Postoperative pain management

The effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain control in idiopathic scoliosis patients undergoing posterior spine fusion surgery: study protocol of a randomized controlled trial

BACKGROUND

Posterior spinal fusion (PSF) for the correction of idiopathic scoliosis is associated with severe postoperative pain. Erector spinae plane block (ESPB) has been proposed to provide analgesia and reduce opioid consumption. We aimed to investigate the effect of bilateral ultrasound-guided single-shot ESPB on postoperative analgesia in pediatric patients undergoing PSF.

METHODS

This double-blinded, randomized controlled trial will enroll 74 AIS patients undergoing elective PSF. Participants will be assigned to the ESPB group or control group at a 1:1 ratio. Patients in the ESPB group will receive ultrasound-guided bilateral ESPB preoperatively, and patients in the control group received sham ESPB using normal saline. The primary joint endpoints are the area under the curve (AUC) of numerical rating scale (NRS) score and opioid consumption in postoperative 24 h. The secondary endpoints are numerical rating scale (NRS) score and opioid consumption at postoperative 0.5, 3, 6, 9, 12, 24, 36, and 48 h, rescue analgesia, recovery outcomes, and adverse events.

DISCUSSION

At present, studies investigating the effect of ESPB on pediatric patients are still needed. This study focuses on the effect of ESPB on pediatric patients undergoing PSF on postoperative pain control and intends to provide a new strategy of multimodal analgesia management for major spine surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300074505. Registered on August 8, 2023.

Thoracoscopic Intercostal Nerve Block with Cocktail Analgesics for Pain Control After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study

Objective

To evaluate whether using a cocktail of intercostal nerve blocks (TINB) during thoracoscopic surgery results in better clinical outcomes than patient-controlled analgesia (PCIA).

Methods

Patients in two medical groups undergoing video-assisted thoracoscopic surgery (VATS) for pulmonary nodules in West China Hospital of Sichuan University were collected consecutively between March 2022 and December 2022. The groups were divided into two subgroups based on their analgesic program, which were TINB group and PCIA group. The primary outcome was the visual analogue scale (VAS) of the two groups at different stage after surgery and after discharge. Any analgesic related adverse events (ARAEs) were also recorded.

Results

A total of 230 patients who underwent VATS were enrolled, in which 113 patients (49.1%) received a cocktail TINB after surgery, and 117 patients (50.9%) received a PCIA. After PSM, 62 patients in each group were selected. The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period (p < 0.05, p < 0.05), and the two groups showed no significant differences in RVAS or AVAS during hospitalization (p = 0.271, p = 0.915). However, the rates of dizziness (4.84% vs 25.81%, p = 0.002), nausea and vomiting (0 vs 22.58%, p < 0.05), fatigue (14.52% vs 34.87%, p = 0.012), and insomnia (0 vs 58.06%, p < 0.05) in TINB group were lower than that in PCIA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PCIA group (p < 0.05, p < 0.05).

Conclusion

Cocktail TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.

Chronic postoperative pain after non-intubated uniportal VATS lobectomy

Introduction

Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.

Methods

Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.

Results

Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not.

Conclusion

Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.

Erector spinae plane block versus intercostal nerve block for postoperative analgesia in lung cancer surgery

BACKGROUND

A recent trend in postoperative analgesia for lung cancer surgery relies on regional nerve blocks with decreased opioid administration. Our study aims to critically assess the continuous ultrasound-guided erector spinae plane block (ESPB) at our institution and compare it to a standard regional anesthetic technique, the intercostal nerve block (ICNB).

PATIENTS AND METHODS

A prospective randomized-control study was performed to compare outcomes of patients, scheduled for video-assisted thoracoscopic (VATS) lung cancer resection, allocated to the ESPB or ICNB group. Primary outcomes were total opioid consumption and subjective pain scores at rest and cough each hour in 48 h after surgery. The secondary outcome was respiratory muscle strength, measured by maximal inspiratory and expiratory pressures (MIP/MEP) after 24 h and 48 h.

RESULTS

60 patients met the inclusion criteria, half ESPB. Total opioid consumption in the first 48 h was 21. 64 ± 14.22 mg in the ESPB group and 38.34 ± 29.91 mg in the ICNB group (p = 0.035). The patients in the ESPB group had lower numerical rating scores at rest than in the ICNB group (1.19 ± 0.73 vs. 1.77 ± 1.01, p = 0.039). There were no significant differences in MIP/MEP decrease from baseline after 24 h (MIP p = 0.088, MEP p = 0.182) or 48 h (MIP p = 0.110, MEP p = 0.645), time to chest tube removal or hospital discharge between the two groups.

CONCLUSIONS

In the first 48 h after surgery, patients with continuous ESPB required fewer opioids and reported less pain than patients with ICNB. There were no differences regarding respiratory muscle strength, postoperative complications, and time to hospital discharge. In addition, continuous ESPB demanded more surveillance than ICNB.

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.

Allergic and other adverse reactions to drugs used in anesthesia and surgery

The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.

Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study

OBJECTIVE

To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure.

METHODS

Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02-0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0-10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3.

RESULTS

Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen's d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen's d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05).

CONCLUSIONS

An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.

Post-thoracotomy analgesia

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

The Effect of Ultrasound-Guided Erector Spinae Plane Block versus Thoracic Epidural Block on Postoperative Analgesia After Nuss Surgery in Paediatric Patients: Study Protocol of a Randomized Non-Inferiority Design Trial

Purpose

The Nuss procedure is a recognized treatment for adolescent pectus excavatum that results in severe postoperative pain. Erector spinae plane block (ESPB) is a novel technique that provides postoperative analgesia and reduces opioid consumption. Our aim is to explore whether ESPB produces analgesia similar to thoracic epidural anaesthesia (TEA) in paediatric patients undergoing Nuss procedure.

Study Design and Methods

This randomized, controlled, non-inferiority trial will enrol 300 paediatric patients undergoing Nuss surgery. Participants will be randomly assigned 1:1 to receive ESPB or TEA preoperatively. The primary, joint endpoint is the average numeric rating scale (NRS) score and cumulative sufentanil consumption. The secondary endpoints are pain scores and sufentanil consumption at different time points after surgery, analgesia-related side effects, and other postoperative complications. Data will be analysed by the intention-to-treat principle.

Discussion

This study investigates the effect of ESPB on postoperative opioid consumption and pain scores and intend to provide a new strategy of analgesia management for Nuss procedure in paediatric patients.

Chronic Chest Pain Control after Trans-Thoracic Biopsy in Mediastinal Lymphomas

Chest pain following a trans-thoracic biopsy often has multiple etiologies, especially in patients with lymphomas. Pathological neuronal mechanisms integrate with an overproduction of IL-6, TNF-α, IL1-β by macrophages and monocytes, which amplifies inflammation and pain. In consideration of this complex pathogenesis, international guidelines recommend diversified analgesia protocols: thoracic epidural, paravertebral block, and systemic administration of opioids. This study reports an attempt to reduce chest pain and prevent chronic pain in 51 patients undergoing trans-thoracic biopsy for mediastinal lymphoma. The entity of pain, measured 72nd hour after biopsy by the Numerical Rating Scale (NRS), was compared with that seen at a 6th month checkpoint in 46 patients. The pain decreased in all cases. At the 6th month checkpoint, among 31 opioid-treated patients, none of the 16 patients with NRS < 6 within the 72nd hour post biopsy had developed chronic chest pain, while 8 of the 15 with higher values did (p < 0.01). Of 10 patients undergoing thoracotomy and treated with opioids, eight had a NRS of no more than 2, of which six had no chronic pain. Of the twenty-one patients who underwent VATS biopsy and were treated with opioids, fifteen had NRS no greater than 2, of which ten had no chronic pain. Subgroups of patients biopsied under mediastinotomy or video-assisted thoracoscopic surgery (VATS) and treated with thoracic epidural analgesia (TEA) or PVB were too small for such analysis.

Patient-Controlled Analgesia (PCA): Intravenous Administration (IV-PCA) versus Oral Administration (Oral-PCA) by Using a Novel Device (PCoA® Acute) for Hospitalized Patients with Acute Postoperative Pain-A Comparative Retrospective Study

Background

Acute postoperative pain delays recovery and increases morbidity and mortality. Opioid therapy is effective but is accompanied by adverse reactions. Patient-controlled analgesia (PCA) enables self-administration of analgesics. Oral-PCA is a safe and beneficial alternative to intravenous (IV) PCA. We have developed a novel Oral-PCA device, which enables self-administration of solid pills to the patient's mouth. This is a retrospective study comparing the effectiveness and usability of this novel Oral-PCA with those of IV-PCA.

Methods

Medical records of patients who received PCA following gynecology and orthopedic surgeries were analyzed. The control cohort (n = 61) received oxycodone by IV-PCA. The test cohort (n = 44) received oxycodone by Oral-PCA via the PCoA Acute device. Outcome measures include the Numeric Rating Scale (NRS) score at rest and movement, side effects, technical difficulties, bolus dose administered, and bolus dose requested.

Results

Patient demographics, initial NRS, and PCA duration were comparable between cohorts. NRS reduction in rest and movement was stronger in the Oral-PCA cohort (rest: 1.61 and 2.27, P = 0.077; movement: 2.05 and 2.84, P = 0.039), indicating better pain control and mobility for Oral-PCA. Side effect rates were comparable between cohorts (9% and 11% of patients who experienced side effects, P = 1.000). The rate of technological difficulties was higher in the Oral-PCoA cohort (19.7% and 36.4%, P = 0.056). The mean total bolus dose administered to patients was comparable in both cohorts (18.32 mg and 21.14 mg oxycodone, P = 0.270). However, the mean total boluses requested by patients during lockout intervals were lower in the Oral-PCA cohort (12.8 mg and 6.82 mg oxycodone, P = 0.004), indicating better pain control.

Conclusions

Oral-PCA by using PCoA® Acute provides pain control and usability which is noninferior to the IV-PCA, as well as superior to pain reduction in rest and movement. These results, along with the noninvasiveness, medication flexibility, and reduced cost, suggest the potential of Oral-PCA, by using PCoA Acute, to replace IV-PCA for postoperative analgesia.

Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief

Background

Systemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.

Results

Sixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).

Conclusion

Continuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.

Paravertebral Block Versus Preemptive Ketamine Effect on Pain Intensity after Posterolateral Thoracotomies: A Randomized Controlled Trial

Severe postoperative pain affects most patients after thoracotomy and is a risk factor for post-thoracotomy pain syndrome (PTPS). This randomized controlled trial compared preemptively administered ketamine versus continuous paravertebral block (PVB) versus control in patients undergoing posterolateral thoracotomy. The primary outcome was acute pain intensity on the visual analog scale (VAS) on the first postoperative day. Secondary outcomes included morphine consumption, patient satisfaction, and PTPS assessment with Neuropathic Pain Syndrome Inventory (NPSI). Acute pain intensity was significantly lower with PVB compared to other groups at four out of six time points. Patients in the PVB group used significantly less morphine via a patient-controlled analgesia pump than participants in other groups. Moreover, patients were more satisfied with postoperative pain management after PVB. PVB, but not ketamine, decreased PTPS intensity at 1, 3, and 6 months after posterolateral thoracotomy. Acute pain intensity at hour 8 and PTPS intensity at month 3 correlated positively with PTPS at month 6. Bodyweight was negatively associated with chronic pain at month 6. Thus, PVB but not preemptively administered ketamine decreases both acute and chronic pain intensity following posterolateral thoracotomies.

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.

Pain Management and Its Possible Implementation Research in North Ethiopia: A before and after Study

BACKGROUND

Though there is an effective intervention, pain after surgical intervention is undermanaged worldwide. A systematic implementation is required to increase the utilization of available evidence-based intervention to manage the inevitable pain after surgery. The aim of this research project is to develop a scalable model for managing pain after cesarean section by implementing the World Health Organization's (WHO) pain management guidelines through a combination of implementation research and quality improvement methods.

METHODS

We implemented the World Health Organization (WHO) pain management guidelines using effective implementation strategies. First, we conducted a formative qualitative exploration to identify enablers and obstacles. In addition, we took base-line assessment on pain management implementation process and outcome using a checklist prepared from the guideline and an adapted American Pain Outcome assessment tool version 2010, respectively. Then, we integrated the guidelines into the existing practice by using collaborative iterative learning strategy. We analyzed the data by Statistical Packages for Social Sciences (SPSS) version 21. We compared the before and after data using chi-squared and Fischer's exact test. A change in any measurement was considered as significant at p value 0.05.

RESULT

We collected data from 106 mothers before and 110 mothers after intervention implementation. We successfully integrated pain as a fifth vital sign in more than 87% (p value <0.001) of patient, and fidelity was approximately 59% (p value <0.001). In addition, we significantly improved pain outcome measures after the implementation of the intervention. Conclusion and Recommendations. A systematic approach to implement pain management guidelines was successful. We recommend the ward sustain these gains and that hospital, the region, and the nation to replicate the success.

Assessment of postoperative pain management and comparison of effectiveness of pain relief treatment involving paravertebral block and thoracic epidural analgesia in patients undergoing posterolateral thoracotomy

Background

TEA (thoracic epidural analgesia) is considered a basic method of analgesia used in thoracic surgeries. PVB (paravertebral block) is an alternative method. The thesis compares effectiveness of both methods in postoperative analgesia with particular focus on assessment of the postoperative pain management quality.

Methods

The study involved 2 groups of patients, each consisting of 30 patients undergoing posterolateral thoracotomy. The study group involved patients anesthetized applying PVB method, while the control group involved patients anesthetized with TEA. Hemodynamic and respiratory parameters as well as severity of pain assessed using NRS (numeric rating scale) during the first 3 days after the surgery, number of days of hospitalization, and the need to use additional pain relievers were taken into account in both groups. Evaluation of postoperative pain management quality was performed applying Clinical Quality Indicators in Postoperative Pain Management.

Results

No statistical significance was demonstrated between the groups in respect of hemodynamic and respiratory parameters values, the need to use additional pain relievers and the number of days of hospitalization. There was no statistically significant difference between the groups in respect of general assessment of pain management quality, except for the assessment of the lowest level of pain within the last 24 h of measurement. This result in TEA group was statistically significantly lower than the one in PVB group (p = 0.019).

Conclusions

In the assessment of postoperative pain management quality both analyzed methods are statistically significantly different only in the category of “lowest level of pain within the last 24 hours of measurement”, to the benefit of TEA group. No statistically significant difference has been observed between the two study groups with respect to the remaining parameters.

Trial registration

KB-0012/71/15. Date of registration 22 June 2015.

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

Background

Patients who undergo surgical procedures that impair the integrity of the chest wall frequently experience extremely severe postoperative pain. Opiates and weaker analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are not sufficiently effective in achieving control of severe pain and might cause respiratory and gastrointestinal complications. In the past decade, there has been an increased interest in the use of regional nerve blocks for post-thoracoscopy and post-thoracotomy analgesia.

Methods

This is a prospective, randomized, double-blind and single-center study. We recruited 104 patients who underwent elective thoracoscopy. Prior to surgery, the participating patients were randomized into one of two study groups: Group 1- the “standard control group” that received standard postoperative pain control with intravenous opioids, NSAIDs and acetaminophen (paracetamol) and Group 2- the “block group” that was treated by ultrasound-guided serratus anterior plane (SAP) block (a single injection of 0.25% bupivacaine hydrochloride 2 mg/kg plus dexamethasone 8 mg) with standard postoperative pain control regimen. We compared the clinical, laboratory, and postoperative pain assessment data of both groups.

Results

Patients in the SAP block Group 2 reported significantly lower levels of pain after thoracic surgery as assessed by their visual analog scale scores, as compared to the patients in the standard pain control Group 1 (P<0.001). The total dosage of morphine and tramadol required for pain relief during the first hours after surgery was significantly lower in the patients who received SAP block. Also, the incidence of vomiting after surgery was significantly lower among the patients who received SAP block than among the patients who received standard pain control.

Conclusion

The results of the present study suggest that SAP block is an effective adjuvant treatment option for post-thoracic surgery analgesia. Compared to the current methods used for post-thoracic surgery pain relief, SAP block has some significant merits, particularly its ease of use and its low potential for side effects.

Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives

The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors' experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.

Anesthesia and analgesia: how does the role of anesthetists changes in the ERAS program for VATS lobectomy

Enhanced recovery after surgery (ERAS) programs are developed to prevent factors that delay postoperative recovery as well as issues that cause complications. The development of video-assist thoracoscopic surgery (VATS) techniques favors the fast recovery after thoracic procedures. ERAS strategies are based on multidisciplinary approach in which the anesthetist plays an important role from the preoperative to the postoperative phase with several goals. After preoperative evaluation and medical optimization, the anesthetist must ensure a tailored anesthetic plan aiming to a fast recovery and adequate pain relief to reduce the response to the surgical stress. The present narrative review presents the major parts of the ERAS anesthetic approach to VATS lobectomy like short-acting drugs, protective one-lung ventilation (OLV), fluid administration and opioid-sparing multimodal analgesia.

The Preventive Role of Low-Dose Intravenous Ketamine on Postoperative Shivering in Children: A Placebo Randomized Controlled Trial

Background

Postoperative shivering is a major problem in children undergoing general anesthesia.

Objectives

The aim of the present study was to investigate the role of low-dose intravenous ketamine for prevention of shivering after induction of general anesthesia in children who had undergone tonsillectomy.

Patients and Methods

This was a randomized, double-blinded, placebo-controlled trial including 80 children, of American society of anesthesiologists (ASA) physical status I or II, scheduled for tonsillectomy under general anesthesia who were randomly assigned to an intravenous ketamine (0.5 mg/kg, n = 40; group K) group or matched dose placebo (n = 40; group N) group. Surgical and demographic data, unexpected side effects, and the occurrence of shivering for each child were assessed by a blinded observer at the following time points: T0, in the recovery room; T10, at 10 minutes; T20, at 20 minutes; T30, and at 30 minutes.

Results

With regards to the demographic and surgical data, no significant differences between the two study groups were observed (P ≥ 0.05). Shivering intensity in children who had received ketamine was significantly lower than children who had not received ketamine, at T0, T10, T20, and T30 after arrival (P < 0.05). There were no significant differences in hallucination, nausea, vomiting, hemodynamic dysfunction, blurred vision, and seizure in the K group compared with the N group (P ≥ 0.05).

Conclusions

Administration of intravenous ketamine at a dosage of 0.5 mg/kg immediately after anesthesia induction had a preventive effect on shivering intensity without hemodynamic alterations in children undergoing general anesthesia for tonsillectomy.

Efficacy of subpleural continuous infusion of local anesthetics after thoracoscopic pulmonary resection for primary lung cancer compared to intravenous patient-controlled analgesia

BACKGROUND

This study compared the efficacy and side effects of intravenous patient-controlled analgesia (IV-PCA) with those of a subpleural continuous infusion of local anesthetic (ON-Q system) in patients undergoing thoracoscopic pulmonary resection for primary lung cancer.

METHODS

We retrospectively reviewed 66 patients who underwent thoracoscopic pulmonary resection for primary lung cancer from January 2014 to August 2015 (36 in the IV-PCA group and 30 in the ON-Q group). The numeric pain intensity scale (NPIS), additional IV injections for pain control, side effects, and early discontinuation of the pain control device were compared.

RESULTS

There were no differences in the general characteristics of the two groups. The NPIS scores gradually decreased with time (P<0.001), but the two groups had differences in pattern of NPIS scores (P=0.111). There were no differences in the highest NPIS score during admission (4.75±2.35 vs. 5.27±1.87, P=0.334) or the number of additional IV injections for pain control in the same period (0.72±0.94 for IV-PCA vs. 0.83±0.65 for ON-Q; P=0.575). Side effects such as nausea, dizziness, and drowsiness were significantly more frequent with IV-PCA (36.1% vs. 10.0%, P=0.014), and early discontinuation of the pain control device was more frequent in the IV-PCA group (33.3% vs. 6.7%, P=0.008).

CONCLUSIONS

The ON-Q system was equivalent to the IV-PCA for postoperative pain control after thoracoscopic pulmonary resection for primary lung cancer, and it also had fewer effects and early discontinuations.