Opioid-free Anesthesia With ESPB in VATS Operation
Condition: Opioid Use
Study type: Interventional

Summary: 
      Patients with an ASA score of 3 and below, who will undergo lobectomy with video-assisted
      thoracic surgery (VATS) method, and who gave informed consent will be included in this study.
      Patients with contraindications for the application of either of the two methods, with known
      chronic pain, opioid use, local anesthetic allergy, spinal deformity or mental or psychiatric
      problems that prevent cooperation, those taking anticoagulants, and those with infection at
      the injection site will not be included in the study. In addition, patients in the ESPB group
      who required intraoperative opioids, patients who failed ESPB, and patients who underwent
      open surgery in both groups will not be included in the analysis. Patients who agree to
      participate in the study will be randomly assigned to one of the study's opioid-free
      anesthesia and ESPB (erector spina plan block) (Group 1) or standard opioid (Group 2,
      control) anesthesia groups. Randomization will be at the ratio of 1:1 and will be done by the
      closed envelope method. Beforehand, a piece of paper with the name of one of the two groups
      will be placed inside the envelopes and the envelopes will be closed and mixed. A closed
      envelope will be drawn at random before the procedure for each patient, and procedures will
      be carried out according to the group specified on the paper.
    

Detailed description: 
      Group 1 (opioid-free ESPB) Before induction of anesthesia, patients in this group will
      undergo ultrasound guidance in a sitting position on the operating table, and an erector
      spina plan block will be performed with bupivacaine and lidocaine, by entering unilaterally
      (to the side to be operated) 3 cm lateral to the T5 spinous process. Under standard
      monitoring (ECG, non-invasive blood pressure, and finger oxygen saturation), anesthesia
      induction will be performed with propofol (2 mg/kg), ketamine 2 mg/kg, and rocuronium 0.6
      mg/kg. Bispectral index (BIS) and analgesia nociception index (ANI) monitoring will be
      started immediately after intubation. Patients will not take any opioids throughout the
      surgery and will be infused with dexmedetomidine instead. Dexmedetomidine infusion will be
      started at a dose of 0.4 microgram/kg/hour, BIS < 50 and the dose of dexmedetomidine will be
      adjusted so that ANI > 50. Patients for whom dexmedetomidine could not be sufficiently
      effective and opioid use became mandatory will not be included in the analysis. Before
      postoperative awakening, patients were given 1 g i.v. paracetamol will be given.

      Group 2 (standard anesthesia with opioid) Under standard monitoring (ECG, non-invasive blood
      pressure, and finger oxygen saturation), anesthesia induction will be performed with propofol
      (2 mg/kg), remifentanil 1 microgram/kg, and rocuronium 0.6 mg/kg. Bispectral index (BIS) and
      analgesia nociception index (ANI) monitoring will be started immediately after intubation.
      Patients will receive an infusion of remifentanil throughout the surgery. Remifentanil
      infusion will be started at a dose of 0.5 microgram/kg/hour, and the dose of remifentanil
      will be adjusted so that BIS < 50 and ANI > 50. Before postoperative awakening, patients were
      given 1 g i.v. paracetamol will be given.

      Perioperative clinical and demographic data of each patient will be collected: age, gender,
      diagnosis, operation, ASA status, duration of surgery, duration of anesthesia.
      Intraoperatively, heart rate, blood pressure, ANI and BIS measurements will be made and
      recorded in all patients at 15-minute intervals. In addition, the total intraoperative opioid
      dose (Group 2) and dexmedetomidine (Group 1) dose will be recorded.

      Post-awakening pain will be assessed and recorded using a visual analog scale (VAS), then
      patient-controlled analgesia (PCA) will be initiated, with all patients locked in 15 minutes
      and given 4 mg of morphine at each application by the patient. Pain assessment will be done
      with VAS at 6, 12, 24 and 48 hours postoperatively. In the postoperative period, the amount
      of morphine administered by PCA (in the first and second 24 hours) and the required
      additional analgesics (tramadol, paracetamol, etc.) will be recorded. Groups will be compared
      for primary outcome measure and secondary outcome measure.

      Although neuropathic pain after VATS is less than the thoracotomy approach, it can still pose
      a significant postoperative problem. Pain management after VATS is especially important to
      prevent respiratory complications. However, intraoperative or postoperative excess morphine
      consumption will also negatively affect postoperative recovery after thoracic surgery. It has
      been shown that opioid-free anesthesia can reduce the need for morphine and reduce related
      complications.

      In the ultrasound-guided erector spina plan block technique, which is a regional anesthesia
      technique that has been defined recently, local anesthetic is injected into the erector spina
      muscle and facial plane and spreads in the caudal and cranial directions. This technique has
      been successfully used as a postoperative analgesia or intraoperative regional anesthesia
      technique in areas such as thoracic surgery and trauma, breast surgery, abdominal surgery,
      and extremity surgery. Erector spina plane block or other block methods have been mostly used
      for postoperative analgesia after VATS, and they have been shown to provide effective
      postoperative analgesia and reduce morphine consumption. However, data on the use of ESPB or
      other block techniques for anesthesia during VATS are limited. Opioid-free anesthesia with
      the help of ESPB may help recovery by reducing total and postoperative morphine consumption.

      The aim of this study is to compare opioid-free anesthesia with ultrasound-guided ESPB in
      patients who underwent lobectomy with VATS, with standard opioid-containing anesthesia in
      terms of postoperative morphine requirement, as well as intraoperative variables,
      postoperative pain management and postoperative recovery, and complications.
    

Intervention name(s): Erector spinae plane block (ESPB) technique without opioid use
Intervention type(s): Procedure
Intervention description(s): Local anesthetic injection to the erector spinae muscle plane at T5 level on the operation side.
Other intervention name(s): Standard opioid anesthesia
Intervention MeSH terms: Analgesics, Opioid
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care