Ultrasound–guided serratus anterior plane block versus thoracic epidural analgesia for acute post–thoracotomy pain: a prospective randomized controlled study

Abstract

Background: Post–thoracotomy pain can result not only in discomfort to the patient but also in pulmonary complications, due to ineffective coughing, which leads to retention of secretions. It can result into chronic post–thoracotomy pain in the long term. Many analgesic techniques are in use to control it, including continuous serratus anterior plane block (SAPB) and thoracic epidural analgesia (TEA). We compared the efficacy and safety of SAPB with continuous TEA in patients undergoing open lung resection.
 Methodology: This randomized, open–labeled, parallel–controlled trial was done in 60 patients aged 20 to 60 y with American Society of Anesthesiologists physical status II–III, who underwent elective thoracotomy for lung cancer surgery. Patients were randomly allocated according to analgesia either via a thoracic epidural catheter (10 ml levobupivacaine 0.25%, followed by 5 ml/h of 0.125%) or an ultrasound–guided SAPB (30 ml levobupivacaine 0.25% followed by 5 ml/h of 0.125%). Mean arterial pressure and heart rate were recorded during and after the surgery. Inj. fentanyl was used as rescue analgesia. Postoperatively VAS at rest and on coughing was used to assess the pain. Any complications were noted.
 Results: After excluding five patients, 27 and 28 patients were allocated to the TEA and SAPB groups, respectively. Intraoperatively and until 24 h after the end of surgery, the mean arterial pressure and heart rate were higher in the SAPB group than in the TEA group. Intraoperatively, the requirement for fentanyl was more in the SAPB group. Postoperatively, VAS at rest and cough were significantly higher in the SAPB group. The occurrence of nausea and vomiting, hypotension, and bradycardia were similar in the groups.
 Conclusions: In patients undergoing open lung resection for cancer, continuous serratus anterior plane block was less effective than thoracic epidural analgesia in controlling postoperative pain and presented similar adverse events.
 Key words: Serratus anterior plane block; Thoracic epidural, Continuous; Thoracotomy pain, Acute
 Abbreviations: PTP – Post–thoracotomy pain; TEA – Thoracic epidural analgesia; VAS – Visual analog scale; SAPB – Serratus anterior plane block; MAP – Mean arterial blood pressure; LA – Local anesthetics
 Preregistration: The study was registered in the institutional board ethical committee (201617026) and on www.clinicaltrials.gov (NCT03933592)
 Citation: Mostafa MM, Bakeer AH, Gamal RM. Ultrasound–guided serratus anterior plane block versus thoracic epidural analgesia for acute post–thoracotomy pain: a prospective randomized controlled study. Anaesth. pain intensive care 2021;25(6):733–740 ;
 DOI: 10.35975/apic.v25i6.1692
 Received: July 09, 2021, Reviewed: October 06, 2021, Accepted: October 09, 2021

Efficacy and safety of the serratus anterior block compared to thoracic epidural analgesia in surgery: Systematic review and meta-analysis

“…Figure 2a and 2b illustrates the risk of bias evaluation for the selected studies. Random allocation was applied in almost all included trials [ 10 , 12 , 19 , 21 , 22 ], except in one trial [ 9 ]. Bias from intended interventions was low due to the awareness of participants and people delivering the intervention.…”

“…All included studies report 24-h postoperative VAS [ 10 , 11 , 12 , 17 , 19 , 20 ]. There was significant heterogeneity among the trials ( χ 2 = 361.54, P < 0.00001, I 2 = 99%).…”

“…Insertion of epidural catheter also has a high degree of error up to 30% [ 9 ]. Several research studying the effects of TEA have revealed a greater prevalence of hypotension [ 10 - 12 ]. A 10-year single-center study of 3126 patients reported multiple incidences of TEA complications such as hypotension (4.8%), pruritus (4.4%), weakness of motor function (2.0%), PONV (1.8%), and postdural puncture headache (PDPH) (0.5%), and though rare, major complication can occur including epidural abscess which led to permanent sequela (0.03%) [ 13 ].…”

“…However, both of these studies did not compare SAPB with recommended analgesic for thoracic surgery, TEA. The occurrence of PONV in two studies suggests a lower incidence in SAPB compared to TEA [ 17 , 18 ], while other studies reported an equal [ 10 ] or a higher incidence of PONV in SAPB [ 11 , 12 , 19 ].…”

“…Three studies [ 10 - 12 ] showed lower Visual Analog Scale (VAS) in TEA than SAPB. Studies from Abdelrahman et al .…”