Regional Analgesic Techniques Research Articles

Comparing Efficacy of Regional Analgesia Techniques After Pediatric Inguinal Procedures.

No abstract.

The effect of ultrasound-guided rectus sheath block on postoperative analgesia in robot assisted prostatectomy: A randomized controlled trial.

Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.

MATHEMATICAL PREDICTION OF CHANGES IN THE LEVELS OF CD40-CD40L TRANSMEMBRANE PROTEIN SYSTEM ACROSS DIFFERENT ANALGESIA TECHNIQUES IN CHILDREN

The impact of the CD40-CD40L on the development of non-communicable neurological conditions is determined by abnormal CD40 expression and may be detrimental to nervous tissue function. Pain is one of the earliest psychophysical functions to develop. Postoperative complications causing pain should be addressed immediately. Regional analgesia techniques can speed up children’s recovery and reduce the need for opioids. They can also lower the incidence of postoperative nausea and vomiting, respiratory complications, and postsurgical pain intensity.The aim of this study was to present a mathematical model that predicts changes in CD40-CD40L levels in children who underwent surgery under various analgesic modalities within the fi rst fi ve days postoperatively. The autoregressive probability model was used to predict the behavior of the experimental data function within 29 days after surgery.Material and Methods. The children were divided into three groups. Group I consisted of 33 children who underwent anterior abdominal wall surgery under general anesthesia with morphine. Group II comprised 27 children who underwent anterior abdominal wall surgery under general anesthesia with the transversalis fascia plane block (TFPB). Group III included 27 children who underwent anterior abdominal wall surgery under general anesthesia with the TFPB, combined with the quadratus lumborum block 4 (QLB-4) via a single injection. The serum CD40L levels were evaluated using the immunoenzymatic assay method. The autoregressive model method based on the Burg algorithm was used to predict the behavior of the experimental data function. To automate the calculation of predictions based on the Burg method, the ‘predict’ function in РТС MathCad Prime 7.0 software was used. All clinical and laboratory studies were conducted in accordance with the World Medical Association Declaration of Helsinki ‘Ethical Principles for Medical Research Involving Human Subjects’. The study is a fragment of the research project of the Department of Children Diseases of Postgraduate Medical Education Faculty, Ivano- Frankivsk National Medical University «Health Status and Adaption of Children from the Precarpathian Region with Somatic Diseases, Their Prevention» 2021-2026, state registration number 0121U111129.Results. On the fi fth day after surgery, the serum CD40-CD40L levels were highest in children who received conventional opioid analgesia. There was no signifi cant diff erence observed between children in the TFPB and TFPB+QLB groups. On the 29th day after surgery, the predicted CD40-CD40L levels were lowest in children who received conventional opioid analgesia combined with the TFPB+QLB.Conclusions. The fi ndings obtained confi rmed the positive eff ect of combined analgesia using opioids and regional nerve block TFPB+QLB in children who received anterior abdominal surgery on suppressing immune mechanisms of pain syndrome involving the CD40-CD40L signaling system.

Single-centre case series report of regional anaesthesia for pain management in vaso-occlusive crisis.

Sickle cell disease is characterised by episodes of vaso-occlusive crisis, a painful complication. Regional anaesthesia has shown promising results in reducing opioid consumption and pain scores. Patients with vaso-occlusive crises who underwent regional anaesthesia in the paediatric intensive care unit were studied. Data regarding pain location, regional analgesia technique, the local anaesthetic used and dose, daily opioid consumption, daily pain scores, use of adjuvants and complications were recorded. The primary outcome was to evaluate the effect of regional anaesthesia on opioid consumption. In this study, we describe 10 cases, referring to six paediatric patients with the vaso-occlusive crisis who underwent regional anaesthesia for severe pain and were unresponsive to increasing doses of opioids. Six cases received epidural analgesia, three continuous peripheral nerve blocks and one received both techniques. Opioid consumption was reduced (58%), and pain scores decreased (72%), both statistically significant reductions.

Comparison of ultrasound-guided erector spinae plane block versus transmuscular quadratus lumborum block for postoperative analgesia after caesarean delivery: a prospective randomized non-inferiority clinical trial

Abstract Background and Aims: Regional techniques are a part of multimodal analgesia following cesarean delivery. Cesarean delivery warrants a regional technique, which can provide somatic and visceral analgesia-like quadratus lumborum block (QLB) and erector spinae plane block (ESPB). In this study, we investigated the non-inferiority of ESPB at T12 and transmuscular-QLB (TQLB) at L2-L3 for postoperative analgesia in cesarean delivery. Material and Methods: In this prospective, randomized, non-inferiority trial, 124 patients undergoing cesarean delivery were enrolled to receive bilateral TQLB or ESPB with 20 mL of 0.25% ropivacaine on each side. All patients received prophylactic acetaminophen and ketorolac for 2 days. Our primary objective was to compare the total tramadol consumption in the first 48 h between the two groups. Secondary objectives were to compare cumulative tramadol consumption, postoperative Numeric Rating Scale (NRS) score at rest, and with movement at various time points, the time for first rescue analgesic requirement, development of complications related to the block, and patient satisfaction with analgesia between the two groups. Results: The total tramadol consumption in 48 h (47.3 ± 34.9 mg in ESPB and 50.9 ± 38.7 mg in TQLB), duration of first rescue analgesic (22.8 ± 15.8 h in ESPB and 22.7 ± 15.6 h in TQLB), and patient satisfaction were similar between the two groups. Both groups had similar pain scores except at rest at 6 h and on movement at 4 h, 6 h, and 36 h, whereas the ESPB group had lower NRS scores (P < 0.05). Conclusion: The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB post-caesarean delivery. Key Message: What is already known about the topic: Cesarean delivery warrants a regional analgesia technique which can provide somatic and visceral analgesia postoperatively. While quadratus lumborum block (QLB) is a well-established technique for cesarean delivery there are very few comparative studies on erector spinae plane block (ESPB) in cesarean delivery. In the studies comparing ESPB for other lower abdominal procedures, it has been given at T9 only. What new information this study adds: The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB performed at L2-L3 with the same volume post-cesarean delivery and can be an important addition to multimodal analgesia protocols after cesarean delivery.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis

Study objectiveRegional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DesignSystematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SettingPostoperative pain treatment. PatientsAdult patients undergoing visceral cancer surgery. InterventionsAny kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MeasurementsPrimary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. Main results59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): −1.35 to −0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: −2.34 to −1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: −1.20 to −0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: −1.34 to −0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. ConclusionsFollowing visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

Analgesia for rib fractures: a narrative review.

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Erector Spinae Plane Block Placement Utilizing Fluoroscopic Guidance Improves Efficiency in Lumbar Surgery

The erector spinae plane block (ESPB) is a novel regional analgesic technique which improves postoperative outcomes in lumbar surgery patients including length of hospitalization, days to ambulation, and postoperative opioid use. Traditionally, the block is administered by anesthesiologists trained in the ultrasound guidance technique. The use of fluoroscopic guidance may improve the efficiency and accessibility of the ESPB for spine surgeons. We aim to measure the time to administer an ESPB using fluoroscopic guidance and localize the anesthetic using intraoperative three-dimensional (3D) imaging. Two neurosurgeons administered an ESPB to patients undergoing lumbar surgery. Time from insertion of the spinal needle to localize the erector spinae plane using C-arm guidance to time of complete injection and removal of the needle from the skin was recorded. One patient underwent O-arm imaging following injection of an Isovue-Exparel solution at the L3 level to visualize spread of the anesthetic. A total of 21 patients were enrolled in this study. The average duration to perform an ESPB under fluoroscopic guidance was 1.2minutes. The Isovue-Exparel solution was injected at the L3 level and was well distributed along the ESP on intraoperative O-arm imaging. The anesthetic dissected the erector spinae muscle from the transverse process at L2, L3, and L4. Fluoroscopic guidance allows efficient and appropriate delivery of the anesthetic to the erector spinae plane. Performing an ESPB with fluoroscopic guidance improves efficiency and accessibility of the analgesic technique for spine surgeons, reducing dependence on anesthesiology personnel trained in administering the block.

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study.

Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery. Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay. A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference. The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

Additive value of superficial parasternal intercostal plane block and serratus anterior plane block in lung transplantation surgery: a retrospective exploratory study

BackgroundAdequate pain control following lung transplantation (LTx) surgery is paramount. Thoracic epidural analgesia (TEA) is the gold standard; however, the potential use of extracorporeal membrane oxygenation (ECMO) and consequent anticoagulation...

Analgesic Effects of Regional Analgesic Techniques in Pediatric Inguinal Surgeries: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

Various regional analgesic techniques have been used in pediatric inguinal surgery to facilitate postoperative recovery. However, each technique's relative performance was undetermined owing to the lack of quantitative analysis. We systematically searched MEDLINE, Cochrane Library, EMBASE, and Web of Science for randomized controlled trials that compared regional analgesia in pediatric inguinal surgeries. After critical study screening and selection, a random-effects network meta-analysis was performed. The primary outcome was the time to the first rescue analgesic after surgery, and the secondary outcomes were the number of patients requiring rescue analgesics after surgery, postoperative pain scores, incidence of postoperative nausea and vomiting, and other adverse events. This network meta-analysis included 69 randomized controlled trials (4636 patients) that compared 10 regional analgesic techniques. Our study revealed that the quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic after pediatric inguinal surgeries, by 7.7 hours (95% confidence interval [CI], 5.0-10.3) and 6.0 hours (95% CI, 3.9-8.2) when compared with the control group, respectively. In the subgroup involving only inguinal hernia repair, the quadratus lumborum block significantly prolonged the time to the first rescue analgesic than all other regional analgesics. In contrast, in the subgroup involving orchidopexies, only the caudal block significantly prolonged the time to the first rescue analgesic when compared with the control group (4.1 hours; 95% CI, 0.7-7.5). Wound infiltration and landmark-based ilioinguinal-iliohypogastric block had relatively poor analgesic effects than other regional analgesics. No serious adverse effects related to the regional analgesic techniques were reported in any of the included studies. The quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic and the least rescue analgesic requirement for pediatric inguinal surgeries. Specifically, the quadratus lumborum block had the longest analgesic duration in inguinal hernia repair, and the caudal block was found to be the only regional analgesia that extended the time to the first rescue analgesic in pediatric orchidopexy. Most included randomized controlled trials had some concern or a high risk of bias, and future studies should focus on providing high-quality evidence to further clarify the analgesic effects of regional analgesia for pediatric inguinal surgeries.

Pain in Colorectal Surgery: How Does It Occur and What Tools Do We Have for Treatment?

Pain is a complex entity with deleterious effects on the entire organism. Poorly controlled postoperative pain impacts the patient outcome, being associated with increased morbidity, inadequate quality of life and functional recovery. In the current surgical environment with less invasive surgical procedures increasingly being used and a trend towards rapid discharge home after surgery, we need to continuously re-evaluate analgesic strategies. We have performed a narrative review consisting of a description of the acute surgical pain anatomic pathways and the connection between pain and the surgical stress response followed by reviewing methods of multimodal analgesia in colorectal surgery found in recent literature data. We have described various regional analgesia techniques and drugs effective in pain treatment, emphasizing their advantages and concerns. We have also tried to identify present knowledge gaps requiring future research. Our review concludes that surgical pain has peculiarities that make its management complex, implying a consistent, multimodal approach aiming to block both peripheral and central pain pathways.

MANAGEMENT OF CHRONIC POSTSURGICAL PAIN AND HYPERALGESIA IN CHILDREN AND ITS INFLUENCE ON COGNITIVE FUNCTIONING

Introduction. Persistent postsurgical pain (PPSP) or chronic postsurgical pain (CPSP) is recognized as a relevantpostoperative complication. Inadequate pain management in the early postoperative period may contribute to the development of hyperalgesia and the use of local anesthetics in regional anesthesia can help in its treatment and prevention.The aim of the study was to study the eff ectiveness of regional analgesia techniques in preventing PPSP and hyperalgesiain children after anterior abdominal wall surgery and to assess quality of life (QoL) using the Cognitive Functioning Scale.Material and Methods. The study included 87 children at the age of 7-18 years who underwent anterior abdominal wallsurgery with diff erent anesthetic techniques. Group I included 27 children who underwent anterior abdominal wall surgery under general anesthesia using the transversalis fascia plane block (TFPB), combined with the quadratus lumborum block 4 (QLB-4). Group II comprised 33 children who underwent anterior abdominal wall surgery under general anesthesia using fentanyl. Group III consisted of 27 children who underwent anterior abdominal wall surgery under general anesthesia using the TFPB. General anesthesia included either inhalation anesthesia or propofol infusion. The control group included 30 healthy children whose cognitive functioning was assessed. All clinical and laboratory studies were conducted in accordance with the World Medical Association Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects”. According to the Law, prior to a subject’s participation in the study, a written informed consent form was signed by each subject (parents/adult guardians). The manuscript was approved by the Ethics Committee of the Communal Non- Profi t Enterprise “Ivano- Frankivsk Regional Children’s Clinical Hospital of Ivano-Frankivsk Regional Council”, as evidenced by an Excerpt from the Minute of the Committee Meeting No. 2 dated February 24, 2022.The results obtained were statistically processed using statistical measures of variation, correlation analysis, Student’s t-test.Diff erences were considered statistically signifi cant at p<0.05. The proportions were statistically compared by a z-test.The study is a fragment of the research project of the Department of Children Diseases of Postgraduate Medical EducationFaculty, Ivano- Frankivsk National Medical University “Health Status and Adaption of Children from the Precarpathian Regionwith Somatic Diseases, Their Prevention” (state registration number 0121U111129; 2021-2026).Results. A signifi cantly higher mechanical pain threshold was observed in children of Group I and Group III both three(226.422.2, 220.318.6, and 182.414.2 g/mm2, respectively, рІ-ІІ<0.05, рІІ-ІІІ<0.05) and six months (288.214.4, 276.414.8,and 174.216.4 g/mm2, respectively, рІ-ІІ<0.05, рІІ-ІІІ<0.05) after surgery.The surface area of hyperalgesia in children of Group I and Group III was signifi cantly smaller as compared to childrenof Group II three (68.69.4, 79.411.4, and 116.814.0 mm2, respectively, рІ-ІІ<0.05, рІІ-ІІІ<0.05) and six months (70.213.0,77.213.2, and 117.212.6 mm2, respectively, рІ-ІІ<0.05, рІІ-ІІІ<0.050) after surgery.The frequency of CPSP was higher in children of Group II (21%) as compared to children in Group I (4%) and Group III(11%). Additionally, assessing chronic pain with the DN4 questionnaire showed its signifi cantly lower level in children of Group Iand Group III as compared to Group II six months after surgery (5.46±0.42, 8.69±0.78, and 13.69±0.38 points, respectively,рІ-ІІ<0.05, рІІ-ІІІ<0.05, рІ-ІІІ<0.05). No statistically signifi cant diff erence in QoL assessment on the Cognitive Functioning Scale was observed on the 7th day following surgery; the QoL scores in all the groups were signifi cantly lower compared to the control group. Three months after surgery, QoL was signifi cantly lower in children of Group II (69.38±6.93 points) as compared to children of Group I (92.08±4.46 points, pІ-ІІ<0.001) and Group III (83.54±4.16 points, pІІ-ІІІ<0.01). Six months following surgery, the lowest QoL was diagnosed in children of Group II (72.08±6.64) as compared to those in Group І (94.17±4.36 points, p<0.001) and Group ІІІ (91.67±4.27, p<0.001).Conclusions.1. The use of general analgesia in combination with regional anesthesia techniques (TFPB or TFPB+QLB) was associatedwith a higher mechanical pain threshold and a smaller area of hyperalgesia around the postoperative wound three and six months after anterior abdominal wall surgery, compared to conventional anesthesia.2. In addition, combined use of regional (TFPB or QLB+TFPB) with general anesthesia demonstrated a lower frequencyof CPSP, a lower level of chronic pain, and a higher level of cognitive functioning in children throughout these time intervals.3. The results obtained provide a foundation for introducing these analgesia techniques (TFPB or TFPB+QLB) in pediatricpatients undergoing anterior abdominal wall surgery, with the aim of mitigating the eff ects of pain syndrome and improving their Qo L.

Living liver donor pain management.

Optimal pain control in living liver donors undergoing hepatectomy is strongly recommended considering their unique status as healthy individuals willingly undergoing surgery for the benefit of the recipient. This review aims to examine and evaluate different strategies aimed at ensuring effective postoperative pain management in living liver donors. Enhanced recovery after surgery (ERAS) protocols have proven effective in optimizing patient outcomes, including in living liver donor hepatectomy. By implementing these protocols, healthcare professionals can enhance postoperative pain control and accelerate recovery. Multimodal analgesia, which combines different techniques and agents, is crucial in pain management for living liver donors. Regional analgesia techniques, such as spinal anesthesia and various peripheral nerve blocks, have shown efficacy in reducing pain and facilitating early recovery. Systemic nonopioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, ketamine, lidocaine, and dexmedetomidine act synergistically to alleviate pain and reduce inflammation. Minimizing the use of opioids is important to avoid adverse effects, and they should be reserved for rescue medication or breakthrough pain. Applying the principles of ERAS and multimodal analgesia to living liver donors can effectively control pain while promoting early recovery.

Analgesia in esophagectomy: a narrative review.

Optimal pain management for esophagectomy facilitates prevention of postoperative complications such as pneumonia, but also chronic pain. Historically, multimodal intravenous analgesia was employed. In the last decades, regional anesthesia including epidural and paravertebral analgesia is frequently used. In this narrative review, we provide a comprehensive overview of the available evidence for the different analgesia regimens for esophagectomy. A search was conducted in the PubMed/MEDLINE database in November 2022. Only reports in English or Dutch were included. Editorials or articles lacking full text were excluded. A review of different analgesia regimens after esophagectomy is provided. Epidural analgesia (EA) was suggested to reduce postoperative pneumonia and prevent chronic postsurgical pain (CPSP) as compared to opioid-based systemic analgesia and was considered the gold standard of pain management for esophagectomy. In the last decades, the side-effects of EA became more evident. Next to mild or moderate side-effects such as hypotension and urinary retention, several reports emphasized the incidence of serious neurologic complications to be much higher than estimated before. In addition, minimally invasive surgery fostered that other regional analgesia (RA) techniques are potential alternatives for EA. Paravertebral catheter placement can be performed under videoscope view during the thoracic phase of esophagectomy, making it a safe and easily placed block. Evidence on the effectiveness of erector spinae plane block (ESPB) is limited in this context. Several analgesia regimens after esophagectomy are described. EA is most common, however paravertebral analgesia is a good alternative. Other techniques are also gaining ground but randomized clinical trials are lacking. Future studies should focus on the efficacy of paravertebral and erector spinae blocks for postoperative pain management for esophagectomy.

Pain management after thoracic surgery or chest trauma.

Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.

Relative efficacy and safety of several regional analgesic techniques following thoracic surgery: a network meta-analysis of randomized controlled trials.

This network meta-analysis was performed to assess the relative efficacy and safety of various regional analgesic techniques used in thoracic surgery. Randomized controlled trials evaluating different regional analgesic methods were retrieved from databases, including PubMed, Embase, Web of Science, and the Cochrane Library, from inception to March 2021. The surface under the cumulative ranking curve) was estimated to rank the therapies based on the Bayesian theorem. Moreover, sensitivity and subgroup analyses were performed on the primary outcomes to obtain more reliable conclusions. Fifty-four trials (3360 patients) containing six different methods were included. Thoracic paravertebral block and erector spinae plane block (ESPB) were ranked the highest in reducing postoperative pain. As for total adverse reactions and postoperative nausea and vomiting, postoperative complications, and duration of hospitalization, ESPB was found to be superior to other methods. It should be noted that there were few differences between various methods for all outcomes. Available evidence suggests that ESPB might be the most effective and safest method for relieving pain after thoracic surgery, shortening the length of hospital stay and reducing the incidence of postoperative complications.

Analgesic effectiveness of serratus anterior plane block in patients undergoing video-assisted thoracoscopic surgery: a systematic review and updated meta-analysis of randomized controlled trials

BackgroundSerratus anterior plane block (SAPB) is a promising regional technique for analgesia in thoracic surgery. Till now, several randomized controlled trials (RCTs) have explored the effectiveness of SAPB for postoperative pain control in patients undergoing video-assisted thoracoscopic surgery (VATS), but the sample sizes were small and conclusions remained in controversy. Therefore, we conducted the present systematic review and meta-analysis.MethodsRCTs evaluating the analgesic performance of SAPB, comparing to control methods (no block, placebo or local infiltration anesthesia), in patients undergoing VATS were searched in PubMed, EMBASE, Web of Science and Cochrane Library from inception to December 31, 2022. Mean difference (MD) and corresponding 95% confidence interval (95%CI) were calculated for postoperative pain scores at various time points, postoperative opioid consumption and length of hospital stay. Pooled relative risk (RR) with 95%CI were calculated for the risk of postoperative nausea and vomiting (PONV) and dizziness. A random-effect model was applied.ResultsA total of 12 RCTs (837 participants) were finally included. Compared to control group, SAPB had significant reductions of postoperative pain scores at 2 h (MD = -1.58, 95%CI: -1.86 to -1.31, P < 0.001), 6 h (MD = -2.06, 95%CI: -2.74 to -1.38, P < 0.001), 12 h (MD = -1.72, 95%CI: -2.30 to -1.14, P < 0.001) and 24 h (MD = -1.03, 95%CI: -1.55 to -0.52, P < 0.001), respectively. Moreover, SAPB conferred a fewer postoperative opioid consumption (MD = -7.3 mg of intravenous morphine equivalent, 95%CI: -10.16 to -4.44, P < 0.001) and lower incidence of PONV (RR = 0.56, 95%CI: 0.41 to 0.77, P < 0.001). There was no difference between both groups regarding length of hospital stay and risk of dizziness.ConclusionSAPB shows an excellent performance in postoperative pain management in patients undergoing VATS by reducing pains scores, postoperative opioid consumption and incidence of PONV. However, due to huge heterogeneity, more well-designed, large-scale RCTs are needed to verify these findings in the future.

Rational Multimodal Analgesia for Perioperative Pain Management.

A multimodal analgesic approach improves postoperative pain relief and reduces opioid use; however, it is not universally implemented. This review presents the evidence assessing multimodal analgesic regimens and recommends optimal analgesic combinations. The evidence for best combinations of individual patients undergoing specific procedures is lacking. Nevertheless, an optimal multimodal regimen may be determined based on identifying efficacious, safe, and inexpensive analgesics interventions. Key components of an optimal multimodal analgesic regimen include the preoperative identification of patients at high risk for postoperative pain in addition to patient and caregiver education. Unless contraindicated, all patients should receive a combination of acetaminophen, non-steroidal anti-inflammatory drug or cycoxygenase-2-specific inhibitor, dexamethasone, and procedure-specific regional analgesic technique and/or surgical site local anesthetic infiltration. Opioids should be administered as rescue adjuncts. Non-pharmacological interventions are important components of an optimal multimodal analgesic technique. It is imperative to integrate multimodal analgesia regimens within a multidisciplinary enhanced recovery pathway.

The analgesic effects of bilateral superficial cervical plexus block in thyroid surgery: A systematic review and meta-analysis.

Thyroid surgery is moderately painful, and many techniques to reduce postoperative pain have been studied. Regional techniques are a part of multimodal analgesia employed for various surgical cases. Bilateral superficial cervical plexus block (BSCPB) is a commonly used regional anaesthesia technique for analgesia for thyroid surgery. A previous meta-analysis by this group had left questions about some facets of the technique, to which further trials have contributed. The systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) CRD42022315499. It is an update to a previously published paper in 2018. An updated systematic search, critical appraisal, and analysis of clinical trials were performed. Trials investigating preoperative or postoperative BSCPB compared to control in patients undergoing thyroid surgery were included in the search. The primary outcome was postoperative opioid consumption. The secondary outcomes were the duration of analgesia (time to request of analgesia), Visual Analogue Scale (VAS) pain scores at 0, 4, 12, and 24 h, postoperatively, rates of postoperative nausea and vomiting (PONV), postoperative rescue analgesic consumption, and intraoperative morphine use. A total of 31 studies and 2,273 patients were included in this analysis. BSCPB significantly reduced post-thyroidectomy opioid consumption (P < 0.001). Additionally, the duration of analgesia was prolonged following BSCPB. VAS scores for 24 h (postoperatively), intraoperative morphine use, and rescue analgesia (postoperatively) remained significantly lower in patients who received BSCPB. There was also a statistically significant reduction in PONV (P = 0.02). BSCPB offers superior postoperative analgesia with a reduction in opioid use, reduction in PONV, and improvement in VAS scores.