Introduction
Early rehabilitation and activation after thoracic surgery are extremely important for maintaining lung function and preventing postoperative complications. The reason for patients' poor participation in rehabilitation is most often pain in the postoperative wound or side effects of opioid analgesics. The hitherto known methods of regional analgesia after thoracic surgery have significant limitations. The purpose of the research is to demonstrate the analgesic effect of a new method of regional anesthesia by delivering local anesthetic through a catheter under the erector spinae muscle (erector spinae plane block ESPB) with a reduction in the consumption of opioid analgesics, less pain at rest and cough, and better rehabilitation in the first 48 hours after video-thoracoscopic lung surgery.
Methods
Adult subjects scheduled for elective video-thoracoscopic (VATS) lung surgery were included in a prospective, randomized, controlled study. Patients were randomly divided into two groups. In the ESPB group, a catheter was inserted preoperatively under the erector spinae muscle on the side of the operation. At the end of the operation, the initial bolus of local anesthetic was delivered through catheter, and then continued with the local anesthetic infusion according to the protocol. Patients in the ICNB group received a standard form of analgesia, which is an intrathoracic intercostal block (ICNB) performed by the surgeon at the end of surgery. All patients received a patient-controlled analgesia pump, through which they administered a dose of opioid analgesic in case of pain >3 on the visual analogue scale (VAS). All patients received additional peripherally acting analgesics. Every hour, except during sleep, the patients assessed the subjective perception of pain at rest and during coughing from 0-10 according to the VAS scale.
On the day of the operation, after 24 and 48 hours, the patients performed measurements of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Postoperative muscle strength was expressed as a percentage of the baseline preoperative value. We also monitored the frequency of side effects of opioid analgesics and the occurrence of possible complications related to the catheter.
Results
We included 60 patients in the study, of which 25 from each group made it to the final analysis. The total consumption of the opioid analgesic piritramide in the ESPB group was 21.64 ± 14.22 mg and in the ICNB group 38.34 ± 29.91 mg (p=0.035) in the first 48 hours postoperatively. Patients in the ESPB group had a lower VAS at rest than patients in the comparison group (1.19 ± 0.73 vs. 1.77 ± 1.01; p=0.039). There were no statistically significant differences between the groups in measurements of maximal inspiratory and expiratory power after 24 hours (MIP p=0.088; MEP p=0.182) or after 48 hours (MIP p=0.110; MEP p=0.645). The groups did not differ in the frequency of postoperative complications and the frequency of opioid side effects. There were also no differences in the time to removal of the thoracic drain and discharge from the hospital.
Conclusions
Patients with continuous ESPB require fewer opioid analgesics and experience less pain than patients with ICNB in the first 48 hours after VATS lung tumor surgery. There were no differences between the groups regarding postoperative respiratory muscle strength, postoperative complications and time to hospital discharge. A catheter under the erector spinae muscle is more difficult to insert and requires more care than ICNB.
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