Continuous Erector Spinae Plane Block or Thoracic Epidural Analgesia Following Video Assisted Thoracic Surgery
Condition: Lung Diseases
MeSH terms: Lung Diseases
Study type: Interventional

Summary: 
      Video assisted thoracic surgery (VATS) has recently been evaluated as the standard surgical
      procedure for lung surgery. Although VATS is less painful than thoracotomy, patients may feel
      severe pain during the first hours at postoperative period. Analgesia management is very
      important for these patients in postoperative period since insufficient analgesia can cause
      pulmonary complications such as atelectasis, pneumonia and increased oxygen consumption. The
      ultrasound (US) guided erector spina plane (ESP) block is a novel interfacial plan block
      defined by Forero et al. at 2016. ESP block provides thoracic analgesia at T5 level and
      abdominal analgesia at T7-9 level. Visualization of sonoanatomy with US is easy, and the
      spread of local anesthesic agents can be easily seen under the erector spinae muscle (12).
      Thus, analgesia occurs in several dermatomes with cephalad-caudad way. In the literature,
      there is not still any randomized study evaluating ESP block efficiency for postoperative
      analgesia management after VATS. The aim of this study is to compare US-guided continuous ESP
      block and TEA for postoperative analgesia management after VATS.
    

Detailed description: 
      Video assisted thoracic surgery (VATS) has recently been evaluated as the standard surgical
      procedure for lung surgery. The advantages of VATS procedures compared with open thoracotomy
      are rapid recovery, short hospital stay and low complication risk. Although VATS is less
      painful than thoracotomy, patients may feel severe pain during the first hours at
      postoperative period. Thoracic epidural analgesia (TEA) which is the gold standard analgesic
      technique after thoracotomy, is generally used for analgesia management after VATS. However,
      since the surgical technique and trauma between open surgery and VATS are different, the
      question of what should be the gold standard for analgesia management after VATS is a topic
      of discussion. Especially due to the difficult administration and adverse effect profile of
      TEA, the opinion of minimally invasive surgical procedures, requiring less invasive analgesic
      techniques is supported. Analgesia management is very important for these patients in
      postoperative period since insufficient analgesia can cause pulmonary complications such as
      atelectasis, pneumonia and increased oxygen consumption.

      The ultrasound (US) guided erector spina plane (ESP) block is a novel interfacial plan block
      defined by Forero et al. at 2016. ESP block provides thoracic analgesia at T5 level and
      abdominal analgesia at T7-9 level. The ESP block contains a local anesthetic injection into
      the deep fascia of erector spinae. This area is away from the pleural and neurological
      structures and thus minimizes the risk of complications due to injury. Visualization of
      sonoanatomy with US is easy, and the spread of local anesthesic agents can be easily seen
      under the erector spinae muscle. Thus, analgesia occurs in several dermatomes with
      cephalad-caudad way. Cadaveric studies have shown that the injection spreads to the ventral
      and dorsal roots of the spinal nerves and creates sensory blockade in both posterior and
      anterolateral thorax. In the literature, it has been reported that ESP block provides
      effective analgesia after open heart surgery, breast surgery and ventral hernia repair in
      randomized controlled studies about ESP block efficiency for postoperative analgesia
      management. In some case series and case reports it has been reported that ESP block provides
      effective analgesia after thoracotomy and VATS. Furthermore, it has been reported that it
      provides effective analgesia in chronic and persistant pain syndromes of thorax.

      The aim of this study is to compare US-guided continuous ESP block and TEA for postoperative
      analgesia management after VATS. The primary aim is to compare perioperative and
      postoperative opioid consumption and the secondary aim is to evaluate postoperative pain
      scores (VAS), adverse effects related with opioids (allergic reaction, nausea, vomiting),
      complications due to blocks (pneumothorax, hematoma), and the time period and number of
      attempt for blocks.
    

Intervention name(s): ESP block (Group A); TEA group (Group B)
Intervention type(s): Other; Other
Intervention description(s): US probe will be placed longitudinally 2-3 cm lateral to the T5 transvers process. From superior to inferior, three muscles will be visualized on the hyperechoic transverse process; trapezius (upper), rhomboideus major (middle), erector spinae (lower). The block needle will be inserted cranio caudal direction and then for correction of the needle 5 ml saline will be injected deep into the erector spina muscle fascia. Following confirmation of the correct position 20G catheter will be inserted 5 cm in caudal direction. 20 ml %0.25 bupivacaine will be administered for block.; Local infiltration with 2% of lidocaine under the skin, in T4/T5 intervertebral space will be administered. An 18 G Tuohy needle will be inserted at T4/T5 intervertebral space to identify epidural space using the loss of resistance technique. 20G catheter will be inserted 3-4 cm in caudal direction in the epidural space. Bolus dose of 0.125% bupivacaine 10 ml will be administered through the catheter after the negative aspiration for blood or cerebrospinal fluid
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Sixty patients aged 18-65 years old with American Society of Anesthesiologists (ASA) classification I-II and scheduled for VATS under general anesthesia will be included in the study. Patients with a history of bleeding diathesis, receiving anticoagulant treatment, known local anesthetics and opioid allergy, infection of the skin at the site of the needle puncture, pregnancy or lactation, and patients who do not accept the procedure will be excluded from the study. Randomization will be achieved using a randomizing computer program. Patients will be randomly divided into two groups (Group A = ESP group, Group B = TEA group) including 25 patients each, before entering the operating room.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Video assisted thoracic surgery; Postoperative pain management; Erector spina plane block; Thoracic epidural analgesia