Intraoperative multiple intercostal nerve blocks exert anesthetic-sparing effect: A retrospective study on the effect-site concentration of propofol infusion in nonintubated thoracoscopic surgery

Efficacy of intraoperative thoracoscopic intercostal nerve blocks in nonintubated and intubated video-assisted thoracic surgery: A randomized study

BACKGROUND

The efficacy of thoracoscopic intercostal nerve blocks (TINBs) for noxious stimulation from video-assisted thoracic surgery (VATS) remains unclear. The efficacy of TINBs may also be different between nonintubated VATS (NIVATS) and intubated VATS (IVATS). We aim to compare the efficacy of TINBs on analgesia and sedation for NIVATS and IVATs intraoperatively.

METHODS

Sixty patients randomized to the NIVATS or IVATS group (30 each) received target-controlled propofol and remifentanil infusions, with bispectral index (BIS) maintained at 40-60, and multilevel (T3-T8) TINBs before surgical manipulations. Intraoperative monitoring data, including pulse oximetry, mean arterial pressure (MAP), heart rate, BIS, density spectral arrays (DSAs), and propofol and remifentanil effect-site concentration (Ce) at different time points. A two way ANOVA with post hoc analysis was applied to analyze the differences and interactions of groups and time points.

RESULTS

In both groups, DSA monitoring revealed burst suppression and α dropout immediately after the TINBs. The Ce of the propofol infusion had to be reduced within 5 min post-TINBs in both NIVATS (p < 0.001) and IVATS (p = 0.252) groups. The Ce of remifentanil infusion was significantly reduced after TINBs in both groups (p < 0.001), and was significantly lower in NIVATS (p < 0.001) without group interactions.

CONCLUSION

The surgeon-performed intraoperative multilevel TINBs allow reduced anesthetic and analgesic requirement for VATS. With lower requirement of remifentanil infusion, NIVATS presents a significantly higher risk of hypotension after TINBs. DSA is beneficial for providing real-time data that facilitate the preemptive management, especially for NIVATS.

Comparisons on the intraoperative desaturation and postoperative outcomes in non-intubated video-assisted thoracic surgery with supraglottic airway devices or high-flow nasal oxygen: A retrospective study

BACKGROUND

Few studies have compared intraoperative oxygenation and perioperative outcomes between non-intubated video-assisted thoracic surgery (NIVATS) with supraglottic airway devices (SADs) and NIVATS with high flow nasal oxygenation (HFNO). The aim of this retrospective study was to compare the intraoperative desaturation rate and postoperative outcomes between NIVATS with SADs and NIVATS with HFNO.

METHODS

Data regarding NIVATS performed for lung cancer from January 2020 to December 2021 were collected. Intraoperative anesthetic results, post-anesthetic adverse effects, and surgical outcomes for patients who received SAD or HFNO were analyzed using propensity score-matched and unmatched analysis.

RESULTS

In total, 199 patients with i-gel™ and 95 patients with HFNO were included. Significantly more female patients (91.6 vs. 82.4%, p = 0.0378) and fewer wedge resections (78.9 vs. 85.4%, p = 0.0258) were observed in the HFNO group. Among 250 patients who underwent NIVATS wedge resections under total intravenous anesthesia, those who received HFNO had a significantly higher desaturation event rate (19.8% vs. 7.9% in i-gel™ group; p = 0.0063), lower nadir SPO₂ (94.0% vs. 96.1% in i-gel™ group; p = 0.0012), and longer hospitalization (4.0 ± 0.8 vs. 3.6 ± 0.6 in i-gel™ group; p < 0.0001). However, propensity score matching analysis revealed no significant between-group difference in the desaturation rate. A log-rank test revealed that smoking (p = 0.0005) and HFNO (p = 0.0074) were associated with intraoperative desaturation.

CONCLUSION

The rate of SAD use in NIVATS was twice the rate of HFNO use, especially for wedge resections. There is uncertain airway patency and limited flow through HFNO during one-lung ventilation, whereas SADs like i-gel™ presented a significantly less intraoperative desaturation rate over time and similar postoperative outcomes.

Intercostal nerve block is effective in open biopsies of the anterior mediastinal region: Case report and review

INTRODUCTION AND IMPORTANCE

Anterior mediastinal masses are rare conditions that can become symptomatic through compression of the airways and vascular structures. Fatal or severe complications can occur during anesthesia and surgery. With this review we aim to describe the state of the art in peri-anesthetic management of mediastinal tumors, which we illustrate with a clinical case.

PRESENTATION OF CASE

We report a case of a young female patient suffering from a large anterior mediastinal mass that underwent an open biopsy after intercostal nerve blocks (INB) in six consecutive right intercostal spaces (2nd to 7th). A right anterior mediastinotomy was performed and an excellent analgesic effect was achieved. The patient was awake and did not experience significant pain or cough, having received paracetamol 1 g and returned home later in the day. The diagnosis of non-Hodgkin's lymphoma was later confirmed.

DISCUSSION

Our review showed that anesthesia for mediastinal masses' resection or open biopsy is rare and prone to severe complications. Such complications are more important in children, patients in supine position, under general anesthesia and already symptomatic prior to the procedure. INB presents some advantages against paravertebral block (PVB) and thoracic epidural anesthesia (TEA), is easier to reproduce and has a shorter learning curve. Airway stenting with a rigid bronchoscope can be an alternative.

CONCLUSION

Multilevel medial axillary line INBs are safer and easier to reproduce than PVB, have less hemodynamic repercussion than TEA and can, therefore, be preferable for open anterior mediastinal biopsies or small masses resection.

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

OBJECTIVE

To evaluate the analgesic efficacy and safety of paravertebral block (PVB) versus intercostal nerve block (INB) in thoracic surgery and breast surgery.

METHODS

The PubMed, Web of Science, Embase and the Cochrane Library were searched up to February 2020 for all available randomized controlled trials (RCTs) that evaluated the analgesic efficacy and safety of PVB compared with INB after thoracic surgery and breast surgery. For binary variables, odds ratio (OR) and 95% confidence interval (CI) was used. For continuous variables, weighted mean difference (WMD) and 95% confidence interval (CI) were used. RevMan5. 3 and Stata/MP 14.0 were used for performing the meta-analysis.

RESULTS

A total of 9 trials including 440 patients (PVB block:222 patients; INB: 218 patients) met the inclusion criteria. In the primary outcome, there was no significant differences between the two groups with respect to postoperative visual analogue scale (VAS) at 1h (Std. MD = -0. 20; 95% CI = -1. 11to 0. 71; P = 0. 66), 2h (Std. MD = -0. 71; 95% CI = -2. 32to 0. 91; P = 0. 39), 24h (Std. MD = -0. 36; 95% CI = -0. 73 to -0. 00; P = 0. 05) and 48h (Std. MD = -0. 04; 95% CI = -0. 20 to 0. 11; P = 0. 57). However, there was significant difference in VAS of non Chinese subgroup at 1h (Std. MD = 0. 33; 95% CI = 0. 25to 0. 41; P<0. 00001) and VAS of Chinese subgroup at 24h (Std. MD = -0.32; 95% CI = -0.49 to-0.14; P = 0.0003). In the secondary outcome, the analysis also showed no significant difference between the groups according to the rates of postoperative nausea and vomit (OR = 0. 63; 95% CI = 0. 38 to 1. 03; P = 0. 06) and the rates of postoperative additional analgesia (OR = 0. 57; 95% CI = 0. 21 to 1. 55; P = 0. 27). There was significant difference in postoperative consumption of morphine (Std. MD = -14. 57; 95% CI = -26. 63 to -0.25; P = 0. 02).

CONCLUSION

Compared with INB, PVB can provide better analgesia efficacy and cause lower consumption of morphine after thoracic surgery and breast surgery.

Non-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases

Background

Non-intubated video-assisted thoracoscopic surgery (NIVATS) has been increasingly used in lobectomy, bullectomy, wedge resection, lung volume reduction, sympathectomy and talc pleurodesis, which may reduce postoperative complications. However, the benefits of non-intubated and intubated methods of VATS remain controversial.

Methods

We comprehensively searched PubMed, Web of Science, Embase and the Cochrane Library, and performed a systematic review to assess the two techniques. Random and fixed-effects meta-analytical models were used based on the low between-study heterogeneity. Study quality, publication bias, and heterogeneity were assessed.

Results

Compared to intubated methods, NIVATS had a lower postoperative complications rate [odds ratio (OR): 0.63; 95% confidence interval (CI), 0.46-0.86; P<0.01], shorter global in-operating time [weighted mean difference (WMD): -35.96 min; 95% CI, -48.00 to -23.91; P<0.01], shorter hospital stay (WMD: -1.35 days; 95% CI, -1.72 to -0.98; P<0.01), shorter anesthesia time (WMD: -7.29 min; 95% CI, -13.30 to -1.29; P<0.01), shorter chest-tube placement time (WMD: -1.04 days; 95% CI, -1.75 to -0.33; P<0.01), less chest pain (WMD: -1.31; 95% CI, -2.45 to -0.17; P<0.05) and lower perioperative mortality rate (OR: 0.13; 95% CI, 0.02-0.99; P=0.05).

Conclusions

NIVATS is a safe, efficient and feasible technique for thoracic surgery and may be a better alternative procedure owing to its advantage in reducing postoperative complications rate, hospital stay, and chest pain.

The comparison of ultrasound-guided thoracic paravertebral blockade and internal intercostal nerve block for non-intubated video-assisted thoracic surgery

Background

To compare the safety and feasibility of ultrasound-guided thoracic paravertebral blockade (TPVB) and internal intercostal nerve block (IINB) for non-intubated video-assisted thoracic surgery (NIVATS).

Methods

Thirty-four patients who underwent NIVATS from April 2016 to May 2017 were retrospectively reviewed and divided into two groups consecutively according to local analgesia treatment, of which 20 patients received TPVB (P group) and the remaining 14 received IINB (I group). A Propensity Score Matching (PSM) analysis was performed to control the selection bias due to nonrandom assignment.

Results

The procedure of propensity scores yielded 2 matched cohorts of 14 patients. There were no significant differences between the two groups regarding gender, age, BMI, and surgical types (P>0.05). Blood-gas analysis 15 minutes after opening the chest showed significantly lower PaCO2 in the P group compared to the I group (P=0.004). The consumption of propofol from anesthesia induction to 15 minutes after opening the chest was also lower in the P group compared with the I group (P=0.012). There were no significant differences in the duration of surgery and visual analogue scale (VAS) pain scores between the two groups (P>0.05).

Conclusions

Ultrasound-guided TPVB can provide safe and reliable local anesthesia for NIVATS.

Paravertebral Block Versus Intercostal Nerve Block in Non-Intubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial

BACKGROUND

Non-intubated uniportal video-assisted thoracoscopic surgery (VATS) has been reported to be safe and feasible for patients with various thoracic diseases, including those who have respiratory dysfunction. This study examined the anaesthetic and analgesic sparing effects of either paravertebral block or intercostal nerve block on the non-intubated technique with spontaneous ventilation in patients under general anaesthesia (GA) using a supraglottic airway device. The primary aim was to compare the anaesthetic sparing effect of paravertebral block versus intercostal nerve block in non-intubated GA with airway support via a supraglottic airway device during VATS surgery. The secondary aim was to compare the recovery characters and postoperative outcomes of the patients.

METHODS

The study included 105 patients with American Society of Anesthesiologists (ASA) physical status II-III who had video-assisted thoracoscopy without endotracheal intubation and using a laryngeal airway. The patients were divided into three groups; each group consisted of 35 patients. Group I (35 patients): control group received only GA. Group 2 (35 patients): received a single-shot paravertebral block before induction of the GA. Group 3 (35 patients): received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. Heart rate, mean arterial pressure (MAP), and oxygen saturation were recorded before induction of GA (T0), after induction of GA (T1), 20 minutes later (T2), and before the end of the surgical procedure (T3).

RESULTS

Heart rate was significantly lower in Groups 2 and 3 compared with Group 1, and lower in Group 2 compared with Group 3. The MAP was significantly lower in Groups 2 and 3 compared with Group 1, and there was no significant difference between Groups 2 and 3. Oxygen saturation was significantly higher in Group 2 and in Group 3 compared with Group 1 and there was no significance difference between Groups 2 and 3. Expiratory fraction of sevoflurane (Ef sevo) was significantly lower in Groups 2 and 3 compared with Group 1, with no difference between Group 2 and 3. Groups 2 and 3 had lower fentanyl requirements, time to spontaneous eye movement, time to spontaneous arm movement, time to purposeful movement, and time to laryngeal mask removal than Group 1.

CONCLUSIONS

Regional anaesthesia by either preoperative paravertebral block or thoracoscopic intercostal nerve block with ipsilateral vagal block provided an anaesthetic sparing effect, guided by lower Ef sevo concentration, with comparable bi-spectral index in patients undergoing uniportal thoracoscopic surgery.

Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery

BACKGROUND

Nonintubated video-assisted thoracic surgery (VATS) has been widely developed during the recent years. Cough reflex is an inevitably encountered problem while approaching lung lesions, and it may induce major bleeding. Sevoflurane anesthesia may attenuate cough reflex by inhibiting the pulmonary irritant receptors. However, the incidence of postoperative nausea and vomiting (PONV) in inhalational anesthesia is higher than in the propofol-based total intravenous anesthesia (TIVA). We investigated the effect of sevoflurane combination with propofol-based TIVA on cough reflex and PONV in nonintubated VATS.

METHODS

Ninety patients undergoing nonintubated VATS with laryngeal mask airway (LMA) and spontaneous breathing were randomly assigned for TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 45), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane (P/S) group (n = 45), 1% sevoflurane anesthesia was added to propofol and fentanyl anesthesia. The primary outcome measurements were cough reflex. In addition, the incidence of PONV and extubation time were investigated.

RESULTS

Patients with cough reflex were significantly fewer in the P/S group than in the TIVA group (10/45 vs 34/45; P < .001). The cough severity (35/5/5/0 vs 11/17/17/0; P < .001) and limb movement (40/5/0/0 vs 28/17/0/0; P < .001) were lower in the P/S group than in the TIVA group. Besides, incremental fentanyl bolus for cough reflex was 5 (0 [0-1]) in the P/S group and 17 (0 [0-3]) in the TIVA group (P < .05). And there was no conversion to general anesthesia, postoperative hemorrhage, aspiration pneumonia, or PONV in the 2 groups. Besides, there was no significant difference in extubation time (TIVA: 5.04 ± 2.88 vs P/S: 4.44 ± 2.98 minutes; P = .33).

CONCLUSION

Sevoflurane attenuated cough reflex under propofol-based TIVA and did not increase the incidence of PONV and extubation time in nonintubated VATS.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer

Background

Minimal invasive surgery is current choice of treatment for lung cancer. Combined nonintubated anesthesia with uniportal thoracoscopic surgery is not well understood. Here, we report the experience of nonintubated uniportal thoracoscopic surgery in the treatment of primary non-small cell lung cancer (NSCLC).

Methods

From January 2014 to December 2015, we retrospectively reviewed 131 consecutive patients with primary NSCLC who underwent nonintubated uniportal thoracoscopic wedge resection and mediastinal lymph node dissection at a single medical center.

Results

Of the 131 patients, 110 (84%) received preoperative computed tomography-guided dye localization. Most of them were diagnosed with early stage invasive adenocarcinoma (N=112, 85.5%; pathological stage IA: 84.7%, N=111), and the mean size of the nodule was small (diameter: 0.85±0.40 cm). All section margins were free of malignancy. In total, 7 of the 131 patients (5.3%) had their treatment converted from uniportal to multi-portal video-assisted thoracoscopic surgery (VATS), and 1 (0.8%) had his treatment converted to endotracheal intubation with general anesthesia. The mean operation time was 91.1±32.6 minutes, and the postoperative complications included pneumonia (0.8%), prolonged air leaks (0.8%), and subcutaneous emphysema (1.5%).

Conclusions

Overall, nonintubated uniportal VATS is a feasible, effective and safe procedure for the treatment of early primary lung cancer.

Nonintubated video-assisted thoracic surgery lobectomy for lung cancer

Nonintubated video-assisted thoracic surgery (VATS) is now well established and is performed in different institutions as a safe and versatile procedure in selected patients. To share the surgical and anesthetic techniques for nonintubated VATS, we present a 56-year-old female patient who underwent nonintubated VATS left upper lobectomy for primary non-small cell lung cancer. Our patient was sedated in a spontaneous breathing status using a target-controlled infusion of propofol. Additionally, regional anesthesia using intercostal block and left-sided intrathoracic vagal block enabled us to do left upper lobectomy and mediastinal lymph node dissection without difficulty. After an uneventful postoperative recovery, our patient was discharged to her home on postoperative day 3. The final pathology showed a well-differentiated adenocarcinoma without any involvement of mediastinal lymph node, measuring 27 mm in its maximal dimension. Nonintubated VATS lobectomy can be a safe and effective procedure providing satisfactory clinical outcomes in the patient.