Dataset Information

Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block.

ABSTRACT:

Background

Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this study was to investigate the incidence of inadvertent intercostal and epidural injections during thoracic SBs.

Methods

Twenty-two patients who were suffering from complex regional pain syndrome or lymphedema after breast cancer surgery were managed with two or three times of thoracic SBs. Therefore, injections of 63 thoracic SBs from 22 patients were enrolled in this study. An investigator who did not attend the procedure evaluated the occurrence of intercostal or epidural spread using anteroposterior fluoroscopic images.

Results

The overall incidence of inadvertent intercostal or epidural spread of contrast was 47.5%. Among the inadvertent injections, intercostal spread (34.9%) was more frequent than epidural spread (12.6%). Only 52.5% of the thoracic SBs demonstrated successful contrast spread without any inadvertent spread. The mean difference in skin temperature between the blocked and unblocked sides was 2.5 ± 1.8ºC. Fifty-nine (93.6%) injections demonstrated more than 1.5ºC difference.

Conclusions

Thoracic SBs showed a high incidence (47.5%) of inadvertent epidural or intercostal injection. Thus, special attention is required for the diagnosis of SMP or the injection of any neurolytic agent around sympathetic ganglion.

SUBMITTER: Hong JH

PROVIDER: S-EPMC7724114 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Publications

Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block.

Hong Ji Hee JH Yi Seung Won SW Kim Ji Seob JS

Anesthesia and pain medicine 20201005 4

<h4>Background</h4>Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this stu ...[more]

PMID: 33329853

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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:IntroductionEpidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure.Methods and analysisThis study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs.Ethics and disseminationThis protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal.Trial registration numberNCT05731973.

Dataset Information

Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block.

Background

Methods

Results

Conclusions

Publications

Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block.

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