Original Article
Evaluation of the effect of serratus anterior plane block for pain treatment after video-assisted thoracoscopic surgery

https://doi.org/10.1016/j.accpm.2017.09.005Get rights and content

Abstract

Background

Analgesia following video-assisted thoracoscopic surgery (VATS) is important for the prevention of postoperative pulmonary complications. Various regional methods of anaesthesia are currently being used to achieve this goal. In our study, we aim to assess the effectiveness of SAPB on postoperative VATS analgesia in our study.

Methods

A total of 40 patients aged between 18 and 70 years, those who were in the Society of Anaesthesiologists (ASA) I–III class and underwent VATS were included in the study. Patients were randomised to either group T (intravenous patient-controlled analgesia tramadol; n = 20) or group S (intravenous patient-controlled analgesia tramadol + SAPB; n = 20). Visual Analogue Scale (VAS) was used for postoperative pain, the primary outcome measure, were evaluated at post-anaesthetic care unit (PACU), 2, 6, 12, and 24 hours. Secondary outcomes included the postoperative 2nd, 6th, 12th, and 24th hour follow-up results were evaluated to identify the quantity of tramadol use, Ramsay sedation scale (RSS), side effect profile, and additional analgesic use.

Results

The VAS scores between the two groups were found to be statistically significantly lower in group S during the PACU observation (P < 0.05). The mean values of the quantity of tramadol use at the 6th, 12th, and 24th hours were found to be statistically significantly lower in group S (P < 0.05). There was no statistically significant difference in the rate of side effects and RSS outcomes between the groups (P > 0.05).

Conclusions

Our study results suggest that SAPB is an effective treatment option for VATS analgesia.

Introduction

Video-assisted thoracoscopic surgery (VATS) provides an opportunity to penetrate the thoracic cavity by video through an incision into the chest wall and facilitate surgical operation of lung pathologies. Frequent use of this method has lately led to the success of procedures such as lobectomy, bullectomy, and wedge resection [1]. The procedure has also been reported to be less expensive, has a better postoperative pulmonary function, early mobilisation and less pain, compared to open surgery [2], [3]. Postoperative VATS-related pain is considered to be moderate, and pain with a possibility of becoming chronic at a rate of 22 to 63% is usually due to intercostal, muscular, and soft tissue damage at the thoracic opening site [4], [5]. The success of postoperative rehabilitation applications in patients undergoing thorax surgery may be increased with minimal invasive surgical interventions (VATS) and pain palliation. “Fast-track” VATS refers to tracheal extubation in the operating room, adequate pain control and 3–4 days of hospital stay in elective surgery applications [6], [7]. Intravenous (IV) medications (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs] and opioids) and regional anaesthetic procedures are used for the management of postoperative VATS pain [6]. Although opioids are frequently used for postoperative VATS analgesia, they have several disadvantages, including dose-dependent pulmonary depression and nausea-vomiting side effects [8], [9]. Nephrotoxic and gastrointestinal side effects of NSAIDs limit their areas of use [5].

Such side effects of IV medications put regional anaesthesia on the forefront. Anaesthetists prefer methods of regional anaesthesia, such as thoracic epidural analgesia (TEA), paravertebral block (PVB), and intercostal block (ICB) [8]. Although TEA has been identified as the gold standard in the management of pain following thoracotomy, TEA and PVB have similar potential effects in the management of postoperative VATS pain [9]. Some drawbacks in neuraxial block applications (including complications due to nerve damage and limitation of postoperative anticoagulation use) have led to alternative regional methods. Increased use of ultrasonography (USG) during regional anaesthesia has paved the way for alternatives to neuraxial methods for postoperative pain management, such as truncal block [quadratus lumborum block, pectoral nerve block (PECS), transverse abdominis plane (TAP) block, and serratus anterior plane (SAP) block] [10], [11], [12]. The PECS and SAP block (SAPB) provide analgesia in the thoracic wall. In 2013, Blanco et al. [12] described the SAPB for breast and chest surgical operations [12]. The SAPB was demonstrated to provide analgesia to the 2nd and 9th thoracic dermatomes, and was successfully used in the management of acute and chronic pain after thoracotomy, postoperative breast operations, and for intensive care weaning [13], [14], [15], [16].

We could not find a study evaluating SAP block efficacy for analgesia after VATS operations in the literature. In this context, we aimed to investigate the effect of SAPB on postoperative VATS analgesia in our study.

Section snippets

Patient selection

This randomised, single, blind study included a total of 50 patients who were scheduled for VATS. A written informed consent was obtained from each patient. The local Ethics Committee approved the study protocol (the decision number is 2011-KAEK-25 2016/13-06). The study was conducted in accordance with the principles of Declaration of Helsinki (clinical trials number is NCT03217292).

Patients aged between 18 and 70 years, those who were in the American Society of Anesthesiologists (ASA) I–III

Results

The study was completed in 40 patients; with in group T (n = 20) and in group S (n = 20). Of the patients, 20 were males and 20 were females with a mean age of 54.20 (range: 68 to 34) years (Table 1). The VAS scores at 2nd, 6th, 12th, and 24th hours were found to be significantly lower than the scores measured at 0 hour in both groups (P < 0.05) (Table 2). Additionally, VAS scores at all measurement times were significantly lower in group S than in group T (P < 0.05) (Table 2). The amounts of PCA

Discussion

We applied bupivacaine at 0.25% concentration after VATS operation and we tried to determine the SAPB effectiveness with VAS and Tramadol consumption amount. Results of our study show that patients who underwent SAPB had a lower VAS and lesser quantity of tramadol use. Being less traumatic than thoracotomy, VATS is currently commonly used for many lung pathologies [1]. Video-assisted thoracic surgery (VATS) quickly replaces the conventional thoracotomy, as it is associated with less morbidity,

Conclusion

Our study results show that SAPB can be an effective treatment option for postoperative VATS analgesia. Current analgesic approaches are designed as multimodal applications; however, treatment schemes may be in use in the coming years for postoperative VATS analgesia. Although SAPB is advantageous due to its relative ease of application, further RCTs are required to investigate the efficacy and indications for SAPB.

Financial disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure of interest

The authors declare that they have no competing interest.

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