Opioid Free Anesthesia in Thoracic Surgery: A Systematic Review and Meta Analysis

Predicting postoperative complications after pneumonectomy using machine learning: a 10-year study

BACKGROUND

Reducing postoperative cardiovascular and neurological complications (PCNC) during thoracic surgery is the key to improving postoperative survival.

OBJECTIVE

We aimed to investigate independent predictors of PCNC, develop machine learning models, and construct a predictive nomogram for PCNC in patients undergoing thoracic surgery for lung cancer.

METHODS

This study used data from a previous retrospective study of 16,368 patients with lung cancer (training set: 11,458; validation set: 4,910) with American Standards Association physical statuses I-IV who underwent surgery. Postoperative information was collected from electronic medical records to help build models based on cause-and-effect and statistical data, potentially revealing hidden dependencies between factors and diseases in a big data environment. The optimal model was analyzed and filtered using multiple machine-learning models (Logistic regression, eXtreme Gradient Boosting, Random forest, Light Gradient Boosting Machine and Naïve Bayes). A predictive nomogram was built and receiver operating characteristics were used to assess the validity of the model. The discriminative power and clinical validity were assessed using calibration and decision-making curve analyses.

RESULTS

Multivariate logistic regression analysis revealed that age, surgery duration, intraoperative intercostal nerve block, postoperative patient-controlled analgesia, bronchial blocker use and sufentanil use were independent predictors of PCNC. Random forest was identified as the optimal model with an area under the curve of 0.898 in the training set and 0.752 in the validation set, confirming the excellent prediction accuracy of the nomogram. All the net benefits of the five machine-learning models in the training and validation sets demonstrated excellent clinical applicability, and the calibration curves showed good agreement between the predicted and observed risks.

CONCLUSION

The combination of machine-learning models and nomograms may contribute to the early prediction and reduction in the incidence of PCNC.

Minimum Effective Concentration of Ropivacaine for Ultrasound-Guided RISS Block in VATS: A Biased Coin Design Approach

Background

Postoperative pain management is essential after video-assisted thoracoscopic surgery (VATS). The rhomboid intercostal and sub-serratus (RISS) block is effective in providing analgesia. This study aims to determine the minimum effective concentration (MEC) of ropivacaine for ultrasound-guided RISS block in patients undergoing VATS, thereby optimizing the analgesia protocol and enhancing its clinical significance.

Methods

The biased coin design sequential method and isotonic regression were used. The ropivacaine initial concentration was 0.25% with a gradient of 0.025%. If the previous patient had a negative block, the concentration for the next patient would increase by 0.025%. If positive, the concentration would be adjusted based on biased coin randomization: an 11% chance of reducing it by 0.025% and an 89% chance of keeping it unchanged. MEC90 was calculated using isotonic regression with 95% confidence intervals (CI).

Results

A total of 49 patients were included in the analysis. The MEC90 of 40mL ropivacaine for RISS block in VATS was 0.220% (95% CI, 0.198 to 0.260%), the MEC95 was 0.248% (95% CI, 0.223 to 0.338%) and the MEC99 was 0.270% (95% CI, 0.261 to 0.351%). There was a negative correlation between ropivacaine concentration and VASpain at 0h, 0.5h, and 6h after surgery and the time of initial analgesia (r = -0.396, -0.594, -0.309, 0.363; P = 0.005, 0.001, 0.031, 0.01). No significant correlation was observed between the VASpain at 12h and 24h after surgery and analgesia consumption (r = -0.184, -0.165; P = 0.205, 0.256).

Conclusion

The MEC90 of 40 mL ropivacaine for RISS block was 0.220%. While the MEC95 was 0.248% and the MEC99 was 0.270%.

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.

Is a Perioperative Opioid-Sparing Anesthesia-Analgesia Strategy Feasible in Open Thoracotomies? Findings from a Retrospective Matched Cohort Study

Background/Objectives: To assess the feasibility and effectiveness of a perioperative opioid-sparing anesthesia-analgesia (OSA-A) technique without regional nerve blocks compared to standard opioid-based technique (OBA-A) in open thoracotomies. Methods: This retrospective, matched cohort study was conducted at a university hospital from September 2019 to February 2021, including adult patients undergoing open thoracotomy for lung or pleura pathology. Sixty patients in the OSA-A group were matched with 40 in the OBA-A group. Outcomes included postoperative pain scores on days 0, 1, and 2; 24-h postoperative morphine consumption; PACU and hospital length of stay; time to bowel movement; and rates of nausea and vomiting. Results: Of 125 eligible patients, 100 had complete records (60 OSA-A, 40 OBA-A). Demographics were similar, but ASA status scores were higher in the OBA-A group. The OSA-A group reported significantly lower pain levels at rest, during cough, and on movement on the first two postoperative days, shorter PACU stay, and required fewer opioids. They also had better gastrointestinal motility (p < 0.0001) and lower rates of nausea and vomiting on postoperative days 1 and 2. A follow-up study with 68 patients (46 OSA-A, 22 OBA-A) assessing chronic pain prevalence found no significant differences between the groups. Conclusions: OSA-A without regional nerve blocks for open thoracotomies is feasible and safe, improving postoperative pain management, reducing opioid consumption, shortening PACU stay, and enhancing early gastrointestinal recovery compared to OBA-A.

Impact of Dexmedetomidine-Based Opioid-Sparing Anesthesia on Opioid Use After Minimally Invasive Repair of Pectus Excavatum: A Prospective Randomized Controlled Trial

Background: Opioid-sparing anesthesia (OSA) using dexmedetomidine has gained attention as an alternative to opioid-based anesthesia (OBA) due to its potential to reduce opioid consumption and the associated side effects. This study aimed to investigate the effect of dexmedetomidine-based OSA on postoperative pain intensity, opioid consumption, and recovery outcomes in patients undergoing a minimally invasive repair of pectus excavatum. Methods: Eighty-four patients undergoing a minimally invasive repair of pectus excavatum were randomized to either the OSA group, receiving dexmedetomidine, or the OBA group, receiving remifentanil. The primary outcome was the total amount of analgesics administered within 24 h postoperatively. The secondary outcomes included pain intensity and analgesic consumption over 48 h, recovery outcomes, intraoperative hemodynamics, and opioid-related complications. Results: The OFA group reported a significantly reduced total morphine-equivalent dose within 24 h (55.4 ± 31.1 mg vs. 80.2 ± 26.7 mg, p < 0.001) and lower VAS scores at 24 h (3.9 ± 1.5 vs. 5.4 ± 2.1, p < 0.001). Pain intensity was lower, and analgesic consumption was reduced in the OSA group 1-6, 6-24, and 24-48 h after surgery. Recovery times and intraoperative hemodynamics were comparable between the groups, with no significant differences in opioid-related complications. Conclusions: Dexmedetomidine-based OSA effectively reduces postoperative pain and opioid use without compromising recovery or hemodynamic stability. These findings support its use as a viable alternative to OBA, particularly in the minimally invasive repair of the pectus excavatum.

Surgeons' knowledge regarding perioperative pain management in patients with opioid use disorder: a survey among 260 members of the American College of Surgeons

BACKGROUND

Patients with opioid use disorder (OUD) are increasing, challenging surgeons to adjust post-operative pain management guidelines. A literature review identified limited information on how to best care for these patients. The purpose of this study was to determine surgical perioperative management of OUD, challenges, and support needed for optimal care.

METHODS

This study utilized an anonymous voluntary survey that was distributed to members of the American College of Surgeons through the association's electronic weekly newsletter. The survey was advertised weekly for three consecutive weeks. The survey included questions regarding surgeons' management of perioperative pain in patients with opioid use disorder and perceived barriers in treatment.

RESULTS

A total of 260 surgeons responded representing all specialties except ophthalmology. General surgery (66.5%) and plastic and reconstructive surgery (7.5%) represented the majority of responders. Ninety-five percent of surgeons reported treating a patient who used opioids in the past month and 86% encountered a patient with OUD. Nearly half (46%) reported being uncomfortable managing postoperative pain in patients with OUD. Most (67%) were not aware of any guidelines or standards pertaining to perioperative management of patients with OUD. While consultation was sought by 86% of surgeons, analyses identified lack of timely response and a lack of care coordination among specialists. Lack of knowledge and fear of harm (contributing further to addiction) were the most common themes.

CONCLUSION

Nearly half of surgeons report discomfort caring for patients with OUD with the vast majority involving a consulting service to assist with their care. Most surgeons believe that it would be helpful to have guidelines regarding the care of these patients. This provides an opportunity for increased education and training on the perioperative management of patients with OUD and further collaboration with addiction medicine, psychiatry and pain management colleagues.

The Year in Thoracic Anesthesia: Selected Highlights from 2022

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy

BACKGROUND

The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS).

METHODS

Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery.

RESULTS

A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups.

CONCLUSIONS

When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

Esketamine opioid-free intravenous anesthesia versus opioid intravenous anesthesia in spontaneous ventilation video-assisted thoracic surgery: a randomized controlled trial

Background

Opioid-free anesthesia (OFA) provides adequate analgesia and can reduce postoperative opioid consumption, but its efficacy in spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has not been demonstrated. We aimed to investigate the hypothesis that OFA could provide the same perioperative pain control as opioid anesthesia (OA), maintain safe and stable respiration and hemodynamics during surgery, and improve postoperative recovery.

Methods

Sixty eligible patients (OFA group: n=30; OA group: n=30) treated between September 15, 2022, and December 15, 2022, at The First Hospital of Guangzhou Medical University were included. They were randomized to receive standard balanced OFA with esketamine or OA with remifentanil combined with sufentanil. The primary outcome was the pain numeric rating score (NRS) at postoperative 24 h, and the secondary outcomes were intraoperative respiratory and hemodynamic data, opioid consumption, vasoactive drug dosage, and recovery in the post-anesthesia care unit and ward.

Results

There was no significant difference in the postoperative pain scores and recovery quality between the two groups. The OFA group had a significantly lower dose of phenylephrine (P=0.001) and a lower incidence of hypotension (P=0.004) during surgery. The OFA group resumed spontaneous respiration faster (P<0.001) and had a higher quality of lung collapse (P=0.02). However, the total doses of propofol and dexmetomidine were higher (P=0.03 and P=0.02), and the time to consciousness was longer (P=0.039) in the OFA group.

Conclusions

OFA provides the same level of postoperative pain control as OA, but it is more advantageous in maintaining circulatory and respiratory stability and improving the quality of pulmonary collapse in SV-VATS.