Dataset Information

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

ABSTRACT:

Objectives

In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia regarding pain control and enhanced recovery.

Methods

A retrospective multicentre analysis with single-center propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either thoracic epidural analgesia or intercostal nerve block. The primary outcome was proportion of pain scores ≥4 (scale 0-10) until postoperative day 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate.

Results

In 218 patients, thoracic epidural analgesia was compared to intercostal nerve block and showed no difference in proportion of pain scores ≥4 (14.3% [IQR 0.0-33.3] versus 11.1% [IQR 0.0-27.3] respectively, p = 0.24, more frequently needed additional opioids on the day of surgery (18% versus 48%) and first postoperative day (20% versus 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] versus 3.0 days [IQR 2.8-4.0]), and were significantly more mobile until postoperative day 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in course whereas thoracic epidural analgesia had higher late (rebound) pain scores.

Conclusions

In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to thoracic epidural analgesia and is linked to improved mobility. Results require randomized confirmation.

SUBMITTER: Spaans LN

PROVIDER: S-EPMC10645434 | biostudies-literature | 2023 Nov

REPOSITORIES: biostudies-literature

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Publications

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

Spaans Louisa N LN van Steenwijk Quirine C A QCA Seiranjan Adelina A Janssen Nicky N de Loos Erik R ER Susa Denis D Eerenberg Jan P JP Bouwman R A Arthur RAA Dijkgraaf Marcel G MG van den Broek Frank J C FJC

Interdisciplinary cardiovascular and thoracic surgery 20231101 5

<h4>Objectives</h4>In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery.<h4>Methods</h4>A retrospective multicentre analysis with single-centre propensity score matching was performed in ...[more]

PMID: 37941433

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Project description:BackgroundAdequate pain control after video-assisted thoracoscopic surgery (VATS) for lung resection is important to improve postoperative mobilisation, recovery, and to prevent pulmonary complications. So far, no consensus exists on optimal postoperative pain management after VATS anatomic lung resection. Thoracic epidural analgesia (TEA) is the reference standard for postoperative pain management following VATS. Although the analgesic effect of TEA is clear, it is associated with patient immobilisation, bladder dysfunction and hypotension which may result in delayed recovery and longer hospitalisation. These disadvantages of TEA initiated the development of unilateral regional techniques for pain management. The most frequently used techniques are continuous paravertebral block (PVB) and single-shot intercostal nerve block (ICNB). We hypothesize that using either PVB or ICNB is non-inferior to TEA regarding postoperative pain and superior regarding quality of recovery (QoR). Signifying faster postoperative mobilisation, reduced morbidity and shorter hospitalisation, these techniques may therefore reduce health care costs and improve patient satisfaction.MethodsThis multi-centre randomised study is a three-arm clinical trial comparing PVB, ICNB and TEA in a 1:1:1 ratio for pain (non-inferiority) and QoR (superiority) in 450 adult patients undergoing VATS anatomic lung resection. Patients will not be eligible for inclusion in case of contraindications for TEA, PVB or ICNB, chronic opioid use or if the lung surgeon estimates a high probability that the operation will be performed by thoracotomy.Primary outcomes(1) the proportion of pain scores ≥ 4 as assessed by the numerical rating scale (NRS) measured during postoperative days (POD) 0-2; and (2) the QoR measured with the QoR-15 questionnaire on POD 1 and 2. Secondary outcome measures are cumulative use of opioids and analgesics, postoperative complications, hospitalisation, patient satisfaction and degree of mobility.DiscussionThe results of this trial will impact international guidelines with respect to perioperative care optimization after anatomic lung resection performed through VATS, and will determine the most cost-effective pain strategy and may reduce variability in postoperative pain management. Trial registration The trial is registered at the Netherlands Trial Register (NTR) on February 1st, 2021 (NL9243). The NTR is no longer available since June 24th, 2022 and therefore a revised protocol has been registered at ClinicalTrials.gov on August 5th, 2022 (NCT05491239).Protocol versionversion 3 (date 06-05-2022), ethical approval through an amendment (see ethical proof in the Study protocol proof).

Project description:ObjectiveTo evaluate the analgesic efficacy and safety of paravertebral block (PVB) versus intercostal nerve block (INB) in thoracic surgery and breast surgery.MethodsThe 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.ResultsA 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).ConclusionCompared with INB, PVB can provide better analgesia efficacy and cause lower consumption of morphine after thoracic surgery and breast surgery.

Project description:BackgroundThe use of thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery (VATS) is controversial. Still, the evidence on omitting it in favour of systemic opioids is inconclusive, and studies are small and non-blinded.ObjectiveWe aimed to compare pain after VATS using epidural analgesia or enteral opioids for postoperative pain management.Design/setting/patients/interventionA randomised, double-blind, controlled trial at a Danish tertiary hospital. Adult patients scheduled for VATS were assigned to multimodal non-opioid baseline analgesia supplemented with either thoracic epidural analgesia (TE Group) or oral morphine (OM Group) for postoperative pain management. We recorded pain five times a day, both at rest and during activity, using the Numeric Rating Scale (NRS) and categorised it into "acceptable pain" or "unacceptable pain". Unacceptable pain was defined as NRS (at rest) ≥3 or NRS (with activity) ≥5 when supplementary analgesics were given.Main outcome measuresThe primary outcomes were the proportions of patients experiencing "unacceptable pain" during the postoperative period and the use of intravenous "rescue" opioids.ResultsOf the 161 included patients, 146 received the allocated treatment and their data were analysed. At rest, 34% of patients in the TE Group and 64% of patients in the OM Group experienced unacceptable pain during the study period, a significant between-group difference of 30% ( P < 0.0005). During activity these percentages were 32% of patients in the TE Group and 59% in the OM group, a difference of 27% ( P < 0.005). The median intravenous rescue morphine consumption during the study period was 4.5 [interquartile range (IQR), 0-10.0] mg in the TE Group and 7.5 [0-19.0] mg in the OM Group ( P < 0.005).ConclusionEpidural analgesia provided better pain relief after VATS than oral morphine. The between-group difference in rescue intravenous morphine consumption was statistically significant but clinically irrelevant.Trial registrationClinicalTrials.gov (NCT02359175).

Dataset Information

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

Objectives

Methods

Results

Conclusions

Publications

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia.

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