Investigation of single-dose thoracic paravertebral analgesia for postoperative pain control after thoracoscopic lobectomy - A randomized controlled trial

Ropivacaine versus ropivacaine plus dexmedetomidine in serratus anterior plane block patients undergoing post-thoracotomy surgery: a randomized, double-blinded clinical trial

BACKGROUND

This study was designed and implemented to investigate the addition of dexmedetomidine to Serratus Anterior Plane Block (SAP) with ropivacaine in reducing pain in patients undergoing post-thoracotomy surgery.

METHODS

This study included patients classified as American Society of Anesthesiology (ASA) Physical Status II, with a body mass index (BMI) under 40, who were undergoing thoracotomy at Imam Khomeini Hospital in Ahvaz. The subjects were randomly divided into two groups using a randomized controlled trial design. After surgery, in the recovery room, SAP was performed for patients with ropivacaine (0.4 ml/kg of 0.2% ropivacaine solution) (group R) and ropivacaine plus dexmedetomidine (0.5 μg/kg) (group RD). Pain (with verbal rating scale, VNRS), blood pressure (systolic, diastolic, and mean arterial pressure (MAP)), heart rate (HR), and blood oxygen saturation (O2 sat) were measured and recorded before the intervention, and 1, 6, 12, 24, and 48 h after the intervention.

RESULTS

Finally, 74 patients were included in this study. Both groups exhibited significant pain reduction at one hour, with sustained pain relief observed in the RD group at 6, 12, and 24 h (P < 0.001). The RD group also showed having lower values HR and MAP at 6 and 12 h (P < 0.001). Patients in the RD group received painkillers faster (P = 0.005) and required lower total narcotic usage (P < 0.0001). Two RD group patients experienced transient bradycardia, which resolved without treatment.

CONCLUSION

The findings of this study show that SAP block with dexmedetomidine is an effective and safe drug along with ropivacaine as a nerve-blocking agent in thoracotomy candidates.

Effects of Ultrasound-Guided Thoracic Paravertebral Nerve Block Combined with Perineural or IV Dexmedetomidine on Acute and Chronic Pain After Thoracoscopic Resection of Lung Lesions: A Double-Blind Randomized Trial

Background

Thoracic paravertebral block (TPVB) analgesia can be prolonged by local anesthetic adjuvants such as dexmedetomidine. This study aimed to evaluate the two administration routes of dexmedetomidine on acute pain and chronic neuropathic pain (NeuP) prevention compared with no dexmedetomidine.

Methods

A total of 216 patients were randomized to receive TPVB using 0.4% ropivacaine alone (R Group), with perineural dexmedetomidine 0.5 μg·kg-1 (RD0.5 Group) or 1.0 μg·kg-1 (RD1.0 Group), or intravenous (IV) dexmedetomidine 0.5 μg·kg-1·h-1 (RDiv Group). The primary outcome was the incidence of chronic NeuP, defined as a Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain score > 12 points at 3-month after surgery.

Results

(1) For the primary outcome, RD0.5 Group and RD1.0 Group demonstrated a decreased incidence of chronic NeuP at 3-month after surgery; (2) Compared with R Group, RDiv Group, RD0.5 Group, and RD1.0 Group can reduce VAS scores at rest and movement and Prince-Henry Pain scores at 12 and 24-h after surgery, the consumption of oral morphine equivalent (OME) and improve QOD-15 at POD1; (3) Compared with RDiv Group, RD0.5 Group and RD1.0 Group can reduce VAS scores at rest and movement and Prince-Henry Pain scores at 12 and 24-h after surgery, the consumption of postoperative OME and improve QOD-15 at POD1; (4) Compared with RD0.5 Group, RD1.0 Group effectively reduced VAS scores at rest at 12 and 24-h after surgery, VAS scores in movement and Prince-Henry Pain scores at 12-h after surgery. However, RD1.0 Group showed an increased incidence of drowsiness.

Conclusion

Perineural or IV dexmedetomidine are similarly effective in reducing acute pain, but only perineural dexmedetomidine reduced chronic NeuP. Moreover, considering postoperative complications such as drowsiness, perineural dexmedetomidine (0.5 μg·kg-1) may be a more appropriate choice.

Clinical Trial Registration

Chinese Clinical Trial Registry (ChiCTR2200058982).

Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study

BACKGROUND

It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery.

METHODS

A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied.

RESULTS

There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups.

CONCLUSIONS

Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.

Optimizing patient outcomes: the impact of multimodal preemptive analgesia in video-assisted thoracoscopic lobectomy

OBJECTIVES

The aim of this study was to evaluate the efficacy of a multimodal preemptive analgesia management approach, specifically incorporating ultrasound-guided thoracic paravertebral block (UG-TPVB) in conjunction with intravenous analgesia, after video-assisted thoracoscopic (VATS) lobectomy under the guidance of enhanced recovery after surgery.

METHODS

A total of 690 patients who underwent VATS lobectomy between October 2021 and March 2022 were divided into the UG-TPVB group (group T, n = 345) and the control group (group C, n = 345). Patients in group T received UG-TPVB prior to the induction of general anaesthesia, while group C did not undergo nerve block. A comparison was conducted between the 2 groups regarding various indicators, including postoperative sedation, static/dynamic numeric rating scale scores, intraoperative fentanyl consumption, duration of mechanical ventilation/anaesthesia recovery/hospitalization, postoperative complications and other relevant factors.

RESULTS

The static/dynamic numeric rating scale scores of group T were lower than those of group C after surgery. Intraoperative fentanyl consumption in group T (0.384 ± 0.095 mg) was lower than that in group C (0.465 ± 0.053 mg). The duration of mechanical ventilation, anaesthesia recovery and hospitalization were significantly shorter in group T compared to group C. Patient satisfaction rate in group T (70.1%) was higher than that in group C (53.6%). All differences were statistically significant (P < 0.05).

CONCLUSIONS

The multimodal preemptive analgesia management strategy effectively reduces postoperative pain, decreases opioid consumption and promotes faster recovery in patients undergoing VATS lobectomy.

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.

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.

Comparison of the Effects of Dexmedetomidine and Lidocaine on Stress Response and Postoperative Delirium of Older Patients Undergoing Thoracoscopic Surgery: A Randomized Controlled Trial

Purpose

We investigated the effects of intraoperative intravenous lidocaine or dexmedetomidine infusion on inflammatory factors and cognitive function in patients undergoing thoracoscopic surgery.

Patients and Methods

Patients aged >65 years undergoing elective thoracoscopic lobectomy or segmentectomy were randomly grouped as dexmedetomidine group (group D), lidocaine group (group L), and control group (group C). The plasma cortisol, interleukin-6, and tumor necrosis factor-α concentrations were measured before anesthesia (T0) and immediately (T1), 24 h (T2), and 48 h postoperatively (T3). Postoperative delirium (POD) was assessed by 3D-CAM on days 2 and 7.

Results

The cortisol concentrations decreased for all groups at T1 from T0 although they were significantly higher at T2. Group L had significantly lower interleukin-6 concentrations at T1 and T2 than the other groups (P<0.05). The interleukin-6 concentrations were significantly higher at T1, T2, and T3 than at T0 for all the groups, significantly lower for groups D and L than for group C at T1 and T2 (P<0.05), and significantly lower for group L than for group D at T2 (P<0.05). The tumor necrosis factor-α concentrations were significantly higher at T1, T2, and T3 than at T0 for all the groups and significantly lower for groups D and L than for group C at T1 and T2 (P<0.05), although they were not statistically significantly different for groups D and L. There were no statistically significant differences in the postoperative incidence of POD between the three groups on days 2 and day 7.

Conclusion

Intraoperative continuous intravenous lidocaine or dexmedetomidine infusion reduced surgical stress and inflammatory responses. The inhibitory effect of lidocaine on surgical stress remained significant for up to 24 h postoperatively without affecting patient awakening. However, the administration of either drug failed to prevent postoperative POD.

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.

Comparison of Edge of Lamina Block with Thoracic Paravertebral Block and Retrolaminar Block for Analgesic Efficacy in Adult Patients Undergoing Video-Assisted Thoracic Surgery: A Prospective Randomized Study

Background

A novel ultrasound-guided paravertebral block, the edge laminar block (ELB) was reported recently. However, it was unclear how effective ELB was in comparison with traditional blocking methods. We conducted a trial to compare the analgesic efficacy of ELB with the thoracic paravertebral block (TPVB) and the retrolaminar block (RLB) in patients undergoing video-assisted thoracic surgery (VATS).

Methods

We identified 90 patients who were scheduled for VATS and randomly assigned them to three groups: ELB group (Group E), TPVB group (Group T), and RLB group (Group R). Each group underwent ELB, TPVB, and RLB, respectively, under ultrasound guidance before general anesthesia induction. All patients received post-operative routine analgesia protocol. Our primary outcome was the extent of dermatomal sensory loss on the midclavicular, midaxillary, and scapular lines, measured using a pinprick 15 minutes after the nerve block. Secondary outcomes included the intraoperative dose of sufentanil, the numerical rating scale (NRS) scores assessed in the post-anesthesia care unit (PACU) and at 6, 12, and 24 hours post-operatively, and pethidine administrated as analgesic rescue dose.

Results

The percentages of nerve block range reaching the midclavicular line, midaxillary line, and scapular line in Group E were 96.7%, 93.3%, 93.3%, and 60% in Group T and 30%, 56.7%, and 96.7% in Group R, respectively. Group E had wider dermatomal sensory loss on the midclavicular line and midaxillary line compared to Group R (P < 0.001) and had a wider range compared to Group T on the scapular line (P < 0.001). There was no significant difference in the intraoperative use of sufentanil in the three groups. Post-operative NRS scores at each time point were significantly lower in Group E than those in the other two groups (P < 0.01).

Conclusion

ELB had a wider nerve block range and applied better post-operative analgesia in comparison with TPVB and RLB.

Dexmedetomidine as an Adjuvant in Peripheral Nerve Block

Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α₂-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.

Effectiveness of Thoracic Wall Blocks in Video-Assisted Thoracoscopic Surgery, a Network Meta-Analysis

Introduction

Thoracic epidural analgesia (TEA) and thoracic paravertebral blocks (PVB) are well-established techniques for pain management in thoracotomy. Here, we examine the efficacy of various thoracic fascial plane blocks vs TEA and PVB for intraoperative and postoperative analgesia for video assisted thoracoscopy surgery (VATS) with network meta-analysis.

Methods

A search for prospective randomized control studies using adult patients undergoing VATS with general anesthesia. The interventions of interest were any regional anesthesia techniques used for postoperative pain control after VATS. Primary outcomes of interest were 24-hour opioid requirement and 24-hour pain scores. A Bayesian network meta-analysis was conducted.

Results

We identified 42 studies that fulfilled our inclusion criteria. For patients who underwent VATS, TEA (MD = -27MME, 95% CI = -46.2 to -9MME), ESP (MD = -20MME, 95% CI -33 to -7.9MME), PVB (MD = -15MME, 95% CI = -26 to -4.5MME) demonstrated significant opioid sparing efficacy, as well as reduction in cumulative 24-hour static pain scores. However, exclusion of one study due to high risk of bias revealed that TEA did not significantly reduce opioid consumption, nor did it reduce the incidence of PONV, pulmonary complications, or LOS when compared to ESP, SAP, PVB, ICN, or PECS blocks.

Conclusion

Our findings suggest that TEA did not provide superior pain relief compared to ESP, SAP, PVB, ICN, or PECS blocks following VATS. Therefore, we propose ESP as a suitable intervention for the prevention of postoperative pain after VATS.

Evidence basis for using dexmedetomidine to enhance the quality of paravertebral block: A systematic review and meta-analysis of randomized controlled trials

Background: Dexmedetomidine is considered an adjunct to local anaesthesia (LA) to prolong peripheral nerve block time. However, the results from a previous meta-analysis were not sufficient to support its use in paravertebral block (PVB). Therefore, we performed an updated meta-analysis to evaluate the efficacy of dexmedetomidine combined with LA in PVB.

Methods: We performed an electronic database search from the date of establishment to April 2022. Randomized controlled trials (RCTs) investigating the combination of dexmedetomidine and LA compared with LA alone for PVB in adult patients were included. Postoperative pain scores, analgesic consumption, and adverse reactions were analyzed.

Results: We identified 12 trials (701 patients) and found that the application of dexmedetomidine as a PVB adjunct reduced the postoperative pain severity of patients 12 and 24 h after surgery compared to a control group. Expressed as mean difference (MD) (95% CI), the results were −1.03 (−1.18, −0.88) (p < 0.00001, I² = 79%) for 12 h and −1.08 (−1.24, −0.92) (p < 0.00001, I² = 72%) for 24 h. Dexmedetomidine prolonged the duration of analgesia by at least 173.27 min (115.61, 230.93) (p < 0.00001, I² = 81%) and reduced postoperative oral morphine consumption by 18.01 mg (−22.10, 13.92) (p < 0.00001, I² = 19%). We also found no statistically significant differences in hemodynamic complications between the two groups. According to the GRADE system, we found that the level of evidence for postoperative pain scores at 12 and 24 h was rated as moderate.

Conclusion: Our study shows that dexmedetomidine as an adjunct to LA improves the postoperative pain severity of patients after surgery and prolongs the duration of analgesia in PVB without increasing the incidence of adverse effects.

Combined Programmed Intermittent Bolus Infusion With Continuous Infusion for the Thoracic Paravertebral Block in Patients Undergoing Thoracoscopic Surgery: A Prospective, Randomized, and Double-blinded Study

BACKGROUND

Continuous thoracic paravertebral block (TPVB) connected with patient-controlled analgesia (PCA) pump is an effective modality to reduce postoperative pain following thoracic surgery. For the PCA settings, the programmed intermittent bolus infusion (PIBI) and continuous infusion (CI) are commonly practiced. However, the comparative effectiveness between the 2 approaches has been inconsistent. Thus, the aim of this study was to explore the optimal PCA settings to treat postthoracotomy pain by combing PIBI and CI together.

METHODS

All enrolled patients undergoing thoracoscopic surgery accepted ultrasound-guided TPVB catheterization before the surgery and then were randomly allocated in to 3 groups depending on different settings of the PCA pump connecting to the TPVB catheter: the PIBI+CI, PIBI, and CI groups. Numerical Rating Scales were evaluated for each patient at T1 (1 h after extubation), T2 (12 h after the surgery), T3 (24 h after the surgery), T4 (36 h after the surgery), and T5 (48 h after the surgery). Besides, the consumptions of PCA ropivacaine, the number of blocked dermatomes at T3, and the requirement for extra dezocine for pain relief among the 3 groups were also compared.

RESULTS

First, the Numerical Rating Scale scores in the PIBI+CI group were lower than the CI group at T2 and T3 (P<0.05) when patients were at rest and were also lower than the CI group at T2, T3, and T4 (P<0.01) and the PIBI group at T3 when patients were coughing (P<0.01). Second, the 2-day cumulative dosage of PCA in the PIBI+CI group was lower than both the CI and PIBI groups (P<0.01). Third, the number of blocked dermatomes in the PIBI and PIBI+CI groups were comparable and were both wider than the CI group at T3 (P<0.01). Finally, a smaller proportion (not statistically significant) of patients in the PIBI+CI group (5.26%, 2/38) had required dezocine for pain relief when compared with the PIBI group (19.44%, 7/36) and the CI group (15.79%, 6/38).

CONCLUSIONS

The combination of PIBI and CI provides superior analgesic modality to either PIBI or CI alone in patients undergoing thoracoscopic surgery. Therefore, it should be advocated to improve the management of postoperative pain, clinical outcomes, and ultimately patient satisfaction.

Ropivacaine with Dexmedetomidine or Dexamethasone in a Thoracic Paravertebral Nerve Block Combined with an Erector Spinae Plane Block for Thoracoscopic Lobectomy Analgesia: A Randomized Controlled Trial

Objective

This study aimed to investigate the effect of ropivacaine with dexmedetomidine or dexamethasone in a thoracic paravertebral nerve block (TPVB) combined with an erector spinae plane block (ESPB) for thoracoscopic lobectomy analgesia.

Methods

A total of 97 patients undergoing thoracoscopic lobectomy under general anesthesia were enrolled in this study and randomly divided into three groups, ie, a ropivacaine group (Group R), a ropivacaine + dexmedetomidine group (Group R1), and a ropivacaine + dexamethasone group (Group R2). Ultrasound-guided TPVB combined with an erector spinae plane block was given after anesthesia induction. The following were applied to each group: Group R received 30 mL of 0.5% ropivacaine + 5 mL of a normal saline mixture; Group R1 received 30 mL of 0.5% ropivacaine + 5 mL of a 1 μg/kg dexmedetomidine mixture; Group R2 received 30 mL of 0.5% ropivacaine + 5 mL of an 8 mg dexamethasone mixture. The primary observation index was the time to the first postoperative remedial analgesia. The secondary observation indexes were the intraoperative consumption of propofol and sufentanil, time to waking from anesthesia, time to extubation, postoperative numerical rating scaltpe (NRS) score, postoperative sufentanil consumption, remedial analgesic dosage, and adverse reactions.

Results

When compared with Group R, the time to first postoperative remedial analgesia was longer, the intraoperative and postoperative sufentanil consumption and flurbiprofen axetil remedial analgesic dose were lower, and the time to waking from anesthesia and time to extubation were shorter in groups R1 and R2 (P < 0.05). The NRS scores at 1, 6, 12, and 24 h postoperatively in groups R1 and R2 were lower than in Group R at the same time points (P < 0.05).

Conclusion

Ropivacaine with dexmedetomidine or dexamethasone in TPVB combined with ESPB could prolong the time to first postoperative remedial analgesia, reduce perioperative sufentanil and postoperative remedial analgesic drug consumption, and decrease the postoperative NRS score in patients undergoing thoracoscopic lobectomy.

Regional Analgesia in Video-Assisted Thoracic Surgery: A Bayesian Network Meta-Analysis

Background

A variety of regional analgesia methods are used during video-assisted thoracic surgery (VATS). Our network meta-analysis (NMA) sought to evaluate the advantages of various methods of localized postoperative pain management in VATS patients.

Methods

PubMed, the Cochrane Library, and EMBASE were searched from their date of inception to May 2021 for randomized controlled trials (RCTs) comparing two or more types of locoregional analgesia in adults using any standardized clinical criteria. This was done using Bayesian NMA.

Results

A total of 3,563 studies were initially identified, and 16 RCTs with a total of 1,144 participants were ultimately included. These studies, which spanned the years 2014 to 2021 and included data from eight different countries, presented new information. There were a variety of regional analgesia techniques used, and in terms of analgesic effect, thoracic epidural anesthesia (TEA) [SMD (standard mean difference) = 1.12, CrI (Credible interval): (-0.08 to -2.33)], thoracic paravertebral block (TPVB) (SMD = 0.67, CrI: (-0.25 to 1.60) and erector spinae plane block (ESPB) (SMD = 0.34, CrI: (-0.5 to 1.17) were better than other regional analgesia methods.

Conclusion

Overall, these findings show that TEA, TPVB and ESPB may be effective forms of regional analgesia in VATS. This research could be a valuable resource for future efforts regarding the use of thoracic regional analgesia and enhanced recovery after surgery.

Systematic Review Registration

Identifier [PROSPERO CRD42021253218].

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations

Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

The Prediction of Acute Postoperative Pain Based on Neural Oscillations Measured before the Surgery

Even with an improved understanding of pain mechanisms and advances in perioperative pain management, inadequately controlled postoperative pain remains. Predicting acute postoperative pain based on presurgery physiological measures could provide valuable insights into individualized, effective analgesic strategies, thus helping improve the analgesic efficacy. Considering the strong correlation between pain perception and neural oscillations, we hypothesize that acute postoperative pain could be predicted by neural oscillations measured shortly before the surgery. Here, we explored the relationship between neural oscillations 2 hours before the thoracoscopic surgery and the subjective intensity of acute postoperative pain. The spectral power density of resting-state beta and gamma band oscillations at the frontocentral region was significantly different between patients with different levels of acute postoperative pain (i.e., low pain vs. moderate/high pain). A positive correlation was also observed between the spectral power density of resting-state beta and gamma band oscillations and subjective reports of postoperative pain. Then, we predicted the level of acute postoperative pain based on features of neural oscillations using machine learning techniques, which achieved a prediction accuracy of 92.54% and a correlation coefficient between the real pain intensities and the predicted pain intensities of 0.84. Altogether, the prediction of acute postoperative pain based on neural oscillations measured before the surgery is feasible and could meet the clinical needs in the future for better control of postoperative pain and other unwanted negative effects. The study was registered on the Clinical Trial Registry (https://clinicaltrials.gov/ct2/show/NCT03761576?term=NCT03761576&draw=2&rank=1) with the registration number NCT03761576.

The Analgesic Effects of Thoracic Paravertebral Block versus Thoracic Epidural Anesthesia After Thoracoscopic Surgery: A Meta-Analysis

Background

To date, there is no definitive evidence for the analgesic effects and side effects of thoracic epidural anesthesia (TEA) versus thoracic paravertebral block (TPVB) after thoracoscopic surgery. In this study, we conducted a meta-analysis of published randomized clinical trials (RCTs) to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery.

Methods

We systematically searched RCTs published by October 26, 2020, in PubMed, EMBASE, and Cochrane library and conducted a meta-analysis to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery. The primary measure was postoperative pain score, and the secondary measures were postoperative 24-hour usage of opioids, hypotension, postoperative nausea, and vomiting.

Results

A total of 458 patients from five RCTs were included in this study. After thoracoscopic surgery, the numerical rating scale (NRS) score for resting pain was higher in the TPVB group than in the TEA group at 1–2 hours and 4–6 hours after surgery (MD = 0.44, 95% CI = 0.24 to 0.64, P < 0.0001, I2 = 0%; MD = 0.47, 95% CI = 0.23 to 0.70, P < 0.0001, I2 = 0%). The postoperative 24-hour usage of morphine was higher in the TPVB group than in the TEA group (SMD = 0.67; 95% CI = 0.03 to 1.31; P = 0.04; I2 = 84%). The incidence of hypotension was significantly lower in the TPVB group than in the TEA group (OR = 4.52; 95% CI = 2.03 to 10.10; P = 0.0002; I² = 0%). No significant between-group difference was observed in postoperative nausea and vomiting (PONV).

Conclusion

Compared with TPVB, TEA provides statistically significant but clinically unimportant short-term benefits following thoracoscopic surgery.

Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults

Purpose

This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults.

Patients and Methods

Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUC_VAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes.

Results

At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUC_VAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUC_VAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group.

Conclusion

cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Effects of virtual reality on relieving postoperative pain in surgical patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pain is a prevalent problem leading to many adverse outcomes in surgical patients. Virtual reality (VR) is an emerging non-pharmacological method of postoperative pain relief, but the effects of it are not clear. This review aimed to explore the effects of VR on relieving postoperative pain.

METHODS

Studies published up to November 2019 were identified by searching the PubMed (Medline), Embase, Web of Science, and other databases. Meta-analyses were conducted to compare VR and usual care for relieving postoperative pain. Subgroup analyses and sensitivity analyses were performed to explain the heterogeneity.

RESULTS

Overall, 8 randomized control trials (RCTs) enrolling 723 participants were included. Our results demonstrated that the patients receiving the VR intervention had lower postoperative pain scores than those receiving the usual care (mean difference [MD] -0.64; 95% CI -1.05 to -0.22; P = 0.002). One subgroup analysis revealed that VR could relieve postoperative pain both in minor surgery (MD -1.48; 95% CI -2.02 to -0.95; P < 0.0001) and major surgery (MD -0.32; 95% CI -0.53 to -0.11; P < 0.03). Another subgroup analysis demonstrated a significant reduction in postoperative pain among patients receiving VR during the intraoperative (MD -1.51; 95% CI -2.04 to -0.97; P < 0.00001) and the postoperative periods (MD -0.50; 95% CI -0.76 to -0.24; P = 0.002). However, there was no significant postoperative pain relief when receiving VR during the preoperative period. Additionally, significant improvements in postoperative satisfaction were reported in two studies. However, another two studies included found that VR could not affect physiological parameters related to pain.

CONCLUSIONS

Applying VR can relieve postoperative pain effectively. The type of surgery and timing of using VR are the main sources of heterogeneity. More rigorous studies about the relationship between VR and postoperative pain relief will be needed.

Efficacy and Safety of Continuous Paravertebral Block after Minimally Invasive Radical Esophagectomy for Esophageal Cancer

Objective

To compare the effects of continuous paravertebral block analgesia and patient-controlled intravenous analgesia after minimally invasive radical esophagectomy for esophageal cancer and their effects on postoperative recovery.

Methods

A retrospective analysis was performed among 233 patients who underwent minimally invasive esophageal cancer radical operation and met the requirements, including 87 patients (group C) who were successfully placed with a continuous paravertebral block device under direct vision and 146 patients (group P) who used a patient-controlled intravenous analgesia device. Visual analogue pain score (VAS) at rest and in motion for 1, 3, 6, 12, 24, 36, and 48 hours after awakening, incidence of adverse reactions of the two analgesic methods, occurrence of pulmonary complications after operation, use of emergency analgesics, and hospital stay after operation was recorded.

Results

The VAS scores of group C in resting and active state at 1, 3, 6, 12, 24, 36, and 48 hours after operation were significantly lower than those of group P (P < 0.001). The incidence of adverse reactions, pulmonary complications, and the use of emergency analgesics in group C were lower than those in group P (P < 0.05). The hospitalization time of group C was significantly shortened, and the satisfaction degree of group C was significantly higher than that of group P (P < 0.05).

Conclusion

Paravertebral block is safe and effective for patients undergoing minimally invasive radical esophagectomy. The incidence of adverse reactions and complications is lower, and the satisfaction of postoperative analgesia is higher, which is beneficial to the rapid recovery of patients after operation.

Uniportal thoracoscopic pulmonary lobectomy in the treatment of Lung Cancer

OBJECTIVE

To investigate the clinical efficacy of uniportal thoracoscopic pulmonary lobectomy in the treatment of lung cancer.

METHODS

One hundred and ten patients with lung cancer who were admitted to our hospital from February 2017 to June 2018 were enrolled and they were divided into the control group (55 patients) and observation group (55 patients) according to the random number table method. The patients in the observation group received uniportal thoracoscopic pulmonary lobectomy, and patients in the control group underwent triportal thoracoscopic pulmonary lobectomy. The surgical condition, postoperative pulmonary functions, postoperative complication incidence, and postoperative quality of life were compared between the two groups.

RESULTS

The intraoperative blood loss and number of dissected lymph nodes of the observation group were (125.31±12.63) mL and (13.91±2.41) respectively, which were not significantly different with (127.54±13.60) mL and (13.96±2.69) of the control group (P>0.05). The incision length of the observation group was (4.22±0.31) cm, shorter than (6.97±0.42) cm of the control group, the postoperative pain score was (2.87±0.69) points, lower than (4.31±1.09) points of the control group, and the operation time was (195.21±19.42) minutes, longer than (162.68±18.52) min of the control group; the differences were significantly different (P<0.05). The postoperative forced vital capacity (FVC), Maximum Ventilatory Volume (MVV) and Forced Expiratory Volume in 1s (FEV1) in the observation group were (1.90±0.75) L, (54.59±16.03) L/minutes and (1.60±0.53) L respectively, larger than (1.06±0.28) L, (38.41±15.59) L/min and (1.02±0.15) L respectively (P<0.05). The scores of Short Form 36-item Health Survey (SF-36) of patients in the observation group was observed one month after surgery, significantly higher than those in the control group, and the difference was statistically significant (P<0.05). The incidence of complications of the postoperative complication of the observation group was 12.7%, which was not significantly different with 14.5% of the control group (P>0.05).

CONCLUSION

Patients who receive uniportal video-assisted thoracoscopic pulmonary lobectomy have milder trauma, which is beneficial to the lung functions and postoperative recovery. Moreover, the number of dissected lymph nodes in uniportal thoracoscopic pulmonary lobectomy is equivalent with that in triportal thoracoscopic pulmonary lobectomy. Hence it is worth clinical promotion.