Ultrasound-guided continuous serratus anterior plane block: dexmedetomidine as an adjunctive analgesic with levobupivacaine for post-thoracotomy pain. A prospective randomized controlled study

Analgesia in esophagectomy: a narrative review

Background and Objective

Optimal pain management for esophagectomy facilitates prevention of postoperative complications such as pneumonia, but also chronic pain. Historically, multimodal intravenous analgesia was employed. In the last decades, regional anesthesia including epidural and paravertebral analgesia is frequently used. In this narrative review, we provide a comprehensive overview of the available evidence for the different analgesia regimens for esophagectomy.

Methods

A search was conducted in the PubMed/MEDLINE database in November 2022. Only reports in English or Dutch were included. Editorials or articles lacking full text were excluded. A review of different analgesia regimens after esophagectomy is provided.

Key Content and Findings

Epidural analgesia (EA) was suggested to reduce postoperative pneumonia and prevent chronic postsurgical pain (CPSP) as compared to opioid-based systemic analgesia and was considered the gold standard of pain management for esophagectomy. In the last decades, the side-effects of EA became more evident. Next to mild or moderate side-effects such as hypotension and urinary retention, several reports emphasized the incidence of serious neurologic complications to be much higher than estimated before. In addition, minimally invasive surgery fostered that other regional analgesia (RA) techniques are potential alternatives for EA. Paravertebral catheter placement can be performed under videoscope view during the thoracic phase of esophagectomy, making it a safe and easily placed block. Evidence on the effectiveness of erector spinae plane block (ESPB) is limited in this context.

Conclusions

Several analgesia regimens after esophagectomy are described. EA is most common, however paravertebral analgesia is a good alternative. Other techniques are also gaining ground but randomized clinical trials are lacking. Future studies should focus on the efficacy of paravertebral and erector spinae blocks for postoperative pain management for esophagectomy.

Dexmedetomidine as an Adjuvant in Peripheral Nerve Block

Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α₂-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.

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.

Comparison of Intercostal Nerve Block with Ropivacaine and Ropivacaine-Dexmedetomidine for Postoperative Pain Control in Patients Undergoing Thoracotomy: A Randomized Clinical Trial

Background

Thoracotomy is one of the most painful surgeries, and failure to alleviate patients' pain can have dangerous consequences.

Objectives

This study aimed to evaluate the addition of dexmedetomidine to ropivacaine in the intercostal block for postoperative pain control in patients undergoing thoracotomy.

Methods

In this randomized clinical trial, 74 patients aged 18 to 60 years with ASA class I or II, BMI less than 40, and no severe systemic problems referred to a teaching hospital in Ahvaz to undergo thoracotomy were included in the study and randomly divided into two groups. After surgery, an ultrasound-guided intercostal block was done with ropivacaine (5 cc of 0.25% solution; group R) or ropivacaine (5 cc of 0.25% solution) plus dexmedetomidine (0.5 µg/kg; group RD) per dermatome. Two dermatomes above and two dermatomes below the level of surgical incision were used. Pain, total opioid consumption, length of ICU stays, time to first rescue analgesic, and time to get out of bed were compared between the two groups.

Results

The intercostal block significantly reduced pain in both groups (P < 0.0001). The pain was lower in the RD group than in the R group from six hours after the intervention up to 24 hours after (P < 0.001). The number of patients who needed rescue analgesia at 12 hours was significantly lower in the RD group (P < 0.05). The RD group also had lower total opioid consumption and a longer time to receive the first rescue analgesia (P < 0.01). There was no significant difference between the two groups in the length of hospitalization and the time to get out of bed.

Conclusions

Dexmedetomidine is an effective and safe choice to be used as an adjunct to ropivacaine in ICB, and it extends the duration of analgesia in combination with ropivacaine after thoracotomy.

Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols

PURPOSE OF REVIEW

Enhanced Recovery After Surgery (ERAS) protocols and interventional locoregional anesthesia (LRA) techniques continuously evolve. This review outlines the latest recommendations for the use of regional anesthesia in ERAS protocols and emerging interventional analgesia techniques.

RECENT FINDINGS

Research in ultrasound-guided regional anesthesia has led to a refinement of the traditional techniques and the introduction of a number of new approaches to complement ERAS strategies. The efficacy and versatility of LRA enable its use in an increasing number of ERAS indications.

SUMMARY

The implementation of ERAS protocols in different surgical procedures reduces overall complications and recovery time. Multimodal analgesia strategies with regional anesthesia techniques are some of the key interventions contributing to the improvement in postoperative outcomes.

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.

Comparative randomized study of continuous serratus anterior plane block versus continuous paravertebral block in post-mastectomy pain

Background

Many analgesic methods have been used to control post-mastectomy pain. Both thoracic paravertebral and serratus anterior blocks are recent regional techniques with promising results. The aim of this study was to compare safety and analgesic efficacy of both techniques in controlling post-mastectomy pain.

Methods

The study was conducted from January 1, 2019, till January 10, 2019, on 60 female patients ASA class ≤ 2 undergoing modified radical mastectomy. After induction of balanced general anesthesia patients received either continuous thoracic paravertebral block (group P) or continuous serratus anterior block (group S). Twenty milliliters of levobupivacaine 0.25% were injected in each technique under ultrasound guidance followed by continuous infusion of 5 ml/h levobupivacaine 0.125% through a 22-gage catheter. IV morphine was given postoperatively by patient-controlled analgesia. In both groups, we measured time to first dose morphine, total 24 and 48 h morphine consumption, vital signs, visual analog scale, and side effects of each technique.

Results

The demographic data (age, body mass index, and duration of surgery) were comparable in both groups. The time for first dose of morphine was significantly longer in group P (368 ± 36 min) than group S (270 ± 37.65 min) with P value < 0.001. Total morphine consumption in milligram at both 24 and 48 h were significantly less in group P (8.1 ± 0.8, and 11.5 ± 1 respectively) than in group S (10.1 ± 1.3 and 14.2 ± 1.4), with limited side effects in both groups.

Conclusion

Both continuous paravertebral and serratus anterior plane blocks are safe good alternatives to control post-mastectomy pain. However continuous paravertebral block provides better analgesic profile.

The Safety and Efficacy of Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Combined with Dexmedetomidine for Patients Undergoing Video-Assisted Thoracic Surgery (VATS): A Randomized Controlled Trial

Background

Although video-assisted thoracic surgery (VATS) can significantly reduce postoperative pain, the incidence is as high as 30–50%. The purpose of this study was to explore the safety and efficacy of ultrasound-guided serratus anterior plane block (SAPB) combined with dexmedetomidine (Dex) for patients undergoing VATS.

Methods

Eighty patients were randomized into two groups (20 mL 0.5% ropivacaine plus 0.5 µg/kg or 1 µg/kg Dex). Primary outcome was the visual analog scale of pain while coughing (VASc) score at 24 h after surgery. Secondary outcomes included hemodynamics, sufentanil consumption, number of patients needing rescue analgesia, time to first rescue analgesic, total dose of rescue analgesic, satisfaction scores of patients and surgeons, time of chest tube removal, length of hospital stay, adverse effects, the prevalence of chronic pain and quality of life.

Results

Compared with D1 group, visual analog scale of pain at rest (VASr) was significantly lower during the first 24 h after surgery, while VASc was significantly lower during the first 48 h after surgery (P<0.05). Mean arterial pressure was significantly decreased from T2 to T8, and heart rate was significantly decreased from T2 to T7 in the D2 group (P<0.05). Consumption of sevoflurane, remifentanil, DEX and the recovery time were significantly reduced in the D2 group (P <0.05). Consumption of sufentanil 8–72 h after surgery was significantly lower in the D2 group (P<0.05). Additionally, the number of patients who required rescue analgesia, the time to the first dose of rescue analgesia, and the total dose of rescue analgesia was significantly lower in the D2 group (P<0.05).

Conclusion

The results of this study show that 1 µg/kg DEX is a beneficial adjuvant to ropivacaine for single-injection SAPB in VATS patients while stable hemodynamics were maintained.

Analgesic Effectiveness of Perioperative Ultrasound-Guided Serratus Anterior Plane Block Combined with General Anesthesia in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis

Objective

To investigate whether perioperative ultrasound-guided serratus anterior plane block (SAPB) combined with general anesthesia is more effective and safer than current analgesic techniques for postoperative analgesia after video-assisted thoracoscopic surgery (VATS).

Methods

PubMed, the Cochrane Library, and EMBASE were searched for clinical trials published up to July 31, 2019. Outcomes, including operative duration, postoperative pain scores, postoperative analgesia use, patient satisfaction with analgesia, time to chest tube removal, length of stay, and adverse effects were analyzed.

Results

Four clinical trials, including 262 patients, met inclusion criteria. Ultrasound-guided SAPB reduced pain scores at zero, 15, 30, 45, and 60 minutes in the postoperative anesthesia care unit (all P &lt; 0.05) and at one, two, six, 12, and 24 hours in the ward (all P &lt; 0.001). Additionally, postoperatively, morphine consumption at 15 and 30 minutes, overall morphine consumption, and total consumption (morphine plus tramadol) were significantly lower in the SAPB cohort (P  &lt; 0.05). Similarly, postoperative tramadol consumption at one, two, six, 12, and 24 hours was also lower in this cohort (all P  &lt; 0.05). The postoperative consumption of fentanyl, tramadol, and total morphine in patient-controlled analgesia (PCA) at 24 hours was significantly reduced (P &lt; 0.05). Moreover, SAPB provided better patient satisfaction with analgesia (P = 0.0038). However, no statistically significant difference was found in duration of operation, time to chest tube removal, length of stay, or side effects (all P &gt; 0.05).

Conclusions

Perioperative ultrasound-guided SAPB combined with general anesthesia provided more effective postoperative analgesia after VATS. However, no significant advantage was found regarding side effects.