Efficacy and safety of paravertebral block versus intercostal nerve block in thoracic surgery and breast surgery: A systematic review and meta-analysis

Comparison of postoperative analgesia by thoracoscopic-guided thoracic paravertebral block and thoracoscopic-guided intercostal nerve block in uniportal video-asssited thoracic surgery: a prospective randomized controlled trial

BACKGROUND

Thoracoscopic-guided thoracic paravertebral nerve block (TG-TPVB) and thoracoscopic-guided intercostal nerve block (TG-INB) are two postoperative analgesia technology for thoracic surgery. This study aims to compared the analgesic effect of TG-TPVB and TG-INB after uniportal video-asssited thoracic surgery (UniVATS).

METHODS

Fifty-eight patients were randomly allocated to the TG-TPVB group and the TG-INB group. The surgical time of nerve block, the visual analog scale (VAS) scores, the consumption of sufentanil and the number of patient-controlled intravenous analgesic (PCIA) presses within 24 h after surgery, the incidence of adverse reactions were compared between the two groups.

RESULTS

The VAS scores were significantly lower during rest and coughing at 2, 6, 12, and 24 h in the TG-TPVB group than in the TG-INB group (P < 0.05). The consumption of sufentanil and the number of PCIA presses within 24 h after surgery were significantly lower in the TG-TPVB group than in the TG-INB group (P < 0.001).The surgical time of nerve block was significantly shorter in the TG-TPVB group than in the TG-INB group (P < 0.001). The incidence of bleeding at the puncture point was lower in the TG-TPVB group than that in the TG-INB group (P < 0.05).

CONCLUSION

TG-TPVB demonstrated superior acute pain relieve after uniVATS, shorter surgical time and non-inferior adverse effects than TG-INB.

The Role of Multilevel Intercostal Nerve Block in Local Anesthetic Thoracoscopy

BACKGROUND

Intercostal nerve block (ICNB) has long been used in thoracic surgery. Local anesthetic thoracoscopy (LAT) is performed under conscious sedation with local anesthesia at the port insertion site. This alone, however, does not anesthetize the parietal pleura from where biopsies are taken and patients can experience pain.

OBJECTIVES

To compare LAT with multilevel ICNB versus standard care to determine whether it reduces pain during and post-LAT, its effect on analgesia use, the hospital length of stay (LOS), and related complications.

METHODS

Prospective analysis of patients undergoing LAT between January and June 2021. In the ICNB group, levobupivacaine/xylocaine is administered at the angle of the rib immediately before LAT (up to 5 rib spaces). Visual Analog Score for pain (0 to 100 mm) was measured at 1 and 2 hours post-LAT and daily including analgesia use.

RESULTS

Twenty patients (10 ICNB vs. 10 standard care group). The mean age is 68 years with 70% males. Visual Analog Score for pain in the ICNB group reduced by 55 mm at 1 and 2 hours post-LAT and 45 mm at day 1 ( P <0.05) (minimal clinically important difference >16 mm]. Median LOS was reduced by 50% in the ICNB group ( P <0.05). Paracetamol use reduced by 56% ( P <0.05).

CONCLUSION

ICNB not only significantly reduces postprocedure pain but also reduces LOS.

Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial

Background

Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients.

Aim

This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration.

Methods

We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery.

Results

Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant.

Conclusions

Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.

Simulation-Based Analysis of Trial Design in Regional Anesthesia

Background

In regional anesthesia, the efficacy of novel blocks is typically evaluated using randomized controlled trials (RCTs), the findings of which are aggregated in systematic reviews and meta-analyses. Systematic review authors frequently point out the small sample size of RCTs as limiting conclusions from this literature. We sought to determine via statistical simulation if small sample size could be an expected property of RCTs focusing on novel blocks with typical effect sizes.

Methods

We simulated the conduct of a series of RCTs comparing a novel block versus placebo on a single continuous outcome measure. Simulation analysis inputs were obtained from a systematic bibliographic search of meta-analyses. Primary outcomes were the predicted number of large trials (empirically defined as N ≥ 256) and total patient enrollment.

Results

Simulation analysis predicted that a novel block would be tested in 16 RCTs enrolling a median of 970 patients (interquartile range (IQR) across 1000 simulations: 806, 1269), with no large trials. Among possible modifications to trial design, decreasing the statistical significance threshold from p < 0.05 to p < 0.005 was most effective at increasing the total number of patients represented in the final meta-analysis, but was associated with early termination of the trial sequence due to futility in block vs. block comparisons.

Conclusion

Small sample size of regional anesthesia RCTs comparing novel block to placebo is a rational outcome of trial design. Feasibly large trials are unlikely to change conclusions regarding block vs. placebo comparisons.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction

BACKGROUND

Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy.

METHOD

Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications.

RESULT

No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates.

CONCLUSION

Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks.

TRIAL REGISTRATION

This trial is registered with Clinical Research Information Service (NCT03653988).

Analgesic comparison of erector spinae plane block with intercostal nerve block for thoracoscopic surgery: A meta-analysis of randomized controlled trials

INTRODUCTION

The analgesic efficacy of erector spinae plane block (ESPB) versus intercostal nerve block (ICNB) for thoracoscopic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the impact of ESPB versus ICNB on thoracoscopic surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane library databases through May 2023 for randomized controlled trials (RCTs) assessing the effect of ESPB versus ICNB on thoracoscopic surgery. This meta-analysis was performed using the random-effect model or fixed-effect model based on the heterogeneity.

RESULTS

Four RCTs and 203 patients are included in the meta-analysis. Overall, compared with ICNB for thoracoscopic surgery, ESPB results in significantly reduced pain scores at 48 hours (SMD [standard mean difference] = -3.49; 95% CI [confidence interval] = -6.76 to -0.21; P = .04), but demonstrated no impact on pain scores at 24 hours (SMD = -0.04; 95% CI = -1.24 to 1.16; P = .95), pain scores at 4 to 6 hours (SMD = -0.16; 95% CI = -2.02 to 1.71; P = .87), pain scores at 12 hours (SMD = -0.16; 95% CI = -2.38 to 2.05; P = .88) or analgesic consumption (SMD = 0.27; 95% CI = -0.80 to 1.35; P = .62).

CONCLUSIONS

ESPB may be comparable with ICNB for the postoperative pain control of thoracoscopic surgery.

The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: A network meta-analysis

Background

Regional anesthesia have been successfully performed for pain management in breast cancer surgery, but it is unclear which is the best regional anesthesia technique. The aim of the present network meta-analysis was to assess the analgesic efficacy and disadvantages of regional anesthesia techniques.

Methods

Multiple databases were searched for randomized controlled trials (RCTs). The association between regional anesthesia and analgesic efficacy was evaluated by Bayesian network meta-analysis.

Results

We included 100 RCTs and 6639 patients in this study. The network meta-analysis showed that paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion were associated with significantly decreased postoperative pain scores, morphine consumption and incidence of postoperative nausea and vomiting compared with no block. Regarding the incidence of chronic pain, no significance was detected between the different regional anesthesia techniques. In the cumulative ranking curve analysis, the rank of the rhomboid intercostal block was the for postoperative care unit pain scores, postoperative 24-hour morphine consumption, and incidence of postoperative nausea and vomiting.

Conclusion

Regional anesthesia techniques including, paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion, can effectively alleviate postoperative acute analgesia and reduce postoperative morphine consumption, but cannot reduce chronic pain after breast surgery. The rhomboid intercostal block might be the optimal technique for postoperative analgesia in breast cancer surgery, but the strength of the evidence was very low.

Systematic review registration

https://www.crd.york.ac.uk/prospero/(PROSPERO), identifier CRD 42020220763.

Thoracic Paravertebral Block Decreased Body Temperature in Thoracoscopic Lobectomy Patients: A Randomized Controlled Trial

Purpose

Thoracic paravertebral block (TPVB) may be highly beneficial for thoracoscopic lobectomy patients, but it may increase the risk of hypothermia. Apart from its anesthetic-reducing effects, this randomized controlled trial aimed to investigate the hypothermic effect of TPVB, and thus optimize its clinical use.

Patients and methods

Adult patients were randomly allocated to two groups: TPVB + general anesthesia (GA) group or GA group. In the TPVB+GA group, the block was performed after GA induction by an experienced but unrelated anesthesiologist. Both the lower esophageal and axillary temperature were recorded at the beginning of surgery (T₀) and every 15 min thereafter (T₁-T₈), and the end of surgery (T_p). The primary outcome was the lower esophageal temperature at T_p. The secondary outcomes included lower esophageal temperature from T₀-T₈ and axillary temperature from T₀-T_p. The total propofol, analgesics, and norepinephrine consumption and the incidence of adverse events were also recorded.

Results

Forty-eight patients were randomly allocated to the TPVB+GA (n=24) and GA (n=24) groups. The core temperature at the end of the surgery was lower in the TPVB+GA group than the GA group (35.90±0.30°C vs 36.35±0.33°C, P<0.001), with a significant difference from 45 min after the surgery began until the end of the surgery (P<0.05). In contrast, the peripheral temperature showed a significant difference at 60 min after the surgery began till the end (P<0.05). TPVB+GA exhibited excellent analgesic and sedative-sparing effects compared to GA alone (P<0.001), though it increased norepinephrine consumption due to hypotension (P<0.001).

Conclusion

Although thorough warming strategies were used, TPVB combined with GA remarkably reduced the body temperature, which is an easily neglected side effect. Further studies on the most effective precautions are needed to optimize the clinical use of TPVB.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Analgesic Efficacy of the Single Erector Spinae Plane Block with Intercostal Nerve Block Is Not Inferior to That of the Thoracic Paravertebral Block with Intercostal Nerve Block in Video-Assisted Thoracic Surgery

This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain (0–10, where 10 = worst imaginable pain) in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction (1–5, where 5 = extremely satisfied) and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups (PACU: 2.0 (1.8, 5.3) vs. 2.0 (2.0, 4.0), p = 0.970; 24 h: 2.0 (0.8, 3.0) vs. 2.0 (1.0, 3.5), p = 0.993; 48 h: 1.0 (0.0, 3.5) vs. 1.0 (0.0, 5.0), p = 0.985). The upper limit of the 95% CI for the differences (PACU: 1.428, 24 h: 1.052, 48 h: 1.176) was within the predefined noninferiority margin of 2. Total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, p = 0.767) and satisfaction scores (3.5 (3.0, 4.0) vs. 4.0 (3.0, 5.0), p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.

Comparison of the efficacy of ultrasound-guided erector spinae plane block and thoracic paravertebral block combined with intercostal nerve block for pain management in video-assisted thoracoscopic surgery: a prospective, randomized, controlled clinical trial

Background

The objective of this study was to compare analgesic efficacy of erector spinae plane block(ESPB) and thoracic paravertebral block(TPVB) combined with intercostal nerve block(ICNB) after video assisted thoracoscopic surgery(VATS).

Methods

Patients were enrolled into three groups according to analgesia technique as ICNB, TPVB + ICNB or ESPB + ICNB: respectively Group C(n = 58), Group T (n = 56) and Group E (n = 59). Patients were followed up by a trained data investigator at 2, 6, 8, 12, 24, 48 h after surgery, and the visual analog scale(VAS) at rest and coughing were recorded. The moderate and severe pain mean VAS ≥ 4 when coughing. The postoperative opioids consumption, incidence of postoperative nausea and vomiting (PONV), supplementary analgesic requirements within 48 h, length of stay in PACU, ambulation time, postoperative days in hospital and potential side effects, such as hematoma, hypotension, bradycardia, hypersomnia, uroschesis, pruritus and apnea were recorded.

Results

The incidence of moderate-to-severe pain was no significant difference between 3 groups in 24 h and 48 h (P = 0.720). There was no significant difference among the 3 groups in the resting pain intensity at 2, 6, 8, 12, 24 and 48 h after surgery(P > 0.05). In 2-way analysis of variance, the VAS when coughing in Group T were lower than that in Group C (mean difference = 0.15, 95%CI, 0.02 to 0.29; p = 0.028). While no difference was found when comparing Group E with Group C or Group T(P > 0.05). There was no difference between the three groups in the sufentanil consumption( within 24 h p = 0.472, within 48 h p = 0.158) and supplementary analgesic requirements(p = 0.910). The incidence of PONV and the length of stay in PACU, ambulation time and postoperative days in hospital were comparable in the 3 groups(P > 0.05). Two patients from Group T developed hematoma at the site of puncture.

Conclusions

The present randomized trial showed that the analgesic effect of TPVB + ICNB was superior to that of INCB after VATS, the analgesic effect of ESPB was equivalent to that of TPVB and ICNB.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2100049578. Registered 04 Aug 2020 Retrospectively registered.

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

Background and Objective

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

Methods

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

Key Content and Findings

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

Conclusions

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

Intramuscular stimulation as a new modality to control postthoracotomy pain: A randomized clinical trial

OBJECTIVE

Postoperative pain after thoracic surgery primarily hinders patients' mobility, decreasing the quality of life. To date, various modalities have been suggested to improve postoperative pain. However, pain alleviation still remains a challenge, resulting in continued reliance on opioids. To tackle this problem, this study introduces a needle electrical twitch obtaining intramuscular stimulation (NETOIMS) as a new effective treatment modality for postoperative pain after thoracoscopic surgery.

METHODS

This randomized clinical trial analyzed patients receiving video-assisted thoracoscopic surgery pulmonary resection between March 2018 and June 2020 at a single institution. A total of 77 patients (NETOIMS, 36; intravenous patient-controlled analgesia, 41) were included. NETOIMS was conducted on the retracted intercostal muscle immediately following the main procedure, just before skin closure. Postoperative pain (numeric rating scale) and oral opioid morphine milligram equivalent were assessed daily until postoperative day 5.

RESULTS

The NETOIMS group had a significantly lower numeric rating scale score on postoperative day (POD) 0 (P < .01), POD2 (P < .001), POD4 (P < .001), and POD5 (P = .01). The predicted time to complete pain resolution was 6.15 days in the NETOIMS group and 20.7 days in the intravenous patient-controlled analgesia group. The oral opioid morphine milligram equivalent was significantly lower in the NETOIMS group on POD0 (P < .001) and POD1 (P < .001).

CONCLUSIONS

NETOIMS appears to be an effective modality in alleviating postoperative pain after thoracoscopic surgery, thereby reducing the reliance on opioid use.

Safety of Ultrasound-Guided Transversus Thoracis Plane Block in Pediatric Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

Ultrasound-guided fascial plane blocks are associated with good postoperative analgesia after pediatric cardiac surgery, with improved safety profile. To the best of the authors' knowledge, this study was the first with the primary aim of assessing the safety profile of transversus thoracis plane (TTP) block in pediatric patients who underwent open cardiac surgery.

DESIGN

This was a retrospective cohort study.

SETTING

University hospital.

PARTICIPANTS

The authors reviewed the medical records of patients aged 6 months to 18 years who underwent open cardiac surgery via median sternotomy incision and who received bilateral transversus thoracis muscle plane block from January 2019 to August 2021 in their institutional hospital.

INTERVENTIONS

Patients received ultrasound-guided bilateral TTP block.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was the incidence of mechanical complications (subcutaneous hematoma, internal mammary vessels injury, pleural puncture, pneumothorax, pericardial puncture, injury of the heart, and hemopericardium). The secondary outcomes were the incidences of hypoxia, hypotension, and bradycardia after local anesthetic injection, allergy to local anesthetic, local infection, and postoperative neuropathic pain at the sternal area. A total of 236 patients who received bilateral TTP block were screened for eligibility, of whom 38 patients were excluded. Left-sided pleural and pericardial puncture occurred in 1 patient (0.5%) without clinical evidence of pneumothorax, hemopericardium, or traumatic cardiac injury as directly seen after sternotomy. One patient (0.5%) developed a self-limiting small subcutaneous hematoma. Pneumothorax, injury of internal mammary vessels, cardiac injury, and hemopericardium were not observed in any patient. No patient developed an allergy to local anesthetic, hypoxia, bradycardia, or hypotension after local anesthetic injection. Poststernotomy neuropathic pain was not recorded in any patient.

CONCLUSION

The above complications were noted in patients who received TTP block, and further prospective studies with more patients are required to comment on its safety.

The postoperative analgesic effect of intercostal nerve block and intravenous patient-controlled analgesia on patients undergoing lung cancer surgery

OBJECTIVE

This research investigated the combined analgesic effects of intercostal nerve block and intravenous patient-controlled analgesia (IV-PCA) on patients after lung cancer surgery.

METHODS

95 patients with thoracoscopic radical resection of lung cancer from April 2017 to July 2020 were enrolled as the research objects, and randomly divided into observation-group (n=50) and control-group (n=45) by random number table. The control-group received intravenous patient-controlled analgesia (IV-PCA), and the observation group received combinative treatment of intercostal nerve block and IV-PCA. The changes of VAS scores and Ramsay sedation scores postoperatively, the satisfaction with analgesia of patients, the number of IV-PCA pump compressions and the incidence of postoperative anaesthetic-related adverse reactions were compared between the two groups.

RESULTS

The VAS score of the observation-group was markedly lower than that of the control-group 2 h, 4 h, 8 h, 12 h and 24 h after surgery (P<0.05). There was no statistically significant difference in Ramsay sedation scores between the two groups 2 h, 4 h, 8 h, 12 h and 24 h after surgery (P>0.05). The satisfaction score of analgesia and the times of IV-PCA pump compressions of the observation group were obviously less than those of the control group (P<0.05). The incidences of nausea and emesia, bradycardia and somnolence between the two groups of objects were statistically insignificant (P>0.05).

CONCLUSION

The combinative treatment of intercostal nerve block and IV-PCA is safe and have obviously postoperative analgesic effect on patients undergoing thoracoscopic resection of lung cancer.

AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria. PERSPECTIVE ITEM: This article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).

Continuous erector spinae plane block versus intercostal nerve block in patients undergoing video-assisted thoracoscopic surgery: a pilot randomized controlled trial

Background

The optimal analgesia method in video-assisted thoracoscopic surgery (VATS) remains controversial. Intercostal nerve blockade (ICNB) is limited by its duration of action. The erector spinae plane (ESP) block has the potential to provide satisfactory analgesia for VATS; however, the effectiveness of continuous ESP versus surgeon-performed ICNB has not been investigated. The objectives of this study were to establish feasibility of patient recruitment and follow-up before undertaking a fully powered randomized controlled trial (RCT); and, secondarily, to compare opioid usage, pain control, and sensory blockade.

Methods

This feasibility RCT was undertaken at St Joseph’s Hospital, Hamilton, Ontario, Canada, and included 24 patients (>18 years) having elective VATS with at least one overnight stay. Exclusion criteria were patient refusal, body mass index >40 kg/m², contraindications to neuraxial analgesia techniques as per the American Society of Regional Anesthesia and Pain guidelines, known allergy to local anesthetics, language or comprehension barriers, procedures with a higher chance of open surgery, and regular opioid use for ≥3 months preoperatively. Patients underwent either continuous ESP (n=12) or surgeon-performed ICNB (n=12). All patients received routine intraoperative anesthesia care and multimodal analgesia. Feasibility criteria were recruitment rate of two patients/week and full follow-up in all patients in-hospital. We compared opioid consumption, postoperative pain scores (0–10 numerical rating scale), adverse events, patient satisfaction, and distribution of sensory blockade as clinical outcomes (secondary).

Results

Feasibility of primary outcomes was successfully demonstrated. Five patients had an epidural in anticipation of open surgery. Mean opioid consumption as equivalent morphine units was less in the ESP group over the first 24 h (mean difference, 1.63 [95% CI –1.20 to 4.45]) and 48 h (mean difference, 2.34 [95% CI –1.93 to 6.61]). There were no differences in adverse effects.

Conclusions

A fully powered RCT is feasible with modifications. Our results also suggest that continuous ESP is safe and can decrease opioid needs. However, it is important to consider procedures to improve compliance to protocol and adherence to assigned interventions.

Trial registration

Clinicaltrials.gov identifier: NCT03176667. Registered June 5, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00801-7.