The Year in Thoracic Anesthesia: Selected Highlights from 2016

Acute pain after serratus anterior plane or thoracic paravertebral blocks for video-assisted thoracoscopic surgery: A noninferiority randomised trial

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.

The Anesthetic Management of Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery

Purpose of Review

This review focuses on describing the procedural and anesthetic management of patients undergoing nonintubated video-assisted thoracoscopy surgery.

Recent Findings

Most thoracic surgery is performed under general endotracheal anesthesia with either a double lumen endotracheal tube or a bronchial blocker. In an attempt to lessen the incidence and severity of postoperative complications, the nonintubated video-assisted thoracoscopic technique was developed, where the surgical procedure is performed under regional anesthesia with sedation. Currently, this technique is recommended for the elderly and in patients with severe cardiopulmonary disease who are at increased risk of complications after general anesthesia. It is the role of the anesthesia team to assist in the decisions whether the patient is a candidate and which block should be performed and to carefully monitor these patients in the operating room.

Summary

Nonintubated video-assisted thoracic surgery is an emerging technique with the goal of reducing postoperative complications. The anesthetic technique is highly variable and ranges from general anesthesia with a laryngeal mask airway with a truncal block to thoracic epidural anesthesia with minimal to no block. It is important to have excellent communication with the surgical team and the patient to ensure a safe, successful procedure.

Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry

OBJECTIVE

Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients.

METHODS

Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of Thoracic Surgery. Univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs were conducted.

RESULTS

We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. One-hundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m² ; a pre-operative forced expiratory volume in 1 second (FEV₁ ) ≤ 60%; a pre-operative arterial oxygen partial pressure (p_a O₂ ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV₁ ≤ 60% (1.9[1.1-3.4] OR [95% CI], P = 0.029); p_a O₂ ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023).

CONCLUSION

Intraoperative amount of crystalloid fluids should be kept below 6 mL/kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.