Thoracic Paravertebral Block With Methylene Blue Visual Confirmation for Postoperative Pain After VATS Lobectomy
Condition: Post Operative Pain; Thoracic Cancer
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The goal of this study is to compare the efficacy in controlling postoperative pain of
      paravertebral block (PVB) with methylene blue visual confirmation and thoracic epidural
      anesthesia (TEA). This is a single center, parallel-group, prospective study. Patients will
      be randomly assigned in a 1:1 ratio to receive either PVB or TEA. Primary end-point is pain
      relief measured with Postoperative Numeric Rating Scale. The secondary end-points are time to
      perform TEA and PVB, total opioid consumption, postoperative outcomes.
    

Detailed description: 
      The management of postoperative pain in patients undergoing thoracoscopic lobectomy is a
      fundamental part of the process of recovery. Uncontrolled thoracic pain in the early
      postoperative period may interfere with the mobilization of the patients, leading to
      increased morbidity and reduction in the quality of life.

      Thoracic paravertebral block (PVB) is an effective strategy for controlling postoperative
      pain after video-assisted thoracoscopic (VATS) lobectomy, but it may be subjected to a high
      rate of failure due to incorrect identification of the site of local anesthetic injection.

      Thoracic epidural anesthesia (TEA) is considered a reliable technique for regional thoracic
      anesthesia, however potential side effects may limit its use.

      Herein the investigators reported a new technique using methylene blue as a visual
      confirmation of the correct anesthetic diffusion during PVB. Then, the investigators will
      compare the efficacy of methylene blue PVB with TEA for the management of postoperative pain
      in patients undergoing VATS lobectomy.

      This is a single center, parallel-group, prospective study. Participants will be randomly
      assigned in a 1:1 ratio to receive either PVB with methylene blue or TEA.

      All participants will receive postoperatively intravenous acetaminophen as additional
      analgesics and intravenous tramadol as rescue analgesic. Primary end-point is pain relief
      measured with Postoperative Numeric Rating Scale at at 1, 12, 24, 48 hours postoperatively.
      The secondary end-points are: (i) time to perform TEA and PVB, (ii) total opioid consumption,
      (iii) postoperative outcomes (including complications, chest drainage duration and length of
      hospital stay).
    

Intervention name(s): Paravertebral block with methylene blue; Thoracic Epidural Anesthesia
Intervention type(s): Procedure; Procedure
Intervention description(s): The paravertebral space is identified under ultrasound guidance and after negative aspiration a 3 ml test dose of anesthetic is injected. After observing widening of the paravertebral space and anterior pleural displacement to confirm the correct needle positioning, a bolus dose of 20 mL 0.5% ropivacaine with a solution of 1 ml 1% methylene blue and 4 ml of saline will be injected in the paravertebral space. At the start of the surgery, the spread of the solution of anesthetic and methylene blue will be assessed through visualization in thoracoscopy and if necessary the block will be repeated. After the surgery, intravenous acetaminophen will be administered 3 times daily and tramadol 50 mg will be prescribed as rescue analgesic.; The epidural catheter will be placed using the loss of resistance technique, and after ruling out intravenous or intrathecal catheter placement with a negative aspiration test dose, an initial dose of 10 mL 0.25% bupivacaine will be injected. Continuous infusion will be started with with 0.125 % bupivacaine + fentanyl 0.5 mcg/ ml at 6-10 ml/hour will be started based on the patient weight for 48 hours postoperatively. After the surgery, intravenous acetaminophen will be administered 3 times daily and tramadol 50 mg will be prescribed as rescue analgesic.
Intervention MeSH terms: Methylene Blue
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: postoperative pain; regional anesthesia; thoracoscopy