Thoracic Paravertebral Block Achieves Better Pain Control Than Erector Spinae Plane Block and Intercostal Nerve Block in Thoracoscopic Surgery: A Randomized Study

Pro's and con's of different blocks for postoperative analgesia after video-assisted thoracic surgery

PURPOSE OF REVIEW

Although there are a lot of studies examining the effects of different blocks for postoperative analgesia after video-assisted thoracic surgery (VATS), the results are controversial.

RECENT FINDINGS

Paravertebral block, serratus anterior plane block and erector spinae plane block appear to be effective and beneficial for post-VATS analgesia, but probably in different manners.

SUMMARY

All three blocks can be suggested for daily practice, the choice should be based on personal experience and preference of the anesthetist. Better studies are required for objective decision.

Comparative analysis of TPVB and ESPB for postoperative pain management in thoracic and breast surgeries

OBJECTIVE

This meta-analysis assesses the efficacy and safety of erector spinae block (ESPB) and paravertebral block (PVB) for managing postoperative pain in thoracic and breast surgeries.

DESIGN

Data from 12 randomized controlled trials (RCTs) published between 2019 and 2022 were included, and selected based on stringent criteria.

SETTING

The RCTs were conducted across various clinical settings, including operating theaters worldwide.

PATIENTS

The analysis involved 844 patients undergoing thoracic or breast surgery under regional anesthesia, representing diverse health statuses.

INTERVENTIONS

Patients received either PVB or ESPB, typically guided by ultrasound, for postoperative pain control.

MAIN FINDINGS

PVB demonstrated superior pain management during rest and mobility, requiring fewer additional analgesics than ESPB. Incidences of postoperative nausea and vomiting (PONV) and opioid consumption did not differ significantly between the methods. ESPB showed more effective block placement.

CONCLUSION

PVB is preferred for reducing analgesic requirements and managing postoperative pain, especially during rest and activity. ESPB offers advantages in block placement. Surgical type and patient preferences should guide the choice between PVB and ESPB, necessitating further research for optimized clinical application.

Effects of esketamine combined with dexmedetomidine on postoperative delirium and quality of recovery in elderly patients undergoing thoracoscopic radical lung cancer surgery: a randomized controlled trial

OBJECTIVE

This study aimed to investigate the effects of esketamine (Esk) combined with dexmedetomidine (Dex) on postoperative delirium (POD) and quality of recovery (QoR) in elderly patients undergoing thoracoscopic radical lung cancer surgery.

METHODS

In this prospective, randomized, and controlled study, 172 elderly patients undergoing thoracoscopic radical lung cancer surgery were divided into two groups: the Esk + Dex group (n = 86) and the Dex group a (n = 86). The primary outcome was the incidence of POD within 7 days after surgery and the overall Quality of Recovery-15 (QoR - 15) scores within 3 days after surgery. Secondary outcomes included postoperative adverse reactions, extubation time, PACU stay, and hospitalization time. Serum levels of IL-6, IL-10, S100β protein, NSE, CD3+, CD4+, and CD8+ were detected from T0 to T5.

RESULTS

Compared with the Dex group, the incidence of POD in the Esk + Dex group was significantly lower at 7 days after surgery (14.6% vs 30.9%; P = 0.013). The QoR - 15 score was significantly increased 3 days after surgery (P < 0.01). Levels of IL-6 and CD8+ were significantly decreased, and IL - 10 levels were significantly increased at T1-T2 (P < 0.05). At T1-T4, NSE levels were significantly decreased, while CD3+ and CD4+/CD8+ values were significantly increased (P < 0.01). At T1-T5, serum S100β protein concentration decreased significantly, and CD4+ value increased significantly (P < 0.01). The incidence of nausea/vomiting and hyperalgesia decreased significantly 48 hours after surgery (P < 0.01). The duration of extubation, PACU stay, and postoperative hospitalization were significantly shortened.

CONCLUSIONS

Esketamine combined with dexmedetomidine can significantly reduce the POD incidence and improve the QoR in patients undergoing thoracoscopic radical lung cancer surgery, which may be related to the improvement of cellular immune function.

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

Background

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

Methods

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

Results

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

Conclusion

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

Comparison of postoperative analgesia by thoracoscopic-guided thoracic paravertebral block and thoracoscopic-guided intercostal nerve block in uniportal video-asssited thoracic surgery: a prospective randomized controlled trial

BACKGROUND

Thoracoscopic-guided thoracic paravertebral nerve block (TG-TPVB) and thoracoscopic-guided intercostal nerve block (TG-INB) are two postoperative analgesia technology for thoracic surgery. This study aims to compared the analgesic effect of TG-TPVB and TG-INB after uniportal video-asssited thoracic surgery (UniVATS).

METHODS

Fifty-eight patients were randomly allocated to the TG-TPVB group and the TG-INB group. The surgical time of nerve block, the visual analog scale (VAS) scores, the consumption of sufentanil and the number of patient-controlled intravenous analgesic (PCIA) presses within 24 h after surgery, the incidence of adverse reactions were compared between the two groups.

RESULTS

The VAS scores were significantly lower during rest and coughing at 2, 6, 12, and 24 h in the TG-TPVB group than in the TG-INB group (P < 0.05). The consumption of sufentanil and the number of PCIA presses within 24 h after surgery were significantly lower in the TG-TPVB group than in the TG-INB group (P < 0.001).The surgical time of nerve block was significantly shorter in the TG-TPVB group than in the TG-INB group (P < 0.001). The incidence of bleeding at the puncture point was lower in the TG-TPVB group than that in the TG-INB group (P < 0.05).

CONCLUSION

TG-TPVB demonstrated superior acute pain relieve after uniVATS, shorter surgical time and non-inferior adverse effects than TG-INB.

Analgesic Efficacy of Single-Shot Erector Spinae Block in Video-Assisted Thoracoscopic Surgery: A Propensity Score-Matched Retrospective Cohort Study

Introduction Video-assisted thoracic surgery (VATS) is a minimally invasive surgical technique though effective analgesia remains a challenge. Erector spinae plane block (ESPB) has gained popularity due to its ease and safety of placement. In this study, we evaluated the analgesic efficacy of ESPB in patients undergoing VATS through a propensity score-matched retrospective cohort study. The primary outcome is the total opioid use in the first 12 postoperative hours. Methods We used binomial logistic regression to model whether patients received ESPB as a function of age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, and surgery type to generate a propensity score for each patient for matching. Results After screening 286 patients, 55 patients each in the ESPB and no-block groups were matched. ESPB was associated with a 1.2 mg (95% CI: -2.2 to -0.2) reduction in opioid use in IV hydromorphone equivalents when compared to no block. However, there was no reduction in the 12-hour pain score area under the curve or incidence of complications between the two groups. Conclusions ESPB was associated with a modest reduction in total opioid consumption although not a difference in pain score. While its analgesic efficacy may be limited, ESPB could be considered a component of multi-modal analgesia in VATS.

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.

Effects of perioperative electroacupuncture on postoperative gastrointestinal recovery after thoracoscopic lung surgery

OBJECTIVE

To study whether perioperative electroacupuncture (EA) can improve postoperative gastrointestinal recovery in patients receiving thoracoscopic lung surgery.

METHODS

This study was a single-center, prospective, randomized open-label trial. 180 patients who underwent video-assisted thoracoscopic segmentectomy or lobectomy were randomized to EA group (three sessions, 24 h prior to surgery, postoperative 4 h and 24 h) or usual care group (UC group). The primary outcomes were time to first flatus and defecation. Secondary outcomes included incidence and degree of abdominal distention, postoperative nausea and vomiting (PONV) and pain scores within 72 h after surgery, postoperative morphine use, time to ambulation, and length of hospital stay.

RESULTS

Time to first flatus (15.4 ± 3.2 h vs. 17.0 ± 3.7 h, P = 0.004) and time to first defecation (75.9 ± 7.9 vs. 79.7 ± 8.1 h, P = 0.002) in the EA group were significantly shorter than the UC group. The incidences of abdominal distension and PONV postoperative 24 h were significantly reduced in the EA group (P < 0.05). There was no difference in postoperative pain intensity, morphine use, time to ambulation, and length of hospital stay between the two groups (P>0.05).

CONCLUSION

Electroacupuncture is a simple intervention for accelerating postoperative gastrointestinal recovery and may be considered as an adjunct strategy in enhanced recovery protocols in thoracoscopic lung surgery.

Erector spinae plane block for postoperative pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

PURPOSE OF REVIEW

Thoracic surgery is evolving, necessitating an adaptation for perioperative anesthesia and analgesia. This review highlights the recent advancements in perioperative (multimodal) analgesia for minimally invasive thoracic surgery.

RECENT FINDINGS

Continuous advancements in surgical techniques have led to a reduction in surgical trauma. However, managing perioperative pain remains a major challenge, impeding postoperative recovery. The traditional neuraxial technique is now deemed outdated for minimally invasive thoracic surgery. Instead, newer regional techniques have emerged, and traditional approaches have undergone (re-)evaluation by experts and professional societies to establish guidelines and practices. Assessing the quality of recovery, evenafter discharge, has become a crucial factor in evaluating the effectiveness of these strategies, aiding clinicians in making informed decisions to improve perioperative care.

SUMMARY

In the realm of minimally invasive thoracic surgery, perioperative analgesia is typically administered through systemic and regional techniques. Nevertheless, collaboration between anesthesiologists and surgeons, utilizing surgically placed nerve blocks and an active chest drain management, has the potential to significantly improve overall patient care.

The Impact of Regional Nerve Blocks on Postoperative Delirium or Cognitive Dysfunction following Thoracic Surgery: A Systematic Review and Meta-Analysis

Regional nerve blocks (NBs) mitigate the occurrence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) in adult patients undergoing thoracic surgery. This study aimed to determine the exact effect of NBs on POCD and POD. Electronic databases, including PubMed, EMBASE, CINAHL, Scopus, and Web of Science, were searched for studies. The primary outcome was the incidence of POD or POCD. The secondary outcome was pain scores assessed 24 and 48 h postoperatively. We calculated the log odds ratio (LOR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). The LOR was converted to an odds ratio (OR). In the analysis of 1010 patients from seven randomized controlled trials, POD and POCD rates were 14.1% and 16.7%, respectively, in the NB group, and higher, at 27.3% and 35.2%, in the control group. NBs reduced the incidence of POD (OR, 0.44; 95%CI 0.30 to 0.64; p < 0.001; I2 = 0.00%) and POCD (OR, 0.43; 95%CI 0.24 to 0.76; p < 0.001; I2 = 0.00%). NBs reduced pain scores at 24 h (SMD, -2.60; 95%CI -3.90 to -1.30, p < 0.001; I2 = 97.68%) and 48 h (SMD, -1.80; 95%CI -3.18 to -0.41, p = 0.01; I2 = 98.14%) postoperatively. NBs mitigated the occurrence of POD and POCD in adult patients after thoracic surgery.

Effect of ultrasound-guided thoracic paravertebral block on perioperative analgesia in elderly patients undergoing video-assisted thoracic lobectomy in China: An interventional clinical randomized controlled trial

BACKGROUND

The aim of this study was to investigate the analgesic effect and safety of ultrasound-guided thoracic paravertebral block (UG-TPVB) in Chinese elderly patients undergoing video-assisted thoracic lobectomy (VATL) and to study the influence of aging factors on these effects.

METHODS

This study was a single-center, single-blind, prospective, randomized, controlled trial. A total of 300 patients scheduled for VATL were recruited and randomly divided into the UG-TPVB group (T group) and conventional anesthesia group (C group) according to the recruitment order, and subgroups were set up according to whether the age was ≥65 years old or not. The postoperative 12, 24, and 48 h static/dynamic visual analog scale (VAS) scores, intraoperative fentanyl consumption, postoperative extubation time, post-anesthesia care unit (PACU) stay time, hospitalization days, postoperative complications, and other indicators were compared between the two groups.

RESULTS

The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group. The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days were significantly lower than those of the C group. The incidence of postoperative 48 h urinary retention in the T group was significantly lower than that in the C group. These advantages showed no significant difference or slight difference between elderly patients and nonelderly patients, indicating that UG-TPVB did not influence the analgesic effect and safety of VATL patients by age or age difference.

CONCLUSION

UG-TPVB is an effective and safe perioperative analgesia method for elderly VATL patients. Its application improves the quality of life and prognosis of elderly VATL patients.

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.

Can Ultrasound-Guided Continuous Paravertebral Block Reduce the Incidence of Chronic Postsurgical Pain in Patients with Thoracoscopic Lung Cancer Surgery? A Randomized Controlled Trial

Background

Thoracoscopic lung cancer surgery is accompanied by severe pain. Both continuous paravertebral block (CPVB) and continuous wound infiltration (CWI) are widely used for perioperative analgesia in thoracoscopic surgery. However, the effects of these different methods on chronic postsurgical pain (CPSP) are still unknown. Patients and Methods. This prospective randomized controlled trial assessed the eligibility of 113 patients. Ninety-seven patients who met the inclusion criteria were randomly divided into a CPVB group and a CWI group, and 80 patients were analyzed in the final study. The primary outcome measures were the incidence and intensity of chronic postsurgical pain (CPSP) at 3, 6, and 9 months after surgery. The secondary outcome measures were the numerical rating scale (NRS) score of rest and activity at 12, 18, and 24 hours and on the 2nd, 3rd, and 7th days postoperatively; the Barthel Activities of Daily Living (ADL) score of activity levels on the 1st, 2nd, 3rd, and 7th days postoperatively; and the long-term quality of the life score at 3, 6, and 9 months postoperatively.

Results

The incidence of chronic postsurgical pain in the CWI group was significantly higher than that in the CPVB group at 3, 6, and 9 months after surgery (all P < 0.05). The intensity of chronic postsurgical pain was significantly decreased in the CPVB group at 3, 6, and 9 months after surgery (P < 0.05). NRS-R and NRS-A scores were significantly decreased in the CPVB group within the first week after thoracoscopic surgery (P < 0.001). ADL scores were increased in the CPVB group within 3 days postoperatively. However, there were no differences in the ADL score on the 7th postoperative day or the long-term quality of the life score at 3, 6, and 9 months postoperatively.

Conclusion

Continuous ultrasound-guided paravertebral block reduced the intensity of acute pain within 7 days postoperatively and reduced the incidence of chronic pain at 3, 6, and 9 months after surgery, but there was no significant advantage in long-term quality of life. This trial is registered with ChiCTR2000038505.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Analgesic Techniques for Rib Fractures-A Comprehensive Review Article

PURPOSE OF REVIEW

Rib fractures are a common traumatic injury that has been traditionally treated with systemic opioids and non-opioid analgesics. Due to the adverse effects of opioid analgesics, regional anesthesia techniques have become an increasingly promising alternative. This review article aims to explore the efficacy, safety, and constraints of medical management and regional anesthesia techniques in alleviating pain related to rib fractures.

RECENT FINDINGS

Recently, opioid analgesia, thoracic epidural analgesia (TEA), and paravertebral block (PVB) have been favored options in the pain management of rib fractures. TEA has positive analgesic effects, and many studies vouch for its efficacy; however, it is contraindicated for many patients. PVB is a viable alternative to those with contraindications to TEA and exhibits promising outcomes compared to other regional anesthesia techniques; however, a failure rate of up to 10% and adverse complications challenge its administration in trauma settings. Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) serve as practical alternatives to TEA or PVB with lower incidences of adverse effects while exhibiting similar levels of analgesia. ESPB can be performed by trained emergency physicians, making it a feasible procedure to perform that is low-risk and efficient in pain management. Compared to the other techniques, intercostal nerve block (ICNB) had less analgesic impact and required concurrent intravenous medication to achieve comparable outcomes to the other blocks. The regional anesthesia techniques showed great success in improving pain scores and expediting recovery in many patients. However, choosing the optimal technique may not be so clear and will depend on the patient's case and the team's preferences. The peripheral nerve blocks have impressive potential in the future and may very well surpass neuraxial techniques; however, further research is needed to prove their efficacy and weaknesses.

Comparison of erector spinae plane block with paravertebral block for thoracoscopic surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of erector spinae plane block versus paravertebral block for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of erector spinae plane block versus paravertebral block on thoracoscopic surgery.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through March 2022 for randomized controlled trials (RCTs) assessing the effect of erector spinae plane block versus paravertebral block on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Seven RCTs are included in the meta-analysis. Overall, compared with erector spinae plane block for thoracoscopic surgery, paravertebral block results in significantly reduced pain scores at 12 h (SMD = 1.12; 95% CI 0.42 to 1.81; P = 0.002) and postoperative anesthesia consumption (SMD = 1.27; 95% CI 0.30 to 2.23; P = 0.01), but these two groups have similar pain scores at 1-2 h (SMD = 1.01; 95% CI - 0.13 to 2.15; P 0.08) and 4-6 h (SMD = 0.33; 95% CI - 0.16 to 0.81; P = 0.19), as well as incidence of nausea and vomiting (OR 0.93; 95% CI 0.38 to 2.29; P = 0.88).

CONCLUSIONS

Paravertebral block may be better for the pain relief after thoracoscopic surgery than erector spinae plane block.

Analgesic comparison of erector spinae plane block with intercostal nerve block for thoracoscopic surgery: A meta-analysis of randomized controlled trials

INTRODUCTION

The analgesic efficacy of erector spinae plane block (ESPB) versus intercostal nerve block (ICNB) for thoracoscopic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the impact of ESPB versus ICNB on thoracoscopic surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane library databases through May 2023 for randomized controlled trials (RCTs) assessing the effect of ESPB versus ICNB on thoracoscopic surgery. This meta-analysis was performed using the random-effect model or fixed-effect model based on the heterogeneity.

RESULTS

Four RCTs and 203 patients are included in the meta-analysis. Overall, compared with ICNB for thoracoscopic surgery, ESPB results in significantly reduced pain scores at 48 hours (SMD [standard mean difference] = -3.49; 95% CI [confidence interval] = -6.76 to -0.21; P = .04), but demonstrated no impact on pain scores at 24 hours (SMD = -0.04; 95% CI = -1.24 to 1.16; P = .95), pain scores at 4 to 6 hours (SMD = -0.16; 95% CI = -2.02 to 1.71; P = .87), pain scores at 12 hours (SMD = -0.16; 95% CI = -2.38 to 2.05; P = .88) or analgesic consumption (SMD = 0.27; 95% CI = -0.80 to 1.35; P = .62).

CONCLUSIONS

ESPB may be comparable with ICNB for the postoperative pain control of thoracoscopic surgery.

The effect of body mass index on thoracic paravertebral block analgesia after video-assisted thoracoscopic surgery; a prospective interventional study

BACKGROUND

To investigate the effects of body mass index (BMI) on intensity postoperative pain in patients who underwent thoracic paravertebral block (TPVB) for postoperative analgesia after video-assissted thoracoscopic surgery (VATS).

METHODS

Patients aged 18-80 years, ASA I-III, and BMI 18-40 kg/m2 who underwent elective VATS were included in the study. The patients were divided into 3 groups according to their BMI levels. TPVB was performed under ultrasound-guidance at the fifth thoracic vertebrae, and 30 ml of 0.25% bupivacaine was injected. The patient-controlled analgesia (PCA) was performed by using morphine and multimodal analgesia was performed. As a rescue analgesic agent, 0.5 mg/kg tramadol was given to patients intravenously when a score of visual analog scale (VAS) at rest was ≥ 4. The primary outcome was determined as VAS scores at rest and cough. Secondary outcomes were determined as postoperative morphine consumption, additional analgesic requirement, and side effects.

RESULTS

The post-hoc test revealed that the VAS resting scores at the 4th hour (p: 0.007), 12th hour (p: 0.014), and 48th hour (p: 0.002) were statistically significantly lower in Group I compared to Group II. Additionally, VAS resting scores were also statistically significantly lower in Group I compared to Group III at all time points (p < 0.05). Similarly, the post-hoc test indicated that the VAS coughing scores at the 4th hour (p: 0.023), 12th hour (p: 0.011), and 48th hour (p: 0.019) were statistically significantly lower in Group I compared to Group II. Moreover, VAS coughing scores were statistically significantly lower in Group I compared to Group III at all time points (p < 0.001). Furthermore, there were statistically significant differences in terms of additional analgesic use between the groups (p: 0.001). Additionally, there was a statistically significant difference in terms of morphine consumption via PCA and morphine milligram equivalent consumption between the groups (p < 0.001).

CONCLUSIONS

Higher postoperative VAS scores with TPVB applied in obese patients and the consequent increase in additional analgesics and complications require more specific postoperative management in this patient group.

Erector spinae plane block versus intercostal nerve block for postoperative analgesia in lung cancer surgery

BACKGROUND

A recent trend in postoperative analgesia for lung cancer surgery relies on regional nerve blocks with decreased opioid administration. Our study aims to critically assess the continuous ultrasound-guided erector spinae plane block (ESPB) at our institution and compare it to a standard regional anesthetic technique, the intercostal nerve block (ICNB).

PATIENTS AND METHODS

A prospective randomized-control study was performed to compare outcomes of patients, scheduled for video-assisted thoracoscopic (VATS) lung cancer resection, allocated to the ESPB or ICNB group. Primary outcomes were total opioid consumption and subjective pain scores at rest and cough each hour in 48 h after surgery. The secondary outcome was respiratory muscle strength, measured by maximal inspiratory and expiratory pressures (MIP/MEP) after 24 h and 48 h.

RESULTS

60 patients met the inclusion criteria, half ESPB. Total opioid consumption in the first 48 h was 21. 64 ± 14.22 mg in the ESPB group and 38.34 ± 29.91 mg in the ICNB group (p = 0.035). The patients in the ESPB group had lower numerical rating scores at rest than in the ICNB group (1.19 ± 0.73 vs. 1.77 ± 1.01, p = 0.039). There were no significant differences in MIP/MEP decrease from baseline after 24 h (MIP p = 0.088, MEP p = 0.182) or 48 h (MIP p = 0.110, MEP p = 0.645), time to chest tube removal or hospital discharge between the two groups.

CONCLUSIONS

In the first 48 h after surgery, patients with continuous ESPB required fewer opioids and reported less pain than patients with ICNB. There were no differences regarding respiratory muscle strength, postoperative complications, and time to hospital discharge. In addition, continuous ESPB demanded more surveillance than ICNB.

Minimally Invasive Surgery in Non-Small Cell Lung Cancer: Where Do We Stand?

In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.

The analgesic efficacy of erector spinae plane block versus paravertebral block in thoracic surgeries: a meta-analysis

Background

Acute postoperative pain after thoracic surgery might lead to chronic postsurgical pain (PSP), which lowers quality of life. The literature suggests thoracic paravertebral block (PVB) as a pain management approach. The ESPB (erector spinae plane block) is regarded to be an effective PVB alternative. The analgesic efficacy of the two analgesic therapies is controversial. The purpose of this study is to compare the analgesic efficacy of ESPB and PVB in preventing acute PSP.

Methods

We searched relevant articles in PubMed, Cochrane Library, Embase, Web of Science, and Google Scholar databases. The primary outcome was postoperative pain score, with secondary outcomes including analgesic consumption, the frequency of rescue analgesia, and postoperative nausea and vomiting.

Results

This meta-analysis included ten RCTs with a total of 670 patients. PVB significantly lowered the pain scores at movement at 12 h following surgery as compared to the ESPB. The PVB group used much less opioids within 24 h after surgery compared to the ESPB group. However, there were no significant differences between the groups in terms of postoperative rescue analgesia or in the incidence of postoperative nausea and vomiting (p > 0.05).

Conclusion

PVB produced superior analgesia than ESPB in patients who underwent thoracic surgeries. In addition, PVB demonstrated greater opioid sparing effect by consuming much less opioids.

Systematic review registration

This trial is registered on PROSPERO, number CRD42023412159.

Comparison of the effects of one-level and bi-level pre-incisional erector spinae plane block on postoperative acute pain in video-assisted thoracoscopic surgery; a prospective, randomized, double-blind trial

BACKGROUND

This prospective, randomized, double-blind trial aimed to compare the postoperative analgesic efficacy of One-Level pre-incisional erector spinae plane block (ESPB) and Bi-Level pre-incisional ESPB in patients undergoing video-assisted thoracic surgery (VATS).

METHODS

This pilot trial was conducted between April 2022 and February 2023 with sixty patients. The patients were randomly divided into two groups. In One-Level ESPB Group (n = 30) block was performed at the thoracal(T)5 level with the 30 ml 0.25% bupivacaine. In the Bi-Level ESPB Group (n = 30) block was performed at T4 and T6 levels by using 15 ml of 0.25% bupivacaine for each level. In the postoperative period, 50 mg dexketoprofen every 12 h and 1 g paracetamol every 8 h were given intravenously (IV). Patient-controlled analgesia (PCA) prepared with morphine was applied to the patients. 0.5 mg/kg of tramadol was administered via IV for rescue analgesia. Visual analog scale (VAS) scores were recorded in the postoperative 1st, 2nd, 4th, 12th, 24th, and 48th -hours. The need for additional analgesics and side effects were recorded. In two groups, patients' demographics and postoperative hemodynamic data were recorded.

RESULTS

VAS scores at resting were statistically significantly higher at the 1st (p: 0.002) and 4th -hour (p: 0.001) in the One-Level ESPB. When the groups were evaluated in terms of VAS coughing scores, the 4th -hour (p: 0.001) VAS coughing scores results were found to be statistically significantly higher in the One-Level ESPB group. In terms of VAS values evaluated during follow-up, the rates of VAS coughing score > 3 values were found to be statistically significantly lower in the Bi-Level ESPB group (p: 0.011). There was no statistically significant difference between the groups in terms of side effects, morphine consumption, and additional analgesic use (p > 0.05).

CONCLUSIONS

Adequate analgesia was achieved in the early postoperative period in the group treated with Bi-Level ESPB with similar morphine consumption and side effects. This may be an advantage, especially in the early postoperative period when the pain is quite intense.

Multimodal evaluation of locoregional anaesthesia efficacy on postoperative pain after robotic pulmonary lobectomy for NSCLC: a pilot study

The primary objectives of the study were to analyse the robotic approach and ultrasound-guided paravertebral block compared to thoracoscopic intercostal nerve block after robotic pulmonary lobectomy on postoperative pain and opioids use. The secondary objectives were to analyse and compare patients' necessity of additional antalgic drugs and patients' performance during respiratory therapy, following robotic surgery and in the two groups. Consecutively, 52 patients undergoing robotic pulmonary lobectomies were treated either with ropivacaine-based intercostal nerve block or paravertebral block from February 2022 to October 2022. When necessary, morphine was administered at day 1. Acetaminophen was administered as an additional antalgic drug on demand up to 3 g per day. Pain was measured 1 h after the end of the surgical procedure and daily through the pain numeric rating scale (NRS). Morphine administration rate and per day and total additional administrations of acetaminophen were recorded. Pain and opioids administration was measured 1 month after the procedure. Data were analysed in the overall population and in the intercostal nerve block group VS paravertebral block group. Overall, 34.6% of the patients required morphine administration and 51.7% of the patients required at least daily acetaminophen administration up to discharge. At 1 month postoperatively, four patients presented with chronic pain and one still was under opioid medication. At intergroup analysis, the paravertebral block group demonstrated lower NRS at fixed time points (p < 0.0001) and lower morphine consumption (45.7%VS11.8%; p = 0.02). Acetaminophen rescue administration at fixed time points was lower in the paravertebral block group (p < 0.0001) and mobility and dynamic pain resulted in better results (p = 0.03; p = 0.04). At 1 month, no differences were found between study groups. Similarly to other minimally invasive techniques, postoperative pain may arise after robotic pulmonary lobectomy. Paravertebral bloc can help to reduce postoperative pain as well as morphine and antalgic drugs administration and improve early mobilization.

Analgesic effectiveness of serratus anterior plane block in patients undergoing video-assisted thoracoscopic surgery: a systematic review and updated meta-analysis of randomized controlled trials

BACKGROUND

Serratus anterior plane block (SAPB) is a promising regional technique for analgesia in thoracic surgery. Till now, several randomized controlled trials (RCTs) have explored the effectiveness of SAPB for postoperative pain control in patients undergoing video-assisted thoracoscopic surgery (VATS), but the sample sizes were small and conclusions remained in controversy. Therefore, we conducted the present systematic review and meta-analysis.

METHODS

RCTs evaluating the analgesic performance of SAPB, comparing to control methods (no block, placebo or local infiltration anesthesia), in patients undergoing VATS were searched in PubMed, EMBASE, Web of Science and Cochrane Library from inception to December 31, 2022. Mean difference (MD) and corresponding 95% confidence interval (95%CI) were calculated for postoperative pain scores at various time points, postoperative opioid consumption and length of hospital stay. Pooled relative risk (RR) with 95%CI were calculated for the risk of postoperative nausea and vomiting (PONV) and dizziness. A random-effect model was applied.

RESULTS

A total of 12 RCTs (837 participants) were finally included. Compared to control group, SAPB had significant reductions of postoperative pain scores at 2 h (MD = -1.58, 95%CI: -1.86 to -1.31, P < 0.001), 6 h (MD = -2.06, 95%CI: -2.74 to -1.38, P < 0.001), 12 h (MD = -1.72, 95%CI: -2.30 to -1.14, P < 0.001) and 24 h (MD = -1.03, 95%CI: -1.55 to -0.52, P < 0.001), respectively. Moreover, SAPB conferred a fewer postoperative opioid consumption (MD = -7.3 mg of intravenous morphine equivalent, 95%CI: -10.16 to -4.44, P < 0.001) and lower incidence of PONV (RR = 0.56, 95%CI: 0.41 to 0.77, P < 0.001). There was no difference between both groups regarding length of hospital stay and risk of dizziness.

CONCLUSION

SAPB shows an excellent performance in postoperative pain management in patients undergoing VATS by reducing pains scores, postoperative opioid consumption and incidence of PONV. However, due to huge heterogeneity, more well-designed, large-scale RCTs are needed to verify these findings in the future.

Regional Anesthesia With Paravertebral Blockade Is Associated With Improved Outcomes in Patients Undergoing Minithoracotomy Cardiac Surgery

OBJECTIVE

Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS.

METHODS

Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors.

RESULTS

A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups.

CONCLUSIONS

The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.

Effects of Erector Spinae Plane Block on Postoperative Pain and Quality of Recovery Questionnaire Scores in Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study

OBJECTIVES

Opioid-free anesthesia with erector spinae plane block (ESPB) has the potential to decrease perioperative opioid need, thereby potentially reducing related complications. This study aimed to compare opioid-free anesthesia with ESPB and standard opioid-based balanced anesthesia in patients undergoing video-assisted thoracic surgery (VATS) in terms of postoperative opioid need (through patient control analgesia) as well as postoperative pain management, recovery quality, and opioid-related side effects.

METHODS

Seventy-four patients, ranging in age from 18 to 75 years, who underwent lobectomy with VATS were included in this randomized-controlled study. The opioid-free group had ESPB, and no opioid was used during anesthesia maintenance. The opioid group received standard anesthesia with opioid use. Postoperative morphine requirement, postoperative pain as measured by the visual analog scale (VAS), intraoperative vital parameters, recovery quality using the Quality of Recovery-40 (QoR-40) questionnaire, and opioid-related complications were compared between groups.

RESULTS

The opioid-free group received a significantly lower total dose of morphine during the first 24 postoperative hours through patient-controlled analgesia (PCA) when compared to the opioid group (7.3±3.4 vs. 21.7±7.9 mg, p<0.001). In addition, the opioid-free group had significantly better postoperative pain scores and QoR-40 scores (184.3±7.5 versus 171.2±6.4, p<0.001), shorter times to mobilization (5.5±0.8 versus 8.1±1.1 hours, p<0.001), and oral intake (5.8±0.6 versus 6.4±0.6 hours, p<0.001), as well as less frequent opioid-related side effects.

CONCLUSION

The findings of this study suggest that opioid-free anesthesia with ESPB represents a promising option for patients undergoing lobectomy with VATS. It has the potential to decrease postoperative opioid need, improve postoperative pain management, and reduce opioid-related unwanted consequences.

Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study

BACKGROUND

The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS).

METHODS

Seventy-five patients were evaluated (three groups: ESPB, TPVB, or combined ESPB-TPVB [comb-group], each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual Analog Scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements.

RESULTS

VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to comb-group; and in all but 24 hours measurement to ESPB) ESPB and comb-group had similar VAS in all measurements (e.g., median VAS in ESPB, TPVB and comb-group at 8^th hour: 3-4-2 [P=0.014] during coughing and 2-3-1 in rest [P<0.001], respectively). Morphine consumption was statistically significantly higher in TPVB than comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (P=0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than comb-group (P=0.009).

CONCLUSIONS

ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than comb-group. ESPB and comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Comparison of analgesic efficacy of different local anesthetic volumes for erector spinae plane block in thoracotomy patients; a prospective randomized trial

BACKGROUND

Erector spinae plane block (ESPB) is a thoracic wall block that has been used frequently in recent years. It was aimed to compare the analgesic efficacy of bupivacaine in different volumes for ESPB in patients undergoing thoracotomy.

METHODS

Patients who were in the age range of 18 to 65 years, ASA I-III, had a body mass index (BMI) of 18-30 kg/m² and were undergoing thoracotomy were included in the study. Patients were assigned to ESPB with 30 ml 0.25% bupivacaine (Group-1) or ESPB with 20 ml 0.25% bupivacaine (Group-2) groups according to the analgesia protocol. In the postoperative care unit, intravenous morphine was administered via a patient-controlled analgesia pump for 24 h. A paracetamol dose of 1 g every 8 h and a dexketoprofen dose of 50 mg twice daily were administered iv for multimodal analgesia.

RESULTS

Visual analog scale (VAS) resting scores, the 1^st (p = 0.001), 2^nd (< 0.001), 4^th (< 0.001), 8^th (< 0.001), 16^th (< 0.010), 24^th (< 0.044), and 48^th (< 0.005)-hour VAS resting results were found to be statistically significantly higher in the 20 ml group than the 30 ml group. VAS cough scores were statistically significantly higher in the 20 ml group at the 1^st (< 0.003), 2^nd (< 0.001), 4^th (< 0.001), 8^th (< 0.001), 16^th (< 0.004), 24^th (< 0.031), and 48^th (< 0.009)-hour. Morphine consumption, and additional analgesic use were found to be statistically significantly higher in the 20 ml group than in the 30 ml group (p < 0.001, p = 0.001, respectively). There was no statistically significant difference between the groups in terms of side effects (p > 0.05).

CONCLUSIONS

The results of ESPB applied with 20 ml and 30 ml of local anesthetic before the surgical incision in thoracotomy patients showed that the use of 30 ml of local anesthetic provided more effective analgesia. In addition, similar side-effect rates show that 30 ml of local anesthetic can be used safely.

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.

Paravertebral block versus erector spinae plane block for analgesia in modified radical mastectomy: a randomized, prospective, double-blind study

BACKGROUND

Pain control after breast surgery is crucial and supported with regional techniques. Paravertebral block (TPVB) is shown to be effective in postoperative pain management. Erector spinae plane block (ESPB) is assumed to have a similar analgesic effect as an easier and safer block. Our aim was to compare TPVB and ESPB for modified radical mastectomy (MRM) in terms of analgesic efficiency and dermatomal spread.

METHODS

Patients were randomized into Group E (ESPB) and Group P (TPVB). Total 83 patients completed study 42 in Group E and 41 in Group P. Blocks were performed under ultrasonography with 20 mL 0.375% bupivacaine at T4 prior to surgery. T1-10 dermatomal block was examined via pin-prick sensation on the midaxillary and midclavicular lines. Primary outcome was 24-hour morphine consumption. Dermatomal coverage, postoperative 0th minute, 30th minute, 1st, 4th, 6th, 12th and 24th hours pain scores, rescue analgesia requirement and adverse events were secondary outcomes.

RESULTS

Morphine consumption was lower in Group P (19.2±2.9 vs. 21±3.1, P=0.007; mean difference 1.8 mg, 95%CI=0.48-3.1 mg). The number of dermatomes with total loss of sensation was higher in Group P. Pain scores were significantly lower in Group P at all time points. The incidence of complications and adverse events was similar in both groups.

CONCLUSIONS

Thoracal paravertebral block reduced morphine consumption compared to ESPB after MRM, albeit a small difference. A through coverage of TPVB may be preferred with experienced operators in MRM due to lower pain scores.

Comparison of the effects of ultrasound-guided thoracic paravertebral block and erector spinae plane block on postoperative acute and chronic pain in patients undergoing video-assisted thoracoscopic surgery

Aim: The aim of the study was to compare the effects of ultrasound (US)-guided Erector spinae plane block (ESPB) and thoracic paravertebral block (TPVB) on postoperative acute and chronic pain. Material and Method: Patients aged range of 18 to 80 years and underwent video-assisted thoracoscopic surgery (VATS) were included in a single-blinded randomized trial. All patients were informed about the study and their written consent was obtained. The primary outcome was determined as acute postoperative visual analog scale (VAS) scores, and secondary outcomes were postoperative morphine consumption and the incidence of chronic pain. US-guided ESPB and TPVB were performed to all patients and they were assigned randomly to ESPB (Group 1) and TPVB (Group 2) groups according to the analgesia protocol. Results: Visual analog scale (VAS) resting and VAS cough scores at the 1st, 2nd, 4th, 8th, and 16th hours were found to be statistically significantly higher in the TPVB group than in the ESPB group (p&lt;0.05) Morphine consumption (p:0.042) and additional analgesic (p:0.037) use were found to be statistically significantly higher in the TPVB group compared to the ESPB group. As complications, only nausea and vomiting were observed with no significant difference between the groups (p&gt;0.05). There was no significant difference in terms of postoperative 30th and 90th day pain characteristics between the groups (p&gt;0.05). Conclusion: ESPB was superior to TPVB in terms of acute postoperative pain management, morphine consumption, and side effects, but the incidence of chronic pain in the first and third months after surgery was similar in both groups.

Efficacy of ultrasound-guided single-injection erector spinae plane block for thoracoscopic wedge resection: a prospective randomized control trial

Background

Despite advances in minimally invasive thoracic surgery, patients remain at risk of adverse pulmonary events with suboptimal postoperative analgesia. Novel methods of regional analgesia are warranted. Our objective was to prospectively evaluate the impact of ultrasound-guided single-injection erector spinae plane (ESP) block with ropivacaine compared with placebo control on standard of care postoperative recovery in subjects undergoing video-assisted thoracoscopic surgery (VATS) wedge resection.

Methods

This prospective, randomized, placebo-controlled, double-blinded study was conducted at a tertiary thoracic surgical center. Consecutive subjects undergoing VATS wedge resection were randomized to receive a single-injection ESP block with 0.5% ropivacaine or 0.9% saline placebo, in addition to the current standard of care of multimodal analgesia including patient-controlled analgesia and surgical local anesthetic wound infiltration. The primary outcome was difference in 40-point Quality of Recovery (QoR-40) on day 1 postoperatively. The secondary outcomes included opioid consumption, Visual Analog Pain Scale (VAS) score, time spent in the postanesthesia care unit (PACU), and block-related and postoperative complications.

Results

Eighty subjects were enrolled, 40 in each group, with 76 completing follow-up (38 subjects in each group). There was no difference in the median QoR-40 score between groups, 169.5 for the ropivacaine group and 172.5 for the control group (difference 3, p=0.843). No significant differences existed between groups in all secondary outcomes, with the exception of the ropivacaine group having lower VAS pain scores measured at 1 hour postoperatively and a shorter duration of stay in the PACU of 117 min.

Conclusions

Following VATS wedge resection, the addition of an ESP block with ropivacaine to standard multimodal analgesia is unlikely to add meaningful clinical value.

Trial registration number

NCT03419117.

The Analgesic Efficacy of the Single Erector Spinae Plane Block with Intercostal Nerve Block Is Not Inferior to That of the Thoracic Paravertebral Block with Intercostal Nerve Block in Video-Assisted Thoracic Surgery

This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain (0–10, where 10 = worst imaginable pain) in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction (1–5, where 5 = extremely satisfied) and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups (PACU: 2.0 (1.8, 5.3) vs. 2.0 (2.0, 4.0), p = 0.970; 24 h: 2.0 (0.8, 3.0) vs. 2.0 (1.0, 3.5), p = 0.993; 48 h: 1.0 (0.0, 3.5) vs. 1.0 (0.0, 5.0), p = 0.985). The upper limit of the 95% CI for the differences (PACU: 1.428, 24 h: 1.052, 48 h: 1.176) was within the predefined noninferiority margin of 2. Total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, p = 0.767) and satisfaction scores (3.5 (3.0, 4.0) vs. 4.0 (3.0, 5.0), p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.

Comparison of the efficacy of ultrasound-guided erector spinae plane block and thoracic paravertebral block combined with intercostal nerve block for pain management in video-assisted thoracoscopic surgery: a prospective, randomized, controlled clinical trial

Background

The objective of this study was to compare analgesic efficacy of erector spinae plane block(ESPB) and thoracic paravertebral block(TPVB) combined with intercostal nerve block(ICNB) after video assisted thoracoscopic surgery(VATS).

Methods

Patients were enrolled into three groups according to analgesia technique as ICNB, TPVB + ICNB or ESPB + ICNB: respectively Group C(n = 58), Group T (n = 56) and Group E (n = 59). Patients were followed up by a trained data investigator at 2, 6, 8, 12, 24, 48 h after surgery, and the visual analog scale(VAS) at rest and coughing were recorded. The moderate and severe pain mean VAS ≥ 4 when coughing. The postoperative opioids consumption, incidence of postoperative nausea and vomiting (PONV), supplementary analgesic requirements within 48 h, length of stay in PACU, ambulation time, postoperative days in hospital and potential side effects, such as hematoma, hypotension, bradycardia, hypersomnia, uroschesis, pruritus and apnea were recorded.

Results

The incidence of moderate-to-severe pain was no significant difference between 3 groups in 24 h and 48 h (P = 0.720). There was no significant difference among the 3 groups in the resting pain intensity at 2, 6, 8, 12, 24 and 48 h after surgery(P > 0.05). In 2-way analysis of variance, the VAS when coughing in Group T were lower than that in Group C (mean difference = 0.15, 95%CI, 0.02 to 0.29; p = 0.028). While no difference was found when comparing Group E with Group C or Group T(P > 0.05). There was no difference between the three groups in the sufentanil consumption( within 24 h p = 0.472, within 48 h p = 0.158) and supplementary analgesic requirements(p = 0.910). The incidence of PONV and the length of stay in PACU, ambulation time and postoperative days in hospital were comparable in the 3 groups(P > 0.05). Two patients from Group T developed hematoma at the site of puncture.

Conclusions

The present randomized trial showed that the analgesic effect of TPVB + ICNB was superior to that of INCB after VATS, the analgesic effect of ESPB was equivalent to that of TPVB and ICNB.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2100049578. Registered 04 Aug 2020 Retrospectively registered.

Evaluation of pain and opioid consumption in local preemptive anesthesia and the erector spine plane block in thoracoscopic surgery: A randomized clinical trial

OBJECTIVE

assess pain and opioid consumption in patients undergoing anesthetic techniques of spinal erector plane block and local anesthetic block in video-assisted thoracic surgery in the immediate postoperative period.

METHODS

ninety-two patients undergoing video assisted thoracic surgery were randomized to receive ESPB or BAL before starting the surgical procedure. Using the numerical verbal scale, the primary outcome assessed was the patient's pain in the immediate postoperative period (POI). The secondary outcome comprises the assessment of opioid consumption in the IPP by quantifying the medication used in an equianalgesic dose of morphine expressed in milligrams, in the immediate post-anesthetic recovery period, 6h, 12h, and 24h after surgery.

RESULTS

the EVN scores in the LBA and ESPB group in the POI had a mean of 0,8 (±1,89) vs 0,58 (±2,02) in the post-anesthesia care room (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) in 6 hours of POI, 0,84 (±1,74) vs 1,19 (±2,01) within 12 hours of POI and 0,95 (±1,88) vs 1 ( ±1,66) within 24 hours of POI, all with p>0.05. Mean opioid consumption in the BAL and ESPB groups in the POI was 12.9 (± 10.4) mg vs 14.9 (±10.2) mg, respectively, with p = 0.416. Sixteen participants in the ESPB group and seventeen in the BAL group did not use opioids during the first 24 hours of the PO analyzed.

CONCLUSION

local anesthesic block and ESP block techniques showed similar results in terms of low pain scores and opioid consumption during the period evaluated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Regional analgesia techniques for video-assisted thoracic surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). This study aimed to determine the relative efficacy of regional analgesic interventions for VATS using a network meta-analysis (NMA).

METHODS

We searched the Medline, EMBASE, Cochrane Controlled Trial Register, Web of Science, and Google Scholar databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of the following interventions: control, thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus plane block (SPB), and intercostal nerve block (INB). The primary outcome was opioid consumption during the first 24-h postoperative period. Pain scores were also collected during three different postoperative periods: the early (0-6 h), middle (6-18 h), and late (18-24 h) periods.

RESULTS

A total of 21 RCTs (1391 patients) were included. TPVB showed the greatest effect on opioid consumption compared with the control (mean difference [MD] = -13.2 mg; 95% CI [-16.2, -10.1]). In terms of pain scores in the early period, ESPB had the greatest effect compared to control (MD = -1.6; 95% CI [-2.3, -0.9]). In the middle and late periods, pain scores showed that TPVB, ESPB and INB had superior analgesic effects compared to controls, while SPB did not.

CONCLUSIONS

TPVB had the best analgesic efficacy following VATS, though the analgesic efficacy of ESPBs was comparable. However, further studies are needed to determine the optimal regional analgesia technique to improve postoperative pain control following VATS.

Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review

Background and Objective

Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.

Methods

We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader.

Key Content and Findings

There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate.

Conclusions

The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.

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].

Anatomical classification and clinical application of thoracic paraspinal blocks

Various techniques for regional anesthesia and analgesia of the thorax are currently being used in clinical practice. A recent international consensus has anatomically classified paraspinal blocks in the thoracic spinal region into the following four types: paravertebral, retrolaminar, erector spinae plane, and intertransverse process blocks. These blocks have different anatomical targets; thus, the spreading patterns of the injectates differ and can consequently exhibit different neural blockade characteristics. The paravertebral block directly targets the paravertebral space just outside the neuraxial region and has an analgesic efficacy comparable to that of the epidural block; however, there are multiple potential risks associated with this technique. Retrolaminar and erector spinae plane blocks target the erector spinae plane on the vertebral lamina and transverse process, respectively. In anatomical studies, these two blocks showed different injectate spreading patterns to the back muscles and the fascial plane. In cadaveric studies, paravertebral spread was identified, but variable. However, numerous clinical reports have shown paravertebral spread with erector spinae plane blocks. Both techniques have been found to reduce postoperative pain compared to controls; however, the results have been more inconsistent than with the paravertebral block. Finally, the intertransverse process block targets the tissue complex posterior to the superior costotransverse ligament. Anatomical studies have revealed that this block has pathways that are more direct and closer to the paravertebral space than the retrolaminar and erector spinae plane blocks. Cadaveric evaluations have consistently shown promising results; however, further clinical studies using this technique are needed to confirm these anatomical findings.

Thoracic Paravertebral Block Combined with General Anaesthesia or General Anaesthesia Alone for Thoracoscopic Lung Adenocarcinoma Surgery: A Retrospective Study

Purpose

To investigate the effects of ultrasound-guided thoracic paravertebral block combined with general anaesthesia or general anaesthesia alone for thoracoscopic lung adenocarcinoma surgery, and to provide new thoughts for improving the clinical outcomes.

Methods

This was a retrospective study. Data were retrieved for 195 patients with lung adenocarcinoma undergoing elective radical lobectomy via video-assisted thoracoscopy between January 2018 and August 2019 in The Second Hospital of Shandong University, including 86 patients who received thoracic paravertebral block (TPVB) combined with general anaesthesia (group TG), and 109 patients who received general anaesthesia alone (group GA). All patients were given self-controlled intravenous analgesia pump for 48 h after surgery. The primary outcome was the recurrence-free survival 2 years postoperatively (the time between surgery and the earliest date of recurrence, metastasis or lung cancer-cause death). The secondary outcomes included the average numeric rating scale (NRS) scores within 48 h postoperatively, the first time of postoperative ambulation, duration of chest tube drainage, length of postoperative hospitalization, perioperative opioid consumption and the postoperative side effects.

Results

There were no statistical differences in the recurrence-free survival 2 years postoperatively between groups (Multivariate hazard ratio 0.706, 95% CI 0.126–3.941, P=0.691). The average NRS scores within 48 h postoperatively were significantly lower in group TG (P<0.05). The first time of postoperative ambulation, duration of chest tube drainage, and length of postoperative hospitalization in group TG were significantly reduced (P<0.05). Opioid consumption was significantly decreased in group TG (P<0.01). Finally, the incidence of postoperative nausea and vomiting (PONV) was significantly lower in group TG (P<0.05).

Conclusion

TPVB for thoracoscopic lung adenocarcinoma surgery did not improve the recurrence-free survival 2 years postoperatively compared with general anaesthesia alone, but it significantly enhanced the postoperative analgesia effect, reduced opioid consumption as well as side effects, and accelerated postoperative early recovery.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-2100050454).

Avaliação da dor e consumo de opioides em anestesia preemptiva local e do plano eretor da espinha em cirurgia torácica videotoracoscópica: Um ensaio clínico randomizado

RESUMO Objetivo: avaliar a dor e o consumo de opioides dos pacientes submetidos a técnicas anestésicas de bloqueio do plano eretor da espinha (ESPB) e bloqueio anestésico local (LBA) em cirurgia torácica vídeo assistida no período pós-operatório imediato (POI). Métodos: noventa e dois pacientes submetidos a cirurgia torácica videotoracoscópica foram randomizados aleatoriamente para receberem ESPB ou LBA antes do início do procedimento cirúrgico. O desfecho primário avaliado foi a dor do paciente no POI através da escala verbal numérica. O desfecho secundário avaliou o consumo de opioides através da quantificação da medicação usada em dose equianalgésica de morfina expressa em miligramas, no período de recuperação pós-anestésica imediata, 6h, 12h e 24h após a cirurgia. Resultados: os escores da Escala Verbal Numérica de dor (EVN) no grupo LBA e ESPB no POI, respectivamente, tiveram média de 0,8 (±1,89) vs 0,58 (±2,02) na sala de recuperação pós anestesia (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) em 6 horas do POI, 0,84 (±1,74) vs 1,19 (±2,01) em 12 horas do POI e 0,95 (±1,88) vs 1 ( ±1,66) em 24 horas do POI, todos com p>0,05. O consumo médio de opioides no grupo LBA e ESPB foi de 12,9 (±10,4) mg vs 14,9 (±10.2) mg, respectivamente, com p=0.416. Dezesseis participantes do grupo ESPB e dezessete do grupo LBA não utilizaram opioides durante as primeiras 24 horas do PO. Conclusões: as técnicas de bloqueio LBA e ESPB apresentaram resultados semelhantes em termos de baixos escores de dor e consumo de opioides durante o período avaliado.

Comparison of the analgesic effect of ultrasound-guided paravertebral block and ultrasound-guided retrolaminar block in Uniportal video-assisted Thoracoscopic surgery: a prospective, randomized study

Background

The optimal modality for postoperative analgesia after uniportal video-assisted thoracoscopic surgery (UVATS) for the treatment of lung cancer has not yet been determined. Both ultrasound-guided paravertebral block (PVB) and retrolaminar block (RLB) have been reported to be successful in providing analgesia after UVATS. However, which block technique provides superior analgesia after UVATS is still unclear. This randomized study was designed to compare the postoperative analgesic effects and adverse events associated with ultrasound-guided PVB and RLB after UVATS.

Methods

Sixty patients with lung cancer were randomized to undergo ultrasound-guided PVB (group P) or ultrasound-guided RLB (group R). In group P, 30 mL of 0.5% ropivacaine was injected at the T3 and T5 levels via ultrasound-guided PVB (15 mL at each level on the operative side). In group R, 30 mL of 0.5% ropivacaine was injected at the T3 and T5 levels via ultrasound-guided RLB (15 mL at each level on the operative side). The primary outcome was the numerical rating scale (NRS) score within 48 h after surgery. The secondary outcomes were total postoperative sufentanil consumption, time to first analgesic request and adverse events.

Results

At 3, 6, 12, 24, 36 and 48 h postoperatively, the NRS score at rest in group P was lower than that in group R (p < 0.05). At 3, 6, 12, 24 and 36 h postoperatively, the NRS score while coughing in group P was lower than that in group R (p < 0.05). The total postoperative sufentanil consumption in group P was significantly lower than that in group R (p < 0.001). Additionally, the time to first analgesic request was longer in group R than in group P (p < 0.0001). The incidence of nausea in group R was higher than that in group P (p < 0.05).

Conclusions

In patients with lung cancer undergoing UVATS, ultrasound-guided PVB with 0.5% ropivacaine provides better analgesia and results in less nausea than ultrasound-guided RLB. Compared with ultrasound-guided RLB, ultrasound-guided PVB seems to be a better technique for analgesia in UVATS.

Trial registration

The name of this study is the Effect And Mechanism Of Ultrasound-guided Multimodal Regional Nerve Block On Acute And Chronic Pain After Thoracic Surgery. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100044060). The date of registration was March 9, 2021.

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.

Postoperative analgesic effects of paravertebral block versus erector spinae plane block for thoracic and breast surgery: A meta-analysis

Background

Paravertebral block (PVB) is the most recognized regional anesthesia technique after thoracic epidural anesthesia for postoperative analgesia in thoracic and breast surgery. Erector spinae plane block (ESPB) is a recently discovered blocking technique, and it has evidenced excellent postoperative analgesia for breast and thoracic surgery with fewer adverse reactions. However, there are controversies about the postoperative analgesic effects of the two analgesic techniques.

Objective

To assess the analgesic effects of PVB versus ESPB in postoperative thoracic and breast surgery.

Methods

We systematically searched PubMed, Cochrane Library, EMBASE, Web of Science, and ScienceDirect databases up to April 5, 2021. The primary outcome was postoperative pain scores. Secondary outcomes included: opioid consumption, additional analgesia, postoperative nausea and vomiting (PONV) 24 hours post-operation, and the time required for completing block procedure. This study was registered in PROSPERO, number CRD42021246160.

Results

After screening relevant, full-text articles, ten randomized controlled trials (RCTs) that met the inclusion criteria were retrieved for this meta-analysis. Six studies involved thoracic surgery patients, and four included breast surgery patients. Thoracic surgery studies included all of the outcomes involved in this meta-analysis while breast surgery did not report pain scores at movement and additional analgesia in 24 hours post-operation. For thoracic surgery, PVB resulted in significant reduction in the following pain scores: 0–1 hours (MD = -0.79, 95% CI: -1.54 to -0.03, P = 0.04), 4–6 hours (MD = -0.31, 95% CI: -0.57 to -0.05, P = 0.02), and 24 hours (MD = -0.42, 95% CI: -0.81 to -0.02, P = 0.04) at rest; significant reduction in pain scores at 4–6 hours (MD = -0.47, 95% CI: -0.93 to -0.01, P = 0.04), 8–12 hours (MD = -1.09, 95% CI: -2.13 to -0.04, P = 0.04), and 24 hours (MD = -0.31, 95% CI: -0.57 to -0.06, P = 0.01) at movement. Moreover, the opioid consumption at 24 hours post-operation (MD = -2.74, 95% CI: -5.41 to -0.07, P = 0.04) and the incidence of additional analgesia in 24 hours of the postoperative course (RR: 0.53, 95% CI: 0.29 to 0.97, P = 0.04) were significantly lower in the PVB group than in the ESPB group for thoracic surgery. However, no significant differences were found in pain scores at rest at various time points postoperatively, and opioid consumption at 24 hours post-operation for breast surgery. The time required for completing block procedure was longer in the PVB group than in the ESPB group for thoracic and breast surgery, and the incidence of PONV between the two groups showed no significant difference.

Conclusion

The postoperative analgesic effects of PVB versus ESPB are distinguished by the surgical site. For thoracic surgery, the postoperative analgesic effect of PVB is better than that of ESPB. For breast surgery, the postoperative analgesic effects of PVB and ESPB are similar.

Efficacy of Erector Spinae Plane Block for Analgesia in Thoracic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to determine whether erector spinae plane block (ESPB) can provide an effective analgesia for managing pain after thoracic surgery and compare the efficacy of ESPB with that of other regional analgesic techniques.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

SETTING

PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science were searched.

PARTICIPANTS

Patients undergoing thoracic surgeries.

INTERVENTION

Erector spinae plane block with local anesthetics for postoperative analgesia.

MEASUREMENT AND MAIN RESULTS

Seventeen studies, including 1,092 patients, were included in the final analysis. Erector spinae plane block reduced 24-hour postoperative opioid consumption (mean difference [MD] -17.49, 95% CI -26.87 to -8.12), pain score at rest (MD -0.82, 95% CI -1.31 to -0.33), and pain score at movement (MD -0.77, 95% CI -1.20 to -0.3) compared to no block. Compared with other regional blocks, various results have been observed. Although statistical results showed that ESPB is inferior to thoracic paravertebral block and intercostal nerve block and superior to serratus anterior plan block in postoperative analgesia, clinical differences remain unclear. The incidence of hematoma was lower in the ESPB group than in the other groups (odds ratio 0.19, 95% CI 0.05-0.73).

CONCLUSION

Erector spinae plane block may provide effective analgesia after thoracic surgery. Compared with other techniques, it is a safer method, without clinically important differences, for postoperative pain control. Therefore, ESPB may be considered as a valuable option for postoperative pain management after thoracic surgery.