Perioperative pain management after thoracotomy

Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials

Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.

Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BACKGROUND

The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.

CASE PRESENTATION

Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.

CONCLUSIONS

Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia

OBJECTIVES

This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery.

DESIGN

A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery.

SETTING

This investigation was performed at a large quaternary referral center.

PARTICIPANTS

Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia.

INTERVENTIONS

Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group.

CONCLUSIONS

The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.

Comparison of deep and combined serratus anterior plane block after video-assisted thoracoscopic surgery; a prospective randomized trial

Aim: Ultrasound-guided plane blocks have been employed frequently in Video-assisted thoracoscopic surgery (VATS). The aim of this study was to evaluate the effect of deep and combined serratus anterior plane block (SAPB) after VATS. Material and Method: The patients, in the age range of 18 to 65 years, with the American Society of Anesthesiologists (ASA) physical status of I-III, and body mass index (BMI) of 18-30 kg/m2, and undergoing lung resection with VATS were included in the study. Patients were informed about the study, and their written consent was obtained. Patients were divided into Deep SAPB (DSAPB) (Group 1) and combined SAPB (CSAPB) (Group 2) groups according to the analgesia protocol. Results: There was no statistically significant difference between the groups in terms of demographic characteristics and surgical features (p > 0.05). When the groups were evaluated in terms of the block performance time, it was found to be statistically significantly longer in the CSAPB group than in the DSAPB group (p < 0.001). When the groups were evaluated in terms of VAS resting scores, the 1st, 2nd, 4th, 8th, and 16th, 24th, and 48th-hour VAS resting results were found to be statistically significantly higher in the DSAPB group than the CSAPB group (p < 0.05). VAS cough scores were statistically significantly higher in the DSAPB group at the 1st, 2nd, 4th, 8th, and 16th, 24th, and 48th-hour (p < 0.05). When the groups were evaluated in terms of the side effects, additional analgesic use, and morphine consumption, they were found to be statistically significantly higher in the DSAPB group than in the CSAPB group (p: 0.026, p: 0.020, p < 0.001, respectively). Conclusion: CSAPB provided effective analgesia after VATS for 48 hours. In addition, morphine consumption and the need for additional analgesics were low in CSAPB. However, the duration of the block procedure was longer in the CSAPB application.

The Effect of Pre-emptive Oral Melatonin versus Placebo on Post-operative Analgesia in Infants after Thoracotomy for Closed Cardiac Surgeries: A Randomized Controlled Study

BACKGROUND: Thoracotomy pain is one of the severest types of pain that should be managed properly, especially in children. Opioids are the most widely prescribed analgesics for post-operative pain, but they can have a number of undesirable side effects. Melatonin could be employed as an adjuvant analgesic therapy during procedural discomfort as it had no known major side effects. STUDY DESIGN: This was a double-blinded, controlled randomized study. METHODS: Fifty patients divided randomly into two equal groups. One hour before surgery, children in M group (n = 25) were given 0.5 mg/kg orally of melatonin 3 mg tablets) and patients in Group P (n = 25) received a placebo (5 ml of water by syringe 5 ml) orally. Post-operative pethidine consumption over the 1st 24 h (mg) was recorded, the intraoperative fentanyl consumption (HR and ABP) at baseline, 1 min after induction, at skin incision, and every 30 min till the end of the surgery were recorded. Neonatal Infant Pain Score (NIPS) at 4 h, 6 h, 8 h, 12 h, 18 h, and 24 h postoperatively was recorded. Other reported data include demographic data, extubation time, days of ICU stay, and complications. RESULTS: Total post-operative pethidine consumption (mg) over 24 h was significantly lower in M group than P group (3.48 ± 2.23 vs. 7.68 ± 4.52 p = 0.01). Intraoperative fentanyl consumption (ug) was significantly lower in M group than P group (10.28 ± 4.98 vs. 17.08 ± 7.39 p < 0.001). As regards NIPS, it was statistically lower in M group than P group in all times except at 8 h and 24 h with significant difference. CONCLUSION: Oral melatonin is an effective and safe pre-emptive drug as it reduces the total post-operative pethidine consumption over the first 24 h and decreased post-operative pain scores without any unpleasant effects in pediatrics undergoing closed heart surgery.

The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting.

METHODS

A retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared.

RESULTS

The maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0-100) mg vs. SI 100 (0-225) mg, P = 0.0001; pethidine: CINB 0 (0-25) mg vs. SI 25 (0-50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3-26.0) h vs. 22.0 (19.0-45.0) h, P = 0.011.

CONCLUSIONS

CINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.

Continuous Incisional Lidocaine in Pediatric Patients following Open Heart Surgery

Continuous incisional lidocaine infusion has been proposed as an adjunctive therapy in the management of postoperative pain in adult patients. The aim of this study was to determine the efficacy and safety of a continuous subcutaneous lidocaine infusion in pediatric patients following open heart surgery. All patients receiving a subcutaneous lidocaine infusion in median sternotomy incisions after open heart surgery during 2 consecutive years were included in the study. A historical cohort of patients was used as a control group. Demographic variables (age, size, and surgical procedure), variables related to sedation and analgesia (COMFORT and analgesia scales, drug doses, and duration), and complications were registered. 106 patients in the lidocaine infusion group and 79 patients in the control group were included. Incisional analgesia was effective for the treatment of pain as it reduced the dose and duration of intravenous fentanyl (odds ratio (OR) 6.26, confidence interval (CI) 95%: 2.48-15.97, p = 0.001; OR 4.30, CI 95%: 2.09-8.84, p = 0.001, respectively). The reduction in fentanyl use was more important in children over two years of age. Adverse effects were seen in three children (2.8%): they all had decreased level of consciousness, and one of them presented seizures as well. Two of these three patients had lidocaine levels over 2 mcg/ml. A continuous lidocaine incisional infusion is effective for the treatment of pain after open heart surgery. This procedure reduced intravenous analgesic drug requirements in pediatric patients undergoing a median sternotomy incision. Although the incidence of secondary effects is low, monitoring of neurologic status and lidocaine blood levels are recommended in all patients.

Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study

BACKGROUND

Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection.

RESULTS

We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different.

CONCLUSIONS

Preoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.

[Effects of different postoperative analgesic strategies on postoperative neurocognitive function and quality of recovery in elderly patients undergoing one lung ventilation]

OBJECTIVE

To evaluate the effects of different postoperative analgesic strategies on neurocognitive function and quality of recovery in elderly patients at 7 days after thoracic surgery with one lung ventilation.

METHODS

Ninety elderly patients undergoing video-assisted thoracic surgery were randomized into 3 groups (n=30) to receive postoperative analgesia with thoracic paravertebral block analgesia (TA), epidural analgesia (EA) and intravenous analgesia (GA). Before and at 7 days after the surgery, the patients' cognitive function was assessed using Mini-Mental State Examination (MMSE), and their early recovery at 7 days postoperatively was evaluated using Quality of Recovery-40 items (QoR-40).

RESULTS

The patients in TA and EA groups had significantly higher MMSE scores and lower incidence of postoperative neurocognitive dysfunction (PNCD) than those in GA group without significant difference between the former two groups. At 7 days after the surgery, serum levels of S100-β and MMP-9 were significantly higher in GA group than in TA and EA group, and did not differ significantly between the latter two groups. QoR-40 scores were significantly higher in TA and EA groups than in GA group, and were higher in TA group than in EA group. The chest intubation time and length of hospital stay were significantly shorter in TA and EA groups than in GA group.

CONCLUSIONS

In elderly patients undergoing surgeries with one lung ventilation, general anesthesia combined with either postoperative continuous thoracic paravertebral block or epidural analgesia can significantly improve postoperative neurocognitive function and quality of recovery, but continuous thoracic paravertebral block analgesia can be more advantageous for improving postoperative quality of recovery.

Perioperative Dexmedetomidine Fails to Improve Postoperative Analgesic Consumption and Postoperative Recovery in Patients Undergoing Lateral Thoracotomy for Thoracic Esophageal Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial

Objectives

Dexmedetomidine is widely used as an adjunct to general anesthesia. In this study, we evaluated the effects of perioperative dexmedetomidine infusion on postoperative analgesia in patients undergoing lateral thoracotomy for thoracic esophageal cancer.

Methods

A total of 62 patients undergoing lateral thoracotomy for thoracic esophageal cancer were randomized to receive adjuvant therapy with either dexmedetomidine (0.5 μg/kg intravenous bolus injection for 10 min before induction of anesthesia, followed by continuous infusion of 0.2-0.4 μg/kg/h until the end of surgery, and 0.06 μg/kg/h for 5 days after surgery) or equal volumes of saline. Acute postoperative pain was treated with patient-controlled intravenous sufentanil and flurbiprofen axetil. The primary outcomes of this study were the numbers of analgesic requirements in the first postoperative 72 h.

Results

Perioperative dexmedetomidine did not decrease the numbers of analgesic requirements in the first postoperative 72 h (dexmedetomidine group: 12.14 ± 4.76, saline group: 10.89 ± 5.66; p=0.367). Likewise, the groups did not differ with respect to total postoperative analgesic requirements, postoperative pain, perioperative inflammation, blood cell count, incidence of adverse events, surgical recovery (assessed at postoperative days 2 and 5 using the surgical recovery scale), length of hospital stay, hospital cost, incidence of chronic pain, or quality of life. Notably, dexmedetomidine had beneficial effects on decreasing intraoperative opioid consumption and improving postoperative sleep quality. Discussion. Perioperative dexmedetomidine has limited analgesic benefits in lateral thoracotomy for esophageal cancer when added to an opioid-based multimodal anesthetic regimen but can reduce opioid consumption.

Regional versus systemic analgesia in video-assisted thoracoscopic lobectomy: a retrospective analysis

Background

The optimal perioperative analgesic strategy in video-assisted thoracic surgery (VATS) for anatomic lung resections remains an open issue. Regional analgesic concepts as thoracic paravertebral or epidural analgesia were used as systemic opioid application. We hypothesized that regional anesthesia would provide improved analgesia compared to systemic analgesia with parenteral opioids in VATS lobectomy and would be associated with a lower incidence of pulmonary complications.

Methods

The study was approved by the local ethics committee (AZ 99/15) and registered (germanctr.de; DRKS00007529, 10th June 2015). A retrospective analysis of anesthetic and surgical records between July 2014 und February 2016 in a single university hospital with 103 who underwent VATS lobectomy. Comparison of regional anesthesia (i.e. thoracic paravertebral blockade (group TPVB) or thoracic epidural anesthesia (group TEA)) with a systemic opioid application (i.e. patient controlled analgesia (group PCA)). The primary endpoint was the postoperative pain level measured by Visual Analog Scale (VAS) at rest and during coughing during 120 h. Secondary endpoints were postoperative pulmonary complications (i.e. atelectasis, pneumonia), hemodynamic variables and postoperative nausea and vomiting (PONV).

Results

Mean VAS values in rest or during coughing were measured below 3.5 in all groups showing effective analgesic therapy throughout the observation period. The VAS values at rest were comparable between all groups, VAS level during coughing in patients with PCA was higher but comparable except after 8–16 h postoperatively (PCA vs. TEA; p < 0.004). There were no significant differences on secondary endpoints. Intraoperative Sufentanil consumption was significantly higher for patients without regional anesthesia (p < 0.0001 vs. TPVB and vs. TEA). The morphine equivalence postoperatively applicated until POD 5 was comparable in all groups (mean ± SD in mg: 32 ± 29 (TPVB), 30 ± 27 (TEA), 36 ± 30 (PCA); p = 0.6046).

Conclusions

Analgesia with TEA, TPVB and PCA provided a comparable and effective pain relief after VATS anatomic resection without side effects. Our results indicate that PCA for VATS lobectomy may be a sufficient alternative compared to regional analgesia.

Trial registration

The study was registered (germanctr.de; DRKS00007529; 10th June, 2015).

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

Serratus Anterior Plane Block for Post-Thoracotomy Analgesia: a Novel Technique for the Surgeon and Anaesthetist

Post-thoracotomy pain is one of the most severe forms of post-operative pain. Anaesthetists usually manage post-thoracotomy pain with an epidural or paravertebral block. However, both of these techniques have their limitations. Ultrasound-guided interfascial plane block like serratus anterior plane block is a new concept and is proposed to provide analgesia to the hemithorax. We report our experience with 10 thoracotomy cases where this block was used as a post-operative analgesic technique. Patients undergoing pulmonary metastasectomy or lobectomy received ultrasound-guided serratus anterior plane block between the serratus anterior and the external intercostal muscles with 0.25% ropivacaine, and a catheter was inserted. Post-operatively, 0.125% ropivacaine with fentanyl (1 mcg/ml) was given as infusion at 5-7 ml/h. Other analgesics were paracetamol and diclofenac. Fentanyl infusion at 0.25 mcg/kg/h was the rescue analgesic if pain persisted. Four out of 10 patients required fentanyl infusion. Uncontrolled pain in two of these patients was at the intercostal drain site; in the third patient, two ribs were resected; and in the 4th patient, there was poor drug spread and the catheter could not be placed in the desired plane due to poor muscle mass. The catheter was kept in situ for a minimum of 48 h to a maximum of 6 days after surgery. Serratus anterior block could be an attractive option for post-thoracotomy analgesia. Further studies can take the help of the surgeon for catheter placement in the desired plane at the time of wound closure to ensure adequate drug spread.

Preventive skin analgesia with lidocaine patch for management of post-thoracotomy pain: Results of a randomized, double blind, placebo controlled study

Background

To evaluate whether pre‐emptive skin analgesia using a lidocaine patch 5% would improve the effects of systemic morphine analgesia for controlling acute post‐thoracotomy pain.

Methods

This was a double‐blind, placebo controlled, prospective study. Patients were randomly assigned to receive lidocaine 5% patch (lidocaine group) or a placebo (placebo group) three days before thoracotomy. Postoperative analgesia was induced in all cases with intravenous morphine analgesia. The intergroup differences were assessed in order to evaluate whether the lidocaine patch 5% would have effects on pain intensity when at rest and after coughing (primary end‐point) on morphine consumption, on the recovery of respiratory function, and on peripheral painful pathways measured with N2 and P2 laser‐evoked potential (secondary end‐points).

Results

A total of 90 patients were randomized, of whom 45 were allocated to the lidocaine group and 45 to the placebo group. Lidocaine compared with the placebo group showed a significant reduction in pain intensity both at rest (P = 0.013) and after coughing (P = 0.015), and in total morphine consumption (P = 0.001); and also showed a better recovery of flow expiratory volume in one second (P = 0.025) and of forced vital capacity (P = 0.037). The placebo group compared with the lidocaine group presented a reduction in amplitude of N2 (P = 0.001) and P2 (P = 0.03), and an increase in the latency of N2 (P = 0.023) and P2 (P = 0.025) laser‐evoked potential.

Conclusions

The preventive skin analgesia with lidocaine patch 5% seems to be a valid adjunct to intravenous morphine analgesia for controlling post‐thoracotomy pain. However, our initial results should be corroborated/confirmed by larger studies.

Role of dexamethasone in the para-vertebral block for pediatric patients undergoing aortic coarctation repair. randomized, double-blinded controlled study

BACKGROUND

Surgery for aortic coarctation requires special care during anesthesia due to severe pain during the lateral thoracotomy incision, intraoperative hemodynamic instability and the need for large doses of intra- and postoperative analgesics and vasodilators. Additionally, the postoperative care of patients is very important.

AIMS

We aimed to compare ultrasound-guided paravertebral block performed using bupivacaine alone and bupivacaine with dexamethasone in terms of the intra- and postoperative analgesic requirements and hemodynamics, postoperative complications and ICU stay.

STUDY DESIGN

This was a prospective, randomized, controlled, double-blinded study.

METHODS

Fifty patients aged four to 12 months scheduled for aortic coarctation surgery were randomly divided into two equal groups (n = 25). Patients in group D (dexamethasone) received 0.5 mg/kg bupivacaine 0.25% mixed with 0.1 mg/kg dexamethasone diluted with isotonic saline and those in group C (control) received 0.5 mg/kg bupivacaine 0.25% diluted with isotonic saline (total volume 15 ml in each group). Intraoperative fentanyl consumption and hemodynamics (heart rate, arterial blood pressure) at baseline, 1 min after induction, at skin incision, after 30 min, after clamping, after declamping and at the end of the surgery were recorded, along with the objective pain score (OPS) immediately postoperatively and at 4 h, 8 h, 12 h and 24 h postoperatively and the time to the first request for pethidine. The intra- and postoperative vasodilator doses, time to extubation, ICU stay duration and postoperative complications were also recorded.

RESULTS

The postoperative OPS was significantly lower at 12 and 24 h in group D than in group C. The time to the first request for analgesia was significantly longer in group D than in group C (3.9 ± 2.23 vs 8.6 ± 0.69). Additionally, the time to extubation was significantly shorter in group D.

CONCLUSION

The use of dexamethasone as an adjuvant in ultrasound-guided paravertebral block in paediatric patients undergoing surgery for aortic coarctation increased the duration of postoperative analgesia with a prolonged time to the first request for analgesics It was also associated with a decreased incidence of postoperative complications.

TRIAL REGISTRATION

Trial registration number: NCT03074773 . (Prospectively registered). The initial registration date was 9/3/2017.

Serratus anterior plane block for minimal invasive heart surgery

BACKGROUND

Minimal invasive heart surgery (MIHS) presents several benefits, but provides intense and prolonged post-operative pain. Our objective was to compare efficacy of serratus anterior plane block (SAPB) with continuous wound infiltration (CWI) for management of post-operative pain following MIHS.

METHODS

It's retrospective, monocentric study between November 2016 to April 2017. The study was performed at the University hospital of Dijon, Burgundy, France. All patients scheduled for MIHS was included. Data was collected retrospectively. During this period, 20 patients had SAPB and 26 had CWI. SAPB was performed before extubation with a single injection of 0.5 mg/kg of ropivacaïne (5 mg/ml). In the CWI group, catheter was inserted in the subcutaneous space by the surgeon at the end of the procedure. A 10 ml bolus of ropivacaïne (7.5 mg/mL) was followed by a continuous infusion (2 mg/ml) between 7 and 12 ml/h for 48 h. Morphine consumption and visual analog score (VAS) were recorded for 48 h. Length of stay in intensive care unit and hospital was also collected.

RESULTS

Morphine consumption and VAS score were significantly lower in SAPB group (p < 0.01). Length of stay in intensive care and hospital was significantly was decreased in SAPB group.

CONCLUSION

SAPB appears effective in reducing postoperative MIHS pain.

A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy

BACKGROUND

Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema.

METHODS

We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n = 21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n = 21).

RESULTS

Inotrope use was reduced by 29% in the WC group (p = 0.03) and the mean intensive care stay reduced by 2.4 days (p = 0.03), as was reintubation rate (p = 0.01) and early mobilisation (p = 0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined.

CONCLUSION

The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.

Influence of Regional Anesthesia on the Rate of Chronic Postthoracotomy Pain Syndrome in Lung Cancer Patients

Purpose: Our study aimed to assess whether the type of regional anesthesia influenced the incidence of chronic postthoracotomy pain syndrome (CPTPS).

Methods: This was a prospective, randomized study that included 300 patients undergoing lung cancer resection using thoracotomy. They were randomized into three groups: paravertebral nerve block (PVB), thoracic epidural anesthesia (TEA), and intercostal nerve block (INB). General anesthesia was similar in the groups. A horizontal visual analogue scale (VAS) was used to assess the intensity of the pain syndrome. It was assessed and recorded 7 days, 1 month, and 6 months after surgery.

Results: At 6 months after surgery, the incidence (p <0.05) of the CPTPS was higher in the INB group (40%) than in the TEA group (23%). The CPTPS frequency in the PVB group did not differ from the other groups (34%).

Conclusion: The use of the TEA in patients who underwent open lung cancer surgery contributed to a significant decline in the CPTPS frequency compared to patients who were administered INB. Using PVB did not decrease the CPTPS frequency.

Postoperative pain management after esophagectomy: a systematic review and meta-analysis

Effective pain management after esophagectomy is essential for patient comfort, early recovery, low surgical morbidity, and short hospitalization. This systematic review and meta-analysis aims to determine the best pain management modality focusing on the balance between benefits and risks. Medline, Embase, and the Cochrane library were systematically searched to identify all studies investigating different pain management modalities after esophagectomy in relation to primary outcomes (postoperative pain scores at 24 and 48 hours, technical failure, and opioid consumption), and secondary outcomes (pulmonary complications, nausea and vomiting, hypotension, urinary retention, and length of hospital stay). Ten studies investigating systemic, epidural, intrathecal, intrapleural and paravertebral analgesia involving 891 patients following esophagectomy were included. No significant differences were found in postoperative pain scores between systemic and epidural analgesia at 24 (mean difference (MD) 0.89; 95% confidence interval (CI) -0.47-2.24) and 48 hours (MD 0.15; 95%CI -0.60-0.91), nor described for systemic and other regional analgesia. Also, no significant differences in pulmonary complication rates were identified between systemic and epidural analgesia (relative risk (RR) 1.69; 95%CI 0.86-3.29), or between systemic and paravertebral analgesia (RR 1.49; 95%CI 0.31-7.12). Technical failure ranged from 17% to 22% for epidural analgesia. Sample sizes were too small to draw inferences on opioid consumption, the risk of nausea and vomiting, hypotension, urinary retention, and length of hospital stay when comparing the different pain management modalities including systemic, epidural, intrathecal, intrapleural, and paravertebral analgesia. This systematic review and meta-analysis shows no differences in postoperative pain scores or pulmonary complications after esophagectomy between systemic and epidural analgesia, and between systemic and paravertebral analgesia. Further randomized controlled trails are warranted to determine the optimal pain management modality after esophagectomy.

Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery

OBJECTIVE

Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function.

DESIGN

Prospective, non-randomized trial from April 2009 to September 2011.

SETTING

Department of Thoracic Surgery, single-center.

PARTICIPANTS

Thoracic surgical patients.

INTERVENTIONS

Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy.

MEASUREMENTS AND MAIN RESULTS

The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups.

CONCLUSIONS

Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.

Pulmonary lobectomies for patients with cognitive impairment: the importance of postoperative respiratory care

BACKGROUND

Patients with cognitive impairment (CI) may have an increased risk of complications after major thoracic surgery. However, little is known about this risk and the corresponding management.

METHODS

Clinical data of patients who underwent pulmonary lobectomy via open thoracotomy between January 2006 and December 2008 in our institution were retrospectively reviewed.

RESULTS

Overall, 1,325 patients who underwent pulmonary lobectomy via open thoracotomy were analyzed retrospectively, in which five patients were diagnosed with CI. Sputum retention was common and led to significant hypoxemia in all five patients. Four patients were re-intubated due to severe respiratory dysfunction, and three underwent tracheotomy 7 days after intubation due to respiratory infection. Regarding to duration of chest tube placement, length of hospital stay, morbidity rate, and hospital cost, CI patients were significant higher compared with cognitively normal patients undergoing lobectomy via open thoracotomy.

CONCLUSIONS

Patients with CI may have difficulties in expectoration after pulmonary lobectomy, and develop multiple respiratory complications, thus increasing hospital stay. Efficacious sputum and airway clearance is critical in these patients.

Reprogramming of in situ spinal cord stimulator for covering newly developed postthoracotomy pain

The objective of this case report is to describe the use of in situ spinal cord stimulator (SCS) for postthoracotomy pain syndrome (PTPS). We report a 39-year-old woman with complex regional pain syndrome type I of the left lower extremity. The patient's pain was relieved by a SCS for 1 month before the patient developed slipping rib syndrome at her T12 rib from an unrelated trauma. After failed conservative treatments and undergoing a thoracotomy procedure, the patient developed PTPS. Conservative management with medications and intercostal nerve blocks provided short-term relief. An already implanted single Octrode with Eon Mini generator (St Jude Neuromodulator, Plano, TX) at the T7 level was reprogrammed in attempt to recruit peripheral fibers to target the patient's additional areas of chest discomfort. This adjustment improved the pain at the left lateral rib area as well as her left leg. The patient was followed for 1 year, and her quality of life improved since her initial presenting symptoms. The use of the SCS in this patient provided significant lasting pain relief for both complex regional pain syndrome and PTPS. We believe that the use of SCS should be considered as a treatment option for patients with PTPS to avoid side effects associated with medications and to provide long-term pain relief.

Nonintubated anesthesia for thoracic surgery

Nonintubated thoracic surgery has been used in procedures including pleura, lungs and mediastinum. Appropriate anesthesia techniques with or without sedation allow thoracic surgery patients to avoid the potential risks of intubated general anesthesia, particularly for the high-risk patients. However, nonintubated anesthesia for thoracic surgery has some benefits as well as problems. In this review, the background, indication, perioperative anesthetic consideration and management, and advantages and disadvantages are discussed and summarized.

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.