Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

Abstract

IMPORTANCEThe use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown. OBJECTIVE To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.DATA SOURCES A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.STUDY SELECTION Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items forSystematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model. MAIN OUTCOMES AND MEASURESThe coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function. RESULTSOf 694 records screened, 608 were excluded based on prespecified exclusion criteria.The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (continued)

Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review

“…Meta-analysis of ICNB versus PVB for thoracic and breast surgery showed that PVB was superior to ICNB with improved analgesia at one and 24 hours, lower opioid consumption, and potentially improved postoperative respiratory function (101). More recently, a large systematic review and meta-analysis demonstrated that ICNB has benefits including improved pain control and reduced opioid consumption in the first 24 hours after thoracic surgery compared to systemic therapy alone (102). There are relatively few studies directly comparing ICNB with TEA or other regional techniques for thoracic surgery, and the limited data has yielded mixed results…”

Efficacy of Intrathoracic Intercostal Nerve Block on Postoperative Acute and Chronic Pains of Patients Undergoing Video-Assisted Thoracoscopic Surgery

“… 15 Perttunen 6 reported no significant difference in acute pains between INB and TPVB, which was not consistent with the other study results that INB was inferior to TPVB. 7 In our study, we found that TPVB and intrathoracic INB could both improve postoperative acute pain. 7 , 10 , 16 , 17 Further comparisons revealed an equivalent analgesic effect during the following 24h between two of them.…”

“…It has been reported that INB could cause acute pains after VATS. 7 , 10 , 14 However, clinical evidence comparing TPVB and INB for pain management is limited, while the efficacies revealed in some experiments are controversial. 15 Perttunen 6 reported no significant difference in acute pains between INB and TPVB, which was not consistent with the other study results that INB was inferior to TPVB.…”

“… 4 , 5 However, clinical evidence comparing TPVB and INB for pain management after VATS has been limited, while the INB efficacy revealed in some experiments has been controversial. 6 , 7 …”

Decreased postoperative complications, neuropathic pain and epidural anesthesia-free effect of uniportal video-assisted thoracoscopic anatomical lung resection: a single-center initial experience of 100 cases

“…When a chest tube could not be removed, epidural analgesia or intravenous fentanyl infusion was stopped by postoperative day 14 according to pain. All patients received intraoperative internal intercostal nerve block (21) and loxoprofen 180 mg/day from the first postoperative day and 25 mg pregabalin twice daily from the second postoperative day through phase I-III (16). Intercostal nerve blocks were performed at port location levels using 20 mL 0.75% lopivacaine.…”