The Effect of Ultrasound Guided Superficial, Deep Serratus Plane Blocks and Thoracic Epidural in Thoracotomy
Condition: Post-thoracotomy Pain Syndrome
Study type: Interventional

Summary: 
      Pain after thoracotomy is known to be sever acute pain that is resulted from retraction,
      resection or fracture of ribs .This pain increases post operative morbidity and if not
      properly managed peri-operatively, chronic post thoracotomy pain syndrome may develop.
      Different methods are described to manage post thoracotomy pain.Thoracic epidural analgesia
      is believed to be the corner stone in the peri-operative care for thoracotomy providing the
      most effective analgesia. Serratus anterior plane (SAP) block has recently been described as
      a regional anesthetic technique to provide analgesia for thoracic wall surgeries. During SAP
      block, local anesthesia are deposited in the fascial plane either superficial to the serratus
      muscle or deep to the serratus anterior muscle in the mid-axillary line . Serratus anterior
      block provides analgesia to a hemithorax by blocking the lateral branches of the intercostal
      nerves. This study aims To compare the effect of superficial, deep serratus plane blocks and
      thoracic epidural analgesia in maintaining hemodynamic and controlling post thoracotomy pain.
    

Detailed description: 
      The aim of thoracotomy surgery is to explore the thoracic cavity and manage different
      pathologies including pulmonary, diaphragmatic, mediastinal, esophageal and vascular
      pathologies. It can be performed posterolaterally, anterolaterally or even anteriorly.

      Pain after thoracotomy is known to be sever acute pain that is resulted from retraction,
      resection or fracture of ribs and dislocation of costovertebral joints; injury of intercostal
      nerves or even irritation of the pleura by chest tubes inserted at the end of surgery. This
      pain increases post-operative morbidity and if not properly managed peri-operatively, chronic
      post thoracotomy pain syndrome may develop.

      Different methods are described to manage post thoracotomy pain. Intravenous (IV) drugs such
      as opioids and non-steroidal anti-inflammatory drugs (NSAIDS), infiltration of local
      anesthetics to the wound and regional anesthetic techniques such as thoracic epidural
      analgesia (TEA), paravertebral block, intercostal block and intra/extra pleural block are
      methods frequently used to relieve post thoracotomy pain.

      Thoracic epidural analgesia is believed to be the corner stone in the peri-operative care for
      thoracotomy providing the most effective analgesia. However, thoracic epidural analgesia is
      associated with serious complications such as hypotension, dural puncture with the needle or
      the catheter, post-dural puncture headache, respiratory depression with adding opioids,
      spinal cord injury and anterior spinal artery syndrome.

      The serratus muscle is a superﬁcial and easily identified muscle that is considered a true
      landmark to implement thoracic wall blocks because the intercostal nerves pierce it.Serratus
      anterior plane (SAP) block has recently been described as a regional anesthetic technique to
      provide analgesia for breast and thoracic wall surgeries. During SAP block, local anesthesia
      are deposited in the fascial plane either superficial to the serratus muscle or deep to the
      serratus anterior muscle in the mid-axillary line .Serratus anterior block provides analgesia
      to a hemithorax by blocking the lateral branches of the intercostal nerves.SAP block is also
      expected to avoid autonomic blockade associated with TEA and other complications involving
      the pleura and central neuraxial structures.

      Ultrasound imaging made the practice of regional anesthesia easier in visualization and
      identification of usual and unusual position of nerves , blood vessels , needle during its
      passage through the tissues, as well as deposition and spread of local anesthetics in the
      desired plane and around the desired nerve.
    

Intervention name(s): Thoracic epidural analgesia , superficial serratus plane block and deep serratus plane block
Intervention type(s): Procedure
Intervention description(s): neuroaxial thoracic epidural analgesia and regional analgesia supeficial and deep serratus plane blocks
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: post thoracotomy pain; thoracic epidural; serratus anterior plane block; ultrasound