1
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Shakeri A, Memary E. Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report. BMC Anesthesiol 2024; 24:57. [PMID: 38331721 PMCID: PMC10851452 DOI: 10.1186/s12871-024-02431-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery. CASE PRESENTATION Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation. CONCLUSIONS Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.
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Affiliation(s)
- Alireza Shakeri
- Anesthesiology Department, Imam Hosein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Memary
- Anesthesiology Department, Imam Hosein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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2
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Granell-Gil M, Murcia-Anaya M, Sevilla S, Martínez-Plumed R, Biosca-Pérez E, Cózar-Bernal F, Garutti I, Gallart L, Ubierna-Ferreras B, Sukia-Zilbeti I, Gálvez-Muñoz C, Delgado-Roel M, Mínguez L, Bermejo S, Valencia O, Real M, Unzueta C, Ferrando C, Sánchez F, González S, Ruiz-Villén C, Lluch A, Hernández A, Hernández-Beslmeisl J, Vives M, Vicente R. Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:266-301. [PMID: 35610172 DOI: 10.1016/j.redare.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/19/2021] [Indexed: 06/15/2023]
Abstract
The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.
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Affiliation(s)
- M Granell-Gil
- Sección en Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Profesor Contratado Doctor en Anestesiología, Universitat de València, Valencia, Spain
| | - M Murcia-Anaya
- Anestesiología, Reanimación y T. Dolor, Unidad de Cuidados Intensivos, Hospital IMED Valencia, Valencia, Spain.
| | - S Sevilla
- Sociedad de Cirugía Torácica, Complejo Hospitalario Universitario de Jaén, Jaén, Spain
| | - R Martínez-Plumed
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - E Biosca-Pérez
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - F Cózar-Bernal
- Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - I Garutti
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - L Gallart
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - I Sukia-Zilbeti
- Fisioterapia, Hospital Universitario Donostia de San Sebastián, Spain
| | - C Gálvez-Muñoz
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, Spain
| | - M Delgado-Roel
- Cirugía Torácica, Complejo Hospitalario Universitario La Coruña, La Coruña, Spain
| | - L Mínguez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - S Bermejo
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - O Valencia
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Doce de Octubre de Madrid, Madrid, Spain
| | - M Real
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Doce de Octubre de Madrid, Madrid, Spain
| | - C Unzueta
- Anestesiología, Reanimación y T. Dolor, Hospital Sant Pau de Barcelona, Barcelona, Spain
| | - C Ferrando
- Anestesiología, Reanimación y T. Dolor, Hospital Clínic Universitari de Barcelona, Barcelona, Spain
| | - F Sánchez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario de la Ribera de Alzira, Valencia, Spain
| | - S González
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Donostia de San Sebastián, Spain
| | - C Ruiz-Villén
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - A Lluch
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - A Hernández
- Anestesiología, Reanimación y T. Dolor, Grupo Policlínica de Ibiza, Ibiza, Spain
| | - J Hernández-Beslmeisl
- Anestesiología, Reanimación y T. Dolor, Complejo Hospitalario Universitario de Canarias, Canarias, Spain
| | - M Vives
- Anestesiología, Reanimación y T. Dolor, Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain
| | - R Vicente
- Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR, Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Universitat de València, Valencia, Spain
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Mendonça FT, Junior AVDAF, Nogueira HCR, Roncolato HH, Goveia CS. Efficacy of type-I and type-II pectoral nerve blocks (PECS I and II) in patients undergoing mastectomy: a prospective randomised clinical trial. Anaesthesiol Intensive Ther 2022; 54:302-309. [PMID: 36458667 PMCID: PMC10156554 DOI: 10.5114/ait.2022.121096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/22/2022] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION The benefits of type I/II pectoral nerve blocks (PECS I/II), which can be dose dependent, have been examined in different studies. Nonetheless, few randomised trials have been performed in South America. The present randomised trial examined the efficacy of PECS I/II with a higher dose of the local anaesthetic to manage perioperative pain after mastectomy in Brazil. MATERIAL AND METHODS This was a randomised, parallel, single-centre, and single-blind trial. Eighty participants undergoing elective mastectomy were randomised (1 : 1) to receive PECS I/II plus ultrasound-guided ropivacaine (0.5%) or standard general anaesthesia. The primary outcome was pain intensity at rest 24 hours after surgery, assessed with a numerical rating scale. Haemodynamic outcomes, consumption of opioids, anaesthe-tics and antiemetics, and post-anaesthetic recovery times were also recorded. RESULTS Sixty participants (75%) completed the study. The mean age was 54 years, with 57% of participants undergoing mastectomy and 43% undergoing quadrantectomy. Median pain intensity (interquartile range) at rest (24 h postoperatively) was lower in the PECS I/II group compared to the control group: 0 (0-1.75) vs. 1 (1-2), P = 0.021. A smaller number of patients in the PECS I/II group required intraoperative fentanyl (23.3% vs. 83.3%; P < 0.001) and postoperative tramadol (20.0 vs. 76.7%; P < 0.001). Mean doses of fentanyl and tramadol were about 4-5 times lower in the PECS I/II group (P < 0.001). PECS I/II significantly reduced sevoflurane consumption during surgery (P = 0.01). No difference was observed regarding adverse effects. CONCLUSIONS PECS I/II blockade with high-dose local anaesthetic is efficacious and safe, resulting in lower levels of perioperative pain after mastectomy compared to standard general anaesthesia.
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Affiliation(s)
- Fabricio Tavares Mendonça
- Teaching and Training Centre in Anaesthesiology, Hospital de Base do Distrito Federal, Brasília, Distrito Federal, Brazil
| | | | - Huana Christina Rosa Nogueira
- Teaching and Training Centre in Anaesthesiology, Hospital de Base do Distrito Federal, Brasília, Distrito Federal, Brazil
| | - Heloisa Helena Roncolato
- Teaching and Training Centre in Anaesthesiology, Hospital de Base do Distrito Federal, Brasília, Distrito Federal, Brazil
| | - Catia Sousa Goveia
- University of Brasília, Anaesthesiology Centre, Brasília, Distrito Federal, Brazil
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The Role of Serratus Anterior Plane Block During in Video-Assisted Thoracoscopic Surgery. Pain Ther 2021; 10:1051-1066. [PMID: 34537952 PMCID: PMC8586293 DOI: 10.1007/s40122-021-00322-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/08/2021] [Indexed: 10/27/2022] Open
Abstract
Although thoracoscopy has characteristics such as a small surgical incision and low stress response, post-surgical pain after a thoracoscopic operation is no less than that after a thoracotomy. Moreover, poor post-surgical pain management is likely to cause an increased incidence of postoperative pulmonary complications (PPCs) and chronic post-surgical pain. The serratus anterior plane block (SAPB) is a regional anesthesia method whereby local anesthetics (LAs) are injected into the serratus anterior space to block the lateral cutaneous branch of the intercostal nerve, long thoracic nerve, and dorsal thoracic nerve. The block range of the SAPB covers the incisions of video-assisted thoracoscopic surgery (VATS) and the site of the chest tube, which are often located in the antero-lateral chest wall. Therefore, the SAPB can achieve effective analgesia in VATS. For example, 0.125% to 0.25% levobupivacaine (20-25 ml) is widely used for thoracic surgery, which can achieve effective analgesia and avoid adverse reactions. Moreover, it has advantages compared with thoracic segmental epidural block (TEA) and thoracic paravertebral block (TPVB), such as simple operation, increased safety, fewer complications, and hemodynamic stability. In addition, adequate analgesia is helpful for pulmonary function recovery and reduces the incidence of PPCs. This article introduces the anatomical mechanism of the SAPB, diverse operation approaches, how to choose drugs and adjuvants, and the resulting impacted area range. It summarizes the advantages and disadvantages of the SAPB compared with other analgesic methods and posits that the SAPB is beneficial to the recovery of postoperative lung function, which provides more options for postoperative analgesia after VATS.
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Thanh Trung T, Van Khoa D, Van Dong T. The comparison of analgesic efficacy between ultrasound-guided continuous thoracic paravertebral block and continuous thoracic epidural block using bupivacaine - fentanyl in patients undergoing lung surgery: A prospective, randomized, controlled trial. Turk J Surg 2021; 37:232-241. [DOI: 10.47717/turkjsurg.2021.5053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/04/2021] [Indexed: 11/23/2022]
Abstract
Objective: This study aimed to compare the efficacy and the safety of ultrasound-guided continuous thoracic paravertebral block (CTPB) to the continuous thoracic epidural block (CTEB) for pain relief in patients undergoing lung surgery.
Material and Methods: Our study included 102 patients after lung surgery at the 74 Central Hospital from 9/2013 to 12/2017. Patients were divided into 2 groups: CTPB group (n= 51) and CTEB group (n= 51). The primary outcomes were the Visual Analogue Scale (VAS) scores when patients were at rest (VR) and movement (VM), the total used dosage of bupivacaine - fentanyl after surgery, plasma glucose, and cortisol levels, additional doses of morphine. Adverse reactions were recorded during the study. The study was approved by the Ethics Committee of the 74 Central Hospital. All participants provided their informed consent.
Results: There were no significant differences between CTPB and CTEB groups in terms of the VR and the VM, total used doses of bupivacaine - fentanyl after 72-hours of surgery (p> 0.05), the increased plasma glucose, and plasma cortisol (p> 0.05), and the additional doses of morphine. The percent of patients in the CTPB group undergoing adverse reactions in the circular system and the respiratory system was lower than in the CTEB group. Adverse reactions included vascular puncture, urinary retention, and itch.
Conclusion: Ultrasound-guided CTPB is an effective intervention of pain relief after lung surgery. Its analgesic efficacy is comparable to CTEB. Also, this method had fewer adverse reactions in circulation and respiration compared to the CTEB.
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Acute pain after serratus anterior plane or thoracic paravertebral blocks for video-assisted thoracoscopic surgery: A noninferiority randomised trial. Eur J Anaesthesiol 2021; 38:S97-S105. [PMID: 34170884 DOI: 10.1097/eja.0000000000001450] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Serratus anterior plane blocks (SAPBs) and thoracic paravertebral blocks (TPVBs) can both be used for video-assisted thoracic surgery. However, it remains unknown whether the analgesic efficacy of a SAPB is comparable to that of a TPVB. OBJECTIVE We tested the primary hypothesis that SAPBs provide noninferior analgesia compared with TPVBs for video-assisted thoracic surgery. DESIGN A noninferiority randomised trial. SETTING Shanghai Chest Hospital, between August 2018 and November 2018. PATIENTS Ninety patients scheduled for video-assisted thoracic lobectomy or segmentectomy were randomised. Patients were excluded if they were unable to perform the visual analogue pain scale, or surgery was converted to thoracotomy. INTERVENTIONS Blocks were performed after induction of general anaesthesia. The three groups were paravertebral blocks (n = 30); serratus anterior plane blocks (n = 29); and general anaesthesia alone (n = 30). PRIMARY OUTCOME MEASURES Visual analogue pain scores (0 to 10 cm) at rest and while coughing, and Prince-Henry pain scores (0 to 4 points) were used to assess postoperative analgesia at 2, 24 and 48 h after surgery. We assessed the noninferiority of SAPBs with TPVBs on all three primary pain outcomes using a delta of 1 cm or one point as appropriate. RESULTS The mean difference (95% confidence intervals) in visual analogue scores between the SAPBs and TPVBs was -0.04 (-0.10 to 0.03) cm at rest, -0.22 (-0.43 to -0.01) cm during coughing and -0.10 (-0.25 to 0.05) for Prince-Henry pain scores. As the upper limit of the confidence intervals were less than 1 (all P < 0.001), noninferiority was claimed for all three primary outcomes. Compared with general anaesthesia alone, the VAS scores at rest and while coughing, and the Prince-Henry pain scores for the two blocks were significantly lower during the initial 2 h after surgery. CONCLUSIONS Serratus anterior plane blocks are quicker and easier to perform than paravertebral blocks and provide comparable analgesia in patients having video-assisted thoracic surgery. Both blocks provided analgesia that was superior to general anaesthesia alone during the initial 2 h after surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, identifier: ChiCTR1800017671.
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Granell-Gil M, Murcia-Anaya M, Sevilla S, Martínez-Plumed R, Biosca-Pérez E, Cózar-Bernal F, Garutti I, Gallart L, Ubierna-Ferreras B, Sukia-Zilbeti I, Gálvez-Muñoz C, Delgado-Roel M, Mínguez L, Bermejo S, Valencia O, Real M, Unzueta C, Ferrando C, Sánchez F, González S, Ruiz-Villén C, Lluch A, Hernández A, Hernández-Beslmeisl J, Vives M, Vicente R. Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00129-8. [PMID: 34330548 DOI: 10.1016/j.redar.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/09/2021] [Accepted: 03/19/2021] [Indexed: 10/20/2022]
Abstract
The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.
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Affiliation(s)
- M Granell-Gil
- Sección en Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Profesor Contratado Doctor en Anestesiología, Universitat de València, Valencia, España
| | - M Murcia-Anaya
- Anestesiología, Reanimación y T. Dolor, Unidad de Cuidados Intensivos, Hospital IMED Valencia, Valencia, España.
| | - S Sevilla
- Sociedad de Cirugía Torácica, Complejo Hospitalario Universitario de Jaén, Jaén, España
| | - R Martínez-Plumed
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - E Biosca-Pérez
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - F Cózar-Bernal
- Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - I Garutti
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Gregorio Marañón, Madrid, España
| | - L Gallart
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | | | - I Sukia-Zilbeti
- Fisioterapia, Hospital Universitario Donostia, San Sebastián, España
| | - C Gálvez-Muñoz
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, España
| | - M Delgado-Roel
- Cirugía Torácica, Complejo Hospitalario Universitario La Coruña, La Coruña, España
| | - L Mínguez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, España
| | - S Bermejo
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - O Valencia
- Anestesiología, Reanimación y T. Dolor. Hospital Universitario Doce de Octubre de Madrid, Madrid, España
| | - M Real
- Anestesiología, Reanimación y T. Dolor. Hospital Universitario Doce de Octubre de Madrid, Madrid, España
| | - C Unzueta
- Anestesiología, Reanimación y T. Dolor. Hospital Sant Pau de Barcelona, Barcelona, España
| | - C Ferrando
- Anestesiología, Reanimación y T. Dolor. Hospital Clínic Universitari de Barcelona, Barcelona, España
| | - F Sánchez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario de la Ribera de Alzira, Valencia, España
| | - S González
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Donostia de San Sebastián, España
| | - C Ruiz-Villén
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Reina Sofía de Córdoba, Córdoba, España
| | - A Lluch
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, España
| | - A Hernández
- Anestesiología, Reanimación y T. Dolor, Grupo Policlínica de Ibiza, Ibiza, España
| | - J Hernández-Beslmeisl
- Anestesiología, Reanimación y T. Dolor, Complejo Hospitalario Universitario de Canarias, Canarias, España
| | - M Vives
- Anestesiología, Reanimación y T. Dolor, Hospital Universitari Dr. Josep Trueta de Girona, Girona, España
| | - R Vicente
- Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR, Anestesiología, Reanimación y T. Dolor. Hospital Universitario La Fe de Valencia, Universitat de València, Valencia, España
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Xu Y, Li XK, Zhou H, Cong ZZ, Wu WJ, Qiang Y, Shen Y. Paravertebral block with modified catheter under surgeon's direct vision after video-assisted thoracoscopic lobectomy. J Thorac Dis 2020; 12:4115-4125. [PMID: 32944323 PMCID: PMC7475592 DOI: 10.21037/jtd-20-1068b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Paravertebral block (PVB) conducted by epidural catheter is a prevalent pain management for patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy. The aim of this study was to assess the efficacy and safety of paravertebral block with a modified PVB (MPVB) catheter under surgeon’s direct vision after video-assisted thoracoscopic lobectomy. Methods Three hundred fifty-six patients undergoing VATS lobectomy were retrospectively reviewed and divided into two groups consecutively according to the catheter applied in PVB procedure (PVB group and MPVB group). In the MPVB group, a modified catheter with a flexible forepart and more apertures distributing along the forepart than the conventional epidural catheter was introduced. An infusion pump containing of 150 mL mixture was connected to the catheter to provide sustained regional analgesia. Intramuscular dezocine 10 mg was administered as a rescue medication when necessary. Postoperative pain management effect was assessed by visual analog scale (VAS) at rest and on coughing. Spirometry values and blood gas analysis were monitored and recorded for the first 3 postoperative days (PODs). Analgesia-related adverse events, characteristics of PVB procedure and postoperative major complication were also compared between the two groups. Results There were 172 patients who received PVB with conventional epidural catheter in the PVB group, and 184 patients were performed PVB with modified paravertebral catheter in the MPVB group. Significantly lower pain score at rest was found in MPVB group at 24 h postoperatively (P=0.006). The pain score on coughing in MPVB group was significantly lower than that in PVB group at 12 and 24 h postoperatively (P=0.037 and P<0.001, respectively). Patients needing for rescue medication was significantly lower in the MPVB group (P=0.028). The incidence of pleural perforation was lower in the MPVB group (P=0.020). Postoperative spirometry values revealed comparable pulmonary function between the two groups, and arterial blood gas analysis showed a normal range of pH and PaCO2 in both groups. There was no significant difference of analgesia-related adverse events as well as major complications between the two groups. Conclusions PVB with modified catheter under surgeon’s direct vision was effective and safe after video-assisted thoracoscopic lobectomy.
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Affiliation(s)
- Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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9
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A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study. Adv Ther 2020; 37:4000-4014. [PMID: 32737760 DOI: 10.1007/s12325-020-01446-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION This study aimed to compare the challenge of puncture and catheterization and the effect of postoperative analgesia of ultrasound-guided continuous thoracic paravertebral block and the continuous epidural analgesia in patients receiving thoracoscopic surgery for lung cancer. METHODS One-hundred and fifty patients received elective unilateral thoracoscopic surgery for lung cancer and were randomized into three groups; test group 1 (T group), test group 2 (P group), and the control group (E group). Both of the test groups received ultrasound-guided continuous thoracic paravertebral block (TPVB) while the control group received continuous epidural analgesia. After the operation, all the patients in the test groups received the same postoperative analgesia; loading dose 0.5 mg kg-1, background dose 0.25 mg kg-1 h-1, patient controlled analgesia (PCA) 0.25 mg kg-1, and a locking time of 60 min, while the patients in the control group received a loading dose of 5 ml, a background dose of 5 ml h-1, and a locking time of 20 min. The outcomes of this study were the success rate of the puncture and catheter placement, the blocked segments, numerical rating scale (NRS) scores at rest and during coughing, and the segments with reduced or lost cold and pinpricking sensation. RESULTS The success rates of the puncture and catheterization in group T were the highest. Compared with group P, the failure rate of the puncture in group E was lower (p < 0.05), but the success rate of catheterization was higher (p < 0.05). The puncture time in group T was the shortest; there was no difference between group E and group T. The time of catheterization in group P was the longest, this was followed by group T, and was the fastest in group E. The stable time of the block level in group E was shorter than that in groups P and T, but was similar between groups P and T. The block level of all three groups in the 4 h postoperative period was similar (p > 0.05), while the 4 h postoperative levels of groups P and T were reduced significantly (p < 0.05). CONCLUSION The continuous analgesia technique of paravertebral space catheterization cannot replace the continuous epidural analgesia in thoracoscopic lung cancer surgery as the latter technique is still considered to be the gold standard. TRIAL REGISTRATION China Clinical Trial Registration Center identifier ChiCTR1900020973.
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Suksompong S, von Bormann S, von Bormann B. Regional Catheters for Postoperative Pain Control: Review and Observational Data. Anesth Pain Med 2020; 10:e99745. [PMID: 32337170 PMCID: PMC7158241 DOI: 10.5812/aapm.99745] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/22/2020] [Accepted: 01/29/2020] [Indexed: 12/11/2022] Open
Abstract
Context Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures. Evidence Acquisition This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. Results As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. Conclusions Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.
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Affiliation(s)
| | | | - Benno von Bormann
- Institute of Medicine, Suranaree University of Technology, Korat, Thailand
- Corresponding Author: Institute of Medicine, Suranaree University of Technology, 111 Maha Witthayalai Rd, Nakhon Ratchasima 30000, Thailand. Tel: +66(0)918825723,
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Mazzinari G, Rovira L, Casasempere A, Ortega J, Cort L, Esparza-Miñana JM, Belaouchi M. Interfascial block at the serratus muscle plane versus conventional analgesia in breast surgery: a randomized controlled trial. Reg Anesth Pain Med 2019; 44:52-58. [DOI: 10.1136/rapm-2018-000004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/17/2018] [Accepted: 04/23/2018] [Indexed: 01/11/2023]
Abstract
Background and objectivesIn the context of opioid-sparing perioperative management, there is still little evidence from randomized controlled trials regarding the effectiveness of interfascial thoracic blocks. This study hypothesizes that receiving a serratus plane block reduces opioid requirements, pain scores, and rescue medication needs.MethodsThis double-blind, randomized controlled study was conducted on 60 adult females undergoing oncologic breast surgery. After general anesthesia, patients were randomly allocated to either conventional analgesia (control group, n=30) or single-injection serratus block with L-bupivacaine 0.25% 30mL (study group, n=30). First 24-hour total morphine consumption (primary outcome), pain scores at 1, 3, 6, 12, and 24 hours, time-to-first opioid rescue analgesia, and adverse effects were recorded.ResultsMedian 24 hours’ opioid dose was greater in the control group (median difference 9 mg (95% CI 4 to 14.5 mg); p<0.001). Proportional odds model showed that the study group has a lower probability of receiving opioid drugs (OR=0.26 (95% CI 0.10 to 0.68); p<0.001), while mastectomies have a higher probability of receiving them (OR=4.11 (95% CI 1.25 to 13.58); p=0.002). Pain scores in the study group were significantly lower throughout the follow-up period (p<0.001). Control group subjects needed earlier morphine rescue and had a higher risk of rescue dose requirement (p=0.002).ConclusionsInterfascial serratus plane block reduces opioid requirements and is associated with better pain scores and lower and later rescue analgesia needs in the first 24 hours, compared with conventional intravenous analgesia, in breast surgery.Trial registration numberNCT02905149.
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Shanthanna H, Moisuik P, O’Hare T, Srinathan S, Finley C, Paul J, Slinger P. Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada. J Cardiothorac Vasc Anesth 2018; 32:1750-1755. [DOI: 10.1053/j.jvca.2018.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 02/06/2023]
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Breivik H, Norum H, Fenger-Eriksen C, Alahuhta S, Vigfússon G, Thomas O, Lagerkranser M. Reducing risk of spinal haematoma from spinal and epidural pain procedures. Scand J Pain 2018; 18:129-150. [DOI: 10.1515/sjpain-2018-0041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractBackground and aims:Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory.Methods:We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures.Results and recommendations:Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients’ comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur.Conclusions:When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH.Implications:There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts’ experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.
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Affiliation(s)
- Harald Breivik
- Oslo University Hospital , Division of Emergencies and Critical Care, Department of Pain Management and Research , PB 4956 Nydalen, 0424 Oslo , Norway , Phone: +47 23073691, Fax: +47 23073690
- University of Oslo , Faculty of Medicine , Oslo , Norway
- Oslo University Hospital , Division of Emergencies and Critical Care, Department of Anaesthesiology , Oslo , Norway
| | - Hilde Norum
- University of Oslo , Faculty of Medicine , Oslo , Norway
- Oslo University Hospital , Division of Emergencies and Critical Care, Department of Anaesthesiology , Oslo , Norway
| | | | - Seppo Alahuhta
- Department of Anaesthesiology , MRC Oulu , University of Oulu, and Oulu University Hospital , Oulu , Finland
| | - Gísli Vigfússon
- Department of Anaesthesia and Intensive Care , University Hospital Landspitalinn , Reykjavik , Iceland
| | - Owain Thomas
- Institute of Clinical Sciences , University of Lund, and Department of Paediatric Anaesthesiology and Intensive Care , SUS Lund University Hospital , Lund , Sweden
| | - Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institute , Stockholm , Sweden
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Breivik H. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough. Scand J Pain 2017; 15:93-95. [DOI: 10.1016/j.sjpain.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Harald Breivik
- University of Oslo , Faculty of Medicine , Oslo , Norway
- Oslo University Hospital , Department of Pain Management and Research , Oslo , Norway
- Oslo University Hospital , Department of Anaesthesiology , Oslo , Norway
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Yeung JHY, Gates S, Naidu BV, Wilson MJA, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; 2:CD009121. [PMID: 26897642 PMCID: PMC7151756 DOI: 10.1002/14651858.cd009121.pub2] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy. OBJECTIVES To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness. SEARCH METHODS We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review. SELECTION CRITERIA We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis). MAIN RESULTS We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs. AUTHORS' CONCLUSIONS Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.
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Affiliation(s)
- Joyce HY Yeung
- Heart of England NHS Foundation Trust, Birmingham Heartlands HospitalAcademic Department of Anaesthesia, Critical Care, Pain and Resuscitation1/F MIDRU Building, Birmingham Heartlands Hospital, Bordersley Green EastBirminghamUKB9 5SS
- University of BirminghamSchool of Clinical and Experimental Medicine, College of Medical and Dental SciencesBirminghamUK
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - Babu V Naidu
- University of BirminghamInstitute of Inflammation and AgeingQueen Elizabeth Hospital Birmingham Edgbaston,BirminghamUKB15 2TT
| | - Matthew JA Wilson
- The University of SheffieldSchool of Health and Related ResearchSheffieldUK
| | - Fang Gao Smith
- Heart of England NHS Foundation Trust, Birmingham Heartlands HospitalAcademic Department of Anaesthesia, Critical Care, Pain and Resuscitation1/F MIDRU Building, Birmingham Heartlands Hospital, Bordersley Green EastBirminghamUKB9 5SS
- College of Medical and Dental Sciences, University of BirminghamSchool of Clinical and Experimental MedicineBirminghamUK
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Teeter EG, Kumar PA. Pro: Thoracic Epidural Block Is Superior to Paravertebral Blocks for Open Thoracic Surgery. J Cardiothorac Vasc Anesth 2015; 29:1717-9. [DOI: 10.1053/j.jvca.2015.06.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 11/11/2022]
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Breivik H. Persistent post-surgical pain (PPP) reduced by high-quality management of acute pain extended to sub-acute pain at home. Scand J Pain 2014; 5:237-239. [DOI: 10.1016/j.sjpain.2014.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Harald Breivik
- University of Oslo and Oslo University Hospital , Departments of Anaesthesiology and Pain Management and Research , Nydalen PB 4950, 0424 Oslo , Norway
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Managing post-thoracotomy pain: Epidural or systemic analgesia and extended care – A randomized study with an “as usual” control group. Scand J Pain 2014; 5:240-247. [DOI: 10.1016/j.sjpain.2014.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022]
Abstract
Abstract
Background and aims
Thoracotomies can cause severe pain, which persists in 21–67% of patients. We investigated whether NSAID + intravenous patient-controlled analgesia (IV-PCA) with morphine is an efficacious alternative to thoracic epidural analgesia (TEA). We also wanted to find out whether an extended controlled pain management protocol within a clinical study can decrease the incidence of persistent post-thoracotomy pain.
Methods
Thirty thoracotomy patients were randomized into 3 intervention groups with 10 patients in each. G1: preoperative diclofenac 75mg orally+150 mg/24h IV for 44h, then PO; G2: valdecoxib 40mg orally+parecoxib 80mg/24h IV for 44h, then PO. IV-PCA morphine was available in groups 1 and 2 during pleural drainage, and an intercostal nerve block at the end of surgery was performed; G3: parac-etamol+patient controlled epidural analgesia (PCEA) with a background infusion of bupivacaine with fentanyl. After PCA/PCEA oxycodone PO was provided when needed. These patients were contacted one week, 3 and 6 months after discharge. Patients (N = 111) not involved in the study were treated according to hospital practice and served as a control group. The control patients’ data from the perioperative period were extracted, and a prospective follow-up questionnaire at 6 months after surgery similar to the intervention group was mailed.
Results
The intended sample size was not reached in the intervention group because of the global withdrawal of valdecoxib, and the study was terminated prematurely. At 6 months 3% of the intervention patients and 24%ofthe control patients reported persistent pain (p<0.01). Diclofenac and valdecoxib provided similar analgesia, and in the combined NSAID group (diclofenac+valdecoxib) movement-related pain was milder in the PCEA group compared with the NSAID group. The duration of pain after coughing was shorter in the PCEA group compared with the NSAID+IV-PCA group. The only patient with persistent painat6 months postoperatively had a considerably longer duration ofpain after coughing than the other Study patients. The patients with mechanical hyperalgesia had more pain on movement.
Conclusions
Both PCEA and NSAID+IV-PCA morphine provided sufficient analgesia with little persistent pain compared with the incidence of persistent pain in the control group. High quality acute pain management and follow-up continuing after discharge could be more important than the analgesic method per se in preventing persistent post-thoracotomy pain. In the acute phase the measurement of pain when coughing and the duration of pain after coughing could be easy measures to recognize patients having a higher risk for persistent post-thoracotomy pain.
Implications
To prevent persistent post-thoracotomy pain, the extended protocol for high quality pain management in hospital covering also the sub-acute phase at home, is important. This study also provides some evidence that safe and effective alternatives to thoracic epidural analgesia do exist. The idea to include the standard “as usual” care patients as a control group and to compare them with the intervention patients provides valuable information of the added value of being a study patient, and deserves further consideration in future studies.
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Vogt A. Paravertebral block – A new standard for perioperative analgesia. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tighe SQM, Karmakar MK. Serratus plane block: do we need to learn another technique for thoracic wall blockade? Anaesthesia 2013; 68:1103-6. [DOI: 10.1111/anae.12423] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - M. K. Karmakar
- Department of Anaesthesia and Intensive Care; The Chinese University of Hong Kong; Prince of Wales Hospital; Shatin Hong Kong
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BREIVIK HARALD, NORUM HILDE. Risks of serious complications after neuraxial blocks: apparent decrease due to guidelines for safe practice? Acta Anaesthesiol Scand 2013; 57:541-4. [PMID: 23574646 DOI: 10.1111/aas.12121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - HILDE NORUM
- Department of Pain Management and Research; Oslo University Hospital, Rikshospitalet; Oslo; Norway
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Published evidence from randomised trials indicates that pain after thoracotomy is more effectively relieved by thoracic epidural analgesia than by paravertebral blocks. Eur J Anaesthesiol 2013; 30:261. [DOI: 10.1097/eja.0b013e32835f9935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Breivik H, Sauter A. Local infiltration analgesia (LIA) and repeated bolus or continuous infusion peripheral nerve blocks for acute postoperative pain: Be ware of local anaesthetic toxicity, especially in elderly patients with cardiac co-morbidities! Scand J Pain 2012; 3:44-45. [DOI: 10.1016/j.sjpain.2011.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Harald Breivik
- University of Oslo and Oslo University Hospital , Department of Pain Management and Pain Research , Oslo , Norway
| | - Axel Sauter
- Oslo University Hospital , Department of Pain Management and Pain Research , Oslo , Norway
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Learning from the past for the present: paravertebral blocks for thoracic surgery are not without risk. Eur J Anaesthesiol 2011; 28:544-5. [DOI: 10.1097/eja.0b013e328344d953] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Norum HM, Breivik H. Thoracic Paravertebral Blockade and Thoracic Epidural Analgesia. Anesth Analg 2011; 112:990; author reply 990-1. [DOI: 10.1213/ane.0b013e318209e130] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Breivik H, Norum HM. [Regional analgesia--risks and benefits]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:392-7. [PMID: 20220867 DOI: 10.4045/tidsskr.08.0220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Local anaesthetics may alleviate pain more effectively than any other anaesthetic method. In regional anaesthesia/analgesia, rare but serious complications make it necessary to always consider the risk-benefit ratio. The article discusses these issues and gives advice on effective and safe conduct. MATERIAL AND METHODS The article is based on non-systematic literature searches in the PubMed and Cochrane databases and our own experience from research and clinical work. RESULTS Regional anaesthesia is obtained by administering local anaesthetics near the spinal cord and nerve roots (spinal, epidural), spinal nerves (paravertebral), or close to peripheral nerves. Parts of the body will then become numb and paralysed. The same techniques are used for regional analgesia, but this is obtained by using more dilute solutions of local anaesthetics, and other analgesic drugs are often added. Pain impulses are inhibited, but sensation of touch and muscle functions are intact. Regional analgesia gives superior relief of pain provoked by movement. This facilitates early postoperative mobilization of patients, even after major surgery in weak patients. For these patients optimally performed regional analgesia may reduce postoperative morbidity and mortality better than general anaesthesia and opioid and non-opioid analgesics administered postoperatively. Infiltration of the wound with local anaesthetics followed by optimally dosed non-opioid and opioid analgesics is a good alternative for some types of surgery. The risk of spinal bleeding has increased due to increased patient age, routine thromboprophylaxis and frequent use of antihaemostatic drugs, including platelet inhibitors. Infections in the spinal cord are caused by insufficient hygiene. Selection of patients who are likely to benefit from regional anaesthesia/analgesia, strict hygienic precautions, optimal technique, close monitoring, and assistance from an acute pain team, as well as hospital protocols for handling rare but serious complications, have reduced the occurrence and consequences of serious complications. INTERPRETATION Optimal regional anaesthesia/analgesia may improve the postoperative result.
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Affiliation(s)
- Harald Breivik
- Institutt for sykehusmedisin, Universitetet i Oslo og Akuttklinikken, Anestesi Oslo universitetssykehus, Rikshospitalet 0027 Oslo, Norway.
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Niemi G, Breivik H. Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications. Scand J Pain 2010; 1:3-4. [DOI: 10.1016/j.sjpain.2009.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Geir Niemi
- Department of Anaesthesia and Intensive Care Medicine , Rikshospitalet , Oslo University Hospital , 0027 Oslo , Norway
| | - Harald Breivik
- Department of Anaesthesia and Intensive Care Medicine , Rikshospitalet , Oslo University Hospital , 0027 Oslo , Norway
- University of Oslo , Medical Faculty , Oslo , Norway
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