Optimization of Perioperative Analgesia Protocol for Uniportal Video-assisted Thoracoscopic Surgery

Study Overview
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Brief Summary
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Trial design Despite video-assisted thoracic technology and procedure specific postoperative pain management (PROSPECT) have been promoted through recent years, thoracic surgery is still considered to be one of the most painful of surgical procedures. This study aims to optimize these conditions according to different perioperative analgesic modes recommended at present. This will be a single-blind randomized study to investigate the optimal analgesic effect of thoracic paravertebral block (TPB), erector spinae block (ESB), or sufentanil patient controlled intravenous analgesia (PCIA) for uniportal video-assisted thoracoscopic surgery (uVATS) and using minimally invasive drainage. Methods One-hundred and two patients undergoing uVATS will be enrolled. Patients will be randomly assigned to PVB group (20mL 0.3% ropivacaine with dexamethasone), ESB group (20mL 0.3% ropivacaine with dexamethasone) or CON group. PCIA with sufentanil will be provided to all patients after surgery. Primary outcome will be total opioid consumption from the end of the surgery to the time of discharge. Secondary outcomes consist of postoperative pain score, postoperative chronic pain, both at rest and during coughing, sensations of touch and pain on the chest wall, non-opioid analgesic drug use, length of stay (LOS), ambulation time, total cost of hospitalization and long-term postoperative analgesia. Adverse reaction to analgesics and adverse event related to regional block will also be recorded. Ethics and dissenmination This study is approved by the Ethics Committee of China-Japan Friendship Hospital (ID 2022-KY-127-1). The results will be published in peer-reviewed journals. Key words: fast-track; Enhanced Recovery After Surgery; uniportal video-assisted thoracoscopic surgery; randomized controlled trial; thoracoscopic; ultrasonic guidance; paravertebral block; erector spinal block

Detailed Description
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This is a prospective, randomized controlled study. Patients who are scheduled for elective uniportal thoracoscopic surgery in our hospital will be enrolled. Patients will be randomly assigned to one of the three groups: ultrasound-guided paravertebral block, ultrasound-guided erector spinae block, or intravenous patient-controlled analgesia pump group. Different nerve block operation schemes will be used in different groups. In any of the three groups, general anesthesia will be performed according to the standard, and multi-mode analgesic treatment will be appied as the combination of NSAIDs analgesics, opioid analgesics, and postoperative rescue analgesic treatment. Participants will be followed up at 1, 4, 12, 18 hours, on 1, 2, 3, 4, 7 days, and in 1, 2, 3, 4, 6 months after surgery. At each follow-up visit, rest and cough pain level will be recorded, and sense of touch and pain in the chest will be examined. Additional analgesic treatment will be given if necessary. Comparisons of the postoperative analgesic use, cough and rest pain, ambulation time, length of hospital stay, and hospital costs will be made in the three groups.

Official Title
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Optimization of Perioperative Analgesia Protocol for Uniportal Video-assisted Thoracoscopic Surgery: a Randomized Controlled Trial

Conditions
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Uniportal Video-assisted Thoracic Surgery

Intervention / Treatment
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* Procedure: Ultrasound-guided paraspinal block and patient-controlled intravenous analgesia pump
* Procedure: Ultrasound-guided erector spinal block and patient-controlled intravenous analgesia pump
* Procedure: Patient-controlled intravenous analgesia pump


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: ≥18 years ASA I-IIa Early stage lung cancer or intrathoracic tissue biopsy, suitable for elective uVATSb Informed consent obtained Exclusion Criteria: ASA≥III History of intrathoracic or chest wall surgery Chronic pain Pre-operative analgesic medication use NSAIDsc contraindications: aspirin asthma, allergic to NSAIDs, peptic ulcer, liver and kidney insufficiency, high risk of thrombotic events Active autoimmune disease Allergic to local anesthetics Severe coagulation dysfunction, contraindicated for nerve block Soft tissue infections of the chest wall

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This will be a parallel-group, single-blind, randomized controlled trial. Patients are expected to be enrolled in the trial within 8 months. Participants will be randomly assigned to one of the three groups: ultrasound-guided paravertebral block (PVB+PCIA group), ultrasound-guided erector spinae block(ESB+PCIA group) , or intravenous patient-controlled analgesia pump group (PCIA group). Different nerve block operation schemes will be used in different groups.Except for different nerve block schemes, all the participants will have the same methods and choices of medicine for other kinds of rescue analgesia regimens.The participants and the follow-up evaluation doctors are not aware of the group assignment, and the surgeon and anesthesiologist will not know the grouping code until the beginning of the surgery. In this way, the analgesic effect of each subject can be fairly evaluated.
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: PVB+PCIA group<br> | Procedure: Ultrasound-guided paraspinal block and patient-controlled intravenous analgesia pump<br>* Patients in this group will receive ultrasound-guided paraspinal block with 0.3% ropivacaine and 5mg dexamethasone in total of 20mL saline at T5 level on the operative side. Patients in all the groups will be treated with PCIA after surgery. PCIA with sufentanil will be applied to all participants, with background infusion at 1.8μg/hour, and total dosage <5μg/hour.<br>Procedure: Patient-controlled intravenous analgesia pump<br>* Patients in this group will not receive regional block. Patients in all the groups will be treated with PCIA after surgery. PCIA with sufentanil will be applied to all participants, with background infusion at 1.8μg/hour, and total dosage <5μg/hour.<br>|
| Experimental: ESB+PCIA group<br> | Procedure: Ultrasound-guided erector spinal block and patient-controlled intravenous analgesia pump<br>* Patients in this group will receive ultrasound-guided erector spinal block with 0.3% ropivacaine and 5mg dexamethasone in total of 20mL saline at T5 level on the operative side. Patients in all the groups will be treated with PCIA after surgery. PCIA with sufentanil will be applied to all participants, with background infusion at 1.8μg/hour, and total dosage <5μg/hour.<br>Procedure: Patient-controlled intravenous analgesia pump<br>* Patients in this group will not receive regional block. Patients in all the groups will be treated with PCIA after surgery. PCIA with sufentanil will be applied to all participants, with background infusion at 1.8μg/hour, and total dosage <5μg/hour.<br>|
| Active Comparator: PCIA group<br> | Procedure: Patient-controlled intravenous analgesia pump<br>* Patients in this group will not receive regional block. Patients in all the groups will be treated with PCIA after surgery. PCIA with sufentanil will be applied to all participants, with background infusion at 1.8μg/hour, and total dosage <5μg/hour.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| total opioid consumption | total opioid (morphine equivalent/body weight) consumption from the end of the surgery to the time of discharge. | up to 6 months, total opioid use from postoperative period till the discontinuation of surgery-related therapy. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| postoperative pain score assessed by Visual Analogue Scale VAS (1-10) | rest and cough pain | from the time at the end of surgery to 24 weeks after surgery | 
| postoperative pain score assessed by Numeric Rating Scales, NRS (1-10) | rest and cough pain | from the time at the end of surgery to 24 weeks after surgery | 
| sensations of touch on the chest wall | difference in tactile sense on bilateral chest-wall. Tactile sensation and cold sensation will be measured at four points (<3cm near the incision, and on the other side on the symmetrical chest wall, and at the point of bilateral mid-clavicular-costal arch) with an alcohol-stained cotton swab | from the time at the end of surgery to 24 weeks after surgery | 
| non-opioid analgesic drug use | number of patients with long-term (≥3 days) use of non-opioid analgesic drug | from the time at the end of surgery to 24 weeks after surgery | 
| length of stay (LOS) | days of hospital stay | up to 1 month, LOS is the amount of days the patient spends in the hospital, determined by subtracting the date of admission from the date of discharge | 
| ambulation time | first time of successful activity off bed, the time between the end of surgery to the time of the first successful ambulation | up to 1 month, ambulation time is the time the patient first ambulated following the surgical procedure | 
| total cost of hospitalization | the in-patients costs total cost of hospitalization=medication cost + hospitalization cost + nursing cost + delay compensation | up to 1 month, total charges settled on the day of discharge | 
| long-term postoperative analgesia | number of patient who needs long-term postoperative analgesia (≥3 days after discharge) | from the time at the end of surgery to 24 weeks after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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paravertebral block, fast-track, Enhanced Recovery After Surgery, uniportal video-assisted thoracoscopic surgery, randomized controlled trial, thoracoscopic; ultrasonic guidance, erector spinal block