The use of intrathecal analgesia in video assisted thorascopic surgery (VATS).
Date First Published:
November 28, 2010
Last Updated:
October 17, 2011
Report by:
David R. McGowan, Medical Student (Brighton and Sussex Medical School)
Three-Part Question:
In [patients undergoing video assisted thorascopic surgery (VATS) procedures] is [intraoperative intrathecal analgesia superior to IV analgesia] for [complication free analgesia]?
Clinical Scenario:
A patient has undergone a video assisted thorascopic surgical procedure and is returned to the cardiac HDU unit. Following surgery the patient requires analgesia and there is the potential for IV or spinal/intrathecal delivery of the analgesia.
Search Strategy:
Medline 1950-present and Embase 1980-present were searched using the nhs healthcare database information resources interface. The cochrane library was also searched on 6th October 2011.
Search Details:
Medline and embase:
("intrathecal morphine" OR "intrathecal opioids" OR "spinal morphine" OR "spinal opioids" OR "intrathecal analgesia" OR "spinal morphine" OR morphine OR opioids).ti,ab AND ("video assisted thoracoscopic surgery" OR "VATS" OR "thoracoscopic surgery" OR "video assisted thoracoscopic" OR "thoracoscopic").ti,ab
Cochrane library:
("analgesia" OR "anal*" OR "morphine") AND "thorac*"
("intrathecal morphine" OR "intrathecal opioids" OR "spinal morphine" OR "spinal opioids" OR "intrathecal analgesia" OR "spinal morphine" OR morphine OR opioids).ti,ab AND ("video assisted thoracoscopic surgery" OR "VATS" OR "thoracoscopic surgery" OR "video assisted thoracoscopic" OR "thoracoscopic").ti,ab
Cochrane library:
("analgesia" OR "anal*" OR "morphine") AND "thorac*"
Outcome:
Medline and embase:
132 abstracts were identified by the search of medline, of which 4 were suitable for this topic.
Cochrane library:
No results matched the search criteria
132 abstracts were identified by the search of medline, of which 4 were suitable for this topic.
Cochrane library:
No results matched the search criteria
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Is intravenous patient controlled analgesia enough for pain control in patients who underwent throacoscopy? Kim JA, Kim TH, Yang M, Gwak MS, Kim GS, Kim MJ, Cho HS, Sim WS. 2009 Korea | 52 patients scheduled for VATS lobectomy were randomly allocated to one of two groups - either epidural patient controlled analgesia (PCA) or IV PCA. 37 patients completed the study (74%) - 18 in epidural PCA group, 19 in IV PCA group. | 2b - Individual low quality RCT (<80% of patients finished study) | Pain Scores | No significant differences between the groups | The study was not blinded to prevent any potential effects of researcher/patient bias. Pain scores were only tested at 1 hour and 24 hours post-operatively, potentially missing increases in pain in the first day. |
| Daily morphine consumption | No significant differences between the groups | ||||
| Forced vital capacity | No significant differences between the groups | ||||
| Forced expiratory volume in 1 second | No significant differences between the groups | ||||
| Satisfaction score | No significant differences between the groups | ||||
| Incidence of side effects | No significant differences between the groups | ||||
| Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Hill SE, Keller RA, Stafford-Smith M, Grichnik K, White WD, D'Amico TA, Newman MF. 2006 USA | 80 patients undergoing unilateral thoracoscopic procedures, double blinded randomisation into two groups (n=40) of either study group or placebo group. | 1 b - Prospective, double-blinded, randomised clinical trial | Intraoperative fentanyl usage | Treated group had significantly less intraoperative fentanyl (p=0.003) | Single use paravertebral block only used, no group withmultiple doses. Patients were low-risk and no emergency operations were undertaken. |
| Postoperative patient-controlled morphine usage (first 6 hours) | Treated group had a 31% smaller cumulative patient-controlled morphine dose (P=0.03) | ||||
| Postoperative patient-controlled morphine usage 12 and 18 hours) | No significant differences between the groups | ||||
| Visual analog pain score | Lower scores were reported in the treated group (P=0.02) | ||||
| Cytokine production | No significant differences between the groups | ||||
| Cortisol levels | No significant differences between the groups | ||||
| Single-injection thoracic paraverteral block for postoperative pain treatment after thoracoscopic surgery. Vogt A, Steiger DS, Theurillat C, Curatolo M. 2005 UK | 45 patients were randomly allocated to two groups for treatment with a paravertebral block - treatment group and placebo control. 40 patients completed the study (n=20 in each group). | 1 b - Prospective, randomised clinical trial | Pain scores | The treatment group has significantly less pain than the control group (P<0.05) | Small patient numbers. Results were taken as cumulative over 48 hours, and more intensive monitoring over a longer period may have improved the validity of the results. |
| Cumulative morphine consumption | No significant differences between the groups | ||||
| Peak expiratory flow rate | No significant differences between the groups | ||||
| Side-effects | No significant differences between the groups | ||||
| Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax? Fernandez MI, Martin-Ucar AE, Lee HD, West KJ, Wyatt R, Waller DA. 2005 UK | 112 patients (77 male, 45 female) who underwent a total of 118 VATS pleurectomies (66 right- and 52 left-sided) for spontaneous pneumothorax. 22 patients received epidural analgesia, the remaining |
3b - Individual case-control study. | Time for patients to receive oral analgesia alone | Higher in control group (56 hours (12-144)) compared to Intrathecal analgesia patients (20 hours (0-96)) (p<0.001) | No randomisation of patients. Retrospective nature of the study. Small proportion of patients were in the intrathecal analgesia group (~19%). |
| Post-operative VAS pain score in the morning of first day after surgery | No significant difference. | ||||
| Peak post-operative VAS pain score at any point during recovery. | No significant difference. | ||||
| Incidence of long-term complications | No significant difference. |
Author Commentary:
Video assisted thoracoscopic procedures are used for the treatment of a wide variety of conditions, and the benefits regarding infection control, mortality and morbidity have been documented elsewhere.
The randomised control studies showed that the majority of outcomes (spirometry, cytokine levels, cortisol levels) were no different between the test and control groups.
There was an improvement in the pain scores in the test group in the immediate time following the operation, but this difference was not significant from 24 hours post-operation.
Patients unergoing VATS procedures are less likely to experience pain similar to thoracotomy patients. Therefore, the increased potential of spinal/intrathecal analgesia to reduce pain may not be required, and IV opioids are suitable for the control of VATS related pain.
The randomised control studies showed that the majority of outcomes (spirometry, cytokine levels, cortisol levels) were no different between the test and control groups.
There was an improvement in the pain scores in the test group in the immediate time following the operation, but this difference was not significant from 24 hours post-operation.
Patients unergoing VATS procedures are less likely to experience pain similar to thoracotomy patients. Therefore, the increased potential of spinal/intrathecal analgesia to reduce pain may not be required, and IV opioids are suitable for the control of VATS related pain.
Bottom Line:
There is no substantial evidence that any form of spinal/intrathecal anaesthesia given intraoperatively is of benefit in patients undergoing VATS procedures, and should only be used in isolted cases where I.V. analgesia is not appropriate/possible.
References:
- Kim JA, Kim TH, Yang M, Gwak MS, Kim GS, Kim MJ, Cho HS, Sim WS.. Is intravenous patient controlled analgesia enough for pain control in patients who underwent throacoscopy?
- Hill SE, Keller RA, Stafford-Smith M, Grichnik K, White WD, D'Amico TA, Newman MF.. Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures.
- Vogt A, Steiger DS, Theurillat C, Curatolo M.. Single-injection thoracic paraverteral block for postoperative pain treatment after thoracoscopic surgery.
- Fernandez MI, Martin-Ucar AE, Lee HD, West KJ, Wyatt R, Waller DA.. Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax?