Search Results (29)

Background: An erector spinae plane block (ESPB) has gained popularity due to its effectiveness and simplicity for pain relief. However, it is uncertain whether an ESPB provides superior analgesia after a VATS or thoracotomy compared to other regional and systemic analgesic techniques. Methods: A retrospective cohort study was conducted from January to June 2023 comparing an ESPB with intravenous combination analgesia (IV–CA) in VATS patients and with thoracic epidural analgesia (TEA) in thoracotomy patients. The primary endpoint was the opioid demand during the first two hours in the post-anesthesia care unit (PACU). The secondary outcomes included the pain scores and adverse events. Results: A total of 61.2% of the 165 included VATS patients and 56.9% of the 72 thoracotomy patients were treated with an ESPB. Following a VATS, an ESPB decreased the median piritramide demand (7.5 [3.0 to 12.0] vs. 10.5 [6.5 to 15.5] mg, p < 0.01). However, after a thoracotomy, an ESPB increased the median piritramide demand (12.0 [6.0 to 15.0] vs. 3.0 [0.0 to 9.0] mg, p < 0.01). The pain scores and adverse events were similar between the groups. Conclusions: An ESPB reduces the piritramide demand in VATS patients compared with IV–CA, providing similar pain relief. However, in thoracotomy patients, an ESPB is associated with an increased piritramide demand compared to TEA. An ESPB is an attractive add-on to IV–CA after a VATS, while TEA remains the gold standard after a thoracotomy. Full article

Background: Caudal anesthesia is an important regional anesthetic technique in neonates. The placement of a catheter can provide excellent analgesia for a prolonged period; the role of adjuvants, in particular morphine, however, remains unclear. We aimed to describe our experience with caudal catheters for major surgery in neonates. Methods: We included all neonates who had a caudal catheter placed for major abdominal and thoracic surgery and explored postoperative pain management and catheter complications. This retrospective case series included neonates with caudal catheter placement from October 2012 to April 2018 at a tertiary university hospital. Results: A total of 33 caudal catheter placements in 32 neonates were included in this study, of which 28 (85%) were a laparotomy and 5 (15%) a thoracotomy. The mean catheter duration was 135 h with a postoperative failure rate of 3%. Patients who did not receive intravenous opioids postoperatively had a significantly shorter stay in the intensive care unit than those who did (341 h vs. 674 h, p = 0.01). All patients received continuous local anesthetics over the catheter, and 79% received additional intermittent epidural morphine postoperatively for a median period of 42 h. No infectious complications were reported. Conclusions: Caudal catheters are a valuable option for perioperative analgesia for major surgery in neonates. We found no serious catheter-related complication. Further research is needed to define the optimal approach and combination of different analgesic techniques. Full article

Background/Objectives: Effective pain management following thoracic surgery remains challenging yet crucial for optimal patient outcomes. This literature review compares the efficacy, safety, and clinical outcomes of different perioperative analgesia methods in thoracic surgery patients, focusing on paravertebral block (PVB), intercostal nerve block (ICNB), epidural analgesia (EPI), erector spinae plane block (ESPB), and patient-controlled analgesia (PCA). Methods: A systematic search was conducted across medical databases, yielding ten relevant randomized controlled trials and meta-analyses. Results: The evidence indicates that paravertebral block provides superior pain control with lower opioid requirements, fewer adverse events, and higher patient satisfaction compared to other methods. While epidural analgesia offers pain control comparable to PVB, it is associated with higher technical failure rates and side effects, including urinary retention, nausea/vomiting, and hypotension. ICNB and ESPB demonstrate efficacy superior to systemic analgesia but generally inferior to PVB in terms of pain scores and opioid consumption. Conclusions: This review highlights the need for individualized approaches to perioperative pain management in thoracic surgery, with paravertebral block emerging as a preferred option due to its favorable efficacy and safety profile. Full article

Background/Objectives: Effective pain management in polytrauma patients with rib fractures is essential, particularly in the critical care setting. While epidural analgesia is considered the gold standard, it is not always feasible, necessitating alternative locoregional approaches. We present the case of a polytrauma patient with multiple, bilateral rib fractures and severe chest pain that hindered weaning from mechanical ventilation. A bilateral Serratus Anterior Plane Block (SAPB) was performed, with catheters placed for continuous administration of local anesthetics. Pain relief was immediate, enabling a rapid weaning from mechanical ventilation, safe extubation, and subsequent discharge to rehabilitation. A review of the literature on this technique in critically ill patients with thoracic trauma and multiple rib fractures is also presented. Methods: We conducted a literature search up to November 2024, identifying studies evaluating the use of SAPB in critically ill patients with chest trauma and rib fractures. Results: Eight studies were identified, including a total of 197 cases, of which only 3 involved a bilateral SAPB. Studies and published case reports demonstrated significant variability in analgesic protocols and reported outcomes. Notably, only two papers addressed specifically its role in facilitating weaning from mechanical ventilation. Conclusions: Pain control is fundamental in managing severe chest trauma. This case and the reviewed literature suggest that the SAPB is a promising option when epidural analgesia is contraindicated or impractical. However, further studies are needed to define its place in clinical practice and optimize its use in critically ill patients. Full article

Background/Objectives: Continuous epidural analgesia is desirable for improving infant outcomes after surgeries. However, its contribution to facilitating extubation is not well known. Methods: A retrospective chart review was conducted at the UPMC Children’s Hospital of Pittsburgh to identify all infants who received an epidural catheter between 2018 and 2024 and required postsurgical admission to the Neonatal Intensive Care Unit (NICU). The study examined the timing of extubation and reintubation, along with associated factors, in 100 infants who underwent major surgeries. Results: In total, 100 infants, 43 females and 57 males, 40 (38.39–42.07) weeks corrected gestational age, 3 (2.52–3.42) kg received epidural catheters. Sixty-two patients had a pulmonary condition. Of 45 infants extubated in the operating room, 32 received fentanyl intraoperatively, and 16 required a morphine infusion in the NICU. Among 55 infants that remained intubated, 24% underwent a thoracic procedure, 46 received intraoperatively fentanyl, and 21 needed an opioid infusion postoperatively. The extubation day was median (IQR) 2 (1–4), and 24% remained intubated beyond day 5. Twelve infants were intubated preoperatively, and six required prolonged ventilation beyond day 5. Of 15 infants that required reintubation, 8 received a morphine infusion. The medians (IQR) of the average of three pain and sedation scores before reintubation were 1.67 (1–3) and 0 (−1.67–0), respectively. Conclusions: Epidural analgesia may facilitate early extubation in some infants undergoing surgeries. Morphine infusion was administered at a similar rate between infants extubated and those who remained intubated, and its role in delaying extubation timing remains unclear. Full article

Background/Objectives: Postoperative analgesia is important for reducing biologically invasive reactions to surgery. In Japan, postoperative analgesia, including indices of analgesia, has not been adequately addressed. This study aimed to determine the relationship between postoperative pain and postoperative course and the importance of analgesia for early recovery. Methods: Patients who underwent any of seven surgical procedures in gastrointestinal, thoracic, and cardiac surgery were enrolled. The primary endpoint was a median Prince Henry Pain Scale score from postoperative days 1 to 3. Secondary endpoints were the quality of recovery on postoperative day 7 (Quality of Recovery-15 [QoR-15]) and the length of postoperative hospital stay. Results: Median postoperative pain levels among surgeries were 3 on day 1, 2 on days 2 and 3, 1 on day 7, and 1 at discharge. In both univariate and multivariate analyses, the use of postoperative epidural analgesia and intravenous patient-controlled analgesia (IV-PCA) were significant predictors of early postoperative pain. Only early postoperative pain was a significant predictor of QoR-15 score. Regular use of acetaminophen, early postoperative pain, no appetite, and postoperative complications were significant in affecting the length of postoperative hospital stay. In the comparison of early postoperative pain according to whether epidural analgesia and IV-PCA were used, the group that used both methods had the least pain. Conclusions: In Japan, early postoperative pain persists after major surgical procedures and affects postoperative quality of recovery and length of hospital stay. The use of epidural analgesia, IV-PCA, or both appeared to be effective in overcoming early postoperative pain, thereby enhancing early postoperative recovery. Full article

Thoracic surgery is associated with significant postoperative pain, which can hinder recovery and elevate morbidity risks. Traditionally, epidural anesthesia has been the cornerstone for pain management, but its drawbacks including technical challenges, side effects, and complications necessitate exploring alternative methods. This narrative review examined recent advances in perioperative analgesic strategies in thoracic surgery, focusing on regional anesthetic techniques like paravertebral blocks (PVBs), erector spinae plane blocks (ESPBs), intercostal blocks, and serratus anterior blocks. Each approach was evaluated for efficacy, safety, and impact on patient outcomes. PVB can provide effective unilateral analgesia with fewer systemic complications compared to epidurals. ESPB provides analgesia through a superficial, ultrasound-guided approach, minimizing risks and offering an alternative for various thoracic procedures. Intercostal blocks are effective but are limited by the need for multiple injections, increasing the complication risks. Serratus anterior blocks, targeting intercostal and thoracic nerves, show promise in managing lateral thoracic wall pain with a low complication rate. Advancements in surgical techniques including minimally invasive approaches further optimize pain control and recovery. A multimodal analgesic approach combining regional anesthesia and systemic therapies enhances outcomes by addressing somatic and visceral pain components. Despite the efficacy of epidural analgesia, alternative regional techniques offer comparable pain relief with fewer complications, suggesting their growing role in thoracic surgery. Collaborative efforts between surgical, anesthetic, and emergency teams are crucial for tailoring pain management strategies to individual patients, improving recovery and reducing long-term morbidity. Future research should continue exploring these methods to refine their application and broaden their accessibility. Full article

Background/Objectives: Esophagectomy is a key component of esophageal cancer treatment, with minimally invasive esophagectomy (MIE) increasingly replacing open esophagectomy (OE). Effective postoperative pain management can be achieved through various analgesic modalities. This study compares the efficacy of thoracic epidural anesthesia (TEA) with non-TEA methods in managing postoperative pain following MIE. Methods: A retrospective review was conducted on 110 patients who underwent MIE between 2018 and 2023. 1. TEA vs. 2. intravenous patient-controlled analgesia (PCA) alone vs. 3. transversus abdominis plane (TAP) catheter with PCA vs. 4. single-shot TAP block with paravertebral catheter (PVB) in combination with PCA were compared. The primary outcome was postoperative pain within the first 72 h, assessed using the numeric rating scale. Secondary outcomes included postoperative surgical complications (Clavien–Dindo classification (CDC)), patient satisfaction, and duration of induction and emergence, among others. Results: The incidence of an NRS > 3 during movement was 47.1%, 51%, 60.1%, and 48.3% for TEA, PCA alone, TAP + PCA, and PVB + PCA, respectively. For pain at rest, the rates were 8.3%, 4.3%, 11.2%, and 5%, respectively. High surgical complication rates were observed across all groups (CDC IIIa-V 31.6% overall), with patient satisfaction similarly high, regardless of the analgesic modality used (85% satisfied or very satisfied). No differences in the other secondary outcomes were observed. Conclusions: PVB combined with PCA offered analgesic efficacy and patient satisfaction comparable to TEA in managing postoperative pain following MIE. Full article

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain control, and the integration of enhanced recovery after surgery (ERAS) protocols to optimize recovery. Double-lumen tubes (DLTs) are essential for one-lung ventilation during thoracic procedures, although they can be invasive. Recent advancements, such as video-assisted laryngoscopes, have improved the success of DLTs and reduced the invasiveness of DLT intubation and extubation. Postoperative pain management is crucial for minimizing complications and enhancing recovery. Techniques like epidural analgesia, nerve blocks, and patient-controlled analgesia improve patient outcomes by allowing early mobility and deep breathing. Dexmedetomidine (DEX), a sedative with minimal respiratory impact, has shown promise in reducing delirium and aiding recovery. This review highlights the importance of teamwork, pain management, and emerging technologies in improving thoracic surgery outcomes. Advances in these areas, particularly within ERAS protocols, continue to enhance patient care and overall surgical success. Full article

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine. Full article

Robotic thoracic surgery is a prominent minimally invasive approach for the treatment of various thoracic diseases. While this technique offers numerous benefits including reduced blood loss, shorter hospital stays, and less postoperative pain, effective pain management remains crucial to enhance recovery and minimize complications. This review focuses on the application of various loco-regional anesthesia techniques in robotic thoracic surgery, particularly emphasizing their role in pain management. Techniques such as local infiltration anesthesia (LIA), thoracic epidural anesthesia (TEA), paravertebral block (PVB), intercostal nerve block (INB), and erector spinae plane block (ESPB) are explored in detail regarding their methodologies, benefits, and potential limitations. The review also discusses the imperative of integrating these anesthesia methods with robotic surgery to optimize patient outcomes. The findings suggest that while each technique has unique advantages, the choice of anesthesia should be tailored to the patient’s clinical status, the complexity of the surgery, and the specific requirements of robotic thoracic procedures. The review concludes that a multimodal analgesia strategy, potentially incorporating several of these techniques, may offer the most effective approach for managing perioperative pain in robotic thoracic surgery. Future directions include refining these techniques through technological advancements like ultrasound guidance and exploring the long-term impacts of loco-regional anesthesia on patient recovery and surgical outcomes in the context of robotic thoracic surgery. Full article

Introduction: Pain management among children following thoracic surgery is an area of significant practice variability. Understanding the risk factors of moderate-to-severe pain intensity will allow for adequate pain relief. The aim of the study was to assess the maximum intensity of pain at rest in pediatric patients within 24 h of thoracic surgery and to investigate the prevalence and predictors of moderate-to-severe pain. Methods and findings: This is a prospective cohort study of patients in observational and randomized controlled trials following thoracic surgery. A secondary analysis of data was conducted using data collected from 446 patients aged 7–18 years undergoing thoracic surgery. The primary endpoint was maximum pain intensity (Numerical Rating Scale; NRS; range: 0–10) and the secondary endpoint was the prevalence and predictors of moderate-to-severe pain (NRS > 2/10). The median maximum pain in the cohort was 3 [0; 4]. During the immediate postoperative period, 54% of patients reported a maximum NRS > 2/10. The infusion of morphine by an intravenous route (vs. epidural route) was a protective factor against moderate-to-severe pain. Taking into account the findings related to the type of epidural analgesia (vs. intravenous morphine), it was found that only the administration of 0.25% bupivacaine combined with morphine or fentanyl was a protective factor against moderate-to-severe postoperative pain. Patients aged 14–18 years (vs. aged 7–13 years) had an increased risk of reporting pain as moderate-to-severe. Conclusions: The route of analgesic administration, type of multimodal analgesia, and patients’ age predict moderate-to-severe pain in pediatric patients after thoracic surgery. Full article

Background: Postoperative pain influences rehabilitation, postoperative complications and quality of life. Despite its impact, there are no uniform treatment guidelines. Different centers seem to use various strategies. This study aims to analyze pain management regimens used after anatomic VATS resections in Austrian thoracic surgery units, with a special interest in opioid usage and strategies to avoid opioids. Methods: A questionnaire was designed to assess the use of regional anesthesia, postoperative pain medication and characteristics of individual pain management regimens. The questionnaire was sent to all thoracic surgery units in Austria, with nine out of twelve departments returning them. Results: All departments use regional anesthesia during the procedure. Four out of nine centers use epidural analgesia or an intercostal catheter for postoperative regional anesthesia in at least 50% of patients. Two departments follow an opioid restrictive regimen, five depend on the visual analogue scale (VAS) and two administer opioids on a fixed schedule. Three out of nine departments use NSAIDs on a fixed schedule. The most used medication is metamizole (eight out of nine centers; six on a fixed schedule, two depending on VAS) followed by piritramide (six out of nine centers; none as a fixed prescription). Conclusions: This study reflects the heterogeneity in postoperative pain treatment after VATS anatomic lung resections. All departments use some form of regional anesthesia in the perioperative period; prolonged regional anesthesia is not utilized uniformly to reduce opioid consumption, as suggested in enhanced recovery after surgery programs. More evidence is needed to optimize and standardize postoperative pain treatment. Full article

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications. Full article