pecs ii block in thoracic outlet decompression

Conditions: Thoracic Outlet Syndrome

Summary: rationale: postoperative pain management after transaxillary thoracic outlet decompression surgery (tatod) is difficult. in a retrospective case-control trial, we found evidence that a pecs ii block is able to reduce pain and morphine consumption. this may ultimately lead to less morphine induced side-effects and improved patient satisfaction. however, the risk of bias in retrospective research is high. to determine the effect of pecs ii in tatod, a randomized controlled double blinded trial could offer more valuable scientific evidence. our hypothesis is that a pecs ii block will reduce pain, opioid use and opioid induced side-effects in patients undergoing transaxillary tod (tatod). objective: the aim of the study is to determine the effect of a pecs ii block on postoperative pain and opioid use in patients undergoing tatod. the secondary objective is to determine the effect of a pecs ii block on opioid induced side effects such as postoperative nausea and vomitus and the quality of recovery study design: single centre randomized controlled double blinded trial study population: all patients with neurogenic thoracic outlet syndrome (ntos) selected for tatod by the tos multidisciplinary workgroup and based on the specifications in 2016 svs reporting standards. intervention: the study group will receive a pecs ii block with 40 ml ropivacaine 5 mg/ml. the control group will receive a pecs ii block with 40 ml nacl 0.9%. main study parameters/endpoints: primary outcome parameters are postoperative pain using the numeric rated scale (nrs) score assessed at rest and when moving and postoperative morphine-equivalent consumption. secondary outcome parameters are postoperative nausea and vomitus (ponv) and quality of recovery questionnaire (qor-15). nature and extent of the burden and risks associated with participation, benefit and group relatedness: all patients will undergo ultrasound guided injection, after induction of anaesthesia. the administration of the injection does not invoke any extra physical discom-fort. possible complications include hematoma and pneumothorax, however, the risk is very low (\<1%)\[1\]. in the intervention group, we expect less pain, a reduced need for pain medica-tion and less postoperative nausea and vomitus. we do not expect an altered postoperative course in the control group. patients will be asked to fill out a questionnaire. extra blood sam-ples, site visits, physical examinations or other test will not be done in this study.


Eligibility criteria:
inclusion criteria: * patients with ntos * selected for a trans-axillary thoracic outlet decompression (tatod) by the tos multidisciplinary workgroup. * fit for surgery, defined as asa (american society of anesthesiologists) classification of i, ii or iii. * 18 years of age or older * sufficient in speaking and writing the dutch language * normal liver and renal function * informed consent exclusion criteria: * patients with a history of tod (redo-surgery) * patients with atos or vtos * asa ≥ 4 * kidney or liver failure with contra-indication for nsaid or paracetamol * mental retardation * pregnancy * patients with chronic strong opioid use (\>3 administrations per week or continuous transdermal therapy, longer than the last 3 months) * allergy to one or more medications used in the study including, ropivacaine, dexamethasone, propofol, sufentanil, succinylcholine, paracetamol, nsaid, morphine, granisetron * patients that have trouble expressing themselves in dutch. questionnaires are completed by the patients and checked by the nurses. the questionnaire is in dutch. if there is a language barrier between the questionnaire, the patient or the health care worker, we believe the validity of the answers is questionable.