUSION

Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery.

CLINICAL TRIAL REGISTRATION

NCT03862612.