The Delineation of Another Standard for Postoperative Pain Management Following Thoracic Surgery

Abstract

Enhanced recovery after surgery pathways have allowed locoregional anesthesia to gather greater momentum in the perioperative pain management for minimally invasive thoracic surgery. 1,2 In this regard, locoregional techniques, including paravertebral blockade (PVB) and intercostal nerve blockade, complement the more traditional thoracic epidural analgesia. Despite these advances, pain control failure continues to be a vexing problem following thoracic operations and contributes to postoperative complications. With respect to ultrasound-guided PVB (PVB-US), pain control may fail for several reasons, including technical errors and poor sonographic visualization in patients with a larger body habitus. Intraoperative PVB (PVB-VATS) confers the advantage of direct visualization of the pleural space, allowing more accurate and precise administration of local anesthesia compared to PVB-US.In the trial reported in this issue of JAMA Surgery, Chenesseau et al 3 demonstrated that intraoperative PVB-vats performed by surgeons was noninferior to preoperative PVB-US performed by anesthesiologists, with respect to average post-PVB opioid consumption in the 48 hours following surgery, as well as other perioperative metrics. Additionally, the duration of anesthesia was shorter following PVB-VATS compared with PVB-US. 3 However, in 6% of the PVB-VATS group, inadequate lung isolation or pleural adhesions precluded relying upon this approach, illuminating one of the downsides to this technique. In the setting of reoperation or highly suspected pleural adhesions, PVB-US would be preferred.

Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery

“…The technique for a thoracic PVB can be performed using either a landmark-based approach or with the aid of ultrasound guidance, which has increased in popularity due to its higher accuracy and safety profile [8,32,33]. The patient is usually in a sitting or lateral decubitus position.…”