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Shelley B, Goebel A, Grant S, Jackson L, Jarrett H, Jepson M, Kerr A, Marczin N, Mehta R, Melody T, Middleton L, Naidu B, Szentgyorgyi L, Tearne S, Watkins B, Wilson M, Worrall A, Yeung J, Smith FG. Study protocol for a randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: 2 (TOPIC 2). Trials 2023; 24:748. [PMID: 37996898 PMCID: PMC10666334 DOI: 10.1186/s13063-023-07463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/15/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain. METHODS TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis. DISCUSSION Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS. TRIAL REGISTRATION NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856 . First patient recruited 8 January 2019.
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Affiliation(s)
- Ben Shelley
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Andreas Goebel
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Stephen Grant
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Louise Jackson
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Marcus Jepson
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amy Kerr
- University Hospitals Birmingham Thoracic Surgical Research Centre, Bristol, UK
| | - Nandor Marczin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | | | - Babu Naidu
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | | | - Ben Watkins
- Birmingham Clinical Trial Unit, Birmingham, UK
| | - Matthew Wilson
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Fang Gao Smith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
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Xu M, Feng Y, Song X, Fu S, Lu X, Lai J, Lu Y, Wang X, Lai R. Combined Ultrasound-Guided Thoracic Paravertebral Nerve Block with Subcostal Transversus Abdominis Plane Block for Analgesia After Total Minimally Invasive Mckeown Esophagectomy: A Randomized, Controlled, and Prospective Study. Pain Ther 2023; 12:475-489. [PMID: 36648745 PMCID: PMC10036694 DOI: 10.1007/s40122-023-00474-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Thoracic paravertebral block (TPVB) and subcostal transverse abdominis plane block (TAP) have been considered to provide an effective analgesic effect for laparoscopic and thoracoscopic surgery, respectively. The purpose of this randomized, controlled, and prospective study was to evaluate the analgesic effect of TPVB combined with TAP in patients undergoing total minimally invasive Mckeown esophagectomy. METHODS Between February 2020 and December 2021, a total of 168 esophageal cancer patients undergoing McKeown esophagectomy at the Cancer Center of Sun Yat-Sen University, China, were randomly assigned to receive patient-controlled epidural analgesia alone (group PCEA, n = 56), patient-controlled intravenous analgesia alone (group PCIA, n = 56), and TPVB combined with TAP and patient-controlled intravenous analgesia (group PVB, n = 56). The primary outcome was a visual analogue scale (VAS) pain score on movement 48 h postoperatively. Secondary endpoints were pain scores at other points, intervention-related side effects, surgical complications, and length of intensive care unit and hospital stay. For the VAS pain score, the Kruskal-Wallis method was conducted for comparison of 3 treatment groups and further pairwise comparison with Bonferroni correction. RESULTS On movement, the VAS in the PVB group was higher than that in the PCEA group at 48 h, 72 h, 96 h, and 120 h postoperatively (p < 0.05) except in the postoperative anesthesia care unit (PACU) and 24 h postoperatively. The VAS in the PCIA group was higher than the PCEA and PVB groups in the first 4 days after surgery. The pulmonary complication rate in the PCIA group was significantly higher than the rate in the PCEA [95% Confidence Interval 0.214 (0.354, 0.067), p = 0.024]. CONCLUSIONS Combined TPVB and TAP was more effective than intravenous opioid analgesia alone, while PCEA was more effective than TPVB combined with TAP and intravenous opioid analgesia for patients after McKeown esophagectomy. TRIAL REGISTRATION Chinese Clinical Trial Registry; ChiCTR2000029588.
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Affiliation(s)
- Mei Xu
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - Yuerou Feng
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - Xiong Song
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - Shuwen Fu
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - XiaoFan Lu
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - Jielan Lai
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China
| | - Yali Lu
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China.
| | - Xudong Wang
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China.
| | - Renchun Lai
- State Key Laboratory of Oncology in Southern China, Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Collaborative Innovation for Cancer Medicine, 651 Dongfeng Dong Lu, Yuexiu District, Guangzhou, Guangdong, China.
- Guangdong Esophageal Cancer Institute, Guangzhou, China.
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Effects of Different Doses of Dexmedetomidine Combined with Thoracic Paravertebral Nerve Block Anesthesia on Agitation and Hemodynamics in Patients Undergoing Thoracotomy during Recovery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7804584. [PMID: 35815292 PMCID: PMC9259226 DOI: 10.1155/2022/7804584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/31/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022]
Abstract
Objective To investigate the effect of different doses of dexmedetomidine combined with thoracic paravertebral nerve block anesthesia on agitation and hemodynamics in patients undergoing thoracotomy during recovery. Methods One hundred patients who underwent thoracotomy in our hospital from August 2018 to April 2021 were enrolled and assigned (1 : 1 : 1 : 1) into 4 groups via the random number table method. The patients in the control group were treated with double-lumen tube general anesthesia + ropivacaine for thoracic paravertebral nerve block anesthesia; patients in experimental group A received double-lumen general anesthesia +0.5 μg·kg-1 dexmedetomidine + ropivacaine for thoracic paravertebral nerve block anesthesia; patients in experimental group B received thoracic paravertebral nerve block anesthesia with double-lumen general anesthesia +1.0 μg·kg-1 dexmedetomidine + ropivacaine; patients in experimental group C received thoracic paravertebral nerve block anesthesia with double-lumen general anesthesia +1.5 μg·kg-1 dexmedetomidine + ropivacaine. The postoperative recovery time and visual analog scale (VAS), level of hemodynamics (heart rate (HR), mean arterial pressure (MAP)), agitation during the recovery period, and complications were compared amongst the 4 groups of patients at different time points. Results The postoperative VAS scores of patients in groups B2 and B3 were slightly lower than those of patients in groups A and B1, but a one-way analysis of variance revealed no statistical difference in the postoperative recovery time and VAS pain scores of the four groups (P > 0.05), and the recovery time of patients in experimental group C was slightly higher than that of patients in group B2. At T0 and T1, there was no significant difference in the levels of HR and MAP among the four groups (P > 0.05). The levels of HR and MAP of the patients in groups B2 and B3 were significantly different from the patients in the control group and experimental group A at T2 and T3 (P < 0.05). The patients in experimental group B and experimental group C showed better outcomes than those in the control group and experimental group A in the assessment of agitation during the recovery period (P < 0.05). There was no significant difference in the incidence of complications among the four groups (P > 0.05). Conclusion In line with the principle of preference for a small anesthesia dose, 1.0 μg·kg-1 dose of dexmedetomidine combined with ropivacaine produces a pronounced efficacy in patients undergoing thoracotomy. It effectively controls the occurrence of agitation during the recovery period and maintains the stability of the patient's hemodynamics, with a high clinical safety profile.
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Sagun A, Rumeli S, Ozdemir L, Azizoglu M, Berkesoglu M, Mutlu V. Intraoperative pectoral block thoracic paravertebral block for postoperative analgesia after breast cancer surgery: A randomized controlled trial. J Surg Oncol 2022; 126:425-432. [PMID: 35536730 DOI: 10.1002/jso.26914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/04/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND METHODS With the increasing rate of breast cancer surgery, the pain management of these patients gains importance. The aim of this study is to compare the ultrasound (US) guided thoracic paravertebral block (TPV) versus intraoperative pectoral nerve block (PECS) with a low volume local anaesthetic for postoperative analgesia after breast cancer surgery. A total of 41 patients underwent mastectomy and sentinel lymph node biopsy or modified radical mastectomy were included in this randomized controlled, single-blinded trial. The patients were divided into two groups as PECS and TPV blocks. In the PECS group, 10 ml of 0.5% bupivacaine was administered to the fascial plane by the surgeon. In the TPV group, 25 ml of 0.25% bupivacaine at T3 level was administered by the anaesthetist under US-guidance. Visual analogue scale (VAS) scores and additional analgesic requirements were recorded at postoperative 0, 6, 12, 24 and 48 h. RESULTS In the TPV group, mean VAS score (VAS0) was significantly lower (p ˂ 0.001). In other time periods, there was no significant difference between the groups. CONCLUSIONS It was observed that intraoperative PECS block was as effective as TPV in providing postoperative analgesia and additional analgesic requirements were similar. This result suggests PECS block may be a good alternative to TPV.
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Affiliation(s)
- Aslinur Sagun
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Sebnem Rumeli
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Levent Ozdemir
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Mustafa Azizoglu
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Mustafa Berkesoglu
- Department of General Surgery, Mersin University School of Medicine, Mersin, Turkey
| | - Veli Mutlu
- Department of General Surgery, Mersin University School of Medicine, Mersin, Turkey
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Khidr AM, Senturk M, El-Tahan MR. Impact of regional analgesia techniques on the long-term clinical outcomes following thoracic surgery. Saudi J Anaesth 2021; 15:335-340. [PMID: 34764840 PMCID: PMC8579497 DOI: 10.4103/sja.sja_1178_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 12/01/2022] Open
Abstract
Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.
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Affiliation(s)
- Alaa M Khidr
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Mert Senturk
- Department of Anesthesiology, College of Medicine, Istanbul University, Istanbul, Turkey
| | - Mohamed R El-Tahan
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
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Kukreja P, Herberg TJ, Johnson BM, Kofskey AM, Short RT, MacBeth L, Paul C, Kalagara H. Retrospective Case Series Comparing the Efficacy of Thoracic Epidural With Continuous Paravertebral and Erector Spinae Plane Blocks for Postoperative Analgesia After Thoracic Surgery. Cureus 2021; 13:e18533. [PMID: 34754683 PMCID: PMC8570225 DOI: 10.7759/cureus.18533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 11/29/2022] Open
Abstract
Perioperative pain management for thoracic surgery plays a vital role in recovery and improved outcomes. In this retrospective study we compare three different regional anesthesia techniques utilized at one institute to provide postoperative analgesia for thoracic surgery. Continuous thoracic epidural analgesia (TEA), thoracic paravertebral block (PVB) and erector spinae plane (ESP) block are compared for postoperative pain management, opioid requirements, postoperative nausea and vomiting (PONV), respiratory events and length of stay. In this study, pairwise comparisons were also performed among the regional techniques with respect to mentioned outcomes.
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Affiliation(s)
- Promil Kukreja
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Timothy J Herberg
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Brittany M Johnson
- Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Alexander M Kofskey
- Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Roland T Short
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Lisa MacBeth
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Christopher Paul
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
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Lo T, Schiller R, Raghunathan K, Krishnamoorthy V, Jawitz OK, Pyati S, Van De Ven T, Bartz RR, Thompson A, Ohnuma T. Changes in analgesic strategies for lobectomy from 2009 to 2018. JTCVS OPEN 2021; 6:224-236. [PMID: 36003558 PMCID: PMC9390760 DOI: 10.1016/j.xjon.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 10/27/2022]
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Hamed IG, Fawaz AA, Rabie AH, El Aziz AEAAA, Ashoor TM. Ultrasound-guided thoracic paravertebral block vs pectoral nerve block for postoperative analgesia after modified radical mastectomy. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2020; 12:30. [DOI: 10.1186/s42077-020-00081-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/13/2020] [Indexed: 09/01/2023]
Abstract
AbstractBackgroundThoracic paravertebral block may be used for analgesia after breast surgery. Ultrasound can be used during the whole technique of paravertebral block to increase success rate and decrease its complications. As well, pectoral nerve block is now used for pain relief after modified radical mastectomy with or without axillary clearance.ObjectiveTo compare thoracic paravertebral block and pectoral nerve block for postoperative analgesia after modified radical mastectomyMethodsThe study was performed over 30 female patients that were randomly divided into 2 groups with 15 patients in group A for thoracic paravertebral block (TPVB) and 15 in group B for pectoral nerve block (PECS) with injection of total 20 ml bupivacaine 0.25% in each block. Outcome measures of the study are postoperative analgesia duration (time to first rescue analgesia (0.5 mg/kg pethidine) after administration of block) and total analgesic dose in 24 h after surgery and postoperative pain which will be assessed using a visual analog scale (VAS, 0–10 as 0 = no pain and 10 = worst imaginable pain). The vital signs and pain score will be recorded at 0, 1, 2, 4, 6, 8, 12, 18, and 24 h after surgery.ResultsOur study showed decrease in systolic blood in PVB group immediately postoperative and in the first 6 h postoperative withpvalue < 0.05. Less time to perform the block in PECS group withpvalue < 0.001. Less VAS score in PECS group with statistically significant difference between groups at 1 h, 2 h, and 4 h. More time is needed for the 1st requested rescue analgesia in PECS group withpvalue < 0.05. Patients in the PECS group received less total dose of pethidine with apvalue < 0.05ConclusionThe PECS can be effectively and safely used, provides better relief of pain and less hemodynamic changes compared with the TPVB, and reduces postoperative analgesic consumption. Therefore, the PECS can be used safely for postoperative analgesia in patients undergoing breast surgeries with axillary dissection.
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Tong C, Zhu H, Li B, Wu J, Xu M. Impact of paravertebral blockade use in geriatric patients undergoing thoracic surgery on postoperative adverse outcomes. J Thorac Dis 2019; 11:5169-5176. [PMID: 32030234 DOI: 10.21037/jtd.2019.12.13] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background While it is known that thoracic paravertebral blockade (TPVB) could reduce pain undergoing thoracic surgery, it has not been confirmed whether this reduction in pain reduces pulmonary complications in an elderly population. Methods We performed a monocentric retrospective analysis for a prospectively collected patients receiving thoracic surgery with or without intraoperative TPVB between November 7, 2018 and April 1, 2019, at Shanghai Chest Hospital. Whether or not to use TPVB depending on anesthesiologists' preference, the chances of harm and benefit of each patients after discussed with their anesthetist. Chest wall resection, bilateral lung resection, conversion to thoracotomy and ipsilateral reoperation were excluded. A total of 154 patients with lung operations were included in the final analysis, 34 of whom received general anesthesia combined with TPVB (GA-TPVB). The primary outcome was the incidence of postoperative pulmonary complications (PPCs). The secondary outcomes were the incidence of cardiovascular and other complications, required analgesia in post anesthesia care unit (PACU), patient controlled analgesia (PCA) pressing frequency in 24h, chest tube duration, ICU stay and the hospital length of stay (LOS). Results The incidence of PPCs undergoing thoracic surgery was about 21.4% (33/154). Compared with GA, GA-TPVB could reduce the incidence of PPCs (25% vs. 9%, P=0.042), mostly reduce postoperative atelectasis (19% vs. 3%, P=0.021). TPVB could reduce the rate of required analgesia in PACU, PCA pressing frequency in 24 h and chest tube duration. However, there were no significant differences on the rate of cardiovascular and other complications, ICU stay and LOS between the two groups (P>0.05). Multivariable logistic regression analysis identified preoperative DLCO% ≥92% (OR =0.293, P=0.006), duration of surgery <75 min (OR =0.278, P=0.008) and GA-TPVB (OR =0.270, P=0.048) was associated with fewer PPCs. Conclusions Our study shows that general anesthesia combined with TPVB may reduce PPCs by reducing postoperative pain in geriatric patients undergoing thoracic surgery compared with general anesthesia alone. Trial registration Chinese Clinical Trial Registry number, ChiCTR1800019526. Registered on Nov 7, 2018.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Hongwei Zhu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Bin Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200025, China
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Choi EJ, Yoon JP, Choi YM, Park JY, Kim HY, Byeon GJ. Intravenous infusion of dexmedetomidine amplifies thoracic epidural analgesic effect after open thoracotomy: A prospective, double-blind, randomized controlled trial. Medicine (Baltimore) 2019; 98:e17983. [PMID: 31770207 PMCID: PMC6890340 DOI: 10.1097/md.0000000000017983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The anesthetic-sparing effect of dexmedetomidine has led to its use as a general adjuvant. The present study aimed to determine intravenous infusion of dexmedetomidine to epidural analgesia after open thoracotomy. METHODS Forty-four patients scheduled for admission to the intensive care unit after open thoracotomy were divided into 2 groups. An epidural catheter was placed at T4 to T7. Thirty minutes before the end of thoracotomy, group D was injected with 0.3 μg/kg/h of dexmedetomidine and group C received an equal dose of normal saline. For patient-controlled epidural analgesia (PCEA), 150 mL of levobupivacaine 300 mg was infused at a rate of 1 mL/h, plus a bolus dose of 3 mL with a lockout time of 30 minutes. The primary outcome evaluated was analgesic efficacy using a visual analog scale (VAS) 48 hours postoperatively. Other outcomes included additional analgesic use, total consumed local analgesia via PCEA, sedation score, blood pressure, heart rate, arterial blood gases, patient satisfaction, and adverse effects. RESULTS The VAS scores in group D were significantly lower than that in group C immediately, 1, 4, 12, 36, and 48 hours after admission to the intensive care unit (P = .016, .009, .015, .002, .001, and .042, respectively). The total dose of additional analgesic was also significantly lower in group D (P = .011). Patient satisfaction was higher in group D (P < .05). There were no significant differences in the other outcomes between groups. CONCLUSION Intravenous infusion of dexmedetomidine amplifies thoracic epidural analgesic effect after open thoracotomy.
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Affiliation(s)
- Eun-Ji Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
| | - Jung-Pil Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
| | - Yun-Mi Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
| | - Ju Yeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
| | - Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Gyeongnam, Republic of Korea
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12
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Li J, Lam D, King H, Credaroli E, Harmon E, Vadivelu N. Novel Regional Anesthesia for Outpatient Surgery. Curr Pain Headache Rep 2019; 23:69. [PMID: 31372836 DOI: 10.1007/s11916-019-0809-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge. RECENT FINDINGS Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events. Some of these novel blocks are particularly suitable for ambulatory procedures, including but not limited to motor-sparing lower extremity nerve blocks and phrenic-sparing nerve blocks for shoulder surgeries. The adoption of peripheral nerve block into outpatient surgery is a multidisciplinary effort that encompasses appropriate patient choice, careful selection of nerve blocks that minimize potential adverse events after discharge, and proper patient follow-up until block effects resolve.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, Yale University, New Haven, CT, USA.
| | - David Lam
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Hanna King
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | | | - Emily Harmon
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, USA
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13
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Licker M. Anaesthetic management and unplanned admission to intensive care after thoracic surgery. Anaesthesia 2019; 74:1083-1086. [PMID: 31175677 DOI: 10.1111/anae.14741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2019] [Indexed: 01/26/2023]
Affiliation(s)
- M Licker
- Thoracic and Emergency Anaesthesia, Department of Acute Medicine, University Hospital of Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Switzerland
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14
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15
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Shelley BG, McCall PJ, Glass A, Orzechowska I, Klein AA. Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit. Anaesthesia 2019; 74:1121-1129. [PMID: 30963555 DOI: 10.1111/anae.14649] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/19/2022]
Abstract
Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.
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Affiliation(s)
- B G Shelley
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - P J McCall
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - A Glass
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - I Orzechowska
- London School of Hygiene and Tropical Medicine, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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16
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van den Berg JW, Tabrett K, Cheong E. Paravertebral catheter analgesia for minimally invasive Ivor Lewis oesophagectomy. J Thorac Dis 2019; 11:S786-S793. [PMID: 31080659 DOI: 10.21037/jtd.2019.03.47] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO). Methods Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, high-dependency unit (HDU) stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed. Results One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve (ICN) block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively. Conclusions Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
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Affiliation(s)
- Jan Willem van den Berg
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Kate Tabrett
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Edward Cheong
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
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Womack J, Pearson JD, Walker IA, Stephens NM, Goodman BA. Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study. Anaesthesia 2019; 74:594-601. [PMID: 30687939 DOI: 10.1111/anae.14580] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2018] [Indexed: 12/12/2022]
Abstract
Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.
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Affiliation(s)
- J Womack
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J D Pearson
- James Cook University Hospital, Middlesbrough, UK
| | - I A Walker
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - N M Stephens
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - B A Goodman
- Royal Victoria Infirmary, Newcastle upon Tyne, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
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18
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Short HL, Kamalanathan K. Has analgesia changed for lung resection surgery? Anaesthesia 2018; 73:412-416. [DOI: 10.1111/anae.14188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/26/2022]
Affiliation(s)
- H. L. Short
- University Hospitals Bristol NHS Trust; Bristol UK
| | - K. Kamalanathan
- Department of Anaesthesia; University Hospitals Bristol NHS Trust; Bristol UK
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