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Li Q, Liao Y, Wang X, Zhan M, Xiao L, Chen Y. Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial. J Clin Anesth 2024; 95:111430. [PMID: 38537393 DOI: 10.1016/j.jclinane.2024.111430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/20/2024] [Accepted: 03/01/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy. DESIGN A double-blind, prospective, randomized, placebo-controlled trial. SETTING University-affiliated tertiary care hospital. PATIENTS 60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy. INTERVENTIONS The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone. MEASUREMENTS The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented. MAIN RESULTS Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016). CONCLUSIONS Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.
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Affiliation(s)
- Qi Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Yi Liao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Xiaoe Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Mingying Zhan
- Department of Anesthesiology, Guangdong Provincial People's Hospital, Guangzhou, China.
| | - Li Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Yu Chen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Kwon HJ, Lee JB, Lee K, Shin JY, Jeong SM, Lee JH, Kim DH. Real-time ultrasound guidance versus fluoroscopic guidance in thoracic epidural catheter placement: a single-center, non-inferiority, randomized, active-controlled trial. Reg Anesth Pain Med 2024; 49:168-173. [PMID: 37353356 DOI: 10.1136/rapm-2023-104406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023]
Abstract
INTRODUCTION Fluoroscopy can improve the success rate of thoracic epidural catheter placement (TECP). Real-time ultrasound (US)-guided TECP was recently introduced and showed a high first-pass success rate. We tested whether real-time US-guided TECP results in a non-inferior first-pass success rate compared with that of fluoroscopy-guided TECP. METHODS In this single-center, non-inferiority, randomized trial, the primary outcome was the comparison of the first-pass success rate of TECP between real-time US guidance (US group) and fluoroscopic guidance (fluoroscopy group). Secondary outcomes included time to identifying epidural space, procedure time, total number of needle passes, number of skin punctures, final success, and cross-over success. RESULTS We randomly assigned 132 patients to the allocated groups. The difference in the first-pass success rate between the groups did not exceed the non-inferiority margin of 15% (US group: 66.7% vs fluoroscopy group: 68.2%; difference -1.5%, 95% exact CI: -14.9% to 11.9%). The difference in the final success rate also did not differ between the groups (98.5% vs 100.0%; difference -1.5%, 95% exact CI: -4.0% to 1.0%). The time to identifying epidural space (45.6 (34-62) vs 59.0 (42-77) s, p=0.004) and procedure time (39.5 (28-78) vs 112.5 (93-166) s, p<0.001) were significantly shorter in the US group. CONCLUSIONS Real-time US guidance provided a non-inferior success rate and shorter time spent on preparation and procedure compared with fluoroscopic guidance in TECP. TRIAL REGISTRATION NUMBER KCT0006521.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kunhee Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Young Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Li W, Wu N, Zhou S, Du W, Xu Z, Liu Z. Factors influencing the use of epidural labor analgesia: a cross-sectional survey analysis. Front Med (Lausanne) 2024; 10:1280342. [PMID: 38384316 PMCID: PMC10880097 DOI: 10.3389/fmed.2023.1280342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/14/2023] [Indexed: 02/23/2024] Open
Abstract
Introduction This study aimed to explore the personal and organizational factors influencing the lack of implementation of epidural labor analgesia (ELA). Methods This study was conducted at the Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China. A total of 451 women who underwent vaginal delivery without ELA between 8 October 2021 and 30 March 2022, were included. A questionnaire was used to collect the relevant data. We derived and validated the variable, without ELA, by using binary logistic regression analysis. Results Of the total 451 included, 355 (78.7%) initially preferred ELA, whereas 96 (21.3%) rejected it directly. Five variables were validated (p < 0.05): multiparas, ELA would lead to back pain, experienced ELA in previous delivery, the inner attitude toward labor pain, and blood routine and coagulation function not being tested within 14 days. The sensitivity and specificity of this model were 96.3 and 69.8%, respectively. Conclusion The corresponding training should be provided to the medical staff to identify women at high risk of rejecting ELA during the prenatal examination process using a questionnaire, then provide them with knowledge regarding ELA, so that ELA can benefit more mothers. Additionally, the existing organizational factor should be addressed in order to efficiently provide ELA services to mothers. Clinical trial registration This study was registered at the Chinese Clinical Trial Registry (Chi CTR 2000034625) on July 12, 2020.
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Affiliation(s)
- Wei Li
- Department of Anesthesiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Na Wu
- Nursing Department of Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine, and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuangqiong Zhou
- Department of Anesthesiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Weijia Du
- Department of Anesthesiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
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Huang C, Chen Y, Kou M, Wang X, Luo W, Zhang Y, Guo Y, Huang X, Meng L, Xiao Y. Evaluation of a modified ultrasound-assisted technique for mid-thoracic epidural placement: a prospective observational study. BMC Anesthesiol 2024; 24:31. [PMID: 38243195 PMCID: PMC10797981 DOI: 10.1186/s12871-024-02415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Although mid-thoracic epidural analgesia benefits patients undergoing major surgery, technical difficulties often discourage its use. Improvements in technology are warranted to improve the success rate on first pass and patient comfort. The previously reported ultrasound-assisted technique using a generic needle insertion site failed to demonstrate superiority over conventional landmark techniques. A stratified needle insertion site based on sonoanatomic features may improve the technique. METHODS Patients who presented for elective abdominal or thoracic surgery requesting thoracic epidural analgesia for postoperative pain control were included in this observational study. A modified ultrasound-assisted technique using a stratified needle insertion site based on ultrasound images was adopted. The number of needle passes, needle skin punctures, procedure time, overall success rate, and incidence of procedure complications were recorded. RESULTS One hundred and twenty-eight subjects were included. The first-pass success and overall success rates were 75% (96/128) and 98% (126/128), respectively. In 95% (122/128) of patients, only one needle skin puncture was needed to access the epidural space. The median [IQR] time needed from needle insertion to access the epidural space was 59 [47-122] seconds. No complications were observed during the procedure. CONCLUSIONS This modified ultrasound-assisted mid-thoracic epidural technique has the potential to improve success rates and reduce the needling time. The data shown in our study may be a feasible basis for a prospective study comparing our ultrasound-assisted epidural placements to conventional landmark-based techniques.
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Affiliation(s)
- Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Ying Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Mengjia Kou
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Xuan Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Wei Luo
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Yuanjia Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Yuting Guo
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiongqing Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Ying Xiao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China.
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Effects of single-injection intercostal nerve block as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction: A double-blinded, prospective, and randomized study. Heliyon 2023; 9:e13631. [PMID: 36851963 PMCID: PMC9958429 DOI: 10.1016/j.heliyon.2023.e13631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/23/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Background ː Pain management is essential in postoperative settings, especially with pediatric patients. Donor site pain after rib cartilage harvest is severe, particularly during the early postoperative period. This study aimed to explore the effectiveness of ultrasound guided single-injection intercostal nerve block (ICNB) as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction. Methods ː Fifty pediatric patients aged 6-16 years and scheduled for 2 rib cartilages harvest surgery were enrolled in this double-blind, prospective and randomized study. Pediatrics were randomly assigned into two groups: the intercostal nerve block group (group B) and the control group (group C). The nerve block was performed with 2 ml 0.25% ropivacaine each intercostal nerve in group B. Patients from group C received Tramadol 2 mg/kg by the end of the surgery as control. Tramadol-based patient-controlled intravenous analgesia and rescue analgesia were given in both groups. The primary outcome was pain scores at early postoperative period (VAS and FLACC scale, 4 h, and 8 h). The secondary outcome was the postoperative Tramadol consumption and time point of first rescue analgesic demand. Results ː VAS score was significantly lower in group B than group C at 4 h and 8 h postoperatively [2.5(2-5) vs. 4(2.5-5.5), p = 0.041 at 4 h; 3(2.5-4.5) vs. 4(3-5), p = 0.047 at 8 h]. Total Tramadol consumption in group B decreased significantly in contrast with group C at 8 h (p < 0.01), 12 h, 24 h and 48 h (p < 0.05, respectively). The first rescue analgesia demand and number of rescue Tramadol in block group was considerably delayed or reduced than control group (p < 0.01, p < 0.05, respectively). Conclusions ː Our findings indicated that ultrasound guided ICNB slightly but significantly reduced pain scores, and Tramadol consumption in pediatric patients after rib cartilage harvest as compared to who didn't receive nerve block at 4 h and 8 h postoperatively. Unified ICNB ropivacaine dosage might detrimental to providing superior analgesia.
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Vijitpavan A, Kittikunakorn N, Komonhirun R. Comparison between intrathecal morphine and intravenous patient control analgesia for pain control after video-assisted thoracoscopic surgery: A pilot randomized controlled study. PLoS One 2022; 17:e0266324. [PMID: 35385557 PMCID: PMC8985927 DOI: 10.1371/journal.pone.0266324] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure, but patients may still experience intense pain, especially during the early postoperative period. Intrathecal morphine (ITM) is an effective pain control method that involves a simple maneuver and has a low risk of complications. This study aimed to study the effectiveness of ITM for pain control in patients who undergo VATS. Materials and methods A randomized controlled study was conducted who were in ASA classes 1–3, aged over 18 years, and scheduled for elective VATS. Patients were randomized into two groups: the ITM group (n = 19) received a single shot of 0.2 mg ITM before general anesthesia; and the control group (n = 19) received general anesthesia only. For 48 hours after surgery, other than intravenous patient-controlled analgesia (IVPCA) morphine, patients received no sedatives or opioid medications except for 500 mg acetaminophen four times daily orally. Postoperative pain scores and IVPCA morphine used, side effects, sedation at specific time-points, i.e., 1, 6, 12, 24, and 48-hours and overall treatment satisfaction scores were assessed. Results Postoperative pain scores (median [IQR]) in ITM group were significantly lower than control group (repeated-measure ANOVA, p = 0.006) and differed at the first (7 [2, 7] vs 8 [6, 9], p = 0.007) and sixth hours (3 [2, 5] vs 5 [5, 7], p = 0.002). The cumulative dose of post-operative morphine (median [IQR]) in ITM group was also lower (6 [3, 20] vs 19 [14, 28], p = 0.006). The incidence of pruritus was significantly higher in ITM group (68.42% vs. 26.32%, p = 0.009). No significant differences in nausea and vomiting, sedation scores, and satisfaction scores were observed between the two groups. Conclusion ITM could reduce pain scores and opioid consumption after VATS compared to IVPCA-opioids. However, pain scores and opioid consumption still remained high. No difference in patient satisfaction was detected.
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Affiliation(s)
- Amorn Vijitpavan
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Nussara Kittikunakorn
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rojnarin Komonhirun
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Dong W, Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Ruan J, Fan F. Comparison of Multimodal Cocktail to Ropivacaine Intercostal Nerve Block for Chest Pain After Costal Cartilage Harvest: A Randomized Controlled Trial. Facial Plast Surg Aesthet Med 2022; 24:102-108. [PMID: 35230140 DOI: 10.1089/fpsam.2021.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: To compare the effectiveness of an intercostal nerve block after costal cartilage harvest when a multimodal cocktail or ropivacaine plus patient-controlled analgesia is used, as measured by visual analog scale (VAS) scores, rescue analgesic consumption, and related complications. Materials and Methods: Eligible patients who underwent costal cartilage harvest were equally randomized to receive a multimodal cocktail (multimodal group) or ropivacaine plus patient-controlled analgesia (ropivacaine group). Results: Of 112 patients assessed, 12 (10.7%) patients were excluded and 100 (89.3%) patients were enrolled and assigned to multimodal group (n = 50) and ropivacaine group (n = 50). The VAS scores in the multimodal group were significantly lower than those in the ropivacaine group both at rest (0.924 ± 0.073 vs. 1.920 ± 0.073, p < 0.001) and during coughing (2.340 ± 0.083 vs. 3.944 ± 0.083, p < 0.001) in mixed-effects model analysis. Rescue analgesic consumption and rate of complications were significantly lower in the multimodal group compared with the ropivacaine group (all p < 0.05). Conclusions: Multimodal cocktail improved chest pain after costal cartilage harvest with less rescue analgesic consumption and complications compared with ropivacaine plus patient-controlled analgesia. Clinical Trial Registration: ChiCTR2100042445.
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Affiliation(s)
- Wenfang Dong
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xin Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Huan Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jianjun You
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Ruobing Zheng
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Yihao Xu
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xulong Zhang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Junsheng Guo
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jingjing Ruan
- Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Fei Fan
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
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Patient-Controlled Intravenous Analgesia With Tramadol and Lornoxicam After Thoracotomy: A Comparison With Patient-Controlled Epidural Analgesia. Int Surg 2022. [DOI: 10.9738/intsurg-d-16-00252.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
To determine efficacy and safety of patient-controlled intravenous analgesia (PCIA) with tramadol and lornoxicam for postoperative analgesia, and its effects on surgical outcomes in patients after thoracotomy.
Summary of background data
Adequate pain relief after thoracic surgery is of particular importance, not only for keeping patients comfortable but also for reducing the incidence of postoperative complications. PCIA with tramadol and lornoxicam could be an acceptable alternative to patient-controlled epidural analgesia (PCEA) for pain management after thoracotomy.
Methods
The records of patients who underwent thoracotomy for lung resection between January 2014 and December 2014 at our institution were reviewed. The patients were divided into 2 groups according to postoperative pain treatment modalities. Patients of PCEA group (n = 63) received PCEA with 0.2% ropivacaine plus 0.5 μg/mL sufentanil, while patients in PCIA group (n = 48) received PCIA with 5 mg/mL tramadol and 0.4 mg/mL lornoxicam. Data were collected for quality of pain control, incidences of analgesia-related side effects and pulmonary complications, lengths of thoracic intensive care unit stay and postoperative hospital stay, and in-hospital mortality.
Results
Pain at rest was controlled well in both groups during a 4-day postoperative period. Patients in PCIA group reported significantly higher pain scores on coughing and during mobilization in the first 2 postoperative days. The incidences of side effects and pulmonary complications, in-hospital mortality, and other outcomes were similar between groups.
Conclusions
PCIA with tramadol and lornoxicam can be considered as a safe and effective alternative with respect to pain control and postoperative outcomes after thoracotomy.
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The Role of Serratus Anterior Plane Block During in Video-Assisted Thoracoscopic Surgery. Pain Ther 2021; 10:1051-1066. [PMID: 34537952 PMCID: PMC8586293 DOI: 10.1007/s40122-021-00322-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/08/2021] [Indexed: 10/27/2022] Open
Abstract
Although thoracoscopy has characteristics such as a small surgical incision and low stress response, post-surgical pain after a thoracoscopic operation is no less than that after a thoracotomy. Moreover, poor post-surgical pain management is likely to cause an increased incidence of postoperative pulmonary complications (PPCs) and chronic post-surgical pain. The serratus anterior plane block (SAPB) is a regional anesthesia method whereby local anesthetics (LAs) are injected into the serratus anterior space to block the lateral cutaneous branch of the intercostal nerve, long thoracic nerve, and dorsal thoracic nerve. The block range of the SAPB covers the incisions of video-assisted thoracoscopic surgery (VATS) and the site of the chest tube, which are often located in the antero-lateral chest wall. Therefore, the SAPB can achieve effective analgesia in VATS. For example, 0.125% to 0.25% levobupivacaine (20-25 ml) is widely used for thoracic surgery, which can achieve effective analgesia and avoid adverse reactions. Moreover, it has advantages compared with thoracic segmental epidural block (TEA) and thoracic paravertebral block (TPVB), such as simple operation, increased safety, fewer complications, and hemodynamic stability. In addition, adequate analgesia is helpful for pulmonary function recovery and reduces the incidence of PPCs. This article introduces the anatomical mechanism of the SAPB, diverse operation approaches, how to choose drugs and adjuvants, and the resulting impacted area range. It summarizes the advantages and disadvantages of the SAPB compared with other analgesic methods and posits that the SAPB is beneficial to the recovery of postoperative lung function, which provides more options for postoperative analgesia after VATS.
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Khidr AM, Senturk M, El-Tahan MR. Impact of regional analgesia techniques on the long-term clinical outcomes following thoracic surgery. Saudi J Anaesth 2021; 15:335-340. [PMID: 34764840 PMCID: PMC8579497 DOI: 10.4103/sja.sja_1178_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 12/01/2022] Open
Abstract
Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.
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Affiliation(s)
- Alaa M Khidr
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Mert Senturk
- Department of Anesthesiology, College of Medicine, Istanbul University, Istanbul, Turkey
| | - Mohamed R El-Tahan
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
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12
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Guerra-Londono CE, Privorotskiy A, Cozowicz C, Hicklen RS, Memtsoudis SG, Mariano ER, Cata JP. Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133394. [PMID: 34779845 PMCID: PMC8593761 DOI: 10.1001/jamanetworkopen.2021.33394] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown. OBJECTIVE To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery. DATA SOURCES A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020. STUDY SELECTION Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model. MAIN OUTCOMES AND MEASURES The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function. RESULTS Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs). CONCLUSIONS AND RELEVANCE In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.
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Affiliation(s)
- Carlos E. Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, University of Texas, Houston
| | | | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Rachel S. Hicklen
- Research Medical Library, MD Anderson Cancer Center, University of Texas, Houston
| | | | - Edward R. Mariano
- Department of Anesthesia, School of Medicine, Stanford University, Stanford, California
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, University of Texas, Houston
- Anesthesiology and Surgical Oncology Research Group, Houston, Texas
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13
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Yamazaki S, Koike S, Eguchi T, Matsuoka S, Takeda T, Miura K, Hamanaka K, Shimizu K. Preemptive Intercostal Nerve Block as an Alternative to Epidural Analgesia. Ann Thorac Surg 2021; 114:257-264. [PMID: 34389301 DOI: 10.1016/j.athoracsur.2021.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The necessity of thoracic epidural analgesia (TEA) during minimally invasive surgery remains unclear. We investigated TEA efficacy in minimally invasive surgery vs. thoracotomy and the non-inferiority of a preemptive intercostal nerve block (ICNB) to TEA in minimally invasive surgery. METHODS We investigated 393 patients who underwent lung resection, with and without TEA, between 2014 and 2019 (242 minimally invasive surgery, 151 thoracotomy) and 93 patients who underwent minimally invasive surgery with ICNB between 2019 and 2020. To address selection bias, 70 TEA and 70 ICNB patients were propensity-score-matched. Endpoints were 1) pain score during hospitalization, 2) postoperative complications, 3) duration of operating room use, 4) analgesia-related adverse effects, and 5) use of supplemental pain medication. RESULTS One-third of patients with minimally invasive surgery discontinued TEA on postoperative day 1 or earlier; those with early TEA discontinuation reported worse pain the next day. TEA was associated with lower pain scores compared to non-TEA, regardless of surgical invasiveness, and a lower complication risk in patients with thoracotomy, but not minimally invasive surgery. For minimally invasive surgery, ICNB was associated with equivalent pain score on postoperative day 1, lower average pain score during hospitalization, shorter duration of operation room use, less frequent use of supplemental pain medication, and similar risk of postoperative complication and analgesia-related adverse effects compared to TEA after matching. CONCLUSIONS Given early TEA discontinuation after minimally invasive surgery and ICNB's non-inferior pain relief, preemptive ICNB can be an alternative for TEA in patients undergoing minimally invasive surgery.
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Affiliation(s)
- Shiori Yamazaki
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Sachie Koike
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Eguchi
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Shunichiro Matsuoka
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tetsu Takeda
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kentaro Miura
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kazutoshi Hamanaka
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kimihiro Shimizu
- Division of General Thoracic Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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14
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Bayman EO, Curatolo M, Rahman S, Brennan TJ. AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain. THE JOURNAL OF PAIN 2021; 22:892-904. [PMID: 33848682 DOI: 10.1016/j.jpain.2021.03.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 12/29/2022]
Abstract
Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria. PERSPECTIVE ITEM: This article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).
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Affiliation(s)
- Emine Ozgur Bayman
- Associate Professor, Departments of Biostatistics and Anesthesia, University of Iowa, Iowa City, Iowa
| | - Michele Curatolo
- Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Siamak Rahman
- Clinical Professor, Department of Anesthesia and Perioperative Medicine, University of California, Los Angeles, California
| | - Timothy J Brennan
- Professor Emeritus, Department of Anesthesia, University of Iowa, Iowa City, Iowa
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15
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Özden Omaygenç D, Çıtak N, İşgörücü Ö, Ulukol A, Büyükkale S, Obuz Ç, Doğru MV, Sayar A. Comparison of Thoracic Epidural and Intravenous Analgesia from the Perspective of Recovery of Respiratory Function in the Early Post-Thoracotomy Period in Lung Cancer Surgery. Turk Thorac J 2021; 22:31-36. [PMID: 33646101 DOI: 10.5152/turkthoracj.2021.19114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 02/28/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Thoracic epidural analgesia (TEA) reduces pulmonary complications after thoracotomy. Hypothetically, this advantage is partially because of the preserved pulmonary function, which is achieved by the reduction of postoperative pain and immobility. This study aimed to compare the principal methods of analgesia through early postoperative spirometric performance and gas exchange parameters after elective lung cancer surgery. TEA or intravenous analgesia (IVA) involving pethidine was used as the principal method in our sample population. MATERIAL AND METHODS A total of 62 patients operated via the posterolateral thoracotomy approach were enrolled. Postoperative analgesia was secured using multimodal analgesia with either TEA with 0.1% bupivacaine or IVA. Pain perception was assessed with the visual analog scale (VAS) while at rest and on coughing. Arterial blood samples were collected at 1, 24, and 72 hours postoperatively. Preoperative and third postoperative day spirometric measurements were recorded. RESULTS There were no significant differences among the groups in terms of demographic characteristics, properties of surgical technique, and disease-associated conditions. VAS scores of the TEA group were lower at the 72-hour follow-up, but a considerable fraction of these differences did not reach statistical significance. Reduction in the forced expiratory volume in the first second and forced vital capacities was more prominent in the IVA group on the third postoperative day, but these were not statistically significant either. Oxygenation parameters favored TEA but remained comparable. Finally, the pH values were significantly lower in the IVA group at 1 and 72 hours postoperatively (p=0.008 and p=0.02, respectively). CONCLUSION We believe that TEA is advantageous over IVA with alteration of respiratory volumes during the early postoperative period.
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Affiliation(s)
- Derya Özden Omaygenç
- Department of Anesthesiology and Reanimation, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Necati Çıtak
- Department of Thoracic Surgery, University of Zurich, Zurich, Switzerland
| | - Özgür İşgörücü
- Department of Thoracic Surgery, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Ayşe Ulukol
- Department of Anesthesiology and Reanimation, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Songül Büyükkale
- Department of Thoracic Surgery, Şişli Memorial Hospital, İstanbul, Turkey
| | - Çiğdem Obuz
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Vedat Doğru
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Adnan Sayar
- Department of Thoracic Surgery, Şişli Memorial Hospital, İstanbul, Turkey
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16
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Abstract
Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.
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18
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Fiorelli S, Leopizzi G, Menna C, Teodonio L, Ibrahim M, Rendina EA, Ricci A, De Blasi RA, Rocco M, Massullo D. Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020; 34:2421-2429. [DOI: 10.1053/j.jvca.2020.01.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 11/11/2022]
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19
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Hodge A, Rapchuk IL, Gurunathan U. Postoperative Pain Management and the Incidence of Ipsilateral Shoulder Pain After Thoracic Surgery at an Australian Tertiary-Care Hospital: A Prospective Audit. J Cardiothorac Vasc Anesth 2020; 35:555-562. [PMID: 32863141 DOI: 10.1053/j.jvca.2020.07.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Ipsilateral shoulder pain (ISP) is a common but variably occurring (42%-85%) complication after thoracic surgery. Multiple potential treatments, including upper limb blocks, intrapleural local anaesthetic infiltration, and systemic opioids, have undergone trials, with limited efficacy. Phrenic nerve infiltration is a potential intervention that may prevent ISP. The aim of this study was to assess the incidence and severity of ISP after thoracic surgery at the authors' institution, where phrenic nerve infiltration is commonly used. DESIGN Observational cohort study. SETTING A single- center study in a tertiary referral center in Brisbane, Australia. PARTICIPANTS This study comprised all adult patients undergoing thoracic surgery at a tertiary- care referral center from May to July 2018. MEASUREMENTS AND MAIN RESULTS Surgical procedures were divided into open thoracotomy, video-assisted thoracic surgery (VATS) and VATS-guided mini-thoracotomy. The primary outcome was a comparison of incidence of ISP among the 3 types of surgical procedures. Data were analyzed using Stata (StataCorp), with significance testing by Kruskal-Wallis equality of populations rank test. A p value of < 0.05 was deemed significant. Sixty thoracic surgeries were performed during the audit period. Nineteen patients had thoracotomies performed for lobectomy or pneumonectomy, all of whom received phrenic nerve infiltration. The incidence of moderate-to-severe ipsilateral shoulder pain among the thoracoctomy cohort was 15.8% (3/19). Of the 36 VATS procedures audited, 7 patients (19.4%) received infiltration of their phrenic nerve, none of whom reported postoperative ISP. Of the remaining twenty-nine patients who did not receive phrenic nerve infiltration, there were 4 cases of moderate-to-severe ipsilateral shoulder pain (11.1%). Four of the 5 patients (80%) who underwent VATS-guided mini-thoracotomies received phrenic nerve infiltration intraoperatively. Three patients reported moderate-to-severe ISP and of these 3 patients, 2 patients had phrenic nerve infiltration, and 1 patient did not receive infiltration. Overall, there were no statistically significant differences in rest or dynamic pain scores across the surgical groups at any time point. Mann-Whitney test revealed that the participants with ISP were significantly older than those without ISP (p = 0.006). However, there were no significant differences in sex or body mass index between those with and without ISP. CONCLUSION The authors observed a lower (15.8%) incidence of moderate-to-severe ISP among their thoracotomy patients than reported in prior literature. Injection of local anesthetic into the phrenic nerve fat pad at the level of the diaphragm appeared to be an effective and safe surgical intervention that may eliminate a significant cause of ISP. None of the VATS patients who received phrenic nerve infiltration experienced ISP. Postoperative pain in VATS is expected to be reduced by avoiding the use of a rib spreader, severing of the intercostal nerves, and division of muscle tissue, which may account for the lower observed rates of ISP in the VATS cohort who did not receive phrenic nerve infiltration. Further randomized controlled trials are warranted to establish if patients undergoing various VATS procedures benefit from this intervention.
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Affiliation(s)
- Anthony Hodge
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; University of Queensland.
| | - Ivan L Rapchuk
- University of Queensland; Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Usha Gurunathan
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
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20
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Ranganathan P, Tadvi A, Jiwnani S, Karimundackal G, Pramesh CS. A randomised evaluation of intercostal block as an adjunct to epidural analgesia for post-thoracotomy pain. Indian J Anaesth 2020; 64:280-285. [PMID: 32489201 PMCID: PMC7259421 DOI: 10.4103/ija.ija_714_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/20/2019] [Accepted: 02/17/2020] [Indexed: 12/31/2022] Open
Abstract
Background and Aims: Post-thoracotomy pain can be severe and disabling. The aim of this study was to examine the efficacy of intercostal nerve block when used as adjunct to thoracic epidural analgesia in patients undergoing posterolateral thoracotomy. Methods: This was a parallel-group randomised patient and assessor-blinded study carried out at a tertiary-referral cancer center. We included 60 adult patients undergoing elective lung resection under general anaesthesia with thoracic epidural analgesia. In addition, the intervention arm received single-shot intercostal blocks with 10 ml of 0.25% bupivacaine at the level of and two levels above and below the thoracotomy. We assessed post-operative pain scores at 2 to 4 hours and 18 to 24 hours after surgery, peri-operative fentanyl requirement, percentage of patients who needed fentanyl PCA and maximum volume achieved on bedside spirometry 18 to 24 hours after surgery. Groups were compared using the unpaired t-test for continuous data and the chi square test for categorical data at a 5% level of significance. Results: 2 to 4 hours post-operatively, mean pain scores at rest were 3.0 in both groups (difference 0.04, 95% CI -1.1 to + 1.1) and on coughing were 4.6 (ICB group) and 4.9 (C group) (difference 0.32, 95% CI -1.0 to + 1.6). There were no differences between the groups for any of the other outcomes. Conclusion: Addition of intercostal block to epidural analgesia does not confer any benefit in terms of post-operative pain, fentanyl requirements or volume achieved on spirometry.
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Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Asharab Tadvi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized, double-blinded, clinical trial. J Clin Anesth 2020; 59:106-111. [DOI: 10.1016/j.jclinane.2019.07.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 11/17/2022]
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Swisher MW, Millar MB, Gabriel RA, Said ET. Analgesic Rescue With Opioid-Only Thoracic Epidural After Surgical Infiltration of Liposomal Bupivacaine: A Case Report. A A Pract 2019; 13:292-294. [DOI: 10.1213/xaa.0000000000001057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kampe S, Wendland M, Welter S, Aigner C, Hachenberg T, Ebmeyer U, Weinreich G. Independent Predictors for Higher Postoperative Pain Intensity During Recovery After Open Thoracic Surgery: A Retrospective Analysis in 621 Patients. PAIN MEDICINE 2019; 19:1667-1673. [PMID: 29635531 DOI: 10.1093/pm/pnx238] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective To evaluate two standard procedure-specific pain regimens and to assess independent predictors for higher pain intensity after thoracic surgery. Methods Patients received either oral opioid analgesia (Opioid Group) or epidural analgesia and were then bridged to systemic opioid analgesia (EDA + O Group) in this retrospective observational study. Medical history, discharge letters, anesthetic protocols, and pain protocols were evaluated in 621 patients after open thoracotomy and assessed with a stepward back elimination in a multivariate logistic regression model. Results Data of 621 thoracotomies in 2014 were analyzed, 309 patients in the Opioid Group and 312 patients in the EDA + O Group. Pain scores at rest and on coughing were significantly lower in the EDA + O Group on postoperative days (PODs) 1-4 (P < 0.001). Stepwise backward elimination in multivariate logistic regression identified preexisting pain disease (P = 0.034), no epidural analgesia (P < 0.001), opioids in preoperative pain therapy (P < 0.001), and antidepressant medication (P = 0.003) as independent risk factors for higher pain intensity at rest on PODs 1-4. Same on PODs 5-8 with regard to opioids in preoperative pain therapy (P < 0.001) and antidepressant medication (P = 0.018). Moreover, on PODs 5-8, male gender had a lower risk (P < 0.003) for pain, and preexisting musculosceletal disease had a lower risk for more postoperative pain (P = 0.009). On coughing, male gender and younger age proved to have a lower risk for postoperative pain on PODs 1-8 and on PODs 1-4, respectively. Opioids in preexisting pain therapy and antidepressant medication were identified as risk factors for pain on PODs 1-8 on coughing, and pain disease was identified as a risk factor for more pain on PODs 1-4 (P = 0.041). Moreover, preexisting cardiac disease indicated more pain on PODs 1-4 (P = 0.05), and musculoskeletal disease and neurological disease indicated more pain on PODs 5-8 (P = 0.041, and P = 0.023). Conclusions We present data on independent risk factors for higher pain intensity during recovery after thoracotomy. The lack of postoperative epidural analgesia, female gender, preexisting opioid pain therapy, and chronic pain are the strongest risk factors for higher pain intensity. Antidepressant medication was identified as an independent risk factor at rest and on coughing on all PODs. Study limitations The study design is retrospective.
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Affiliation(s)
- Sandra Kampe
- Departments of Anesthesiology and Pain Medicine.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | | | - Stefan Welter
- Thoracic Surgery and Thoracic Endoscopy, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Clemens Aigner
- Thoracic Surgery and Thoracic Endoscopy, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Hachenberg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Uwe Ebmeyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Gerhard Weinreich
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Jin J, Min S, Chen Q, Zhang D. Patient-controlled intravenous analgesia with tramadol and lornoxicam after thoracotomy: A comparison with patient-controlled epidural analgesia. Medicine (Baltimore) 2019; 98:e14538. [PMID: 30762794 PMCID: PMC6408084 DOI: 10.1097/md.0000000000014538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
To determine efficacy and safety of patient-controlled intravenous analgesia (PCIA) with tramadol and lornoxicam for postoperative analgesia, and its effects on surgical outcomes in patients following thoracotomy.The records of patients who underwent thoracotomy for lung resection between January 2014 and December 2014 at our institution were reviewed. The patients were divided into 2 groups according to postoperative pain treatment modalities. Patients of the patient-controlled epidural analgesia (PCEA) group (n = 63), received PCEA with 0.2% ropivacaine plus 0.5 μg/mL sufentanil, while patients in the PCIA group (n = 48), received PCIA with 5 mg/mL tramadol and 0.4 mg/mL lornoxicam. Data were collected for the quality of pain control, incidences of analgesia related side effects and pulmonary complications, lengths of thoracic intensive care unit stay and postoperative hospital stay, and in-hospital mortality.Pain at rest was always controlled well in both groups during the 4-day postoperative period. Patients in the PCIA group reported significantly higher pain scores on coughing and during mobilization in the first 2 postoperative days. The incidences of side effects and pulmonary complications, in-hospital mortality and other outcomes were similar between groups.PCIA with tramadol and lornoxicam can be considered as a safe and effective alternative with respect to pain control and postoperative outcomes for patients underwent thoracotomy.
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Effects of patient-controlled analgesia with hydromorphone or sufentanil on postoperative pulmonary complications in patients undergoing thoracic surgery: a quasi-experimental study. BMC Anesthesiol 2018; 18:192. [PMID: 30567490 PMCID: PMC6300916 DOI: 10.1186/s12871-018-0657-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/30/2018] [Indexed: 12/11/2022] Open
Abstract
Objective To compare the analgesic effects of patient-controlled intravenous analgesia (PCA) with hydromorphone and sufentanil after thoracic surgery on postoperative pulmonary complications (PPCs). Methods A total of 142 patients who were scheduled for thoracic surgery were randomly allocated to receive PCA with hydromorphone (group A: experimental group): hydromorphone 0.2 mg/kg + dezocine 0.5 mg/kg + ramosetron 0.6 mg diluted with normal saline to 200 mL; or with sufentanil (group B: control group): sufentanil 3.0μg/kg + dezocine 0.5 mg/kg + ramosetron 0.6 mg diluted with normal saline to 200 mL. The parameters of intravenous analgesia pump were set as background dose 4 ml/h, PCA dose 1 mL, locking time 15 min. Pain NRS (numerical rating scale), Ramsay sedation score, nausea or vomiting score were evaluated at 0 h, 6 h, 12 h, 24 h, 48 h after operation. The cases of PPCs (atelectasis, pulmonary infection, respiratory failure), CRP (C-reaction protein) and inflammatory cells (white cell count and percentage of neutrophils) and blood gas analysis at 12 h after operation, length of ICU and postoperative stay were recorded for each patient. Results Data of 136 patients were analyzed. Compared with group B (4[IQR:2,2]), the pain NRS in group A (2[IQR:4,4]) was significantly lower at 6 h after operation (P = 0.000). The CRP in group A (69.79 ± 32.13 mg/L) were lower than group B (76.76 ± 43.42 mg/L) after operation, but the difference was not significant (P = 0.427). No difference of nausea or vomiting was found between group A (7.3%) and group B (5.8%) postoperatively (P = 0.999). The PPCs were happened in 11 patients in group A (16.2%) and 22 patients in group B (32.4%) and the difference between two groups was significant (P = 0.027). Seven patients in group A (10.3%) and eighteen patients in group B (26.5%) had clinical evidence of pneumonia and the difference between two groups was significant (P = 0.014). The length of ICU and postoperative stay in group A were 2.73 h and 1.82 days less than group B respectively but the differences were not significant (P = 0.234, P = 0.186 respectively). Conclusion Compared with sufentanil, hydromorphone may provide better postoperative analgesic effect with less pulmonary complications for patients undergoing thoracic surgery, and it may accelerate patients’ rehabilitation. Trial registration Randomized Controlled Trials ChiCTR1800014282c. Registered 3 January 2018.
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Elfokery BM, Tawfic SA, Abdelrahman AM, Abbas DN, Abdelghaffar IM. Comparative study on the analgesic effect of acute ipsilateral shoulder pain after open thoracotomy between preoperative ultrasound guided suprascapular nerve block (SNB) and intraoperative phrenic nerve infiltration (PNI) in cancer lung patients. J Egypt Natl Canc Inst 2018; 30:27-31. [DOI: 10.1016/j.jnci.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 12/30/2022] Open
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Darr C, Cheufou D, Weinreich G, Hachenberg T, Aigner C, Kampe S. Robotic thoracic surgery results in shorter hospital stay and lower postoperative pain compared to open thoracotomy: a matched pairs analysis. Surg Endosc 2017; 31:4126-4130. [DOI: 10.1007/s00464-017-5464-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/13/2017] [Indexed: 01/26/2023]
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Evaluation of Ultrasound-Assisted Thoracic Epidural Placement in Patients Undergoing Upper Abdominal and Thoracic Surgery. Reg Anesth Pain Med 2017; 42:204-209. [DOI: 10.1097/aap.0000000000000540] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Elmore B, Nguyen V, Blank R, Yount K, Lau C. Pain Management Following Thoracic Surgery. Thorac Surg Clin 2015; 25:393-409. [DOI: 10.1016/j.thorsurg.2015.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Kessler J, Marhofer P, Hopkins P, Hollmann M. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth 2015; 114:728-45. [DOI: 10.1093/bja/aeu559] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Fujiwara S, Komasawa N, Minami T. Pectral nerve blocks and serratus-intercostal plane block for intractable postthoracotomy syndrome. J Clin Anesth 2015; 27:275-6. [PMID: 25690279 DOI: 10.1016/j.jclinane.2015.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/21/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Shunsuke Fujiwara
- Assistant Professor Department of Anesthesiology, Osaka Medical College, Osaka, Japan
| | - Nobuyasu Komasawa
- Assistant Professor Department of Anesthesiology, Osaka Medical College, Osaka, Japan.
| | - Toshiaki Minami
- Professor and Chief Department of Anesthesiology, Osaka Medical College, Osaka, Japan
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Wu L, Dong YP, Sun L, Sun L. Low Concentration of Dezocine in Combination With Morphine Enhance the Postoperative Analgesia for Thoracotomy. J Cardiothorac Vasc Anesth 2014; 29:950-4. [PMID: 25543218 DOI: 10.1053/j.jvca.2014.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVE When morphine and dezocine are mixed together, the clinical interactions with analgesic effects and adverse events remain unknown. The authors aimed to investigate the efficacy of low concentrations of dezocine in combination with morphine for postoperative pain. DESIGN A prospective, randomized, double-blinded clinical trial. SETTING Cancer Institute and Hospital, National Cancer Center, China. PARTICIPANTS Sixty patients undergoing thoracotomy were randomized into 3 groups to investigate the analgesic efficacy of different ratios of morphine and dezocine. INTERVENTIONS The morphine group (Group M) received morphine (1 mg/mL) alone for patient-controlled analgesia (PCA); the morphine+dezocine 1 group (Group MD1) received morphine (1 mg/mL) combined with dezocine (0.05 mg/mL) at a ratio of 20:1 for PCA; the morphine+dezocine 2 group (Group MD2) received morphine (1 mg/mL) combined with dezocine (0.1 mg/mL) at a ratio of 10:1 for PCA. Cumulative morphine consumption, verbal rating scores (VRS), and adverse events were evaluated throughout a 48-hour postoperative period. MEASUREMENTS AND MAIN RESULTS Cumulative morphine requirements were (1) statistically higher in Group M than in Group MD2 at 24 and 48 hours after surgery and (2) statistically higher in Group M than Group MD1 at 48 hours after surgery. Postoperative VRS for evaluating pain were similar among the 3 groups. The incidence of postoperative nausea and pruritus was statistically higher in Group M than in Groups MD1 and MD2. The incidence of dizziness was not significantly different among groups. CONCLUSIONS The combination of morphine and dezocine at the concentrations [morphine (mg/mL)]/[dezocine (mg/mL)] of 1/0.05 (ratio 20:1) and 1/0.1 (ratio 10:1) may enhance postoperative analgesia after thoracotomy.
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Affiliation(s)
- LinXin Wu
- Department of Anesthesiology, Cancer Institute and Hospital, National Cancer Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yan Peng Dong
- Department of Anesthesiology, Cancer Institute and Hospital, National Cancer Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Liang Sun
- Department of Anesthesiology, Cancer Institute and Hospital, National Cancer Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Li Sun
- Department of Anesthesiology, Cancer Institute and Hospital, National Cancer Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Kampe S, Weinreich G, Darr C, Eicker K, Stamatis G, Hachenberg T. The impact of epidural analgesia compared to systemic opioid-based analgesia with regard to length of hospital stay and recovery of bowel function: retrospective evaluation of 1555 patients undergoing thoracotomy. J Cardiothorac Surg 2014; 9:175. [PMID: 25417134 PMCID: PMC4246432 DOI: 10.1186/s13019-014-0175-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/28/2014] [Indexed: 11/25/2022] Open
Abstract
Background To assess the protocols of epidural analgesia versus systemic opioid-based analgesia retrospectively in 1555 thoracotomies in our thoracic centre during 2011–2013. Methods Pain therapy is aggressive and standardized in our thoracic centre thoughout the complete postoperative stay. Patients receive either standardized epidural analgesia with ropivacaine + sufentanil 4–8 mls/h (500 mls bag) and are bridged when the epidural bag is finished to a standardized controlled-release oxycodone protocol with non opioid every 6 hours (EDA Group), or patients receive immediately postoperative standardized oral analgesic protocol with controlled-released oxycodone and non opioid every 6 h (Opioid Group). All patients are visited daily by a pain specialist throughout the whole stay. Results Data of 1555 thoracotomies from 2011-2013 were analysed, 838 patients in the EDA Group and 717 patients in the Opioid Group. There was no difference with regard to sex or age between groups. 7.5% of patients in the EDA Group and 13% in the Oxy Group had a preexisting pain therapy (p = 0.001). In the EDA Group epidural analgesia was performed for 4.6 ± 1.5 days. Length of hospital stay was the same in both groups (EDA: 9.9.6 ± 4.9 vs Opioid: 9.6 ± 5.8 days). 84.7% of patients in the EDA Group and 79.1% of patients of the Oxy Group were dismissed with oral opioid (p < 0.004). When patients were dismissed with opioid medication patients in the EDA Group were dismissed with higher oxycodone opioid doses than patients in the Opioid Group (29.5 ± 15.2 mg vs 26.9 ± 15.2 mg, p = 0.01). There was no difference with regard to dejection time between the two groups (EDA: 3.8 ± 2.2 days vs Opioid: 3.7 ± 1.6 days, n.s.). Conclusion We first present data monitoring postoperative analgesic protocols after thoracotomies throughout the whole stay in hospital until dismission. Our retrospective data indicate that patients with epidural analgesia stay as long in hospital as patients with systemic opioid based therapy. Patients with initial epidural analgesia are dismissed with higher oxycodone opioid doses than patients with initial opioid based postoperative analgesia. We found no difference in recovery of bowel function. Study limitations The study design is retrospectively and results might be biased.
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Affiliation(s)
- Sandra Kampe
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Gerhard Weinreich
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Christopher Darr
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Kolja Eicker
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Georgios Stamatis
- Department of Thoracic Surgery and Thoracic Endoscopy, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Thomas Hachenberg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany.
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Lee JH, Park JH, Kil HK, Choi SH, Noh SH, Koo BN. Efficacy of intrathecal morphine combined with intravenous analgesia versus thoracic epidural analgesia after gastrectomy. Yonsei Med J 2014; 55:1106-14. [PMID: 24954344 PMCID: PMC4075374 DOI: 10.3349/ymj.2014.55.4.1106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA) with respect to postoperative pain control after conventional open gastrectomy. MATERIALS AND METHODS Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphine combined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative 0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analog scale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects related to analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated. RESULTS This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2±263.7 μg vs. 1048.9±71.7 μg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group. CONCLUSION ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation, postoperative ileus and pulmonary complications.
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Affiliation(s)
- Jae Hoon Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ha Park
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Noh
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Preemptive ultrasound-guided paravertebral block and immediate postoperative lung function. Gen Thorac Cardiovasc Surg 2014; 63:43-8. [DOI: 10.1007/s11748-014-0442-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/20/2014] [Indexed: 12/28/2022]
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Romero A, Garcia JEL, Joshi GP. The State of the Art in Preventing Postthoracotomy Pain. Semin Thorac Cardiovasc Surg 2013; 25:116-24. [DOI: 10.1053/j.semtcvs.2013.04.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2013] [Indexed: 11/11/2022]
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:289-98. [DOI: 10.1097/spc.0b013e328353e091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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