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Kanani F, Nugzar R, Shimonov M, Akar FA. Comparative Analysis of Perioperative Analgesia Methods in Thoracic Surgery: A Literature Systemic Review. J Clin Med 2025; 14:2484. [PMID: 40217933 PMCID: PMC11989615 DOI: 10.3390/jcm14072484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2025] [Revised: 03/28/2025] [Accepted: 04/03/2025] [Indexed: 04/14/2025] Open
Abstract
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.
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Affiliation(s)
- Fahim Kanani
- Department of Surgery, The Edith Wolfson Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (F.K.); (M.S.)
| | - Rijini Nugzar
- Department of Anaesthesia, The Edith Wolfson Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Mordechai Shimonov
- Department of Surgery, The Edith Wolfson Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (F.K.); (M.S.)
| | - Firas Abu Akar
- Department of Thoracic Surgery, The Edith Wolfson Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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van Zyl T, Ho AMH, Klar G, Haley C, Ho AK, Vasily S, Mizubuti GB. Analgesia for rib fractures: a narrative review. Can J Anaesth 2024; 71:535-547. [PMID: 38459368 DOI: 10.1007/s12630-024-02725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).
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Affiliation(s)
- Theunis van Zyl
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Christopher Haley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), School of Medicine, Queen's University, Kingston, ON, Canada
| | - Susan Vasily
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Kingston General Hospital, Victory 2 Wing, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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Liu Q, Zhong Q, Zhou NN, Ye L. Giant tumor resection under ultrasound-guided nerve block in a patient with severe asthma: A case report. World J Clin Cases 2022; 10:3200-3205. [PMID: 35603332 PMCID: PMC9082712 DOI: 10.12998/wjcc.v10.i10.3200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/05/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND General anesthesia in critically ill patients is associated with increased risk of complications. Nerve block anesthesia is an alternative, but could be challenging in cases with surgical field that involves multiple dermatomes.
CASE SUMMARY We report resection of a giant lipoma in the left shoulder and upper back under supraclavicular brachial plexus block plus T3-4 paravertebral block in an older patient with severe asthma. A 70-year-old patient presented with a slow-growing giant mass (25, 15 and 5 cm in length, width and depth, respectively) that extended from the lateral side of the left scapula to the axillary midline, and from the T5 thoracic vertebra intercostal to the mid-medial section of the left upper arm. He had sharp intermittent pain over the mass for the past 7 d. The patient also had severe bronchial asthma for the past 8 years. A pulmonary function test revealed only 20% of the predicted forced expiratory volume in 1 second (FEV1, 0.49 L). After controlling asthma with glucocorticoid, the tumor was resected under ultrasound-guided supraclavicular brachial plexus block and T3-4 paravertebral block. The surgery was completed without incident.
CONCLUSION Ultrasound-guided regional nerve block is a viable alternative for patients with poor cardiopulmonary function undergoing shoulder, back and axillary surgery.
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Affiliation(s)
- Qian Liu
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing Zhong
- Department of Anesthesiology, The People's Hospital of Jianyang City, Jianyang 610041, Sichuan Province, China
| | - Ni-Na Zhou
- Department of Anesthesiology, Zigong First People’s Hospital, Zigong 643000, Sichuan Province, China
| | - Ling Ye
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Al-Talabani BG, Abdullah HO, Kakamad FH, Abdulla BA, Salih KM, Mohammed SH, Salih AM. Bilateral brachial plexus block as alternative to general anaesthesia in high-risk patient; a case report and literature review. Ann Med Surg (Lond) 2022; 75:103378. [PMID: 35242325 PMCID: PMC8881413 DOI: 10.1016/j.amsu.2022.103378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/04/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Bilateral brachial plexus blocks can be an alternative to general anaesthesia in the surgery of arm, forearm, wrist, or hand. This study aims to report a case in which a risky patient underwent amputation surgery under regional anaesthesia. Case presentation A 64-year-old male was admitted to the hospital for an amputation operation. Ultrasonography revealed normal findings regarding internal organs, aside from grade II increased echogenicity of both kidneys and a small bladder cyst. Echocardiography revealed mildly left ventricular dilation, moderate systolic left ventricular dysfunction, ejection fraction 38%, left ventricular wall hypokinesia with left ventricular dilation. The amputation was performed under a bilateral supraclavicular brachial plexus block with the guidance of ultrasound. Discussion Theoretically, there are some advantages to regional anaesthesia in comparison to general anaesthesia, such as decreasing the ordinary body response to stress in the presence of low levels of cortisol and catecholamines, increasing blood flow and peripheral vasodilatation, decreasing hypercoagulability, lower risk of arterial and venous thrombosis and it aids to prevent endotracheal intubation and mechanical ventilation. Conclusion Bilateral brachial plexus blocks, as a type of regional anaesthesia under ultrasound guidance, can be depended upon as a reliable substitute for general anaesthesia in perilous conditions.
Bilateral brachial plexus blocks (BBPB) are a kind of regional anaesthesia that can be used instead of general anaesthesia. Several complications may be encountered during the process of BBPB, including diaphragmatic paralysis. In this study, BBPB has been discussed with literature review.
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Sun L, Li Q, Wang Q, Ma F, Han W, Wang M. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study. BMC Anesthesiol 2019; 19:101. [PMID: 31185919 PMCID: PMC6560727 DOI: 10.1186/s12871-019-0768-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/24/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG. METHODS This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016-2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events. RESULTS Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups. CONCLUSIONS Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA.
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Affiliation(s)
- Lixin Sun
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Qiujie Li
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Qiang Wang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Fuguo Ma
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Wei Han
- Department of Respiratory Medicine, Qingdao Municipal Hospital, 1 Jiaozhou Road, Qingdao, 266011, Shandong, China.
| | - Mingshan Wang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
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Mudumbai SC, Auyong DB, Memtsoudis SG, Mariano ER. A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain Manag 2018; 8:475-485. [DOI: 10.2217/pmt-2018-0017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.
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Affiliation(s)
- Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - David B Auyong
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Departments of Anesthesiology and Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
PURPOSE OF REVIEW Breast surgery, performed for medical or cosmetic reasons, remains one of the most frequently performed procedures, with over 500,000 cases performed annually in the USA alone. Historically, general anesthesia (GA) has been widely accepted as the gold-standard technique, while epidural anesthesia was largely considered too invasive and thus unnecessary for breast surgery. Over the past years, paravertebral block (PVB) has emerged as an alternative analgesic or even anesthetic technique. Substantial evidence supports the use of PVB for major breast surgery. RECENT FINDINGS In patients receiving PVB, immediate and long-term analgesia is superior to systemic analgesia while opioid use and typical adverse effects of systemic analgesia such as nausea and vomiting are decreased. The benefits may also include an improved oncological survival with PVB after mastectomy for malignancy. PVB offers clinically significant benefits for perioperative care of patients undergoing breast surgery. The benefits of continuous PVB are most firmly supported for major breast surgery and include both effective short-term pain control and reduction in burden of chronic pain. On the other hand, minor breast surgery should be effectively manageable using multimodal analgesia in the majority of patients, with PVB reserved as analgesic rescue or for patients at high risk of excessive perioperative pain.
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Fang G, Wan L, Mei W, Yu HH, Luo AL. The minimum effective concentration (MEC90 ) of ropivacaine for ultrasound-guided supraclavicular brachial plexus block. Anaesthesia 2016; 71:700-705. [PMID: 26945818 DOI: 10.1111/anae.13445] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 12/31/2022]
Abstract
The aim of this study was to determine the minimum effective concentration of ropivacaine for ultrasound-guided supraclavicular brachial plexus block. Fifty-one patients undergoing arm surgery received double-injection ultrasound-guided supraclavicular block using ropivacaine 40 ml. The concentration of ropivacaine administered to each patient started at 0.225% and then depended on the response of the previous one, based on a biased coin design up-and-down sequential method. In case of failure, the ropivacaine concentration was increased by 0.025% w/v in the next subject. In the case of a successful block, the next patient was randomised to the same concentration or a concentration 0.025% w/v less. Success was defined as complete sensory blockade of the brachial plexus 30 min after the block together with pain-free surgery. The minimum effective ropivacaine concentration in 90% of subjects was 0.257% w/v (95% CI 0.241-0.280%).
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Affiliation(s)
- G Fang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - L Wan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - W Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - H H Yu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - A L Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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