Erector Spinae Block, Epidural Analgesia and Intrathecal Analgesia in Thoracic Surgery

Study Overview
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Brief Summary
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Pulmonary thoracic surgery is often responsible for severe postoperative pain, which is associated with an increase in postoperative morbidity and mortality. Moreover, postoperative thoracic pain has a strong impact on patient rehabilitation and is associated with an increase in hospital stay. Various analgesic techniques allow effective management of pain in the context of thoracic surgery. Regional anesthesia, particularly, allows a powerful analgesia, and limits the use of opioids and their side effects. Among regional anesthesia techniques, thoracic epidural analgesia has become the gold standard for post-thoracotomy analgesia. However, it induces a sympathetic block that promotes in particular per and postoperative hypotension and acute urinary retentions. Thus, new regional anesthesia techniques have been developed and assessed in thoracic surgery in order to avoid side effects related to epidural analgesia, particularly paravertebral block and erector spinae block, but also intrathecal analgesia. Paravertebral block has shown analgesic efficacy after thoracic surgery, and its interest in reducing the risk of hypotension, acute urinary retention, pruritus and postoperative nausea and vomiting compared with the epidural analgesia. Erector spinae block, recently described and evaluated in this context of thoracic surgery, seems to have the same interests and to be easier to achieve than the paravertebral block, but has been little studied. Finally, intrathecal morphine is frequently used because of an easy and rapid realization, and because it allows an adequate analgesia and the reduction of the duration of stay in intensive care compared to the epidural one. However, despite its frequent use, very few studies have compared intrathecal anesthesia with the epidural and other peri-spinal blocks. These three types of analgesia, epidural analgesia, intrathecal morphine, and erector spinae block are regional anesthesia methods regularly used for pulmonary surgery in the department of the investigators. All of these techniques have shown their analgesic efficacy, but each seems to have particular respective interests, in terms of achievement, management, or perioperative rehabilitation. The objective of the investigators study is to evaluate the effectiveness of each of its techniques to treat postoperative pain and improve the rehabilitation of these patients.

Official Title
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Efficacités comparées du Bloc Des Muscles érecteurs du Rachis, du Bloc péridural et de la rachianalgésie en Chirurgie Thoracique Majeure.

Conditions
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Pulmonary Surgery

Intervention / Treatment
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* Procedure: Epidural anesthesia
* Procedure: Intrathecal morphine
* Procedure: Erector spinae block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Thoracic surgery for pulmonary resection Scheduled regional anesthesia: epidural anesthesia, intrathecal morphine or erector spinae block Exclusion Criteria: No epidural anesthesia or no intrathecal morphine or no erector spinae block performed

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Epidural anesthesia<br>At physician discretion (observational study) | Procedure: Epidural anesthesia<br>* Preoperative epidural anesthesia at physician discretion<br>|
| Intrathecal morphine<br>At physician discretion (observational study) | Procedure: Intrathecal morphine<br>* Preoperative intrathecal morphine at physician discretion<br>|
| Erector spinae block<br>At physician discretion (observational study) | Procedure: Erector spinae block<br>* Preoperative erector spinae block at physician discretion<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain assessment at H+48 | Numerical pain rating scale: 0 (no pain at all) to 10 (worst imaginable pain) | Day 2 after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total consumption of morphine (per and postoperative) |  | Hour 2, Day 1, Day 2 and Day 3 after surgery. | 
| Length of stay in intensive care unit |  | Through study completion, an average of 1 year | 
| Length of hospital stay |  | Through study completion, an average of 1 year | 
| Impact on respiratory function | Peak Flow in L/min | Day 1, Day 2 and Day 3 after surgery. | 
| Frequency of adverse effects related to morphine Frequency of morphine side effects |  | Hour 2, Day 1, Day 2 and Day 3 after surgery. | 
| Postoperative pain assessment at other times | Numerical pain rating scale: 0 (no pain at all) to 10 (worst imaginable pain) | Hour 2, Day 1, and Day 3 after surgery. |