The debate around anesthesia management of lung surgery has made quite a few developments in the past decade. Perioperative pain can be extremely intense for patients undergoing thoracic incisions. Without proper anesthesia, patients may experience difficulties breathing and painful coughing which can lead to adverse outcomes, including chronic post-thoracotomy pain syndrome (Lederman et al., 2019). Providing appropriate anesthesia and analgesia is essential to improving postoperative pulmonary function and decreasing adverse outcomes of surgery. However, this brings up an important discussion on balancing the risks of analgesic techniques with sufficient pain management.
Thoracic epidural anesthesia (TEA) with local anesthetic (LA) and opioids was once regarded as the gold standard for pain control after lung surgery (Yeung et al, 2016). The most effective technique of TEA is insertion of the epidural catheter beginning in the pre or intraoperative period and continuing anesthesia 2-3 days after surgery (Joshi et al., 2008). Epidural anesthesia carries the highest rates of patient satisfaction with analgesia at rest and during movement, and this method is associated with decreased use of parenteral opioids (Lederman et al., 2019). However, TEA risks include hypotension and rarely, epidural hematoma. Insertion of the epidural itself also carries risks such as accidental dural puncture and local neurologic toxicity (Yeung et al., 2016). Patients with contraindications to TEA include those with local infections, prior spinal surgery, clotting disorders, and those who are taking anti-clotting medications (Yeung et al., 2016).
Paravertebral block (PVB) with LA is perhaps the most promising alternative technique to TEA. This technique has been found to be as effective as epidural anesthesia with LA, with a reduced risk of hypotension and other long-term consequences (Joshi et al., 2008). PVB is safer for patients with circulatory disease and requires less postoperative monitoring (Yeung et al., 2016). Even so, failure rate of PVB is up to 10%, and fewer practitioners are trained to perform this block (Lederman et al., 2019). Though PVB provides some advantages compared to TEA, no distinction has yet been found between PVB and TEA in terms of 30-day mortality, major complications and length of hospital stay (Yeung et al., 2016).
Other regional methods of managing pain, such as erector spinae plan block (ESPB) and serratus anterior plane block (SAPB), are safer and easier to perform than both TEA and PVB. Of note, ESPB appears to be superior to SAPB in providing postoperative analgesia (Elsabeeny et al., 2021). While PVB may provide better pain management, there is a higher incidence of adverse effects and a higher technical difficulty when compared to ESPB (Koo et al., 2021). Like PVB, these local ultrasound-guided techniques had a lower incidence of hypotension compared to TEA in a 24-hour postoperative period, according to one study (Elsabeeny et al., 2021). More research on the efficacy of these techniques compared to PVB and TEA is warranted.
Ultimately, anesthesia management of lung surgery is quite complex and depends on type of surgery, timing of anesthesia, and patient risk factors. While thoracic epidural analgesia is the cited gold standard for thoracotomy pain treatment, there are other regional techniques that are as effective and may be associated with fewer adverse outcomes, especially paravertebral block. While PVB carries a lower risk profile and provides comparable pain relief to epidural block, it still has a high failure rate and is a more technically demanding procedure compared to other regional techniques such as ESPB and ASPB. Future research should aim to estimate health care costs and compare long-term risks and consequences of each technique.
References
Elsabeeny, W. Y., Ibrahim, M. A., Shehab, N. N., Mohamed, A., & Wadod, M. A. (2021). Serratus Anterior Plane Block and Erector Spinae Plane Block Versus Thoracic Epidural Analgesia for Perioperative Thoracotomy Pain Control: A Randomized Controlled Study. Journal of cardiothoracic and vascular anesthesia, 35(10), 2928–2936. https://doi.org/10.1053/j.jvca.2020.12.047
Joshi, G. P., Bonnet, F., Shah, R., Wilkinson, R. C., Camu, F., Fischer, B., Neugebauer, E. A., Rawal, N., Schug, S. A., Simanski, C., & Kehlet, H. (2008). A systematic review of randomized trials evaluating regional techniques for post thoracotomy analgesia. Anesthesia and analgesia, 107(3), 1026–1040. https://doi.org/10.1213/01.ane.0000333274.63501.ff
Koo, C. H., Lee, H. T., Na, H. S., Ryu, J. H., & Shin, H. J. (2021). Efficacy of Erector Spinae Plane Block for Analgesia in Thoracic Surgery: A Systematic Review and Meta-Analysis. Journal of cardiothoracic and vascular anesthesia, S1053-0770(21)00536-X. Advance online publication. https://doi.org/10.1053/j.jvca.2021.06.029
Lederman, D., Easwar, J., Feldman, J., & Shapiro, V. (2019). Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia. Annals of translational medicine, 7(15), 356. https://doi.org/10.21037/atm.2019.03.67