Continuous erector spinae plane block versus intercostal nerve block in patients undergoing video-assisted thoracoscopic surgery: a pilot randomized controlled trial

Dillon Horth, William Sanh, Peter Moisiuk, Turlough O'Hare, Yaron Shargall, Christian Finley, Waël Hanna, John Agzarian, Mauricio Forero, Kim Davis, Thuva Vanniyasingam, Lehana Thabane, Harsha Shanthanna, Dillon Horth, William Sanh, Peter Moisiuk, Turlough O'Hare, Yaron Shargall, Christian Finley, Waël Hanna, John Agzarian, Mauricio Forero, Kim Davis, Thuva Vanniyasingam, Lehana Thabane, Harsha Shanthanna

Abstract

Background: The optimal analgesia method in video-assisted thoracoscopic surgery (VATS) remains controversial. Intercostal nerve blockade (ICNB) is limited by its duration of action. The erector spinae plane (ESP) block has the potential to provide satisfactory analgesia for VATS; however, the effectiveness of continuous ESP versus surgeon-performed ICNB has not been investigated. The objectives of this study were to establish feasibility of patient recruitment and follow-up before undertaking a fully powered randomized controlled trial (RCT); and, secondarily, to compare opioid usage, pain control, and sensory blockade.

Methods: This feasibility RCT was undertaken at St Joseph's Hospital, Hamilton, Ontario, Canada, and included 24 patients (>18 years) having elective VATS with at least one overnight stay. Exclusion criteria were patient refusal, body mass index >40 kg/m2, contraindications to neuraxial analgesia techniques as per the American Society of Regional Anesthesia and Pain guidelines, known allergy to local anesthetics, language or comprehension barriers, procedures with a higher chance of open surgery, and regular opioid use for ≥3 months preoperatively. Patients underwent either continuous ESP (n=12) or surgeon-performed ICNB (n=12). All patients received routine intraoperative anesthesia care and multimodal analgesia. Feasibility criteria were recruitment rate of two patients/week and full follow-up in all patients in-hospital. We compared opioid consumption, postoperative pain scores (0-10 numerical rating scale), adverse events, patient satisfaction, and distribution of sensory blockade as clinical outcomes (secondary).

Results: Feasibility of primary outcomes was successfully demonstrated. Five patients had an epidural in anticipation of open surgery. Mean opioid consumption as equivalent morphine units was less in the ESP group over the first 24 h (mean difference, 1.63 [95% CI -1.20 to 4.45]) and 48 h (mean difference, 2.34 [95% CI -1.93 to 6.61]). There were no differences in adverse effects.

Conclusions: A fully powered RCT is feasible with modifications. Our results also suggest that continuous ESP is safe and can decrease opioid needs. However, it is important to consider procedures to improve compliance to protocol and adherence to assigned interventions.

Trial registration: Clinicaltrials.gov identifier: NCT03176667 . Registered June 5, 2017.

Keywords: Erector spinae plane block; Intercostal nerve blockade; Perioperative analgesia; Video-assisted thoracoscopic surgery.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Consort flow diagram
Fig. 2
Fig. 2
Pain scores (box and whisker plot)
Fig. 3
Fig. 3
Comparison of sensory blockade. a Sensory blockade at the anterior chest. b Sensory blockade at the mid-clavicular level. c Sensory blockade at the mid-scapular level. d Sensory blockade at the mid-axillary level
Fig. 4
Fig. 4
Cumulative opioid consumption (box and whisker plot)

References

    1. Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg. 2000;70:1644–1646. doi: 10.1016/S0003-4975(00)01909-3.
    1. McKenna RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg. 2006;81:421–426. doi: 10.1016/j.athoracsur.2005.07.078.
    1. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg. 1999;68:194–200. doi: 10.1016/S0003-4975(99)00467-1.
    1. Scott WJ, Allen MS, Darling G, Meyers B, Decker PA, Putnam JB, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139:976–983. doi: 10.1016/j.jtcvs.2009.11.059.
    1. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50–55. doi: 10.1097/00002508-199603000-00009.
    1. Zhang S, Huang Q, Xie J, Xu B, Cao G, Pei F. Factors influencing postoperative length of stay in an enhanced recovery after surgery program for primary total knee arthroplasty. J Orthop Surg Res. 2018;13:29. doi: 10.1186/s13018-018-0729-x.
    1. Jamison RN, Ross MJ, Hoopman P, Griffin F, Levy J, Daly M, et al. Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain. 1997;13:229–236. doi: 10.1097/00002508-199709000-00008.
    1. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107:1026–1040. doi: 10.1213/01.ane.0000333274.63501.ff.
    1. Kim JA, Kim TH, Yang M, Gwak MS, Kim GS, Kim MJ, et al. Is intravenous patient controlled analgesia enough for pain control in patients who underwent thoracoscopy? J Korean Med Sci. 2009;24:930–935. doi: 10.3346/jkms.2009.24.5.930.
    1. Fernandez MI, Martin-Ucar AE, Lee HD, West KJ, Wyatt R, Waller DA. Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax? Eur J Cardiothoracic Surg. 2005;27:671–674. doi: 10.1016/j.ejcts.2004.12.045.
    1. Yoshioka M, Mori T, Kobayashi H, Iwatani K, Yoshimoto K, Terasaki H, et al. The efficacy of epidural analgesia after video-assisted thoracoscopic surgery: a randomized control study. Ann Thorac Cardiovasc Surg. 2006;12:313–318.
    1. Karmakar MK, Chung DC. Variability of a thoracic paravertebral block. Are we ignoring the endothoracic fascia? Reg Anesth Pain Med. 2000;25:325–327. doi: 10.1097/00115550-200005000-00029.
    1. Huan S, Deng Y, Wang J, Ji Y, Yin G. Efficacy and safety of paravertebral block versus intercostal nerve block in thoracic surgery and breast surgery: a systematic review and meta-analysis. PloS one. 2020;15(10):e0237363. doi: 10.1371/journal.pone.0237363.
    1. Wurnig PN, Lackner H, Teiner C, et al. Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia? Eur J Cardio-Thorac Surg. 2002;21(6):1115–1119. doi: 10.1016/S1010-7940(02)00117-3.
    1. Bolotin G, Lazarovici H, Uretzky G, Zlotnick AY, Tamir A, Saute M. The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain. Ann Thorac Surg. 2000;70:1872–1875. doi: 10.1016/S0003-4975(00)01757-4.
    1. Taylor R, Massey S, Stuart-Smith K. Postoperative analgesia in video-assisted thoracoscopy: the role of intercostal blockade. J Cardiothorac Vasc Anesth. 2004;18:317–321. doi: 10.1053/j.jvca.2004.03.012.
    1. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–627. doi: 10.1097/AAP.0000000000000451.
    1. Bonvicini D, Boscolo-Berto R, De Cassai A, et al. Anatomical basis of erector spinae plane block: a dissection and histotopographic pilot study. J Anesth. 2021;35:102–11.
    1. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. A A Case Rep. 2017;8:254–256. doi: 10.1213/XAA.0000000000000478.
    1. American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. Anesthesiology. 2010;112:530–545. doi: 10.1097/ALN.0b013e3181c4c7d8.
    1. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition) Reg Anesth Pain Med. 2018;43:263–309. doi: 10.1097/AAP.0000000000000763.
    1. Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: executive summary 2015. Reg Anesth Pain Med. 2015;40:401–430. doi: 10.1097/AAP.0000000000000286.
    1. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10:390–392. doi: 10.1197/aemj.10.4.390.
    1. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud. 2016;2:64. doi: 10.1186/s40814-016-0105-8.
    1. Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharmaceut Statist. 2005;4:287–291. doi: 10.1002/pst.185.
    1. Fang B, Wang Z, Huang X. Ultrasound-guided preoperative single-dose erector spinae plane block provides comparable analgesia to thoracic paravertebral block following thoracotomy: a single center randomized controlled double-blind study. Ann Transl Med. 2019;7:174. doi: 10.21037/atm.2019.03.53.
    1. Chen N, Qiao Q, Chen R, Xu Q, Zhang Y, Tian Y. The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: a randomized, double-blinded, clinical trial. J Clin Anesth. 2020;59:106–111. doi: 10.1016/j.jclinane.2019.07.002.
    1. Gaballah KM, Soltan WA, Bahgat NM. Ultrasound-guided serratus plane block versus erector spinae block for postoperative analgesia after video-assisted thoracoscopy: a pilot randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;33:1946–1953. doi: 10.1053/j.jvca.2019.02.028.
    1. Taketa Y, Irisawa Y, Fujitani T. Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery: a prospective randomized non-inferiority trial. Reg Anesth Pain Med. 2019;rapm-2019-100827. Online ahead of print.
    1. Scimia P, Ricci EB, Droghetti A, Fusco P. The ultrasound-guided continuous erector spinae plane block for postoperative analgesia in video-assisted thoracoscopic lobectomy. Reg Anesth Pain Med. 2017;42:538–539. doi: 10.1097/AAP.0000000000000616.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner