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

Ultrasound-guided proximal intercostal block for cervicothoracic sympathetic blockade: a proof-of-concept cadaveric study

BACKGROUND

The ultrasound-guided proximal intercostal block (PICB) is a regional anesthesia technique used for thoracic surgeries and sympathetic blockade in refractory ventricular arrhythmias. However, the anatomical extent of injectate spread to specific targets when PICB is performed at the upper thoracic levels has not been studied comprehensively. This cadaveric study aims to evaluate the spread of moderate-volume injections at the upper thoracic level, focusing on the cervicothoracic sympathetic chain and proposing possible mechanisms of the PICB effects in patients with refractory ventricular arrhythmias.

METHODS

Seven PICBs were performed in five soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the proximal segment of the first intercostal space (ICS-1). Fluoroscopy and dissection were performed to examine the injectate spread.

RESULTS

In the six successful PICBs, both fluoroscopy and dissection revealed injectate spread within the ipsilateral ICS-1 (T1-2) with direct anteromedial fascial spread and consistent coverage of the upper thoracic and/or inferior cervical sympathetic chain in all specimens. Injectate spread to the adjacent paravertebral space was observed in 67% of specimens by fluoroscopy (2-6 segments) and 83% by dissection (1-4 segments). Limited spread to the epidural space was observed in 33% of specimens by fluoroscopy (2-5 segments) and 67% by dissection (2-6 segments).

CONCLUSIONS

Ultrasound-guided PICB at PICS-1 produced consistent injectate spread to the adjacent cervicothoracic sympathetic chain in all specimens. The inconsistent paravertebral and epidural spread suggests that direct interfascial spread to the sympathetic chain is likely to be the main mechanism of sympathetic block for refractory ventricular arrhythmia.

Impact of erector spinae plane block on postoperative recovery quality in spinal surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative recovery quality (QoR) is a key indicator for evaluating the restoration of patients' functional status and overall quality of life post-surgery. Moreover, it is an essential metric for assessing the effectiveness of patient-centered anesthetic care. The erector spinae plane block (ESPB) is an innovative regional analgesia technique that has garnered considerable attention for its potential use in spinal surgeries. Although some studies suggest that ESPB may improve QoR, the results remain contentious and inconclusive. This meta-analysis aims to systematically evaluate the effects of ESPB on the subjective quality of recovery in patients undergoing spinal surgery, with the objective of providing more robust evidence to support its clinical application.

METHODS

On September 23, 2024, we conducted a systematic search across the PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases to identify randomized controlled trials (RCTs) relevant to ESPB. The studies evaluated the effect of ESPB compared to conventional analgesia on QoR in patients undergoing spinal surgery. The primary outcome measure of this study was postoperative the 24-hour QoR score, as assessed by validated QoR scales (QoR-15 and QoR-40). Secondary outcome measures included the QoR score at 48 h postoperatively, the incidence of postoperative nausea and vomiting (PONV), and the consumption of opioid analgesics in the first 24 h postoperatively.

RESULTS

This meta-analysis included eight studies, with a total of 578 patients. The results demonstrated that, compared to the control group, the ESPB group showed improvements in overall QoR-15 scores (mean difference [MD]: 9.76; 95% confidence interval [CI]: 8.39-11.13; P < 0.01; I² = 0%) and QoR-40 scores (MD: 11.8; 95% CI: 6.35-17.25; P = 0.000), indicating clinically meaningful benefits. Additionally, although the QoR-15 (MD: 3.69; 95% CI: 2.60-4.78; P < 0.01; I² = 2.31%) and QoR-40 scores (MD: 5.70; 95% CI: 0.11-11.29; P = 0.046) at 48 h postoperatively demonstrated a statistical improvement, the magnitude of this change did not reach the threshold for clinical relevance. Moreover, ESPB reduced the incidence of PONV (log odds ratio [log(OR)]: -0.63; 95% CI: -1.11--0.14; P = 0.01; I² = 24.62%) and the 24-hour postoperative opioid consumption(SMD: -0.56; 95% CI: -0.83--0.29; P < 0.01; I² = 0%).

CONCLUSION

ESPB was associated with an improvement in the quality of recovery within the first 24 h postoperatively in patients undergoing spinal surgery, along with a reduction in the incidence of PONV and opioid consumption. However, while the improvement in recovery quality at 48 h postoperatively was statistically significant, its clinical significance was limited. These findings suggest that ESPB may be a beneficial adjunct for enhancing postoperative recovery, but further studies are needed to validate its long-term impact and clinical applicability.

Comparing postoperative pain control after modified radical mastectomy: a pilot study of ultra-sound guided erector spinae plane block vs intraoperative tramadol administration in oncology patients

PURPOSE

This study aimed to compare the effectiveness of ultrasound-guided erector spinae plane block (ESPB) with intraoperative Tramadol for postoperative pain management after modified radical mastectomy (MRM). The primary focus was on pain intensity within the first 24 h, while secondary outcomes included the need for rescue analgesia, nausea, vomiting, and patient satisfaction.

METHODS

In this retrospective cohort study, 49 female patients (ASA I-II, aged 30-80) who underwent MRM from 2021 to 2023 were analyzed. Patients were divided into two groups: one receiving ESPB preoperatively (25 patients) and the other receiving Tramadol during surgery (24 patients). Pain levels were measured using the Numeric Rating Scale (NRS), and data on rescue analgesia, vital signs, nausea, vomiting, and patient satisfaction were collected.

RESULTS

The ESPB group reported significantly lower pain levels during the first six postoperative hours (NRS scores of 0 vs. 3; p = 0.005), along with a reduced need for rescue analgesia (88% vs. 54.2%; p = 0.010). Moreover, patient satisfaction was higher in the ESPB group (64% vs. 37.5%; p = 0.03). The intraoperative heart rate was also lower in the ESPB group (65.3 vs. 72.0 bpm; p = 0.030). No significant differences were found in nausea, vomiting, or length of hospital stay.

CONCLUSION

Overall, ESPB demonstrates superior early postoperative pain control and improved patient satisfaction compared to Tramadol. Further studies are needed to confirm these findings.

Evolution of pain management in lung cancer surgery: from opioid-based to personalized analgesia

Pain management in lung cancer resection has undergone a paradigm shift from opioid-centric approaches to multimodal analgesia, and more recently, personalized strategies that integrate the principles of precision medicine. Historically, opioids have been the mainstay of perioperative analgesia. However, concerns regarding opioid-related adverse effects, including respiratory depression, immunosuppression, and potential oncologic implications, have driven the adoption of opioid-sparing techniques. Current strategies emphasize multimodal analgesia, combining nonsteroidal antiinflammatory drugs, acetaminophen, regional anesthesia, and adjunctive agents to enhance pain control while minimizing opioid exposure. However, growing evidence suggests that perioperative analgesics may differentially influence tumor biology depending on molecular and genetic factors, necessitating a more tailored approach. This has led to the emergence of precision oncoanesthesia, which aims to integrate tumor-specific genomic insights into perioperative pain management. Although promising, the clinical implementation of precision oncoanesthesia remains in its early stages, with key challenges including the lack of large-scale prospective studies, limited real- time genomic profiling in anesthetic planning, and variability in patient responses to analgesics. Future research should focus on identifying biomarkers that predict individual responses to perioperative analgesia and establishing evidence-based guidelines for precision- based pain management. By evolving beyond traditional opioid reliance and standard analgesic protocols, perioperative pain management in lung cancer surgery can align with emerging precision medicine approaches, ensuring effective pain control and optimized oncologic outcomes.

Regional Anesthesia with Spontaneous Breathing for Trans-Axillary Surgery in Thoracic Outlet Syndrome: A Retrospective Comparative Study

Background: Thoracic outlet syndrome (TOS) is an uncommon condition defined by the compression of neurovascular structures within the thoracic outlet. When conservative management strategies fail to alleviate symptoms, surgical decompression becomes necessary. The purpose of this study is to evaluate and compare the efficacy and safety of regional anesthesia (RA) using spontaneous breathing in contrast to general anesthesia (GA) for patients undergoing surgical intervention for TOS. Methods: We conducted a retrospective comparative study involving 68 patients who underwent trans-axillary first rib resection for TOS. The patient cohort was divided into two groups: 29 patients in the GA group and 39 patients in the RA group. The RA technique employed consisted of supraclavicular brachial plexus (SBP) and pectoral nerve (PECS II) blocks, accompanied by deep sedation. Key outcome measures such as pain scores, opioid consumption, and various perioperative parameters were systematically analyzed. Results: Postoperative pain levels recorded in the recovery room were significantly lower in the RA group, with a median numerical rating scale (NRS) score of zero compared to two in the GA group (p = 0.0443). Additionally, both intraoperative and postoperative opioid consumption showed a marked reduction in the RA group, with p-values of less than 0.001 and 0.0418, respectively. The RA approach was associated with shorter surgical durations (p = 0.0008), a decrease in the incidence of postoperative nausea and vomiting (PONV) (p = 0.0312), and a lower occurrence of intraoperative lung injuries (p < 0.0001). Furthermore, the length of hospital stay was significantly reduced for patients in the RA group. Conclusions: Although both groups reported low postoperative pain scores, the regional anesthesia approach exhibited distinct advantages in terms of opioid consumption, surgical duration, and overall perioperative outcomes. The utilization of SBP and PECS II blocks facilitated surgical procedures and mitigated complications, thereby positively influencing the postoperative recovery trajectory. Future prospective studies are essential to validate these findings further and to investigate long-term outcomes associated with the use of regional anesthesia in TOS surgery.

Effect of Perioperative Factors on Short-Term Outcomes in Patients with Non-Small Cell Lung Cancer Over 60 Years of Age

Background

People in China have gradually entered old age society, and the number of lung cancer cases is expected to increase annually among the elderly. This study aimed to retrospectively explore the association between perioperative factors and short-term outcomes in elderly patients with non-small cell lung cancer (NSCLC).

Methods

A total of 490 elderly patients with NSCLC between January 1, 2003, and December 31, 2009, were selected. Perioperative factors were grouped and analyzed according to postoperative complications (PPCs) and length of hospital stay. A logistic regression analysis model was used to screen for the independent predictors of patient prognosis. The primary endpoint was postoperative complications and the secondary endpoint was postoperative hospital stay.

Results

Of all patients, 344 (70.2%) developed postoperative complications, and the average length of stay after surgery was 14.0±5.6 days. Perioperative fentanyl equivalents>28.7μg/kg and duration of surgery>4.4h were associated were associated with an increased risk of postoperative complications (P < 0.05); intraoperative blood loss (IBL) > 200 mL was associated with extended hospital stay (P < 0.05).

Conclusion

This study suggested that Perioperative factors may affect the short-term prognosis of elderly NSCLC patients after surgery. Perioperative fentanyl equivalents>28.7μg/kg, surgery duration, and IBL may be independent predictors of short-term outcomes in elderly patients.

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

PURPOSE OF REVIEW

Thoracic surgery is evolving, necessitating an adaptation for perioperative anesthesia and analgesia. This review highlights the recent advancements in perioperative (multimodal) analgesia for minimally invasive thoracic surgery.

RECENT FINDINGS

Continuous advancements in surgical techniques have led to a reduction in surgical trauma. However, managing perioperative pain remains a major challenge, impeding postoperative recovery. The traditional neuraxial technique is now deemed outdated for minimally invasive thoracic surgery. Instead, newer regional techniques have emerged, and traditional approaches have undergone (re-)evaluation by experts and professional societies to establish guidelines and practices. Assessing the quality of recovery, evenafter discharge, has become a crucial factor in evaluating the effectiveness of these strategies, aiding clinicians in making informed decisions to improve perioperative care.

SUMMARY

In the realm of minimally invasive thoracic surgery, perioperative analgesia is typically administered through systemic and regional techniques. Nevertheless, collaboration between anesthesiologists and surgeons, utilizing surgically placed nerve blocks and an active chest drain management, has the potential to significantly improve overall patient care.

Analgesic efficacy and safety of erector spinae versus serratus anterior plane block in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) are regional anesthesia techniques that have shown favorable results in pain management following thoracic surgeries; however, their relative superiority is unclear. This review (PROSPERO: CRD42023443018) aims to compare the analgesic efficacy of ESPB and SAPB in patients undergoing thoracic surgeries through the pooled analysis of co-primary outcomes: postoperative oral-morphine-equivalent (mg) consumption in 24 h and pain scores (static) at 24 h.

METHODS

A literature search was conducted across PubMed, Cochrane Library, and Google Scholar to identify randomized controlled trials (RCTs) from inception to May 2023, comparing ESPB and SAPB in thoracic surgeries. Statistical pooling was done using Review Manager 5.4.1. Bias assessment employed the Cochrane Collaboration Risk-of-Bias 2.0 tool. The strength of evidence was assessed using the guidelines from the GRADE working group.

RESULTS

Nine RCTs (485 patients) were included in the study. Postoperative pain scores (static) at 24 h (mean difference (MD) =  - 0.31 [- 0.57, 0.05], p = 0.02) and postoperative oral-morphine-equivalent (mg) consumption in 24 h (MD =  - 19.73 [- 25.65, - 13.80], p < 0.00001) were significantly lower in the ESBP group. However, the MDs did not exceed the set threshold for clinical importance. No significant differences were observed in the opioid-related adverse effects and block-related complications.

CONCLUSION

Our statistically significant results imply that ESPB has superior analgesic efficacy compared to SAPB; however, this difference is clinically unimportant. The safety profile of the two blocks is comparable; hence, current evidence cannot define the relative superiority of one block over the other. Our findings warrant further research with standardized methodologies and a longer duration of analgesic efficacy assessment to yield robust evidence for better clinical applications.