Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction

Introduction

Enhanced recovery after surgery (ERAS) protocols have been implemented to decrease opioid use and decrease patient hospital length of stay (LOS, days). Serratus anterior plane (SAP) blocks anesthetize the T2 through T9 dermatomes of the breast and can be applied intraoperatively. The purpose of this study was to compare postoperative opioid (OME) consumption and LOS between a control group, an ERAS group, and an ERAS/local anesthetic cocktail group in patients who underwent implant-based breast reconstruction.

Methods

In this study, 142 women who underwent implant-based breast reconstruction between 2004 and 2020 were divided into Group A (46 patients), a historical cohort; Group B (73 patients), an ERAS/no-block control group; and Group C (23 patients), an ERAS/anesthetic cocktail study group. Primary outcomes of interest were postanesthesia care unit (PACU), inpatient and total hospital OME consumption, and PACU LOS.

Results

A significant decrease was observed from Group A to C in PACU LOS (103.3 vs. 80.2 vs. 70.5; p = 0.011), OME use (25.1 vs. 11.4 vs. 5.7; p < 0.0001), and total hospital OME (120.3 vs. 95.2 vs. 35.9; p < 0.05). No difference was observed in inpatient OMEs between the three groups (95.2 vs. 83.8 vs. 30.8; p = 0.212). Despite not reaching statistical significance, Group C consumed an average of 50-60 % less opioids per patient than did Group B in PACU, inpatient, and total hospital OMEs.

Conclusion

Local anesthetic blocks are important components of ERAS protocols. Our results demonstrate that a combination regional block with a local anesthetic cocktail in an ERAS protocol can decrease opioid consumption in implant-based breast reconstruction.

Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study

Background

Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h.

Methods

We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery.

Results

Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P<0.01) and 48 h (-50, 95% CI -97 to -2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC.

Conclusions

This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.

Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial

INTRODUCTION

Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure.

METHODS

The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay.

RESULTS

Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption.

CONCLUSION

Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).

Chronic Pain Following Breast Reconstruction: A Scoping Review

BACKGROUND

Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being.

METHODS

To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed.

RESULTS

The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain.

CONCLUSION

This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.

Ultrasound-Guided Serratus Posterior Superior Intercostal Plane Block in Modified Radical Mastectomy Surgeries: A Case Series

Effective pain management is crucial for modified radical mastectomy (MRM) surgeries. The Serratus Posterior Superior Intercostal Plane Block (SPSIPB), introduced in 2023, shows promise for postoperative analgesia. This study was designed to demonstrate the analgesic efficacy of the SPSIPB in MRM surgeries. SPSIPB was administered to 7 patients who underwent MRM for postoperative analgesia. NRS scores of patients were ≤4 and total tramadol consumption was 0 mg in 3 of 7 patients. In conclusion, SPSIPB appears to be an effective, safe, and easily applicable option for analgesia.

Safety and efficacy of surgically performed continuous superficial serratus anterior plane block in uniportal video-assisted thoracic surgery

INTRODUCTION

The 'surgically performed' continuous superficial serratus anterior plane block (continuous s-SAPB) was never described before in uniportal video-assisted thoracic surgery (uniportal VATS) surgery. The aim of the study was to evaluate the safety and efficacy of the technique.

PATIENTS AND METHODS

Between March 2022 and April 2023, 50 patients, undergone uniportal VATS surgery at our thoracic surgery department, were scheduled for a surgically performed continuous s-SAPB as post-operative analgesia protocol.

RESULTS

The mean execution time for the block was 3.92 ± 2.56 min. Ten patients (20%) required morphine for a visual analogue scale (VAS) score >4 immediately after surgery. The recorded VAS score at chest tube removal was 1.87 ± 1.41, whereas 2 h after the manoeuvre was 0.42 ± 0.72. No complication related to block insertion was recorded. The onset of chronic pain was observed in a total of 2 patients (4%).

CONCLUSIONS

The surgically performed continuous s-SAPB in uniportal VATS seems to be safe and easy to perform, and it provides a satisfactory analgesic effect.

Efficacy and safety of the serratus anterior plane block (SAP block) for pain management in patients with multiple rib fractures in the emergency department: a retrospective study

PURPOSE

Chest trauma is a severe and frequent cause of admission to the emergency department (ED). The serratus anterior plane (SAP) block seems to be an effective method of pain management; however, data on efficacy and safety of a single SAP block performed in the ED by emergency physicians (EP) are limited. This study aimed to compare SAP block performed by the EP in the ED plus standard therapy to standard therapy alone in terms of pain severity at 0-3-6-12-18 and 24 h, total opioid consumption (milligrams of morphine equivalents, MME), respiratory function (SpO2/FiO2 ratio), and adverse events (i.e. pneumothorax, infections in the site of injection, or Local Anaesthetic Systemic Toxicity syndrome due to SAP block) in the first 24 h.

METHODS

This retrospective, monocentric study included adult patients admitted to the Sub-intensive Care Unit (SICU) of the ED with multiple rib fractures between 01/2022 and 03/2023.

RESULTS

156 patients (65.4% male; median age 62 years; median injury severity score 16; median thoracic trauma severity score 8) were included. 75 (48.2%) underwent SAP block. Patients undergoing SAP block showed significantly less pain 3-6-18 h after a single block, required less MME (0 [0-20] vs. 20 [0-40], p < 0.001), showed higher SpO2/FiO2 ratio, and no adverse events were reported.

CONCLUSION

The SAP block, in combination with standard therapy, appeared to be more effective in providing pain relief than standard therapy alone in patients admitted to the SICU for traumatic rib fractures.

Effects of ultrasound-guided serratus plane block combined with general anesthesia on postoperative early quality of recovery and analgesia in patients undergoing transapical transcatheter aortic valve implantation surgery: study protocol for a randomized controlled trial

BACKGROUND

Compared to traditional thoracotomy, transapical transcatheter aortic valve implantation (TAVI) surgery offers reduced trauma and faster recovery, fostering the adoption of enhanced recovery after surgery (ERAS) protocols in cardiac surgery. Despite these advancements, postoperative pain management has received insufficient attention. The potential effects of multi-mode analgesia, including ultrasound-guided serratus anterior plane block (SAPB), on postoperative pain and early quality of recovery have not been widely studied, lacking comprehensive prospective evidence. Therefore, this study aims to investigate the impact of SAPB combined with general anesthesia on early recovery quality and analgesic efficacy in transapical TAVI patients.

METHODS

This prospective, randomized controlled study will enroll 70 patients undergoing transapical TAVI, randomly allocated to either the SAPB group or the control group. The primary outcome, assessed using Quality of Recovery-40 (QOR-40) scale, focuses on the quality of recovery at 24 h and 48 h postoperatively. Secondary outcomes include the visual analog scale (VAS) pain scores at rest and during coughing at 6 h, 12 h, 24 h, and 48 h after surgery, frequency of patient-controlled analgesia (PCA) utilization at 24 h and 48 h, opioid consumption at 24 h and 48 h, time and frequency of rescue analgesia and severe pain at 24 h and 48 h, incidence of nausea and vomiting at 48 h after surgery, and dosage of antiemetic drugs.

DISCUSSION

The purpose of our study is to evaluate the effects of ultrasound-guided SAPB combined with general anesthesia on postoperative early quality of recovery and analgesia in transapical TAVI patients. The results obtained may provide valuable insight for the implementation of multi-mode analgesia and enhanced ERAS in this specific patient population.

TRIAL REGISTRATION

China Clinical Trial Register ChiCTR2300068584. Registered on 24 February 2023.

Hydromorphone combined with ropivacaine for erector spinae plane block in patients undergoing modified radical mastectomy: A prospective randomized controlled trial

BACKGROUND

Combining hydromorphone with ropivacaine in ultrasound-guided erector spinae plane blocks enhances postoperative analgesia and reduces interleukin-6 expression in breast surgery patients.

METHODS

In this study, breast cancer patients undergoing modified radical mastectomy were randomized into 3 groups for anesthesia (30 patients in each group): standard general (group C), Erector Spinae Plane Block (ESPB) with ropivacaine (group R), and ESPB with ropivacaine plus hydromorphone (group HR). Diagnosis: Breast cancer patients. Postsurgery, pain levels, IL-6, anesthetic doses, additional analgesia needs, and recovery milestones were compared to evaluate the efficacy of the ESPB enhancements.

RESULTS

The 3 groups were not significantly different in baseline characteristics, operation time, number of cases with postoperative nausea, and serum IL-6 concentrations at T1 (the time of being returned to the ward after surgery). At T2 (at 6:00 in the next morning after surgery), the serum IL-6 concentration in group HR was significantly lower than that in groups R and C (P < .05); the intraoperative doses of remifentanil, sufentanil, and propofol were significantly lower in groups HR and R than those in group C (P < .05); Groups HR and R had significantly lower visual analog scale scores at T3 (4 hours postoperatively), T4 (12 hours postoperatively), and T5 (24 hours postoperatively) than those in group C (P < .05); the proportions of patients receiving postoperative remedial analgesia were significantly lower in groups HR and R than in group C (P < .05); groups HR and R had significantly lower proportions of patients with postoperative nausea than group C (P < .05); the time to the first anal exhaust and the time to the first ambulation after surgery were significantly shorter in groups HR and R than those in group C (P < .05).

CONCLUSION

Hydromorphone combined with ropivacaine for ESPB achieved a greater postoperative analgesic effect for patients receiving MRM under general anesthesia. The combined analgesia caused fewer adverse reactions and inhibited the expression level of the inflammatory factor IL-6 more effectively, thereby facilitating postoperative recovery. ESPB using hydromorphone with ropivacaine improved pain control post-MRM, reduced adverse effects, and more effectively suppressed IL-6, enhancing recovery.

Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment

BACKGROUND

Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time.

METHODS

This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions.

RESULTS

Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%.

CONCLUSION

The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.

Serratus plane block versus standard of care for pain control after totally endoscopic aortic valve replacement: a double-blind, randomized controlled, superiority trial

INTRODUCTION

Serratus anterior plane block has been proposed to reduce opioid requirements after minimally invasive cardiac surgery, but high-quality evidence is lacking.

METHODS

This prospective, double-blinded, randomized controlled trial recruited patients undergoing totally endoscopic aortic valve replacement. Patients in the intervention arm received a single-injection serratus anterior plane block on arrival to the intensive care unit added to standard of care. Patients in the control group received routine standard of care, including patient-controlled intravenous analgesia. Primary outcome was piritramide consumption within the first 24 hours after serratus anterior plane block placement. We hypothesized that compared with no block, patients in the intervention arm would consume 25% less opioids.

RESULTS

Seventy-five patients were analyzed (n=38 in intervention arm, n=37 in control arm). When comparing the serratus anterior plane group with the control group, median 24-hour cumulative opioid use was 9 (IQR 6-19.5) vs 15 (IQR 11.3-23.3) morphine milligram equivalents, respectively (p<0.01). Also, pain scores at 4, 8 and 24 hours were lower in the intervention arm at 4, 8 and 24 hours, respectively.

CONCLUSION

Combined deep and superficial single-injection serratus anterior plane block is superior to standard of care in reducing opioid requirements and postoperative pain intensity up to 24 hours after totally endoscopic aortic valve replacement.

TRIAL REGISTRATION NUMBER

NCT04699422.

Perioperative Analgesic Effect of Serratus Anterior Plane Block for Breast Surgery: A Randomized Control Study at a Large Teaching Hospital in Ghana

Background Pain after breast surgery has been described as moderate to severe in intensity and, if inadequately treated, increases postoperative morbidity, hospital cost, and the incidence of persistent postoperative pain. Serratus anterior plane (SAP) block is an interfascial injection technique for analgesia of the chest wall. There is a lack of data with regard to its analgesic and possible opioid-sparing effects in Sub-Saharan Africa. This study aimed to determine the perioperative analgesic effect of serratus anterior plane block administered for breast surgery. Methods This was a prospective, randomized, double-blinded study involving 52 patients and was randomized into the intervention (n = 26) and control (n = 26) groups. One patient in the control group did not receive the allocated intervention, while one in the intervention group lost to follow-up. Complete data of 50 participants, comprising intervention (n=25), was used in the analysis. Patients' demographic and health characteristics, pre-induction, intra-operative, and postoperative hemodynamic parameters were noted. After induction of anesthesia, a blinded anesthetist performed an ultrasound-guided serratus anterior plane block with 0.25% plain bupivacaine or a sham block using 0.9% normal saline (control). Numerical rating scale (NRS) score and incidence of postoperative nausea and vomiting (PONV) were recorded immediately after surgery and at 1, 4, 8, and 24 postoperative hours. Patient satisfaction with analgesic management within the first 24 postoperative hours was also assessed. Results Patients who received SAP block had lower NRS scores at all measured time points, but this was only statistically significant at the fourth postoperative hour (p-value = 0.002). Compared to controls, patients who received SAP had lower intraoperative (11.3±1.5 mg vs. 11.9±1.5 mg, p value = 0.131) and postoperative (4.6±5.7mg vs. 10.5±6 mg, p value=0.001) mean opioid consumption. However, only the reduction in postoperative opioid consumption was found to be statistically significant. Most participants (> 90%) in this study did not experience PONV and were very satisfied with their postoperative pain management. Conclusion Serratus anterior plane block reduces NRS pain scores postoperatively. It also significantly reduces postoperative opioid consumption but does not significantly reduce intraoperative opioid consumption.

Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery

Robotic thoracic surgery is a prominent minimally invasive approach for the treatment of various thoracic diseases. While this technique offers numerous benefits including reduced blood loss, shorter hospital stays, and less postoperative pain, effective pain management remains crucial to enhance recovery and minimize complications. This review focuses on the application of various loco-regional anesthesia techniques in robotic thoracic surgery, particularly emphasizing their role in pain management. Techniques such as local infiltration anesthesia (LIA), thoracic epidural anesthesia (TEA), paravertebral block (PVB), intercostal nerve block (INB), and erector spinae plane block (ESPB) are explored in detail regarding their methodologies, benefits, and potential limitations. The review also discusses the imperative of integrating these anesthesia methods with robotic surgery to optimize patient outcomes. The findings suggest that while each technique has unique advantages, the choice of anesthesia should be tailored to the patient's clinical status, the complexity of the surgery, and the specific requirements of robotic thoracic procedures. The review concludes that a multimodal analgesia strategy, potentially incorporating several of these techniques, may offer the most effective approach for managing perioperative pain in robotic thoracic surgery. Future directions include refining these techniques through technological advancements like ultrasound guidance and exploring the long-term impacts of loco-regional anesthesia on patient recovery and surgical outcomes in the context of robotic thoracic surgery.

Serratus Anterior Plane Block: A Better Modality of Pain Control after Pectus Excavatum Repair

Background

Postoperative pain management following minimally invasive repair of pectus excavatum (MIRPE) remains a critical concern due to severe post-procedural pain. Promising results have been reported for cryoanalgesia following MIRPE; however, its invasiveness, single-lung ventilation, and additional instrumentation requirements remain obstacles. Serratus anterior plane block (SAPB) is a regional block technique capable of covering the anterior chest wall at the T2-9 levels, which are affected by MIRPE. We hypothesized that SAPB would be a superior alternative pain control modality that reduces postoperative pain more effectively than conventional methods.

Methods

We conducted a retrospective study of patients who underwent MIRPE between March 2022 and August 2023. The efficacy of pain control was compared between group N (conventional pain management, n=24) and group S (SAPB, n=26). Group N received intravenous patient-controlled analgesia (IV-PCA) and subcutaneous local anesthetic infusion. Group S received bilateral continuous SAPB with 0.3% ropivacaine after a bilateral bolus injection of 30 mL of 0.25% ropivacaine with baseline IV-PCA. Pain levels were evaluated using a Visual Analog Scale (VAS) at 1, 3, 6, 12, 24, 48, and 72 hours postoperatively and total intravenous rescue analgesic consumption by morphine milligram equivalents (MME).

Results

Mean VAS scores were significantly lower in group S than in group N throughout the 72-hour postoperative period (p<0.01). Group S showed significantly lower MME at postoperative 72 hours (group N: 108.53, group S: 16.61; p<0.01).

Conclusion

SAPB improved immediate postoperative pain control in both the resting and dynamic states and reduced opioid consumption compared to conventional management.

Comparison Between Erector Spinae Plane Block versus Serratus Anterior Plane Block Regarding Analgesia and Stress Response After Modified Radical Mastectomy: Randomized Controlled Trial

Background

Modified radical mastectomy (MRM) is the primary surgical treatment for breast cancer, yet it leads to significant postoperative pain.

Objectives

This randomized controlled trial evaluates the effects of an erector spinae plane block (ESPB) versus a serratus anterior plane block (SAPB) on post-MRM pain management and stress response reduction.

Methods

Sixty individuals scheduled for unilateral MRM under general anesthesia from October 2021 to October 2022 were divided into three groups. Group A comprised 20 patients who received ultrasound-guided ESPB (20 mL of 0.25% bupivacaine). Group B included 20 patients who received ultrasound-guided SAPB (20 mL of 0.25% bupivacaine). Group C was treated with intravenous morphine based on pain scores. Anesthesia was induced using 2 μg/kg of fentanyl and 2 - 3 mg/kg of propofol. The study compared the three groups regarding pain scores using a numerical rating scale, serum cortisol levels, total fentanyl, and morphine consumption, changes in mean arterial blood pressure (MAP) and heart rate (HR) during surgery, and the occurrence of postoperative complications.

Results

Statistically significant reductions in pain scores were observed in group A compared to groups B and C. Moreover, group A exhibited a significant decrease in postoperative morphine consumption, serum cortisol levels 1 hour post-surgery (P = 0.021), MAP, and postoperative vomiting and nausea compared to group B. Furthermore, groups A and B showed statistically significant improvements in all parameters compared to group C.

Conclusions

The study demonstrates that ESPB provides superior analgesic effects compared to SAPB in patients undergoing MRM, with reduced morphine use and lower postoperative cortisol levels. Both blocks offer more effective pain control than intravenous morphine alone.

Role of tramadol as an adjuvant in ultrasound-guided serratus anterior muscle block for modified radical mastectomy - A randomized control trial

Background and Aims

Modified radical mastectomy (MRM) is associated with significant acute post-operative pain that may progress to chronic pain syndromes in 25-60% of patients. Serratus anterior muscle (SAM) block has proved to be an excellent analgesic option in patients undergoing MRM. Although many adjuvants have been utilized for the prolongation of analgesia, the role of tramadol in SAM has not been studied as yet. We hypothesize that the addition of tramadol to ropivacaine for SAM block may reduce morphine consumption in the post-operative period in patients undergoing elective MRM surgeries. The primary aim of the study was to compare cumulative post-operative morphine consumption over 24 h in patients receiving SAM block with or without tramadol. The secondary aims were to observe adverse events related to the procedure or medications. The other parameters recorded were non-invasive blood pressure (NIBP), pulse rate, respiratory rate, and nausea or vomiting.

Material and Methods

Patients scheduled to undergo MRM were randomly allocated by block randomization into two groups. The study group (Group T) received a SAM block with 0.25% ropivacaine (18 ml) with tramadol 100 mg while the control group (Group P) received a SAM block with 18 ml of 0.25% ropivacaine and 2 ml of saline. Patients were assessed for pain scores, analgesic requirement, time to first analgesic request, hemodynamic variables, and any side-effects at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h post-operatively.

Results

Cumulative morphine consumption over 24 h in the post-operative period was less in the group T (3.06 ± 1.53 mg vs 4.34 ± 1.53 mg; P 0.001). Time to the first analgesic requirement was more in group T (10.44 ± 5.04 h vs 6.11 ± 2.73 h; P < 0.001). Pain scores were significantly lower in the group T at all time points.

Conclusion

Tramadol, when used as an adjuvant to ropivacaine for SAM block reduces post-operative pain scores in the first 24 h and prolongs the time of first morphine requirement.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome

INTRODUCTION

Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option.

RESULTS

This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome.

CONCLUSION

This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Fascial plane blocks for cardiothoracic surgery: a narrative review

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Analgesia-nociception index accurately predicts inadequate pectoralis muscle fascia block (PECS) in patients undergoing breast surgery: A prospective observational study

BACKGROUND

Postoperative opioid administration has been largely replaced by regional anesthesia techniques. We aimed to determine whether intraoperative Analgesia-Nociception Index (ANI) can aid in early evaluation of the effectiveness of regional blocks such as the pectoralis muscle fascia block (PECS, pectoserratus and interpectoral plane blocks) and predicting the need for analgesics postoperatively.

METHODS

This prospective observational study enrolled 30 women (age: 20-80 years) undergoing unilateral, non-intubated, breast tumor excision alone or in conjunction with sentinel lymph node biopsy. PECS block was performed following sedation. ANI readings were obtained at 1-min intervals, and polar coordinates were assigned to the distance from the nipple (0.5-cm intervals) and o'clock position (15-min intervals) for each reading. Pain scores were assessed using a numeric rating scale from 0 to 10, and analgesics were administered depending on pain score post-operatively.

RESULTS

8 (27%), 19 (63%), and 3 (10%) patients received morphine, tramadol, and no analgesics, respectively. In total, 954 ANI measurements were obtained. At the proposed cut-off of 50, the sensitivity and specificity of the ANI nadir for need of post-operative opioids were 0.875 and 0.932, respectively. Block effectiveness was most satisfactory in the upper lateral quadrant of the breast with nipple-areolar complex (NAC) sparing effect. Most average ANI measurements for the NAC were <50. No patient experienced postoperative nausea/vomiting, although one reported dizziness.

CONCLUSIONS

The intraoperative ANI nadir <50 was strongly correlated with need for postoperative opioids. The ANI may aid in objectively evaluating the effectiveness of pectoralis muscle fascial blocks and predicting postoperative need for analgesics.

Efficacy of Peripheral Nerve Stimulator Guided Pectoral Nerve Block-1 and Serratus Anterior Plane Block for Post-operative Analgesia in Modified Radical Mastectomy: A Randomized Controlled Study

BACKGROUND

Breast carcinoma is one of the most common cancers in present-day women worldwide, hence surgical intervention for the same is inevitable. General anesthesia being the preferred technique, the selection of appropriate postoperative pain management is a major concern in which superficial fascial plane chest wall blocks play a pivotal role. We aimed to prove the efficacy of peripheral nerve stimulator-guided pectoral nerve-1 (PEC 1) block and serratus anterior plane (SAP) block for postoperative analgesia in modified radical mastectomy.

METHODS

This prospective randomized controlled clinical study comprised 60 females undergoing modified radical mastectomy and was randomly allocated to two groups. Group A patients received general anesthesia while, in addition to general anesthesia, group B patients received PEC 1 and SAP blocks. Postoperatively the active and passive visual analog score (VAS), duration of analgesia, cumulative requirement of rescue analgesics in the first 24 hours and associated perioperative complications were noted. All quantitative data were analyzed by student t-test and qualitative data by chi-square test using MedCalc software 12.5.

RESULTS

VAS score for first 24 hours in group B was lower at rest, on pressure over the surgical site as well as on movements compared with the patients in group A with the p-value being < 0.0001 at all time intervals. Time for receiving first rescue analgesia was shorter (1.25±0.56hour vs 20.05±7.78hour, p<0.001) with the significantly higher requirement of cumulative doses of tramadol in the first 24 hours in patients belonging to group A (233.33±47.95mg vs 110±31.62 mg, p<0.001).

CONCLUSION

PEC 1 and SAP blocks given under peripheral nerve stimulator guidance have a high success rate and are reliable in providing adequate postoperative analgesia for patients undergoing modified radical mastectomy.

An ultrasound-guided serratus anterior plane block with continuous local anaesthetic infusion and epidural analgesia for rib fracture pain

BACKGROUND

We compared analgesia with an ultrasound (US)-guided serratus anterior plane block (SAPB) to thoracic epidural analgesia (EA) with continuous local anaesthetic infusion in patients with unilateral multiple traumatic rib fractures. EA often carries contraindications in patients with multiple rib fractures (MRFs), whereby having alternative effective methods to treat rib fracture pain remains important to patient care. Thus, we hypothesised that both regional anaesthetic techniques would provide effective pain relief.

METHODS

In this study, we included 59 patients with unilateral MRFs and a numerical rating scale (NRS) pain score ≥4 at rest or upon movement. Patients were randomised to receive a US-guided SAPB or continuous infusion EA with 2 mg/mL ropivacaine. Patients were given a patient-controlled analgesia (PCA) device with intravenous oxycodone boluses for rescue medication. The primary outcome was a change in the NRS score at rest and upon movement from baseline to Day 2 following the block. We also measured the forced expiratory volume in 1 s of expiration (FEV1) and FEV1% at the same time points when NRS was measured. The total consumption of oxycodone with PCA was measured at 24 and 48 h after the block.

RESULTS

We detected a significant reduction (≥2) in NRS for both groups; however, EA associated with a greater reduction in NRS upon movement after block initiation. The mean reduction in NRS upon movement within 1 h was 3 (1.8, p < .01) in the SAPB group versus 4.7 (2.4, p < .01) in the EA group. We found no significant difference between groups in pain scores on Days 1 and 2 following the block. In the EA group, FEV1% increase in the first 12 h from baseline. Finally, PCA oxycodone consumption did not differ between groups.

CONCLUSIONS

SAPB with continuous local anaesthetic infusion is an effective alternative to treat rib fracture pain when EA is contraindicated. We found that SABP significantly reduces pain in patients with unilateral MRFs, although EA achieves better analgesia over the first 12 h following the block.

Percutaneous electrical nerve stimulation in post-mastectomy neuropathic pain: A case report

Post-mastectomy pain syndrome (PMPS) is a type of chronic postsurgical pain that can be severe, debilitating and frequently encountered in clinical practice. Multiple studies have focused on prevention, identifying risk factors and treating this condition. Nonetheless, PMPS remains a complex condition to treat effectively. In this case report, we describe the use of percutaneous electrical nerve stimulation in a breast cancer patient who experienced PMPS refractory to conventional treatments.

[Common and New Regional Anaesthesia Techniques Under Review - From Head to Abdomen]

By implementation of sonography regional anesthesia became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety during needle placement. Thereby new truncal blocks got enabled. Next to the blocking of specific nerve structures, plane blocks got established which can also be described as interfascial compartment blocks. The present review illustrates published and established blocks in daily practice concerning indications and the procedural issues. Moreover, the authors explain potential risks, complications and dosing of local anesthetics.

Perioperative and Anesthetic Considerations in Vascular Rings and Slings

Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.

Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.

Efficacy of Serratus Anterior Plane Block Versus Paravertebral and Intercostal Blocks for Pain Control After Surgery:: A Systematic Review and Meta-analysis

OBJECTIVE

Our study aimed to compare the analgesic efficacy of serratus anterior plane block (SAB) with the paravertebral block (PVB) and intercostal block (ICB) for patients undergoing surgical procedures.

MATERIALS AND METHODS

A literature search was performed on the databases of ScienceDirect, Google Scholar, PubMed, and Embase from inception to October 24, 2021. Only randomized controlled trials comparing SAB with either PVB or ICB and reporting pain outcomes were included.

RESULTS

A total of 16 randomized controlled trials were included. Thirteen compared SAB with PVB and 3 with ICB. Comparing SAB with PVB, we noted no difference in 24-hour morphine consumption between the groups (mean difference: 1.37; 95% CI: -0.33, 3.08; I2 = 96%; P = 0.11). However, the exclusion of 1 study indicated significantly increased analgesic consumption with the SAB. No difference was found in pain scores between SAB and PVB at 2, 4, 6, 8, 12, and 24 hours. Meta-analysis failed to demonstrate any statistically significant difference in time to the first analgesic request between the two groups (mean difference: -0.79; 95% CI: -0.17, 1.75; I2 = 94%; P = 0.11). We also noted no statistically significant difference in the incidence of nausea/vomiting with SAB or PVB (odds ratio: 0.79; 95% CI: 0.41, 1.51; I2 = 0%; P = 0.47).

CONCLUSIONS

Evidence on the analgesic efficacy of the SAB versus the PVB is conflicting. Twenty-four-hour total analgesic consumption may be higher with the SAB as compared with PVB but with no difference in pain scores and time to the first analgesic request. Data on the comparison of the SAB with the ICB is insufficient to draw strong conclusions.

Additive value of superficial parasternal intercostal plane block and serratus anterior plane block in lung transplantation surgery: a retrospective exploratory study

BACKGROUND

Adequate pain control following lung transplantation (LTx) surgery is paramount. Thoracic epidural analgesia (TEA) is the gold standard; however, the potential use of extracorporeal membrane oxygenation (ECMO) and consequent anticoagulation therapy raises safety concerns, prompting clinicians to seek safer alternatives. The utility of thoracic wall blocks in general thoracic surgery is well established; however, their role in the context of LTx has been poorly investigated.

METHODS

In this retrospective exploratory study, we assessed the effect of adding a superficial parasternal intercostal plane (sPIP) block and serratus anterior plane (SAP) block to standard anesthetic and analgesic care on tracheal extubation rates, pain scores and opioid consumption until 72 hours postoperatively in LTx.

RESULTS

Sixty patients were included in the analysis; 35 received the standard anesthetic and analgesic care (control group), and 25 received sPIP and SAP blocks in addition to the standard anesthetic and analgesic care (intervention group). We observed higher tracheal extubation rates in the intervention group at 8 hours postoperatively (16.0% vs 0.0%, p=0.03). This was also shown after adjusting for known prognostic factors (OR 1.18; 95% CI 1.04 to 1.33, p=0.02). Furthermore, we noted a lower opioid consumption measured by morphine milligram equivalents at 24 hours in the intervention group (median 405 (IQR 300-490) vs 266 (IQR 168-366), p=0.02). This was also found after adjusting for known prognostic factors (β -118; 95% CI -221 to 14, p=0.03).

CONCLUSION

sPIP and SAP blocks are safe regional analgesic techniques in LTx involving ECMO and clamshell incision. They are associated with faster tracheal extubation and lower opioid consumption. These techniques should be considered when TEA is not appropriate. Further high-quality studies are warranted to confirm these findings.

The Efficacy of Continuous Serratus Anterior and Erector Spinae Plane Blocks vs Intercostal Nerve Block in Uniportal-Vats Surgery: A Propensity-Matched Prospective Trial

BACKGROUND

To evaluate the analgesic efficacy of continuous erector spinae plane block(c-ESPB) and serratus anterior plane block(c-SAPB) versus the intercostal nerve block (ICNB) in Uniportal-VATS in terms of pain control, drug consumption, and complications.

METHODS

Ninety-three consecutive patients, undergone one of the three peripheral nerve blocks after Uniportal-VATS, were prospectively enrolled. A 1:1 propensity score matching was used to minimize bias.

RESULTS

C-ESPB and c-SAPB groups had no difference in morphine request upon awakening compared to ICNB. A higher VAS-score was recorded in c-ESPB compared to ICNB in the first 12 h after surgery. A significantly lower consumption of paracetamol in II postoperative day (p.o.d.) and tramadol in I and II p.o.d. was recorded in the c-ESPB group compared to the ICNB group. A higher dynamic VAS score was recorded at 24 h and 48 h in the ICNB group compared to the c-SAPB. No difference was found in safety, VAS-score and drug consumption between c-ESPB and c-SAPB at any given time, except for a higher tramadol request in c-SAPB in II p.o.d.

CONCLUSIONS

C-ESPB and c-SAPB appear to have the same safety and analgesic efficacy when compared between them and to ICNB in Uniportal-VATS approach. C-ESPB showed a delayed onset of analgesic effect and a lower postoperative drug consumption compared to ICNB.

Analgesic efficacy of erector spinae plane block versus paravertebral block in lung surgeries-A non-inferiority randomised controlled trial

BACKGROUND

Pain management plays an essential role in postoperative recovery after lung surgeries. The Erector Spinae Plane Block (ESPB) is a widely used regional anaesthesia technique; however, few clinical trials have compared this block to active control in thoracic surgeries. This study evaluated the non-inferiority of the analgesia provided by ESPB when compared to paravertebral block (PVB) in lung surgeries.

METHODS

Randomised, active-controlled, blinded for patients and assessors, non-inferiority trial. Patients who underwent unilateral lung surgeries were divided into two groups according to the regional anaesthesia technique-continuous ESPB or PVB at the T5 level. The primary outcome was to assess pain using a numerical rating scale (NRS) with a test of the interaction of three measures over 24 h postoperatively. An NRS score ≥ 7 was considered analgesia failure, and the prespecified non-inferiority margin was 10%.

RESULTS

In the interim analysis that terminated this study, 120 participants were enrolled. ESPB patients reported higher mean NRS general values over 24 h, 4.6 ± 3.2 in the ESPB group versus 3.9 ± 2.9 in the PVB group, with a difference of -0.67 (-15.2%) and 95%CI: -1.29 to -0.05 (p = .02), demonstrating not non-inferiority. In addition, the ESPB group presented higher NRS failure of analgesia over 24 h (p < .01) and required more postoperative opioids (p = .01 over 24 h). There was no difference in patient satisfaction between groups.

CONCLUSION

This trial demonstrated that a continuous erector spinae plane block was not non-inferior to a continuous paravertebral block for analgesia after lung surgery but resulted in higher levels of postoperative pain and opioid consumption.

Patient Satisfaction and Quality of Recovery With Ambulatory Serratus Plane Catheter After Mastectomy: A Service Evaluation

Background Acute moderate to severe pain after mastectomy is common and impedes patient recovery. Ambulatory serratus plane catheter with infusion pump (ASPIP) is a novel method to provide continuous delivery of local anaesthetic agents in the immediate postoperative period for extended analgesia, early mobility, and return to function after mastectomy. The aim of this project was to evaluate the introduction of ASPIP service and its effect on postoperative pain, opioid use, hospital stay, and recovery. Methods This was a service evaluation project. Eligible mastectomy patients were included over six months. All patients provided consent for intraoperative catheter insertion and ASPIP use. The numerical rating scale (NRS) and the Quality of Recovery-15 (QoR-15) tool were used to assess postoperative pain and the quality of recovery, respectively. Overall satisfaction, sleep quality, and recommendations for the catheter were collected. Day-case rates of mastectomy with or without reconstruction were also measured. Data were presented using descriptive statistics. Mean (SD) and median (quartiles) were used for the continuous variables with percentages to report rates. Approval of the institution's Audit & Quality Improvement Department was obtained. Results Thirty-two consecutive mastectomy patients were included over six months. The mean age was 60 years and the mean BMI was 25.8. Mean pain NRS (10 maximum) at rest and on movement were 1.88 vs. 2.56, 2.03 vs. 2.84, and 1.85 vs. 2.3 out of 10 on postoperative day (POD) one, two, and three, respectively. Six patients required opioids on POD one, four patients on POD two, and none on the third day. Sleep disturbance was observed in three, five, and three patients in the first three days, respectively. The mean overall satisfaction was 9.25/10 (SD: 1.18). All patients recommended ASPIP to other patients. QoR-15 scores reported as median (quartiles) were 143 (136, 147) preoperatively and 135 (126.5, 143) postoperatively, with a median difference of -3 (95% CI: -6 to 0). The day-case rate for mastectomy +/- reconstruction was 66% and 39%, respectively. There were no major complications from the catheter with minor issues in four patients. Conclusion The ASPIP is an effective and safe method of managing postoperative pain after mastectomy with positive patient experience and reduced opioid requirement. As part of an enhanced recovery pathway, it can also increase mastectomy day-case rates, including immediate implant reconstruction.

Building consensus on the selection criteria used when providing regional anaesthesia for rib fractures. An e-Delphi study amongst a UK-wide expert panel

BACKGROUND

Rib fractures are associated with significant morbidity and mortality, and providing adequate analgesia is paramount in preventing early complications from these injuries. Multiple regional anaesthetic techniques can be used to provide analgesia for these injuries; however, few evidence-based guidelines exist for their use. The aim of this study was to establish consensus within an expert group on the selection criteria used when choosing regional anaesthetic techniques for rib fractures.

METHODS

The Delphi technique is a mixed-methods study format which uses a longitudinal survey process to develop consensus opinion amongst an expert group. A three-round modified e-Delphi study was undertaken using an online survey platform. Round one established cohort characteristics and identified key factors considered important by the group when selecting regional anaesthetic techniques for rib fractures. Subsequent rounds used Likert scales and free text comments to rate the participants' level of agreement with various statements generated from the first-round responses. The final consensus threshold was established as at least 70% of respondents stating, 'Strongly Disagree' or 'Disagree' or alternatively 'Agree' or 'Strongly Agree'.

RESULTS

An expert panel of UK-based consultants in anaesthesia and/or intensive care medicine was recruited. Participants worked in a variety of tertiary- and non-tertiary trauma care settings and were varied in their years of experience, approximate annual rib fracture caseload and preference for various anaesthetic techniques in rib fracture management. 54 participants took part in round one and generated 60 statements which were further analysed in an iterative process involving a total of three rounds. A total of 28 statements ultimately reached the pre-defined threshold for consensus within the expert group.

CONCLUSIONS

This e-Delphi study succeeded in building consensus across multiple statements relating to the selection criteria for regional anaesthesia in patients with rib fractures. These consensus statements can inform clinical practice, guide future research priorities and can be integrated into decision-making pathways across multiple hospital settings.

Regional anesthesia and POCUS in the intensive care unit

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge

BACKGROUND

There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population.

METHODS

We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain.

RESULTS

Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block.

CONCLUSION

Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.

Serratus anterior plane block and postoperative pain control in obese patients undergoing S-ICD implantation: A case series and literature analysis

We report five case series of obese patients with severe left ventricular ejection fraction impairment undergoing Serratus Anterior Plane Block during S-ICD Implantation. This anesthesia approach has a reduced impact on the patient's hemodynamics and adequately manages postprocedural pain.

Abstract

Subcutaneous implantable cardioverter-defibrillator (S-ICD) procedures are frequently performed under analgosedation or general anesthesia, leading to prolonged postoperative hospital stays and increased costs. This anesthetic technique may also have a greater hemodynamic impact, particularly in obese and cardiac patients. However, an alternative anesthetic technique can be employed: ultrasound-guided serratus anterior plane block (US-SAPB). We analyzed the anesthetic clinical course in 5 patients, 3 males and 2 females, who were obese (BMI ≥ 30) and underwent S-ICD implantation for primary prevention using a two-incision intermuscular technique and ultrasound-guided serratus anterior plane block. All patients had a left ventricular ejection fraction less than or equal to 35%. It significantly facilitated pain control during the procedure and, especially, in the postoperative phase. However, the data available in the literature are mostly derived from case reports and small comparative studies. Therefore, further studies with a larger sample size and direct comparison with general anesthesia or deep sedation are needed.

Ultrasound-guided serratus anterior plane block to prevent neurocognitive impairment in elderly patients after thoracoscopic lobectomy: protocol for a single-centre, double-blind, randomised controlled trial

INTRODUCTION

Postoperative neurocognitive dysfunction (PND), including postoperative delirium (POD), is a common complication in elderly patients after major surgeries, often leading to poor postoperative recovery. Although the pathological mechanism underlying PND is still unclear, postoperative pain is strongly associated with the development of PND. The ultrasound-guided serratus anterior plane block (SAPB) has been reported to relieve postoperative pain in thoracic surgery. Therefore, this prospective trial hypothesises that SAPB may reduce the incidence of PND in the elderly undergoing thoracoscopic lobectomy.

METHODS AND ANALYSIS

This study is designed as a single-centre, double-blind, randomised controlled clinical trial. A total of 256 elderly patients scheduled to undergo thoracoscopic lobectomy at Shanghai Pulmonary Hospital will be randomly assigned to general anaesthesia group or SAPB group. The primary outcome is the incidence of PND 7 days postoperatively or before discharge from hospital. The secondary outcomes include the occurrence of POD, the postoperative pain scores, Quality of Recovery at 1-2 days postoperatively and incidence of PND at 3 months postoperatively. The levels of fasting blood glucose in peripheral blood will be examined before and 1-2 days postoperatively.

ETHICS AND DISSEMINATION

The trial has been approved by the Clinical Research Ethics Committee of Shanghai Pulmonary Hospital (identifier: K20-290). All participants will be required to provide written informed consent before any protocol-specific procedures. Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice.

TRIAL REGISTRATION NUMBER

ChiCTR2100052633.

Safety and feasibility of ultrasound-guided serratus anterior plane block and intercostal nerve block for management of post-sternotomy pain in pediatric cardiac patients: A prospective, randomized trial

BACKGROUND

Postoperative analgesia in the cardiothoracic ICU has traditionally relied on intravenous opioids. Thoracic nerve blocks are attractive alternatives for analgesia that reduce the requirement for opioids, but their safety and feasibility remain unclear.

METHODS

Sixty children were allocated randomly to three groups: group C received intravenous opioids alone, while group SAPB (deep serratus anterior plane block) and group ICNB (intercostal nerve block) received opioids combined with ultrasound-guided regional nerve blocks (0.2% ropivacaine 2.5 mg.kg-1) after patients were transferred to the ICU. The primary outcome was opioid requirement in the first 24 h after surgery. Other outcomes included the postoperative FLACC scale value, tracheal extubation time, and plasma ropivacaine concentrations after the block.

RESULTS

The mean [sd] cumulative dose of opioids administered postoperatively within 24 h in the SAPB (168.6 [76.9] μg.kg-1) and ICNB groups (170.0 [86.8] μg.kg-1) were significantly lower by nearly 53% than those in group C (359.3 [125.3] μg.kg-1, p = 0.000). The tracheal extubation time was shorter in the regional block groups than that in the control group, but the difference was not statistically significant (p = 0.177). The FLACC scale values at 0, 1, 3, 6, 12, and 24 h post-extubation were similar in the three groups. The mean peak plasma ropivacaine concentrations in the SAP and ICNB groups were 2.1 [0.8] and 1.8 [0.7] mg.L-1, respectively, 10 min post-block and then slowly decreased. No noticeable complications associated with regional anesthesia were observed.

CONCLUSIONS

Ultrasound-guided SAPB and ICNB provided safe and satisfactory early postoperative analgesia while reducing opioid consumption following sternotomy in pediatric patients.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiChiCTR2100046754.

Comparison of erector spinae plane block and serratus anterior plane block for postoperative analgesia in uniportal thoracoscopic lobectomy: a randomized controlled trial

BACKGROUND

Postoperative pain remains a significant concern following uniportal thoracoscopic surgery. The analgesic efficacy of erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in terms of postoperative opioid consumption in uniportal thoracoscopic surgery still needs further studies.

METHODS

A randomized controlled trial was conducted, enrolling 150 patients who underwent uniportal thoracoscopic lobectomy. The patients were randomly allocated to three groups in a 1:1:1 ratio: the ESPB group (administered 20 ml of 0.5% ropivacaine), the SAPB group (administered 20 ml of 0.5% ropivacaine), and the standard care (control) group. The primary endpoint was the consumption of sufentanil during the first 24 h following surgery. Secondary endpoints assessed the area under the curve (AUC) of pain numerical rating scale (NRS) scores, occurrence of moderate to severe pain, time to initial sufentanil request, and postoperative adverse events.

RESULTS

No significant difference was observed in the consumption of sufentanil during the first 24 h following surgery between the ESPB and SAPB groups (adjusted difference, 1.53 [95% CI, -5.15 to 2.08]). However, in comparison to the control group, both intervention groups demonstrated a significant decrease in sufentanil consumption, with adjusted differences of -9.97 [95% CI, -13.10 to -6.84] for the ESPB group and -12.55 [95% CI, -15.63 to -9.47] for the SAPB group. There were no significant differences in AUC of NRS scores during rest and movement between the ESPB and SAPB groups, with adjusted differences of -7.10 [95% CI, 1.33 to -15.55] for the rest condition and 5.61 [95% CI, -13.23 to 2.01] for the movement condition. At 6 h postoperatively, there were fewer patients with moderate to severe pain in the ESPB group compared with those in the SAPB group (adjusted difference, -1.37% [95% CI, -2.29% to -0.45%]. The time to first sufentanil request significantly differed among the three groups (ESPB vs Control P < 0.01, SAPB vs Control P < 0.01, ESPB vs SAPB P = 0.015).

CONCLUSIONS

In patients undergoing uniportal thoracoscopic lobectomy, although the differences between the two groups are not statistically significant, both the ESPB and SAPB demonstrate effective reduction in postoperative opioid consumption and the need for rescue analgesics compared to the control group. Moreover, the ESPB group experienced a significantly lower incidence of moderate to severe pain at 6 h postoperatively compared to the SAPB group.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (registration No: ChiCTR1900021695, Date of registration: March 5th, 2019).

Comparing Continuous and Intermittent Infusion Effects on Serratus Anterior Plane Blocks in Video-Assisted Thoracoscopic Surgery: A Randomized Clinical Trial

Objective

The programmed intermittent bolus infusion (PIBI) of local anesthetic produces wider sensory blockade and better analgesia than continuous infusion (CI). We designed this trial to compare the effects of these two different infusion methods combined with Serratus Anterior Plane Blocks (cSAPBs) on postoperative pain relief in patients undergoing video-assisted thoracoscopic surgery.

Methods

We randomly allocated 66 patients under going elective video-assisted thoracoscopic unilateral lung resection surgery to two groups (PIBI group and CI group, n=33 per group). After the surgical operation, the patients received ultrasound-guided ipsilateral SAPB, we randomized them to receive either automated intermittent boluses or continuous infusion of 0.3% ropivacaine. Tramadol consumption during the 48 hours following surgery was the primary outcome. Secondary outcomes included cumulative tramadol consumption during the first 24-h and the second 24-h periods after surgery, pain scores, patient satisfaction, blocked dermatomes, and adverse events.

Results

During 48h, tramadol consumption in the PIBI group was significantly lower than in the CI group (190 mg [125, 305] vs 220 mg [170, 480], p= 0.034). As compared to the CI group, the PIBI group consumed less tramadol during the first 24 hours (145 mg [87.5, 210] vs 190 mg [140, 400], p=0.012). The dermatomes anesthetized to the pinprick and cold test were significantly more abundant in the PIBI group than in the CI group (3 [3,4] vs. 5 [4,5], p<0.001). Both groups had similar VAS scores at rest and when moving (p>0.05). Additionally, the PIBI group showed greater patient satisfaction. Both groups experienced similar adverse events (p>0.05).

Conclusion

Compared with CI, PIBI administration regimen (0.3% ropivacaine 5 mL/h) for cSAPBs resulted in lower tramadol consumption, superior analgesia during the initial 12 h after the operation, and higher patient satisfaction. PIBI combined with cSAPBs was a better choice for postoperative analgesia in patients undergoing video-assisted thoracoscopic surgery.

A Review on the Management of Peripheral Neuropathic Pain Following Breast Cancer

Postmastectomy pain syndrome (PMPS) is a common and debilitating form of postsurgical pain with neuropathic characteristics, presenting as burning, stabbing, or pulling sensations after mastectomy, lumpectomy, or other breast procedures. With a prevalence of 31%, the risk factors for PMPS include younger age, psychosocial factors, radiotherapy, axillary lymph node dissection, and a history of chronic pain. This review evaluates the pharmacological and surgical options for managing PMPS. Pharmacological treatment options include antidepressants, gabapentinoids, levetiracetam, capsaicin, and topical lidocaine. Procedural and surgical options include fat grafting, nerve blocks, radiofrequency ablation, peripheral nerve surgery, serratus plane block, and botulinum toxin injections. Despite the variety of therapeutic options available for patients, further randomized trials are required to conclude whether these treatments reduce the intensity of neuropathic pain in patients with PMPS. In particular, comparative studies and the inclusion of patients across a range of pain intensities will be essential to developing a treatment algorithm for PMPS. In conclusion, current management for these patients should be tailored to their individual requirements.

Global Trends in Research of Perioperative Analgesia Over Past 10 Years: A Bibliometric Analysis

Background

The postoperative acute pain caused by surgery has been a major problem plaguing anesthesiologists, and even some acute pain progresses to chronic pain syndrome, terribly reducing the quality of life of patients. To this end, increasing attention has been paid to the management of perioperative analgesia. At present, with the increase of research on perioperative analgesia, the understanding and solution of this clinical problem have been further developed. Bibliometrics can estimate research hot-spots and trends of related fields in a certain period of time. However, a systematic bibliometric analysis has not been conducted to explore current research hotspots and future development trends, which is thus the purpose of this study.

Methods

Articles and reviews published from 2012 to 2021 were retrieved from the Web of Science Core Collection (WoSCC) database, and the bibliometric analysis of the keywords and references of articles was performed using VOSviewer1.6.18. Besides, the number of articles related to perioperative analgesia in term of countries, affiliations, authors, and journals were analyzed.

Results

Finally, 3157 articles meeting the screening requirements were retrieved, and it was hereby found that the research on perioperative analgesia had received more attention and interest in the past 10 years, with the United States making more contributions, where there were eight of the top ten affiliations by the number of publications. Kaye AD was the most active researcher in this field. Most related articles were published in Anesthesia and Analgesia, accounting for 2.76% of all literature. Enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention were the main trends and hotspots.

Conclusion

Perioperative analgesia has attracted considerable academic interest. In the past decade, the effects of enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention on perioperative analgesia have become the research hotspots, which are also likely to be the focus of future study.

Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection

AIMS

TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study.

METHODS AND RESULTS

The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802).

CONCLUSION

TauroPace is safe but more effective than H2O2 in reducing CIED infection.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05576194.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain.

RECENT FINDINGS

Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

Ultrasound-guided serratus anterior plane block versus paravertebral block on postoperation analgesia and safety following the video-assisted thoracic surgery: A prospective, randomized, double-blinded non-inferiority clinical trial

BACKGROUND

Both the anesthetic efficacy of ultrasound-guided serrate anterior plane block (SAPB) and the ultrasound-guided paravertebral block (PVB) in alleviating postoperative pain have been well concerned. This study primarily aims to evaluate whether the ultrasound-guided SAPB and ultrasound-guided PVB can provide comparable analgesia for video-assisted thoracic surgery. Secondarily, the safety and clinical satisfaction of the two blocks are evaluated.

METHODS

It was a prospective, randomized, double-blinded non-inferiority clinical trial involving 99 patients with lung nodules receiving video-assisted thoracic surgery with ultrasound-guided SAPB or PVB on T4 and T7 vertebra using 0.375% ropivacaine at 3 mg/kg. The Visual Analogue Scale (VAS) scores at rest and cough at 24 h/48 h postoperatively and the incidence and severity of chronic pain at 3 and 6 months postoperatively were the primary outcome. Secondary outcomes included the complications and block application time of two kinds of blocks, and consumption of sufentanil as an analgesic rescue.

RESULTS

A total of 92 eligible patients were recruited, including 46 in the SAPB group and 46 in the PVB group. No significant differences in VAS scores at rest and cough at first 48 h, 3 months, and 6 months postoperatively between the SAPB group and PVB group were detected (all P > 0.05). The SAPB group had fewer complications and higher patient satisfaction(P＜0.05).

CONCLUSION

The ultrasound-guided SAPB was not inferior to PVB in alleviating postoperative pain following the VATS with fewer complications and higher patient satisfaction.

Efficacy and safety of the serratus anterior block compared to thoracic epidural analgesia in surgery: Systematic review and meta-analysis

Objectives

The objective of this study was to compare the efficacy and safety of serratus anterior plane block (SAPB) and thoracic epidural analgesia (TEA) in thoracic region surgery.

Materials and Methods

We implemented a systematic search of PubMed, ScienceDirect, SCOPUS, and Web of Science and through gray literature for all randomized controlled trials that compared SAPB, a novel thoracic wall nerve block, and TEA in surgery. The evaluated outcomes included the Visual Analog Scale (VAS), hypotension, and postoperative nausea and vomiting (PONV). Review Manager, version 5.4.1, was implemented for the analysis of statistics.

Results

The pooled analysis included six trials that fulfilled the inclusion criteria. In total 384, surgery had received regional blocks (162 - SAPB and 163 - TEA). VAS did not differ significantly between SAPB and TEA, with a mean difference of 0.71, P = 0.08. PONV incidence did not differ significantly between SAPB and TEA (odds ratio = 0.25, P = 0.07). Hypotension incidence was lower in SAPB compared to TEA (odds ratio = 0.10, P = 0.0001).

Conclusion

SAPB yielded comparable VAS with TEA in pain management of thoracic region surgery. The incidence of hypotension was lower in SAPB than in TEA. No difference in PONV incidence was observed. SAPB can be a viable alternative to TEA in thoracic region surgery.