Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review

Abstract

Background and Objective: Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.Methods: We searched PubMed and Google Scholar databases from inception to May 2021 using the terms "thoracic surgery", "thoracic surgery AND pain management", "thoracic surgery AND analgesia", "thoracic surgery AND regional anesthesia", "thoracic surgery AND epidural". We considered articles written in English and available to the reader.

Regional block techniques for pain management after video-assisted thoracoscopic surgery: a covariate-adjusted Bayesian network meta-analysis

“…ICNB is injected in multiple segments, which can counteract postoperative pain caused by the drainage tube, but this contradicts the result: in this study, network meta-regression was performed, and no effect of block segment on morphine dosage was found. SAPB covers the lateral cortical branch of the intercostal nerve and does not block pleural/internal sensation transmitted through sympathetic fibers [ 76 ], which could explain this phenomenon: the dose of postoperative opioids was slightly and insignificantly lower in the SAPB group compared to the control group.…”

Would the width of a metal rib spreader affect postoperative pain in patients who undergo video-assisted mini-thoracotomy (VAMT)?

“…In recent years, an increasing number of studies have investigated the postoperative quality of life and postoperative pain in patients with lung cancer ( 20 , 21 ). Postoperative pain not only brings great discomfort to patients, but it also leads to changes in respiratory and circulatory function, immune function, and other complications such as pneumonia, atelectasis, and even chronic pain; these changes can seriously affect the patient’s functional recovery, treatment effects, and quality of life ( 22 , 23 ). The effect that the width of expansion of a metal rib spreader can have on postoperative pain was previously unclear; therefore, we performed a retrospective analysis.…”

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

“…Cryoablation of intercostal nerves is an interesting element for acute postoperative analgesia but further research is required into the long-term effects. www.co-anesthesiology.com pneumothorax, winged scapula, and thoracodorsal artery puncture [10].…”

“…This block provides analgesia to the thoracic region by blocking the lateral cutaneous branches of the intercostal nerves from T2 to T9 [8]. Possible adverse effects of SAPB include pneumothorax, winged scapula, and thoracodorsal artery puncture [10].…”