Comparison of the intraoperative analgesic efficacy between ultrasound-guided deep and superficial serratus anterior plane block during video-assisted thoracoscopic lobectomy: A prospective randomized clinical trial

Advances in Anesthesia Techniques for Postoperative Pain Management in Minimally Invasive Cardiac Surgery: An Expert Opinion

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Analgesic efficacy and safety of erector spinae plane block versus serratus anterior plane block in breast surgery-a meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Mastectomy and breast-conserving surgery are key interventions for breast cancer, a leading cause of cancer-related mortality in women. Many undergoing breast surgery experience postoperative pain compromising their functionality and quality of life. While multiple pain management strategies are available, evidence comparing the erector spinae (ESPB) and serratus anterior plane blocks (SAPB) for improving post-surgical pain management in breast cancer surgery patients is limited. Therefore, we investigated the efficacy and safety of these two regional anesthesia techniques.

METHODS

After PROSPERO registration, we systematically searched PubMed, Google Scholar, and Cochrane Library until May 2024. Risk ratios (RR) were calculated for dichotomous outcomes and standard mean differences (SMD) or mean differences (MD) were computed for continuous data. RevMan Review Manager 5.4.1 was used for the data analysis and generation of forest plots as well as funnel plots. The Cochrane Risk of Bias tool 2.0 (18) and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines were used to appraise and evaluate the evidence (19).

RESULTS

A total of 9 randomized control trials enrolling 550 patients were included. Static pain scores at 0, 6, 8, 12, and 24 h after surgery, dynamic pain scores computed at 0, 8, 12, and 24 h after surgery and area under the curve (AUC) static pain score at all time points between 0 and 24 h (SMD (HKSJ 95% CI) - 0.27 [- 0.99, 0.45]) did not significantly vary with either plane block. Postoperative morphine consumption in the first 24 h and the number of patients requesting analgesia were significantly greater in those receiving SAPB [MD: - 1.41 (95% C.I. - 2.70, - 0.13), p = 0.03] and [RR: 1.28 (95% C.I. 1.00, 1.63), p = 0.05], respectively. The time to first postoperative analgesic use was significantly greater among those administered ESPB [MD: 1.55 h, (95% C.I. 1.02, 2.09), p < 0.01]. Patient satisfaction scores and the incidence of nausea and vomiting were similar across both groups.

CONCLUSIONS

While pain scores with either block are comparable, ESPB reduces postoperative morphine consumption and may be the favorable option in breast cancer patients undergoing surgery.

Relative Perioperative Analgesic Efficacy of Superficial Versus Deep Approach of Serratus Anterior Plane Block for Anterior Chest Wall Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Both superficial and deep serratus anterior plane (SAP) blocks are effective for anterior chest wall surgeries, but there is little clarity on which is more effective. Hence, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the comparative efficacy of the 2 approaches for SAP block after anterior chest wall surgery.

MATERIALS AND METHODS

A systematic literature search was performed using PubMed, Embase, Scopus, and Cochrane Central Registers of Controlled Trials for eligible RCTs from inception until August 2023. The primary outcome was opioid consumption during the first 24 hours of the postoperative period. The secondary outcomes included pain scores at various intervals, intraoperative opioid consumption, time to first analgesic request, block-related complications, opioid-related side effects, and patient satisfaction scores. Statistical analysis of the pooled data was performed using Review Manager Version 5.3.

RESULTS

We identified 7 RCTs published between 2020 and 2022, enrolling 371 patients (186 in the superficial SAP block and 187 in the deep SAP block). Moderate certainty of evidence suggests that both the approaches (deep and superficial) of SAP block were comparable for 24-hour oral morphine equivalent consumption with a mean difference (MD) of 3.78 mg (95% CI: -1.70 to 9.29; P = 0.18; I2 = 87%). The results of other secondary outcomes were comparable, including resting pain scores with an MD of 0.08 (95% CI: -0.27 to 0.43; P = 0.67; I2 = 87%) for early pain and MD of 0.63 (95% CI: -1.28 to 0.01; P = 0.05; I2 = 95%) for late pain scores, time to first analgesic request with MD of -0.41 hour (95% CI: -1.40 to 0.59; P = 0.42; I2 = 90%), and incidence of postoperative nausea and vomiting (odds ratio: 1.45 (95% CI: 0.72 to 2.90; P = 0.30; I2 = 0%).

CONCLUSION

Current evidence does not support the preference for one approach of SAP block over the other for postoperative pain. Based on the available data, we recommend further future trials to determine any differences between these interventions.

Ultrasound-guided Serratus Anterior Plane Block Versus Paravertebral Block for Postoperative Analgesia in Children Undergoing Video-assisted Thoracoscopic Surgery: A Randomized, Comparative Study

OBJECTIVES

This study compared the postoperative analgesic efficacy of serratus anterior plane block (SAPB) and thoracic paravertebral block (PVB) in children undergoing video-assisted thoracoscopic surgery.

SETTING

Operating room and intensive care unit of a tertiary care hospital.

DESIGN

A single-center, randomized, comparative, open-labeled study.

PARTICIPANTS

Seventy pediatric patients aged 2 to 10 years who underwent video-assisted thoracoscopic surgery were enrolled.

INTERVENTIONS

Patients were equally randomized into 2 groups. In the SAPB group, patients were injected with 0.4 mL/kg 0.25% bupivacaine under ultrasound guidance into the deep SAPB and in the PVB group, patients were injected with 0.4 mL/kg 0.25% bupivacaine under ultrasound guidance into the thoracic paravertebral space.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was morphine consumption within the first 24 hours after surgery. The secondary outcomes were Children's Hospital of Eastern Ontario Pain Scale pain score, intraoperative fentanyl consumption, and the time required to perform the block. The median (Q1, Q3) morphine consumption (mg/kg) in the first postoperative 24 hours was similar in the SAPB and PVB groups (0.15 [0.1-0.2], 0.1 [0.1-0.2], respectively). The Children's Hospital of Eastern Ontario Pain Scale pain score was similar in both the SAPB and PVB groups at all-time points. Intraoperative fentanyl consumption was comparable in both groups. Time needed to perform the block was shorter in SAPB than PVB.

CONCLUSIONS

SAPB provides effective postoperative pain control, similar to thoracic PVB. Moreover, it is technically easier and has a shorter time to perform than PVB. Therefore, SAPB is an effective and safe alternative to thoracic PVB.

Continuous serratus anterior plane block for postoperative analgesia following lung transplantation via anterolateral incision: a pilot study

Background

Unilateral or bilateral anterolateral thoracotomy May lead to severe acute pain in lung transplantation (LTx). Although serratus anterior plane block (SAPB) is apparently effective for pain control after open thoracic surgery, there remains a lack of evidence for the application of SAPB for postoperative analgesia after LTx.

Objective

In this case series pilot study, we describe the feasibility of continuous SAPB after lung transplantation and provide a preliminary investigation of its safety and efficacy.

Methods

After chest incisions closure was complete, all patients underwent ultrasound-guided SAPB with catheter insertion. Numerical rating scale (NRS), additional opioid consumption, time to endotracheal tube removal, ICU length of stay, and catheter-related adverse events were followed up and recorded for each patient within 1 week after the procedure.

Results

A total of 14 patients who received LTx at this center from August 2023 to November 2023 were included. All patients received anterolateral approaches, and 10 (71.4%) of them underwent bilateral LTx. The duration of catheter placement was 2 (2-3) days, and the Resting NRS during catheter placement was equal to or less than 4. A total of 11 patients (78.6%) were supported by extracorporeal membrane oxygenation (ECMO) in LTx, whereas 8 patients (57.1%) removed the tracheal tube on the first day after LTx. Intensive care unit (ICU) stay was 5 (3-6) days, with tracheal intubation retained for 1 (1-2) days, and only one patient was reintubated. The morphine equivalent dose (MED) in the first week after LTx was 11.95 mg, and no catheter-related adverse events were detected.

Limitations

We did not assess the sensory loss plane due to the retrospective design. In addition, differences in catheter placement time May lead to bias in pain assessment.

Conclusion

Although continuous SAPB May be a safe and effective fascial block technique for relieving acute pain after LTx, it should be confirmed by high-quality clinical studies.

Fascia Iliaca Block Reduces Remifentanil Requirement in Conscious Sedation for Transcatheter Aortic Valve Implantation - A Randomized Clinical Trial

BACKGROUND

Whether nerve block improves the quality of conscious sedation (CS) in patients undergoing transcatheter aortic valve implantation (TAVI) is unclear. This study investigated whether fascia iliaca block (FIB) reduced the remifentanil requirement and relieved pain in CS for TAVI.

METHODS AND RESULTS

This prospective study randomized 72 patients scheduled for elective TAVI under CS into 2 groups, with (FIB) and without (control) FIB (n=36 in each group). The sedation targeted a Bispectral Index <90 with a Richmond Agitation-Sedation Scale of -2 to -1. Dexmedetomidine (0.7 µg/kg, i.v.) combined with remifentanil (0.03 µg/kg/min, i.v.) and propofol (0.3 mg/kg/h, i.v.) was used to commence sedation. FIB using 30 mL of 0.185% ropivacaine was implemented 2 min before TAVI. Patient sedation was maintained with dexmedetomidine (0.4 µg/kg/h, i.v.) supplemented with remifentanil (0-0.02 µg/kg/min, i.v.). Remifentanil (20 µg, i.v.) was used as a rescue dose for intraprocedural pain. Compared with the control group, FIB reduced the both the total (median [interquartile range] 83.0 [65.0-98.0] vs. 34.5 [26.0/45.8)] µg; P<0.001) and continuous (25.3 [20.9/31.5] vs. 9.5 [6.8/12.5] ng/kg/min; P<0.001) doses of remifentanil administered.

CONCLUSIONS

FIB reduced the remifentanil requirement and relieved pain in patients undergoing TAVI with CS. Therefore, FIB improved the quality of CS in TAVI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Efficacy of Intrathoracic Intercostal Nerve Block on Postoperative Acute and Chronic Pains of Patients Undergoing Video-Assisted Thoracoscopic Surgery

Background

Patients undergoing video-assisted thoracoscopic surgery (VATS) frequently suffered postoperative acute and chronic pains. In recent years, intrathoracic intercostal nerve block (INB) is regularly used thanks to its safety and accuracy, especially under the circumstance of lacking ultrasound or in face of the contraindications of the thoracic paravertebral block (TPVB). However, clinical evidence of comparing TPVB and INB for pain management after VATS has been limited and the observation of the chronic pain has been less than clear.

Methods

A total of 180 patients undergoing VATS were randomly divided into three groups: A single multi-point paravertebral nerve block (Group P), intrathoracic intercostal nerve block (Group I), and general anesthesia without any regional block (Group C). Postoperative acute pain was scored at rest and coughing by the Visual Analog Scale (VAS) for recording 24h, 48h and 72h after VATS. All patients were interviewed 1, 3 and 6 months after the surgery to investigate both the incidence and intensity of chronic pains.

Results

There were significantly less incidence and intensity of acute pain in Group P and Group I, compared to those in Group C. The patients in Group I showed the least incidence and intensity of chronic pain after 3 months compared with those in Group P and Group C. There are 89 of 98 patients suffering pains after 1 month, which grew into chronic pains after 3 months and 78 of them still suffered chronic pains even after 6 months.

Conclusion

The intrathoracic INB offers excellent relief from acute and chronic pains, which does as effectively as TPVB. Besides, one-month postoperative pain could increase the risk of a chronic one.

Superficial vs. deep serratus anterior plane block for analgesia in patients undergoing mastectomy: A randomized prospective trial

STUDY OBJECTIVE

In the initial description of the serratus anterior plane block (SAPB), both superficial and deep SAPB provided effective blockade. The purpose of this study was to investigate the difference in opioid consumption and postoperative analgesia between superficial and deep SAPB for patients undergoing mastectomy.

DESIGN

Randomized prospective trial.

SETTING

Academic hospital.

PATIENTS

64 women, >18 years of age, ASA I-III, undergoing single or bilateral mastectomy, with and without lymph node biopsy, with and without tissue expander reconstruction.

INTERVENTION

Either superficial or deep SAPB by an ultrasound-guided technique in addition to multimodal analgesia.

MEASUREMENTS

The primary outcome was opioid consumption in the first 24 h. Secondary outcomes were pain scores, satisfaction scores, incidence of PONV, length of stay and block performance time.

RESULTS

Subjects who received a deep SAPB required 30% less oral morphine equivalents (OME) (113.5 mg vs. 147 mg, p = 0.009) and reported lower pain scores. There were no significant differences in satisfaction scores, incidence of PONV, LOS, or block performance time between the two groups.

CONCLUSION

There was a significant difference in opioid consumption between the deep and superficial SAPB groups. Subjects in the deep SAPB group had lower pain scores at 12 h; however, the difference was not statistically significant at other time points. While both the superficial and the deep SAPB can be used for post-operative analgesia in patients undergoing mastectomy, our study suggests that the deep SAPB may improve analgesia to a greater degree than the superficial SAPB as shown through decreased opioid consumption of 30% over a 24-h period post-block. CLINICAL TRIAL NUMBER AND REGISTRY URL: clinicaltrials.gov: NCT03154658.

Continuous serratus anterior plane block improved early pulmonary function after lung cancer surgery

BACKGROUND

Serratus anterior plane block (SAPB) has been proven to be an efficient way to control postoperative pain. This study explored whether the use of continuous SAPB in combination with flurbiprofen could improve early pulmonary function in lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS).

METHODS

From July 2019 to April 2020, patients who scheduled for elective lung resection undergoing thoracoscopic surgery were randomly allocated to receive patient-controlled SAPB in combination with intravenous flurbiprofen or patient-controlled intravenous analgesia. Postoperative pulmonary function parameters, including forced expiratory volume in 1 second, and forced vital capacity were collected before and 24, 48, and 72 hours after surgery. Pain intensity was measured at rest and on coughing. Comfort score during breathing exercises, postoperative pulmonary complications and adverse events were recorded.

RESULTS

A substantial reduction in lung function was exhibited in both groups after surgery (P < 0.001), but lung function parameters in continuous SAPB group were significantly higher (P < 0.001) throughout postoperative period up to 72 hours, regardless of the surgery type. Meanwhile, there were significant differences of pain intensity at rest and on coughing between both groups (P < 0.001). The incidence of pneumonia, pulmonary atelectasis, hypoxemia, vomiting and the comfort score in continuous SAPB group was significantly lower (P< 0.05).

CONCLUSIONS

Postoperative acute pain treatment with continuous SAPB in combination with flurbiprofen enhanced pulmonary function and reduced postoperative pulmonary complications in lung cancer patients undergoing VATS.