Improvement of recovery parameters using patient-controlled epidural analgesia for video-assisted thoracoscopic surgery lobectomy in enhanced recovery after surgery: A prospective, randomized single center study

Epidural analgesia versus oral morphine for postoperative pain management following video-assisted thoracic surgery: A randomised, controlled, double-blind trial

BACKGROUND

The use of thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery (VATS) is controversial. Still, the evidence on omitting it in favour of systemic opioids is inconclusive, and studies are small and non-blinded.

OBJECTIVE

We aimed to compare pain after VATS using epidural analgesia or enteral opioids for postoperative pain management.

DESIGN/SETTING/PATIENTS/INTERVENTION

A randomised, double-blind, controlled trial at a Danish tertiary hospital. Adult patients scheduled for VATS were assigned to multimodal non-opioid baseline analgesia supplemented with either thoracic epidural analgesia (TE Group) or oral morphine (OM Group) for postoperative pain management. We recorded pain five times a day, both at rest and during activity, using the Numeric Rating Scale (NRS) and categorised it into "acceptable pain" or "unacceptable pain". Unacceptable pain was defined as NRS (at rest) ≥3 or NRS (with activity) ≥5 when supplementary analgesics were given.

MAIN OUTCOME MEASURES

The primary outcomes were the proportions of patients experiencing "unacceptable pain" during the postoperative period and the use of intravenous "rescue" opioids.

RESULTS

Of the 161 included patients, 146 received the allocated treatment and their data were analysed. At rest, 34% of patients in the TE Group and 64% of patients in the OM Group experienced unacceptable pain during the study period, a significant between-group difference of 30% ( P  < 0.0005). During activity these percentages were 32% of patients in the TE Group and 59% in the OM group, a difference of 27% ( P  < 0.005). The median intravenous rescue morphine consumption during the study period was 4.5 [interquartile range (IQR), 0-10.0] mg in the TE Group and 7.5 [0-19.0] mg in the OM Group ( P  < 0.005).

CONCLUSION

Epidural analgesia provided better pain relief after VATS than oral morphine. The between-group difference in rescue intravenous morphine consumption was statistically significant but clinically irrelevant.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02359175).

[Perioperative pain therapy in minimally invasive thoracic surgery]

Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.

Accuracy Evaluation Trial of Mixed Reality-Guided Spinal Puncture Technology

Purpose

To evaluate the accuracy of mixed reality (MR)-guided visualization technology for spinal puncture (MRsp).

Methods

MRsp involved the following three steps: 1. Lumbar spine computed tomography (CT) data were obtained to reconstruct virtual 3D images, which were imported into a HoloLens (2nd gen). 2. The patented MR system quickly recognized the spatial orientation and superimposed the virtual image over the real spine in the HoloLens. 3. The operator performed the spinal puncture with structural information provided by the virtual image. A posture fixation cushion was used to keep the subjects' lateral decubitus position consistent. 12 subjects were recruited to verify the setup error and the registration error. The setup error was calculated using the first two CT scans and measuring the displacement of two location markers. The projection points of the upper edge of the L3 spinous process (L3↑), the lower edge of the L3 spinous process (L3↓), and the lower edge of the L4 spinous process (L4↓) in the virtual image were positioned and marked on the skin as the registration markers. A third CT scan was performed to determine the registration error by measuring the displacement between the three registration markers and the corresponding real spinous process edges.

Results

The setup errors in the position of the cranial location marker between CT scans along the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) axes of the CT bed measured 0.09 ± 0.06 cm, 0.30 ± 0.28 cm, and 0.22 ± 0.12 cm, respectively, while those of the position of the caudal location marker measured 0.08 ± 0.06 cm, 0.29 ± 0.18 cm, and 0.18 ± 0.10 cm, respectively. The registration errors between the three registration markers and the subject's real L3↑, L3↓, and L4↓ were 0.11 ± 0.09 cm, 0.15 ± 0.13 cm, and 0.13 ± 0.10 cm, respectively, in the SI direction.

Conclusion

This MR-guided visualization technology for spinal puncture can accurately and quickly superimpose the reconstructed 3D CT images over a real human spine.

Postoperative Pain in Patients Undergoing Cancer Surgery and Intravenous Patient-Controlled Analgesia Use: The First and Second 24 h Experiences

INTRODUCTION

Postoperative cancer pain imposes severe physical and psychological problems. We aimed to investigate the pain experiences of patients with cancer after surgery, analyze the impact of infusion volume by patient-controlled analgesia (PCA), and explore the variations between day 1 and day 2.

METHODS

Data were retrospectively extracted from a large health data platform. Descriptive statistics were presented for the demographic and clinical profiles of patients. Multiple logistic regression analyses were performed to evaluate associations between intensity of pain and PCA use after adjustment for risk factors.

RESULTS

Among 11,383 patients with cancer, the incidence of pain (moderate to severe pain) was 93.3% (18.3%) at the first 24 h after operation, while the respect values decreased to 91.1% and 9.5% at the second 24 h. Further, female patients consistently experienced higher risk of pain over the whole 48 h postoperatively. Surgical sites were related to pain risk, with the highest risk among the respiratory system (OR 2.077, 95% CI 1.392-3.100). High doses of continuous volume (OR 2.453, 95% CI 1.742-3.456) and total volume (OR 2.830, 95% CI 2.037-3.934) of infusions were related to 1-3-fold elevated pain risk. Additionally, the observed associations were mostly repeated and could be up to over 10 times when pain was evaluated with number of PCA pump compressions instead of Numerical Rating Scale (NRS).

CONCLUSIONS

High risk of postoperative cancer pain, particularly among the high PCA dose group, could possibly indicate inadequate pain control, and presence of modifiable risk factors warrants more aggressive pain management strategies perioperatively.

Patient-controlled intravenous analgesia with opioids after thoracoscopic lung surgery: a randomized clinical trial

Background

Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME).

Methods

This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days.

Results

Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups.

Conclusions

Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery.

Trial registration

This study was registered at (ChiCTR2100045614, 19/04/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01785-4.

Utilization of Supplemental Regional Anesthesia in Lobectomy for Lung Cancer in the United States: A Retrospective Study

Background

Pulmonary lobectomy is the standard of care for the treatment of early-stage non-small cell lung cancer. This study investigated the rate of utilization of supplemental anesthesia in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy using a national database and assessed the effect of regional block (RB) on postoperative outcomes.

Methods

Patients who underwent lobectomy for lung cancer between 2014–2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The patients’ primary mode of anesthesia and supplemental anesthesia were recorded. Preoperative characteristics and postoperative outcomes were compared between 2 surgical groups those who underwent general anesthesia (GA) alone versus GA with RB. Multivariable regression analyses were performed on the outcomes of interest.

Results

In total, 13,578 patients met the study criteria, with 87% undergoing GA and the remaining 13% receiving GA and RB. The use of neuraxial anesthesia decreased over the years, while RB use increased up to 20% in 2019. Age, body mass index, and preoperative comorbidities were comparable between groups. Patients who underwent VATS were more likely to receive RB than those who underwent thoracotomy. RB was most often utilized by thoracic surgeons. An adjusted analysis showed that RB use was associated with shorter hospital stays and a reduced likelihood of prolonged length of stay, but a higher rate of surgical site infections (SSIs).

Conclusion

In a large surgical database, there was underutilization of supplemental anesthesia in patients undergoing lobectomy for lung cancer. RB utilization was associated with a shorter length of hospital stay and an increase in SSI incidence.

Intravenous patient-controlled analgesia plus psychoeducational intervention for acute postoperative pain in patients with pulmonary nodules after thoracoscopic surgery: a retrospective cohort study

Background

The association of psychological factors with postoperative pain has been well documented. The incorporation of psychoeducational intervention into a standard analgesia protocol seems to be an attractive approach for the management of acute postoperative pain. Our study aimed to evaluate the impact of psychoeducational intervention on acute postoperative pain in pulmonary nodule (PN) patients treated with thoracoscopic surgery.

Methods

In this study, 76 PN patients treated with thoracoscopic surgery and intravenous patient-controlled analgesia (IV-PCA) plus psychoeducational evaluation and intervention were selected as the psychoeducational intervention group (PG). Another 76 PN patients receiving IV-PCA without psychoeducational intervention after thoracoscopic surgery, treated as the control group (CG), were identified from the hospital database and matched pairwise with PG patients according to age, sex, preoperative body mass index (BMI), opioid medications used for IV-PCA and the educational attainment of patients.

Results

The most common psychological disorders were anxiety and interpersonal sensitivity, which were recorded from 82.9% (63/76) and 63.2% (48/76) of PG patients. The numerical rating scale (NRS) pain scores of the PG patients were significantly lower than those of the CG patients at 2 and 24 h after surgery (P < 0.001). Total opioid consumption for acute postoperative pain in the PG was 52.1 mg of morphine equivalent, which was significantly lower than that (67.8 mg) in the CG (P = 0.038). PG patients had a significantly lower incidence of rescue analgesia than CG patients (28.9% vs. 44.7%, P = 0.044). Nausea/vomiting was the most common side effect of opioid medications, recorded for 3 (3.9%) PG patients and 10 (13.2%) CG patients (P = 0.042). In addition, no significant difference was observed between PG and CG patients in terms of grade 2 or higher postoperative complications (10.5% vs. 17.1%, P = 0.240).

Conclusions

Psychoeducational intervention for PN patients treated with thoracoscopic surgery resulted in reduced acute postoperative pain, less opioid consumption and fewer opioid-related side effects.

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations

Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

The Effect of Oblique Lumbar Interbody Fusion Compared with Transforaminal Lumbar Interbody Fusion Combined with Enhanced Recovery after Surgery Program on Patients with Lumbar Degenerative Disease at Short-Term Follow-Up

Purpose

Oblique lumbar interbody fusion (OLIF) approach has been increasingly frequently performed in recent years. However, neither studies of OLIF approach nor the researches of the application of enhanced recovery after surgery (ERAS) in spinal surgery are relatively rare. Here, our study is aimed at investigating the therapeutic effects of the application of OLIF compared with transforaminal lumbar interbody fusion (TLIF) approach combined with ERAS in dealing with this disorder at short-term follow-up. Material and Methods. Thirty-eight patients who undergone OLIF and forty patients who undergone TLIF with pedicle screws were included in our study. The concept of ERAS was applied in the perioperative period of the patients. Preoperative and postoperative laboratory test indexes of blood were examined and evaluated in all individuals. Visual analogue scale (VAS), Oswestry disability index (ODI), and Clinical Symptom Score of the Japanese Orthopaedic Association (JOA) were used in preoperative evaluation and postoperative follow-up. Satisfaction survey was also performed after surgery.

Result

The postoperative results of red blood count, C-reaction protein, D-dimer, and albumin were still within the reference ranges in most of the patients. It was shown that objective evaluations including VAS score, ODI index, and JOA score were significantly improved after OLIF and TLIF surgery. The follow-up of 6 months after surgery showed that VAS, ODI, and JOA were improved more in the OLIF group than that in the TLIF group. The overall satisfaction (satisfied and very satisfied) was 95% and 97.4% in the TLIF group and the OLIF group, respectively, and there was no difference between the two groups.

Conclusion

This study indicated that OLIF and TLIF approach were both rather effective therapies for patients with lumbar degenerative diseases. The effect of OLIF procedure could be better than TLIF procedure in the early stage after surgery.

Preemptive Intercostal Nerve Block as an Alternative to Epidural Analgesia

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.

Continuous Paravertebral Analgesia versus Continuous Epidural Analgesia after Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial

Background: Whether continuous thoracic epidural analgesia (TEA) and continuous paravertebral block (PVB) have similar analgesic effects in patients undergoing video- assisted thoracic surgery (VATS) lobectomy was compared in this study.

Methods: In all, 86 patients undergoing VATS lobectomy were enrolled in the prospective, randomized clinical trial. Group E received TEA. Group P received PVB. The primary endpoint was postoperative 24-hour visual rating scale (VAS) on coughing. Side effects and postoperative complications were also analyzed.

Results: Pain scores at rest or on coughing at 24 and 48 h postoperatively were significantly lower in group E than in group P (P <0.05). At 24 h postoperatively, more patients in group E suffered from vomiting (32.6% vs 11.6%, P = 0.019), dizziness (55.8% vs 12.9%, P = 0.009), pruritus (27.9% vs 2.3%, P = 0.002), and hypotension (32.6% vs 4.7%, P = 0.002) than those in group P. Patients in group E were more satisfied (P = 0.047). Four patients in group P and two patients in group E suffered from pulmonary complications (P >0.05). The length of hospital and intensive care unit (ICU) stays were not significantly different.

Conclusions: Though TEA has more adverse events than PVB, it may be superior to PVB in patients undergoing VATS lobectomy.

Association Between Intercostal Nerve Block and Postoperative Glycemic Control in Patients With Diabetes Undergoing Video-Assisted Thoracoscopic Pulmonary Resection: A Retrospective Study

OBJECTIVES

The present study was performed to investigate the possible association between intercostal nerve block (INB) and postoperative glycemic control in patients with diabetes undergoing video-assisted thoracoscopic pulmonary resection.

DESIGN

A retrospective study.

SETTING

Single-center tertiary academic hospital.

PARTICIPANTS

Patients with diabetes, ages 18 to 79 years, who had undergone elective video-assisted thoracoscopic pulmonary resection (segmentectomy or lobectomy) from January 1, 2015, to December 31, 2018.

INTERVENTIONS

Postoperative blood glucose levels and insulin dosage were extracted from the record.

MEASUREMENTS AND MAIN RESULTS

Patients with diabetes who received INB before closure of surgical incisions were compared with those who did not receive INB. The primary outcome was the daily blood glucose (BG) level. Univariate analyses and multivariate regression analysis were performed to explore risk factors of hyperglycemia within 48 hours after the surgery. Baseline characteristics were comparable between the two groups. Patients who received INB had a lower maximum BG level and amplitude of glycemic excursion from zero-to-24 hours after surgery (p = 0.007 and p = 0.041, respectively) and lower maximum and minimum BG levels from 24-to-48 hours after surgery (p = 0.023 and p = 0.006, respectively). Meanwhile, the daily insulin dose increment during zero-to-24 hours and 24-to-48 hours after surgery decreased (p = 0.010 and p = 0.003, respectively), the white blood cell counts within 48 hours after surgery were lower (p = 0.021), and the length of postoperative stay decreased in the INB group (p = 0.044). Multivariate regression analysis further confirmed that INB was an independent protective factor of postoperative hyperglycemia (Nagelkerke R² value 0.229; odds ratio 0.298; 95% confidence interval 0.099-0.901; p = 0.032).

CONCLUSION

INB, performed before closure of surgical incisions, was associated with improved glycemic control in patients with diabetes within 48 hours after video-assisted thoracoscopic pulmonary resection.

Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery: A randomized controlled study

BACKGROUND

Thoracic epidural analgesia is the preferred method for postoperative analgesia following thoracic surgery. However, intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. This study was conducted because few scientific reports exist comparing fentanyl-based IVPCA including a low dose of ketamine (fk-IVPCA) with thoracic patient-controlled epidural analgesia (t-PCEA) for the treatment of postoperative pain after video-assisted thoracic surgery (VATS).

METHODS

This prospective, and randomized study included 70 patients randomized into fk-IVPCA and t-PCEA groups. Pain at rest and during movement, successful and unsuccessful triggers after pressing the PCA device button, the need for rescue analgesia, drug-related adverse events, and patient satisfaction were recorded for 48 hours postoperatively.

RESULTS

No significant differences in the intensity of pain at rest or during movement were observed between the 2 groups within 48 hours postoperatively. The number of unsuccessful PCA triggers in the t-PCEA group 0 to 4 hours after surgery was significantly higher than that in the fk-IVPCA group. However, the numbers of successful PCA triggers in the fk-IVPCA group at 4 to 12 and 0 to 24 hours after surgery were significantly higher than those in the t-PCEA group. The incidence of analgesic-related side effects and patient satisfaction were similar in both groups.

CONCLUSIONS

Compared with t-PCEA, the addition of a subanesthetic dose of ketamine to fentanyl-based IVPCA resulted in similar pain control after VATS with no increase in the incidence of drug-related adverse effects. The results confirm that both multimodal intravenous analgesia and epidural analgesia can provide sufficient pain control and are safe strategies for treating acute post-thoracotomy pain.