Ultrasound-guided serratus anterior plane block for analgesia after thoracic surgery

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.

Efficacy of Ice Compress Combined With Serratus Anterior Plane Block in Analgesia After Thoracoscopic Pneumonectomy: A Randomized Controlled Study

PURPOSE

To explore the analgesic effect of the ice pack combined with serratus anterior plane block after thoracoscopic pulmonary resection.

DESIGN

A randomized controlled trial design.

METHODS

This prospective randomized controlled trial recruited patients who underwent thoracoscopic pneumonectomy in a grade A tertiary hospital from October 2021 to March 2022. The patients were randomly divided into the control group, the serratus anterior plane block group, the ice pack group, and the ice pack combined with serratus anterior plane block group. The analgesic effect was evaluated by collecting the postoperative visual analog score.

FINDINGS

A total of 133 patients agreed to participate in this study, of which 120 patients were eventually included (n = 30/group). The primary outcome was that the pain in SAP block group, ice pack group, and ice pack combined with SAP block group decreased significantly within 24 hours compared with the control group (P < .05). Also, significant differences were noted in other secondary outcomes, such as Prince-Henry pain score within 12 hours, 15-item quality of recovery (QoR-15) score within 24 hours, and fever times within 24 hours. No significant difference was detected in the C-reactive protein value, white blood cell count, and the use of additional analgesics within 24 hours postoperatively (P > .05).

CONCLUSIONS

For patients after thoracoscopic pneumonectomy, ice pack, serratus anterior plane block, and ice pack combined with serratus anterior plane block produce better postoperative analgesic effects than intravenous analgesia. The combined group exhibited the best outcomes.

Assessment of Ultrasound-Guided Continuous Low Serratus Anterior Plane Block for Pain Management After Hepatectomy: A Randomized Controlled Trial

Purpose

Adequate postoperative analgesia is a key to earlier recovery from open surgery. This work investigated the pain control and quality of patient recovery after hepatectomy to evaluate the modified continuous serratus anterior plane block (called low SAPB) for postoperative analgesia.

Patients and Methods

This single-center, blinded, randomized, controlled study included 136 patients who underwent hepatectomy under general anesthesia. For postoperative analgesia, the patients in the SAPB group were given a continuous low SAPB at the 7th intercostal space in the right mid-axillary line, and the patients in the control group were given continuous intravenous opioid analgesia. The numeric pain rating scale (NPRS) was used for pain assessment. The postoperative assessment focused on the remedial drug consumption, the occurrence of adverse postoperative analgesic reactions, and the quality of patient recovery evaluated with the QoR-15 questionnaire.

Results

Compared to the controls, the SAPB patients had significantly lower NPRS scores at 12 h and 24 h at rest and 6 h, 12 h, and 24 h in motion, and a longer time to first use of remedial analgesics at 24 h, and higher overall QoR-15 scores at 24 h [124 (121, 126) vs 121 (120, 124)] and 48 h [129 (126, 147) vs 126 (125, 128)], after surgery. There was no significant difference in the incidence of analgesia-related adverse reactions between the two groups.

Conclusion

The continuous low SAPB could achieve superior pain control, especially for motor pain, to intravenous opioid analgesia during the first 24 h post-surgery. Even with no significant difference in the incidence of postoperative adverse reactions, patients with continuous low SAPB appeared to have a higher quality of recovery in the first two days post-surgery than patients with continuous intravenous analgesia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Ultrasound-Guided Multipoint Fascial Plane Block in ElderlyPatients Undergoing Combined Thoracoscopic-Laparoscopic Esophagectomy: A Prospective Randomized Study

INTRODUCTION

We estimated the safety and efficacy of ultrasound-guided multipoint fascial plane block, including serratus anterior plane block (SAPB) and bilateral transversus abdominis plane block (TAPB) in elderly patients who underwent combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

The authors enrolled 80 patients in this prospective study after patient selection using the inclusion and exclusion criteria who were scheduled for elective TLE from May 2020 to May 2021. Patients were randomly assigned to the treated group (group N) or the control group (group C) (n = 40 per group) using the sealed-envelope method. Multipoint fascial plane blocks, including serratus anterior plane block (SAPB) and bilateral TAPB, were performed on patients undergoing TLE using a solution of 60 mL 0.375% ropivacaine plus 2.5 mg dexamethasone by 3 injections of 20 mL each (group N) or no interventions (group C).

RESULTS

Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at T incision and 30 min after T incision were significantly higher in group C than in group N, and also significantly higher than at baseline (P < 0.01). Blood glucose at 60 min, 2 h after T incision, was significantly higher in group C than in group N and significantly higher than at baseline (P < 0.01). Compared to group N, the dosages of propofol and remifentanil used during surgery in group C were more than those in group N (P < 0.01). The time to first rescue analgesic in group C was earlier than in group N. The total postoperative use of sufentanil, and the number of patients requiring rescue analgesics in group C, were more than in group N (P < 0.01).

CONCLUSIONS

This study showed that applying the multipoint fascia pane block technique in TLE for elderly patients could significantly reduce postoperative pain, decrease the dosages of drugs used in general anesthesia, improve the quality of the awakening, and have no obvious adverse reactions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR-2000033617).

Erector Spinae Plane Block Combined with Serratus Anterior Plane Block Versus Thoracic Paravertebral Block for Postoperative Analgesia and Recovery After Thoracoscopic Surgery: A Randomized Controlled Non-inferiority Clinical Trial

OBJECTIVE

This study aimed to compare the postoperative analgesia and recovery of ultrasound-guided erector spinae plane block combined with serratus anterior plane block (ESPB combined with SAPB) versus thoracic paravertebral block (PVB) after thoracoscopic surgery.

METHODS

Ninety-two patients who underwent video-assisted thoracoscopic surgery (VATS) were randomly divided into group S (n=46) and group P (n=46). After anesthesia induction, the same anesthesiologist performed ultrasound-guided ESPB at T5 and T7 levels combined with SAPB at the level of the fifth rib in the midaxillary line in group S and ultrasound-guided PVB at T5 and T7 levels in group P. Patients in both groups were given 40 mL of 0.4% ropivacaine. Eighty-six patients completed the study (group S, n=44; group P, n=42). The morphine consumption, visual analogue scale (VAS) scores at rest and coughing, and frequency of remedial analgesia were recorded at 1, 2, 4, 8, and 24 h postoperatively. Pulmonary function parameters were recorded at 1, 4, and 24 h postoperatively, and the quality of recovery (QoR)-15 score at 24 h postoperatively. The adverse effects, duration of chest tube drainage and length of stay were also recorded.

RESULTS

The morphine consumption at postoperative 4 and 8 h and the incidence of ipsilateral shoulder pain (ISP) were significantly lower in group S than in group P. The QoR-15 questionnaire score at postoperative 24 h was significantly lower in group P than in group S (P<0.05). The morphine consumption was lower at 24 h postoperatively in group S than in group P, with no significant difference found yet. The morphine consumption at other observed times, VAS scores, pulmonary function parameters, frequency of remedial analgesia, duration of chest tube drainage, length of stay, and incidence of other adverse events were comparable between group S and group P.

CONCLUSION

Ultrasound-guided ESPB combined with SAPB is non-inferior to PVB in terms of morphine consumption at postoperative 24 h and postoperative recovery. But, this approach can significantly reduce morphine consumption in the early postoperative period (0-8 h) after thoracoscopy with lower incidence of ISP. It is a simpler and safer operation.

The effect of peripheral regional analgesia in thoracic surgery: a systematic review and a meta-analysis of randomized-controlled trials

BACKGROUND

Several peripheral regional anaesthesia (RA) techniques are commonly used in thoracic surgery even in the absence of precise indications regarding their effectiveness on postoperative pain management.

OBJECTIVE

This systematic review and meta-analysis aims to describe and evaluate the relative effectiveness of different peripheral regional blocks and systemic analgesia in the context of video-assisted thoracoscopic surgery (VATS) or thoracotomy.

DESIGN

Systematic review of randomized controlled clinical trials (RCTs) with meta-analyses.

DATA SOURCES

We searched PubMed and Embase for all RCTs comparing the 24 hour morphine equivalents (MMEs) consumption following peripheral regional blocks and systemic analgesia (SA).

ELIGIBILITY CRITERIA

We selected only RCTs including adult participants undergoing thoracic surgery, including esophagectomy and reporting on postoperative pain outcomes including 24 hour MMEs consumption.

RESULTS

Among the 28 randomized studies including adult participants undergoing thoracic surgery and reporting on 24 hour opioid consumption, 11 reporting a comparison of individual blocks with systemic analgesia were meta-analyzed. RA was effective for almost all peripheral blocks. Regarding intercostal block, its antalgic effect was not well evaluated SMD -1.57 (CI -3.88, 0.73). RA in VATS was more effective in reducing MMEs than thoracotomy SMD -1.10 (CI -1.78, -0.41).

CONCLUSIONS

RA is a useful choice in thoracic surgery. However, it is still not possible to determine the most appropriate block in the individual surgical settings to be performed due to RCTs paucity.

Effectiveness of Thoracic Wall Blocks in Video-Assisted Thoracoscopic Surgery, a Network Meta-Analysis

Introduction

Thoracic epidural analgesia (TEA) and thoracic paravertebral blocks (PVB) are well-established techniques for pain management in thoracotomy. Here, we examine the efficacy of various thoracic fascial plane blocks vs TEA and PVB for intraoperative and postoperative analgesia for video assisted thoracoscopy surgery (VATS) with network meta-analysis.

Methods

A search for prospective randomized control studies using adult patients undergoing VATS with general anesthesia. The interventions of interest were any regional anesthesia techniques used for postoperative pain control after VATS. Primary outcomes of interest were 24-hour opioid requirement and 24-hour pain scores. A Bayesian network meta-analysis was conducted.

Results

We identified 42 studies that fulfilled our inclusion criteria. For patients who underwent VATS, TEA (MD = -27MME, 95% CI = -46.2 to -9MME), ESP (MD = -20MME, 95% CI -33 to -7.9MME), PVB (MD = -15MME, 95% CI = -26 to -4.5MME) demonstrated significant opioid sparing efficacy, as well as reduction in cumulative 24-hour static pain scores. However, exclusion of one study due to high risk of bias revealed that TEA did not significantly reduce opioid consumption, nor did it reduce the incidence of PONV, pulmonary complications, or LOS when compared to ESP, SAP, PVB, ICN, or PECS blocks.

Conclusion

Our findings suggest that TEA did not provide superior pain relief compared to ESP, SAP, PVB, ICN, or PECS blocks following VATS. Therefore, we propose ESP as a suitable intervention for the prevention of postoperative pain after VATS.

Regional anesthesia for thoracic surgery: a narrative review of indications and clinical considerations

Background and Objective

Surgical procedures involving incisions of the chest wall regularly pose challenges for intra- and postoperative analgesia. For many decades, opioids have been widely administered to target both, acute and subsequent chronic incisional pain. Opioids are potent and highly addictive drugs that can provide sufficient pain relief, but simultaneously cause unwanted effects ranging from nausea, vomiting and constipation to respiratory depression, sedation and even death. Multimodal analgesia consists of the administration of two or more medications or analgesia techniques that act by different mechanisms for providing analgesia. Thus, multimodal analgesia aims to improve pain relief while reducing opioid requirements and opioid-related side effects. Regional anesthesia techniques are an important component of this approach.

Methods

For this narrative review, authors summarized currently used regional anesthesia techniques and performed an extensive literature search to summarize specific current evidence. For this, related articles from January 1985 to March 2022 were taken from PubMed, Web of Science, Embase and Cochrane Library databases. Terms such as "pectoral nerve blocks", "serratus plane block", "erector spinae plane block" belonging to blocks used in thoracic surgery were searched in different combinations.

Key Content and Findings

Potential advantages of regional anesthesia as part of multimodal analgesia regiments are reduced surgical stress response, improved analgesia, reduced opioid consumption, reduced risk of postoperative nausea and vomiting, and early mobilization. Potential disadvantages include the possibility of bleeding related to regional anesthesia procedure (particularly epidural hematoma), dural puncture with subsequent dural headache, systemic hypotension, urine retention, allergic reactions, local anesthetic toxicity, injuries to organs including pneumothorax, and a relatively high failure especially with continuous techniques.

Conclusions

This narrative review summarizes regional anesthetic techniques, specific indications, and clinical considerations for patients undergoing thoracic surgery, with evidence from studies performed. However, there is a need for more studies comparing new block methods with standard methods so that clinical applications can increase patient satisfaction.

Use of Ultrasound-Guided Interfascial Plane Blocks in Anterior and Lateral Thoracic Wall Region as Safe Method for Patient Anesthesia and Analgesia: Review of Techniques and Approaches during COVID-19 Pandemic

Ultrasound-guided interfascial plane blocks performed on the anterior and lateral thoracic wall have become an important adjuvant method to general anesthesia and an independent method of local anesthesia and pain management. These procedures diminish the harmful effects of anesthesia on respiratory function and reduce the risk of phrenic nerve paralysis or iatrogenic pneumothorax. In postoperative pain management, interfascial plane blocks decrease the dosage of intravenous drugs, including opioids. They can also eliminate the complications associated with general anesthesia when used as the sole method of anesthesia for surgical procedures. The following procedures are classified as interfascial plane blocks of the anterior and lateral thoracic wall: pectoral nerve plane block (PECS), serratus anterior plane block (SAP), transversus thoracic muscle plane block (TTP), pectoral interfascial plane block (PIF), and intercostal nerve block (ICNB). These blocks are widely used in emergency medicine, oncologic surgery, general surgery, thoracic surgery, cardiac surgery, orthopedics, cardiology, nephrology, oncology, palliative medicine, and pain medicine. Regional blocks are effective for analgesic treatment, both as an anesthesia procedure for surgery on the anterior and lateral thoracic wall and as an analgesic therapy after trauma or other conditions that induce pain in this area. In the era of the COVID-19 pandemic, ultrasound-guided interfascial plane blocks are safe alternatives for anesthesia in patients with symptoms of respiratory distress related to SARS-CoV-2 and appear to reduce the risk of COVID-19 infection among medical personnel.

Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review

Background and Objective

Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.

Methods

We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader.

Key Content and Findings

There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate.

Conclusions

The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.

Comparison between intrathecal morphine and intravenous patient control analgesia for pain control after video-assisted thoracoscopic surgery: A pilot randomized controlled study

Background

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure, but patients may still experience intense pain, especially during the early postoperative period. Intrathecal morphine (ITM) is an effective pain control method that involves a simple maneuver and has a low risk of complications. This study aimed to study the effectiveness of ITM for pain control in patients who undergo VATS.

Materials and methods

A randomized controlled study was conducted who were in ASA classes 1–3, aged over 18 years, and scheduled for elective VATS. Patients were randomized into two groups: the ITM group (n = 19) received a single shot of 0.2 mg ITM before general anesthesia; and the control group (n = 19) received general anesthesia only. For 48 hours after surgery, other than intravenous patient-controlled analgesia (IVPCA) morphine, patients received no sedatives or opioid medications except for 500 mg acetaminophen four times daily orally. Postoperative pain scores and IVPCA morphine used, side effects, sedation at specific time-points, i.e., 1, 6, 12, 24, and 48-hours and overall treatment satisfaction scores were assessed.

Results

Postoperative pain scores (median [IQR]) in ITM group were significantly lower than control group (repeated-measure ANOVA, p = 0.006) and differed at the first (7 [2, 7] vs 8 [6, 9], p = 0.007) and sixth hours (3 [2, 5] vs 5 [5, 7], p = 0.002). The cumulative dose of post-operative morphine (median [IQR]) in ITM group was also lower (6 [3, 20] vs 19 [14, 28], p = 0.006). The incidence of pruritus was significantly higher in ITM group (68.42% vs. 26.32%, p = 0.009). No significant differences in nausea and vomiting, sedation scores, and satisfaction scores were observed between the two groups.

Conclusion

ITM could reduce pain scores and opioid consumption after VATS compared to IVPCA-opioids. However, pain scores and opioid consumption still remained high. No difference in patient satisfaction was detected.

Serratus Anterior Block for Long-Term Post-Thoracoscopy Pain Management

Purpose

Neuropathic, chronic pain is a common and severe complication following thoracic surgery, known as post-thoracotomy pain syndrome (PTPS). Here we evaluated the efficacy of an ultrasound-guided serratus anterior plane block (SAPB) on pain control compared to traditional pain management with intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) six months after thoracic surgery.

Patients and Methods

In this retrospective observational study, we analyzed data from a questionnaire survey. We interviewed all patients who underwent elective video-assisted thoracoscopy surgery (VATS) at Soroka University Medical Center between December 2016 and January 2018. The responses of ninety-one patients were included.

Results

Participants reported PTPS in both groups, 43% of patients in the SAPB group and 57% of patients in the standard group, which failed to reach significance. However, we demonstrated that the percentage of pain occurrence trended lower in the SAPB group. There was significantly less burning/stitching or shooting, shocking, pressure-like, and aching pain in SAPB patients compared to the standard protocol group. Patients in the SAPB group had significantly less pain located in the upper and lower posterior thorax anatomical regions compared to the standard protocol group. Moreover, we found a significant difference in occurrence of PTPS depending on the type of thoracic surgery. From both study groups, 69% of patients who underwent lobectomy reported pain, compared with 41.9% of those in the segmental (wedge resection) procedure, and 42.1% of patients in other procedures.

Conclusion

While the present study did not demonstrate a statistically significant reduction of PTPS after SAPB concerning postoperative pain control, there was a trend of a decrease. We also found significance in the type of pain and location of pain after thoracic surgery between the two groups, as well as a significant difference between pain occurrence in types of thoracic surgeries from both groups.

The Efficacy and Safety of Ultrasound-Guided, Bi-Level, Erector Spinae Plane Block With Different Doses of Dexmedetomidine for Patients Undergoing Video-Assisted Thoracic Surgery: A Randomized Controlled Trial

Background: The anesthetic characteristics of ultrasound-guided bi-level erector spinae plane block (ESPB) plus dexmedetomidine (Dex) remain unclear. We compared the efficacy and safety of ultrasound-guided bi-level ESPB plus different doses of Dex in patients undergoing video-assisted thoracic surgery (VATS).

Methods: One-hundred eight patients undergoing VATS were randomized into three groups: R group (n = 38, 15 ml of 0.375% ropivacaine with 0.1 mg/kg dexamethasone), RD1 group (n = 38, 15 ml of 0.375% ropivacaine plus 0.5 μg/kg DEX with 0.1 mg/kg dexamethasone) and RD2 group (n = 38, 15 ml of 0.375% ropivacaine plus 1.0 μg/kg DEX with 0.1 mg/kg dexamethasone). The primary outcome was the pain 12 h after surgery. Secondary outcomes included the Prince Henry Hospital Pain Score; hemodynamics; consumption of sufentanil; anesthetized dermatomal distribution; recovery time; rescue analgesia; satisfaction scores of patients and surgeon; quick recovery index; adverse effects; the prevalence of chronic pain and quality of recovery.

Results: The visual analog scale (VAS) and the Prince Henry pain score were significantly lower in both the RD1 and RD2 groups during the first 24 h after surgery (P < 0.05). Both VAS with coughing and the Prince Henry pain score were significantly lower in the RD2 group than in the RD1 group 8–24 h after surgery (P < 0.05). Both heart rate and mean arterial pressure were significantly different from T2 to T6 in the RD1 and RD2 groups (P < 0.05). The receipt of remifentanil, propofol, Dex, and recovery time was significantly reduced in the RD2 group (P < 0.05). The requirement for sufentanil during the 8–72 h after surgery, less rescue medication, and total press times were significantly lower in the RD2 group (P < 0.05). The time to the first dose of rescue ketorolac was significantly longer in the RD2 group (P < 0.05). Further, anal exhaust, removal of chest tubes, and ambulation were significantly shorter in the RD2 group (P < 0.05). The incidence of tachycardia, post-operative nausea and vomiting, and chronic pain was significantly reduced in the RD2 group, while the QoR-40 score was significantly higher in the RD2 group (P < 0.05).

Conclusions: Pre-operative bi-level, single-injection ESPB plus 1 μg/kg DEX provided superior pain relief and long-term post-operative recovery for patients undergoing VATS.

Clinical Trial Registration:http://www.chictr.org.cn/searchproj.aspx.

Evaluation of the Effectiveness of Modified Pectoral Nerve Blocks Type II (PECS II) for Vascular Access Port Implantation Using Cephalic Vein Venesection

The vascular access port implantation procedure can be performed using the venesection method by inserting a catheter into the cephalic vein in the region of the deltopectoral groove. This method eliminates the need for catheter tunneling. An alternative method to infiltration anaesthesia for port implantation may be a modified pectoral nerve block type II (PECS II). This study aimed to evaluate the effectiveness of modified PECS II for vascular access port implantation using cephalic vein venesection. This retrospective observational study was conducted at the 4th Military Clinical Hospital in Wroclaw, Poland. A group of 114 patients underwent the modified PECS II block and additional cutaneous infiltration anesthesia at the incision line. Pain intensity was assessed on the NRS scale measured intraoperatively at four points. The QoR-15 questionnaire was used to assess patient satisfaction during the first 24 h after surgery. The operator’s condition assessment score was used to assess surgical conditions and operator comfort. The analysis showed that the median pain intensity during vascular port implantation was 0. A statistically significant difference in pain intensity was demonstrated between the specialist’s group and the resident’s group at the second and third measurement points (p < 0.008; p < 0.012). The mean value on the QoR-15 scale was 132. There was a significant difference between the pain scores of the groups. The mean score in the pain position in the specialist’s group was 18 points and in the resident’s group, it was 19 points (p < 0.029). In conclusion, the present study revealed that the modified PECS II block is an effective and safe method of anesthesia for Port-A-Cath implantation.

The Role of Serratus Anterior Plane Block During in Video-Assisted Thoracoscopic Surgery

Although thoracoscopy has characteristics such as a small surgical incision and low stress response, post-surgical pain after a thoracoscopic operation is no less than that after a thoracotomy. Moreover, poor post-surgical pain management is likely to cause an increased incidence of postoperative pulmonary complications (PPCs) and chronic post-surgical pain. The serratus anterior plane block (SAPB) is a regional anesthesia method whereby local anesthetics (LAs) are injected into the serratus anterior space to block the lateral cutaneous branch of the intercostal nerve, long thoracic nerve, and dorsal thoracic nerve. The block range of the SAPB covers the incisions of video-assisted thoracoscopic surgery (VATS) and the site of the chest tube, which are often located in the antero-lateral chest wall. Therefore, the SAPB can achieve effective analgesia in VATS. For example, 0.125% to 0.25% levobupivacaine (20-25 ml) is widely used for thoracic surgery, which can achieve effective analgesia and avoid adverse reactions. Moreover, it has advantages compared with thoracic segmental epidural block (TEA) and thoracic paravertebral block (TPVB), such as simple operation, increased safety, fewer complications, and hemodynamic stability. In addition, adequate analgesia is helpful for pulmonary function recovery and reduces the incidence of PPCs. This article introduces the anatomical mechanism of the SAPB, diverse operation approaches, how to choose drugs and adjuvants, and the resulting impacted area range. It summarizes the advantages and disadvantages of the SAPB compared with other analgesic methods and posits that the SAPB is beneficial to the recovery of postoperative lung function, which provides more options for postoperative analgesia after VATS.

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 ultrasound-guided serratus anterior plane block in addition to intrathecal morphine on early postoperative period after video-assisted thoracoscopic surgery

Background

The aim of this study was to evaluate the effect of serratus anterior plane block in addition to intrathecal morphine for early postoperative period after video-assisted thoracoscopic surgery on the amount of morphine consumption and the Visual Analog Scale scores.

Methods

This single-blind, randomized-controlled study included a total of 64 patients (39 males, 25 females; mean age: 53.6±17.0 years; range, 20 to 89 years) who were scheduled for video-assisted thoracoscopic surgery in a tertiary hospital between September 2019 and March 2020. Postoperative pain control was achieved with intrathecal morphine 0.6 mg addition to serratus anterior plane block (Group ITM+SAPB) or with only intrathecal morphine (Group ITM) after an induction of anesthesia. The serratus anterior plane block was performed with a single injection of 0.4 mL/kg of 0.25% bupivacaine at the level of fifth rib with ultrasound guidance. Morphine consumption, pain scores, and side effects were recorded in the postoperative period.

Results

The mean morphine consumption was significantly lower in the ITM+SAPB group at all time points. Compared to the control group, the Visual Analog Scale-resting and coughing scores were significantly lower in the first 12 h after surgery. Pain scores were significantly higher in the ITM+SAPB group in patients where the trocar was inserted at upper level of the fifth rib than the lower level (3-5 vs. 5-8) during the first 6 h after surgery.

Conclusion

The use of serratus anterior plane block in addition to intrathecal morphine is a safe and effective way to improve pain control for early postoperative period after video-assisted thoracoscopic surgery. The serratus anterior plane block ensures better analgesia until the peak effect of spinal morphine occurs.

Serratus Anterior Plane Block in Pediatric Patients Undergoing Thoracic Surgeries: A Randomized Controlled Trial

OBJECTIVE(S)

This study was designed to evaluate the efficacy and safety of serratus anterior plane block (SAPB) as an analgesic technique for thoracotomies in pediatric patients.

DESIGN

Double-blinded randomized controlled trial.

SETTING

A single-center study at Aboelrish Pediatric Hospital, one tertiary hospital of Cairo University Hospitals.

PARTICIPANTS

Seventy pediatric patients aged six months-to-three years scheduled for thoracotomies.

INTERVENTIONS

Patients were randomized into two groups, group SF and group F. Group SF received an ultrasound-guided SAPB (n = 35), whereas group F (n = 35) did not. All groups received an intraoperative fentanyl infusion (at 0.5 μg/kg /h).

MEASUREMENTS

The primary outcome was the total dose of postoperatively administrated fentanyl in the first 24 hours. The secondary outcomes included the total dose of intraoperative additional fentanyl boluses; time of the first postoperative rescue analgesia; and postoperative Face, Legs, Activity, Cry, Consolability scale (FLACC) score values.

MAIN RESULTS

The main results of this study showed that the administrated fentanyl in the 24 hours postoperatively was significantly lower in SF group than in F group (p value ˂ 0.001). In addition, significant decreases of the postoperative FLACC pain score (p value ˂ 0.001), reduction of intraoperative fentanyl consumption (p value ˂ 0.001), and delay of the first rescue analgesia (p value ˂ 0.001) were recorded in SF group in relation to F group without significant complications in both groups.

CONCLUSIONS

Serratus anterior plane block can provide a safe, effective, and easy-to-perform regional technique for children undergoing thoracotomies.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Application of a new serratus anterior plane block in modified radical mastectomy under ultrasound guidance: A prospective, randomized controlled trial

STUDY OBJECTIVES

Post-operative pain is a significant concern following modified radical mastectomy in breast cancer patients. The serratus anterior plane block has recently been described as an effective technique for post-operative analgesia of modified radical mastectomy. The purpose of this study was to evaluate the analgesic efficacy and safety of a new serratus anterior plane (SAP) block for post-operative pain of mastectomy.

DESIGN

A randomized controlled trial.

SETTING

Single university teaching hospital, from October 2019 to April 2020.

PATIENTS

Eighty-seven female breast cancer patients aged 30-81 years scheduled for unilateral modified radical mastectomy.

INTERVENTIONS

Participants were randomly allocated to receive either general anesthesia plus SAP block (SAP block group, n = 43) or general anesthesia alone (Control group, n = 44). A single injection of 20 ml of 0.5% ropivacaine was administered into fascial plane between the pectoralis major and the serratus anterior in SAP block group. In the Control group, no block intervention was applied.

MEASUREMENTS

The primary outcome measure of the study was the VAS pain scores at different time-points (1, 6, 12, 24, 48 h) after modified radical mastectomy whereas the secondary outcome measures were the consumption of opioid analgesics.

MAIN RESULTS

Breast cancer patients in SAP block group had lower VAS pain scores compared with the Control group during the early post-operative period (1 h and 6 h after modified radical mastectomy), both at rest and with movement. In addition, the consumption of propofol was similar in two groups (P = 0.406), and the consumption of sufentanil and remifentanil in SAP block group were significantly lower than that of Control group (P = 0.000 and P = 0.000, respectively).

CONCLUSIONS

SAP block significantly attenuated post-operative pain and decreased opioids consumption in breast cancer patients undergoing modified radical mastectomy.

TRIAL REGISTRATION

This trial is registered in the Chinese Clinical Trial Registry (ChiCTR1900026989).

Serratus anterior plane block for video-assisted thoracoscopic surgery: A meta-analysis of randomised controlled trials

BACKGROUND

The serratus anterior plane block (SAPb) is a promising interfascial plane technique able to provide profound thoracic analgesia. As only a few studies with quite small patient samples are presently available, the analgesic efficacy of adding SAPb to general anaesthesia in video-assisted thoracoscopic surgery (VATS), compared with general anaesthesia only, remains unclear.

OBJECTIVES

Our primary aim was to assess the analgesic efficacy of SAPb for VATS peri-operative pain control. The secondary aims were to evaluate differences in postoperative opioid use, intra-operative hypotension, postoperative side-effects and complications, time to chest tube removal, length of hospital stay.

DESIGN

Systematic review of randomised controlled trials (RCTs) with meta-analyses.DATA SOURCES PubMed, Web of Science, Google Scholar and the Cochrane Library, searched up to 6 December 2019.ELIGIBILITY CRITERIA RCTs including adult patients undergoing VATS who received single shot SAPb (cases), compared with general anaesthesia (controls).

RESULTS

Seven RCTs, with a total of 489 patients were included. SAPb reduced pain scores peri-operatively, compared with controls: 6 h [mean difference -1.86, 95% confidence interval (CI) -2.35 to -1.37, P < 0.001]; 12 h (mean difference -1.45, 95% CI -1.66 to -1.25, P < 0.001); 24 h (mean difference -0.98, 95% CI -1.40 to -0.56, P < 0.001). SAPb also reduced the use of postoperative opioids (mean difference: -4.81 mg of intravenous morphine equivalent, 95% CI -8.41 to -1.22, P < 0.03) and decreased the incidence of nausea and vomiting (risk ratio 0.53, 95% CI 0.36 to 0.79, P < 0.002).

CONCLUSION

Compared with general anaesthesia only and if no other locoregional techniques are used, SAPb significantly reduces postoperative pain and nausea and vomiting in patients undergoing VATS. Grading of Recommendations Assessment, Development and Evaluation rating are, nonetheless, quite low, due to high heterogeneity. Well designed and properly powered RCTs are necessary to confirm these preliminary findings.

Serratus Anterior Plane Block and Erector Spinae Plane Block Versus Thoracic Epidural Analgesia for Perioperative Thoracotomy Pain Control: A Randomized Controlled Study

OBJECTIVES

This study was designed to evaluate the safety and efficacy of erector spinae plane block and serratus anterior plane block versus thoracic epidural in perioperative pain control for patients with cancer undergoing lung surgeries.

DESIGN

Single blinded, randomized, controlled trial.

SETTING

The study was carried out at the National Cancer Institute in Cairo, Egypt.

PARTICIPANTS

Fifty-one patients with cancer.

INTERVENTIONS

Patients were allocated randomly into three groups: thoracic epidural analgesia (TEA) group, serratus anterior plane block (SAPB) group, and erector spinae plane block (ESPB) group.

MEASUREMENTS AND MAIN RESULTS

Outcome measures were 24 hours postoperative visual analog scale (VAS), intraoperative rescue fentanyl consumption, perioperative heart rate, mean blood pressure (mean arterial pressure [MAP]), and total postoperative morphine consumption. VAS scores at rest were significantly lower in the TEA group at the postanesthesia care unit and 24 hours. VAS scores with cough were significantly higher in the SAPB group at eight and 24 hours. The first time to receive morphine was significantly longer in the TEA group. No patients in the TEA group required postoperative morphine, whereas 88.2% and 47.1% required morphine in the SAPB and ESPB groups, respectively, p < 0.001. In the TEA group, intraoperative MAP values were lower than the other two groups, p < 0.05.

CONCLUSIONS

Erector spinae plane block can be used as an effective and safe alternative to thoracic epidural analgesia and shows superior analgesic profile to serratus anterior plane block for patients with lung cancer undergoing posterolateral thoracotomy.

Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults

Purpose

This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults.

Patients and Methods

Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUC_VAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes.

Results

At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUC_VAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUC_VAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group.

Conclusion

cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Serratus anterior plane block in modified radical mastectomy surgery: a case series

Background

Postoperative breast pain may lead to poorer outcome if left untreated. Common analgesia modalities for postoperative breast pain include opioids and regional anesthesia. However, both of these modalities can cause significant side effects or complications. Serratus anterior plane (SAP) block is a new procedure that is relatively easier to perform and safer, compared with other modalities. Previous studies have reported its usefulness in reducing the need for both intraoperative and postoperative opioids.

Case

We reported 2 patients that underwent SAP block combined with general anesthesia in modified radical mastectomy (MRM). Patient 2 was given rescue analgesia during the intraoperative period. The administration of postoperative opioids did not exceed 24 h in both patients. Pain assessment using numeric rating scale (NRS) showed minimal postoperative pain. No side effects were found during 24-h monitoring period.

Conclusion

SAP block can be used as one of the modalities in managing the pain of MRM surgery.

Future in regional anesthesia: new techniques and technological advancements

Regional anesthesia has a very interesting long history, initially preferred over general anesthesia because of safety concerns, then for a period general anesthesia became safer and was preferred. The use of innovative technologies such as ultrasound technology has made the blocks safer and successful by directly visualizing targeted nerves and the location of local anesthetics. With the wide use of ultrasound in the regional anesthesia field success rate of peripheral nerve blocks increased and novel blocks techniques developed. Moreover, new extended-release local anesthetic agents have begun to be promising time-efficient and longer duration of analgesia with a single injection. In this article, we attempt to summarize some of the novel block techniques, pharmacological agents, and new technologies in the field of regional anesthesia.

Are Thoracic Wall Blocks Efficient After Video-Assisted Thoracoscopy Surgery-Lobectomy Pain? A Comparison Between Serratus Anterior Plane Block and Intercostal Nerve Block

OBJECTIVES

Video-assisted thoracoscopy surgery-lobectomy is less invasive than conventional thoracotomy and is associated with fewer complications. However, the pain related is classified as moderate and requires adequate treatment. Ultrasound-guided serratus anterior plane block (SAPB) provides analgesia by blocking the lateral branches of the intercostal nerves, avoiding the complications of epidural analgesia and paravertebral block. The aim of the present study was to evaluate the efficacy and safety of the SAPB compared with the intercostal nerve block (ICNB).

DESIGN

This was a non-randomized prospective study, in which surgery-lobectomy pain after video-assisted thoracoscopy was treated with the following multimodal approach: SAPB or ICNB, morphine-patient controlled analgesia, and paracetamol.

SETTING

The study was undertaken in a single community hospital.

PARTICIPANTS

The study comprised 40 patients.

INTERVENTIONS

Execution of ultrasound-guided SAPB.

MEASUREMENTS AND MAIN RESULTS

Nineteen (47.5%) men and 21 (52.5%) women were enrolled, and the mean age was 67.22 ± 11 years. Both groups showed any visual analog scale values >4, which was significantly lower in the SAPB group at the 6th hour and at the 12th and 24th hours only during coughing (p < 0.05). The sedation score was significantly lower in the ICNB group at 0 and at the 2nd and 4th hours; it was lower in the SAPB group at the 6th hour. All patients had a sedation score <1, and they all were awake and oriented. After 24 hours, the total morphine requirement was 19.3 ± 14.4 mg and 11.3 ± 8.5 mg (p = 0.038); after 48 hours, it was 12.2 ± 7.9 mg and 8.2 ± 5.8 mg in the ICNB and SAPB groups, respectively.

CONCLUSIONS

The multimodal approach of SAPB, morphine-patient controlled analgesia, and paracetamol is effective, safe, and time efficient.

Effect of Regional Analgesia Techniques on Opioid Consumption and Length of Stay After Thoracic Surgery

BACKGROUND

We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.

METHODS

We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.

RESULTS

Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.

CONCLUSIONS

Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.

The serratus anterior plane block for analgesia after thoracic surgery: A meta-analysis of randomized controlled trails

BACKGROUND

The serratus anterior plane (SAP) block is a newer method that can be used in patients undergoing thoracic surgeries. The postoperative analgesia efficacy of SAP blocks for thoracic surgery remains controversial. We conduct a meta-analysis to evaluate the analgesia of SAP blocks after thoracic surgery.

METHODS

We searched PubMed, Embase, EBSCO, the Cochrane Library, Web of Science, and CNKI for randomized controlled trials (RCTs) regarding the postoperative pain control of a SAP block on thoracic surgery. All of the dates were screened and evaluated by two researchers and meta-analysis was performed using RevMan5.3 software.

RESULTS

A total of 8 RCTs involving 542 patients were included. The meta-analysis showed statistically significant differences between the two groups with respect to postoperative pain scores at 2 h (standardized mean difference [Std.MD] = -1.26; 95% confidence interval [CI] = -1.66 to -0.86; P < .0001); 6 h (SMD = -0.50; 95%CI = -0.88 to -0.11; P = .01); 12 h (SMD = -0.63; 95%CI = -1.10 to -0.16; P = .009); 24 h (SMD = -0.99; 95%CI = -1.44 to -0.51; P < .0001); postoperative opioid consumption at 24 h (SMD = -0.83; 95%CI = -1.10 to -0.56; P < .00001); and postoperative nausea and vomiting (PONV) rates (RR = 0.39; 95% CI = 0.21-0.73; P = .003).

CONCLUSION

The SAP block can play an important role in the management of pain after thoracic surgery by reducing both pain scores and 24-h postoperative opioids consumption. In addition, there is fewer incidence of PONV in the SAP block group.

Single nucleotide polymorphisms associated with postoperative inadequate analgesia after single-port VATS in Chinese population

Background

Postoperative inadequate analgesia following video-assisted thoracoscopic surgery (VATS) is a common and significant clinical problem. While genetic polymorphisms may play role in the variability of postoperative analgesia effect, few studies have evaluated the associations between genetic mutations and inadequate analgesia after single-port VATS.

Methods

Twenty-eight single nucleotide polymorphisms (SNPs) among 18 selected genes involved in pain perception and modulation were genotyped in 198 Chinese patients undergoing single-port VATS. The primary outcome was the occurrence of inadequate analgesia in the first night and morning after surgery which was defined by a comprehensive postoperative evaluation. Multivariable logistic regression analyses were used to identify the association between genetic variations and postoperative inadequate analgesia.

Results

The prevalence of postoperative inadequate analgesia was 45.5% in the present study. After controlling for age and education level, association with inadequate analgesia was observed in four SNPs among three genes encoding voltage-gated sodium channels. Patients with the minor allele of rs33985936 (SCN11A), rs6795970 (SCN10A), and 3312G > T (SCN9A) have an increased risk of suffering from inadequate analgesia. While the patients carrying the minor allele of rs11709492 (SCN11A) have lower risk experiencing inadequate analgesia.

Conclusions

We identified that SNPs in SCN9A, SCN10A, and SCN11A play a role in the postoperative inadequate analgesia after single-port VATS. Although future larger and long-term follow up studies are warranted to confirm our findings, the results of the current study may be utilized as predictors for forecasting postoperative analgesic effect for patients receiving this type of surgery.

Trial registration

This study was retrospectively registered in the ClinicalTrials.gov Registry (NCT03916120) on April 16, 2019.

Effects of Ropivacaine Concentration on Analgesia After Ultrasound-Guided Serratus Anterior Plane Block: A Randomized Double-Blind Trial

Purpose

Serratus anterior plane (SAP) block is effective for analgesia after breast surgery. Whether a higher local anesthetic concentration prolongs sensory block duration and improves postoperative analgesia remains unclear. The aim of this study was to compare the analgesic effects of SAP block with different concentrations of ropivacaine.

Patients and Methods

Sixty patients scheduled for breast surgery were enrolled in this randomized double-blind trial. SAP block was induced with 20 mL of 0.375%, 0.5%, or 0.75% ropivacaine in Group R0.375, Group R0.5, and Group R0.75, respectively. The primary endpoint was the area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores at rest over time. The secondary endpoints were AUC of NRS pain intensity scores on movement over time, active sensory block duration, tramadol consumption, and the elapsed time between completion of surgery and the first administration of rescue analgesia.

Results

The AUC of NRS pain intensity scores at rest of Group R0.375 was significantly higher than that of Groups R0.5 and R0.75 (P=0.025, and P=0.001). The AUC of NRS pain intensity scores on movement of Group R0.375 was also significantly higher than that of Groups R0.5 and R0.75 (both P<0.001). At higher ropivacaine concentrations, the duration of SAP sensory block increased (P<0.001). Tramadol consumption and the elapsed time between completion of surgery and the first administration of rescue analgesia were similar in the three groups (P>0.05).

Conclusion

A comparison of 0.5% and 0.75% ropivacaine showed no significant difference in postoperative analgesia, but both were superior to 0.375% ropivacaine, although higher ropivacaine concentration lengthened the duration of SAP block. Therefore, SAP block with 0.5% ropivacaine is recommended for postoperative analgesia in breast surgery.

The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The serratus plane block (SPB) is a novel chest wall interfascial plane block. Its analgesic efficacy compared with non-block care and paravertebral block (PVB) is unestablished.

METHODS

We conducted a random-effects meta-analysis of randomized controlled trials (RCTs) recruiting adult surgical patients that compared a SPB to non-block care or PVB for postoperative analgesia. Visual analog scale pain scores were the primary outcome. Database sources were Medline, Embase, the Cochrane Library, and Google Scholar searched up to July 29, 2019 without language restriction. Risk of bias was assessed using Cochrane methodology.

RESULTS

Nineteen RCTs that comprised 1260 patients were included. Six trials involved thoracic surgery patients and 13 studied breast surgery patients. SPB reduced pain scores 0 hour postoperatively (-1.62 cm; 99% CI -2.43 to -0.81; p<0.001; I2=92%), at 2-4 hours (-1.29 cm; 99% CI -2.08 to -0.49; p<0.001; I2=92%), at 6 hours (-1.69 cm; 99% CI -3.19 to -0.20; p=0.004; I2=99%), and up to 24 hours compared with non-block care. SPB also prolonged the time to first analgesic request (193.2 min; 95% CI 7.2 to 379.2 min; p=0.04; I2=99%), reduced 24-hour postoperative opioid consumption (-11.27 mg of IV morphine equivalent; -17.36 to -5.18 mg; p<0.001), and reduced postoperative nausea and vomiting (RR 0.51; 95% CI 0.38 to 0.68; p<0.001; I2=12%). In contrast, no meaningful differences were detected in any of the outcomes for the SPB versus PVB data.

CONCLUSIONS

SPB reduced postoperative pain scores (Grading of Recommendations Assessment, Development, and Evaluation rating: low; due to heterogeneity and deficiencies in blinding) in breast and thoracic surgery patients compared with non-block care. Based on five trials only, SPB was not appreciably different from PVB.