Intercostal Nerve Blocks With Liposomal Bupivacaine: Demonstration of Safety, and Potential Benefits

Mehran, Reza J.; Walsh, Garrett L.; Zalpour, Ali; Cata, Juan P.; Correa, Arlene M.; Antonoff, Mara B.; Rice, David C.

doi:10.1053/j.semtcvs.2017.06.004

Cited by 31 publications

(33 citation statements)

References 13 publications

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“…Among 66 studies included in the qualitative analysis, 55 studies [52][53][54][55][56][57][58][59]61,[64][65][66][67][68][69][70][71]73,74,[76][77][78][80][81][82] (3024 patients) were experimental, and 11 studies 50,51,60,62,63,72,75,79,[83][84][85] (2160 patients) were observational. Because analgesic techniques vary based on the type of surgery performed, we divided the populations accordingly.…”

Section: Qualitative Synthesismentioning

confidence: 99%

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

et al. 2021

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IMPORTANCEThe use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown. OBJECTIVE To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.DATA SOURCES A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.STUDY SELECTION Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items forSystematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model. MAIN OUTCOMES AND MEASURESThe coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function. RESULTSOf 694 records screened, 608 were excluded based on prespecified exclusion criteria.The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (continued)

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Section: Qualitative Synthesismentioning

confidence: 99%

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

et al. 2021

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“…Initially, we used opioid thoracic epidurals in conjunction with postoperative intravenous infusions of lidocaine and ketamine in the ERAS-T pathway. By June 2016 our pharmacy committee granted approval for liposomal bupivacaine (lipoB) surgical site injection for thoracotomy patients, at which point we began using posterior intercostal nerve block (PINB) with lipoB [7,17,18] in conjunction with subarachnoid morphine and 24-hour intravenous ketamine infusion for the ERAS-T pathway [19]. This remains our current strategy.…”

Section: Refinement Of the Protocolmentioning

confidence: 99%

Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year

Martin

Sarosiek

Harrison

et al. 2018

The Annals of Thoracic Surgery

140

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“…The thoracic surgery unit nursing staff was regularly provided extensive in-service training regarding all components of the postoperative care, pain assessment and administration of PRN opioid analgesics commensurate to patient-reported pain levels. For intraoperative regional analgesia, LipoB was diluted with 50 mL of injectable saline and the initial 30 mL was used to infiltrate the sub-dermis of the entire intended thoracotomy prior to skin incision, upon entrance into the pleural cavity and the remaining 40 mL of the mixture was used to infiltrate 9 intercostal spaces as well as the soft tissue at the posterior thoracotomy site above and below the incision, similar to the technique described by Mehran and colleagues under direct vision using a 21 gauge spinal needle (9,10). The nursing staff routinely performed scheduled objective pain assessments using the visual analog pain scale and administered rescue opioid analgesics (as prescribed) at their discretion.…”

Section: Development and Implementation Of Eratsmentioning

confidence: 99%

Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients—achieving better pain control with less (schedule II) opioid utilization

Kodia¹,

Stephens-McDonnough²,

Alnajar³

et al. 2021

J Thorac Dis

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Background: Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra-and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. Methods: This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. Results: A total of 98 patients (43 pre-and 55 post-protocol implementation) were included in this study.There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5-16.5) (ERATS) vs. 19.5 (12.6-36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0-330.0) vs. 800.0 (450.0-975.0), P<0.0001 and schedule II MME: 90.0 (0-242.2) vs. 800.0 (450.0-975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group. Conclusions: Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.

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Intercostal Nerve Blocks With Liposomal Bupivacaine: Demonstration of Safety, and Potential Benefits

Cited by 31 publications

References 13 publications

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year

Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients—achieving better pain control with less (schedule II) opioid utilization

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