An ultrasound-guided serratus anterior plane block with continuous local anaesthetic infusion and epidural analgesia for rib fracture pain.

BACKGROUND: We compared analgesia with an ultrasound (US)-guided serratus anterior plane block (SAPB) to thoracic epidural analgesia (EA) with continuous local anaesthetic infusion in patients with unilateral multiple traumatic rib fractures. EA often carries contraindications in patients with multiple rib fractures (MRFs), whereby having alternative effective methods to treat rib fracture pain remains important to patient care. Thus, we hypothesised that both regional anaesthetic techniques would provide effective pain relief. METHODS: In this study, we included 59 patients with unilateral MRFs and a numerical rating scale (NRS) pain score ≥4 at rest or upon movement. Patients were randomised to receive a US-guided SAPB or continuous infusion EA with 2 mg/mL ropivacaine. Patients were given a patient-controlled analgesia (PCA) device with intravenous oxycodone boluses for rescue medication. The primary outcome was a change in the NRS score at rest and upon movement from baseline to Day 2 following the block. We also measured the forced expiratory volume in 1 s of expiration (FEV1) and FEV1% at the same time points when NRS was measured. The total consumption of oxycodone with PCA was measured at 24 and 48 h after the block. RESULTS: We detected a significant reduction (≥2) in NRS for both groups; however, EA associated with a greater reduction in NRS upon movement after block initiation. The mean reduction in NRS upon movement within 1 h was 3 (1.8, p < .01) in the SAPB group versus 4.7 (2.4, p < .01) in the EA group. We found no significant difference between groups in pain scores on Days 1 and 2 following the block. In the EA group, FEV1% increase in the first 12 h from baseline. Finally, PCA oxycodone consumption did not differ between groups. CONCLUSIONS: SAPB with continuous local anaesthetic infusion is an effective alternative to treat rib fracture pain when EA is contraindicated. We found that SABP significantly reduces pain in patients with unilateral MRFs, although EA achieves better analgesia over the first 12 h following the block.

The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery.

BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

Comparing the Analgesic Effects Between the Pre- and Post-costal Cartilage Harvest Cohorts Using Ultrasound-Guided Deep Serratus Anterior Plane Block in Children with Microtia Undergoing Auricular Reconstruction: A Randomized Clinical Trial.

PURPOSE: Pain following costal cartilage harvest surgery is the most common complaint of auricular reconstruction (AR). Anesthesiologists are continuously searching for an effective postoperative pain control method. METHODS: This study was conducted from 10 April 2022 to 10 June 2022. Sixty children undergoing AR using costal cartilage were randomly assigned to either a serratus anterior plane block performed before costal cartilage harvest (SAPB-pre-cohort; n = 30) or the SAPB-post-cohort (Post-costal cartilage Harvest Cohort: n = 30). The primary endpoint measures were the Numerical Rating Scale (NRS) scores of the chest and ear pain degrees recorded at 1-, 6-, 12-, 24-, and 48-h after surgery. Intraoperative anesthetic and analgesic dosages, sufentanil consumption and rescue analgesia consumption during the first 24 h post-operation, cough score during extubation, extubation agitation score, length of stay, the extubation time, first ambulatory time, analgesia duration, and opioid-related adverse effects and SAPB-related adverse effects were the secondary endpoints. RESULTS: The rest and coughing NRS scores were significantly reduced in the SAPB-pre-cohort 6 and 12 h post-operation in comparison with the SAPB-post-cohort (rest 6 h p = 0.002, others p < 0.001). No significant difference in the NRS ear scores existed between the two cohorts (p > 0.05). The use of propofol and remifentanil for general anesthesia during the SAPB-pre-procedure was significantly reduced compared to the SAPB-post-group, with statistical significance (p < 0.001). Sufentanil consumption and rescue analgesia consumption were significantly reduced in the SAPB-pre-cohort (p = 0.001, p = 0.033). The extubation time and first ambulatory time were markedly shorter in the SAPB-pre-cohort (all p < 0.001). Analgesia duration was markedly longer in the SAPB-pre-cohort (p < 0.001). No significant differences were noted in the cough score during extubation, extubation agitation score, length of stay between the two cohorts (all p > 0.05). Opioid-related adverse effects occurred more in the SAPB-post-cohort, while there was no statistical significance (16.7 vs. 36.7%; p = 0.082). There were no blockade-related complications observed in either cohort. CONCLUSION: The analgesic effect of the SAPB-pre-cohort was better than the SAPB-post-cohort suggesting both efficacy and feasibility of preemptive analgesia. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review.

PURPOSE OF REVIEW: The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain. RECENT FINDINGS: Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

Rhomboid intercostal block versus serratus block for postoperative analgesia after thoracoscopic sympathectomy for primary palmar hyperhidrosis: a randomized controlled trial.

BACKGROUND: Although thoracoscopic sympathectomy is made via small incisions, it is associated with severe postoperative pain. Both Rhomboid intercostal block (RIB) and serratus anterior plane block (SABP) are recent techniques used for pain control after such procedures. Herein, we compared RIB and SAPB regarding pain control in patients undergoing thoracoscopic sympathectomy for palmar hyperhidrosis. PATIENTS AND METHODS: Three groups were enrolled in this prospective randomized study (71 patients in each group); Group S received SAPB, Group R received RIB and Group C as controls. The block procedures were performed after general anesthesia and prior to the skin incision. RESULTS: The three groups showed comparable demographics and operative time (P ˃ 0.05). Pain scores showed a significant decline with the two block procedures compared to controls during the first day following surgery (both P ˂ 0.05), but Group R had better scores compared to Group S. Both block techniques were associated with a significant prolongation of the time to first rescue analgesic and less fentanyl consumption compared to controls (both P ˂ 0.05). However, both parameters were improved with RIB rather than SAPB (both P ˂ 0.05). Both blocks led to a significant improvement in patient satisfaction than in the control group (both P ˂ 0.05), but it was comparable between the two approaches (P ˃ 0.05). CONCLUSION: Both RIB and SAPB are safe and effective in pain reduction after thoracoscopic sympathectomy procedures in patients with hyperhidrosis. Moreover, RIB is superior to SAPB as it is associated with better analgesic outcomes. TRIAL REGISTRATION: Pan African Trial Registry PACTR202203766891354. https://pactr.samrc.ac.za/Researcher/TrialRegister.aspx?TrialID=21522.

Comparison of erector spinae plane block and serratus anterior plane block for postoperative analgesia in uniportal thoracoscopic lobectomy: a randomized controlled trial.

BACKGROUND: Postoperative pain remains a significant concern following uniportal thoracoscopic surgery. The analgesic efficacy of erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in terms of postoperative opioid consumption in uniportal thoracoscopic surgery still needs further studies. METHODS: A randomized controlled trial was conducted, enrolling 150 patients who underwent uniportal thoracoscopic lobectomy. The patients were randomly allocated to three groups in a 1:1:1 ratio: the ESPB group (administered 20 ml of 0.5% ropivacaine), the SAPB group (administered 20 ml of 0.5% ropivacaine), and the standard care (control) group. The primary endpoint was the consumption of sufentanil during the first 24 h following surgery. Secondary endpoints assessed the area under the curve (AUC) of pain numerical rating scale (NRS) scores, occurrence of moderate to severe pain, time to initial sufentanil request, and postoperative adverse events. RESULTS: No significant difference was observed in the consumption of sufentanil during the first 24 h following surgery between the ESPB and SAPB groups (adjusted difference, 1.53 [95% CI, -5.15 to 2.08]). However, in comparison to the control group, both intervention groups demonstrated a significant decrease in sufentanil consumption, with adjusted differences of -9.97 [95% CI, -13.10 to -6.84] for the ESPB group and -12.55 [95% CI, -15.63 to -9.47] for the SAPB group. There were no significant differences in AUC of NRS scores during rest and movement between the ESPB and SAPB groups, with adjusted differences of -7.10 [95% CI, 1.33 to -15.55] for the rest condition and 5.61 [95% CI, -13.23 to 2.01] for the movement condition. At 6 h postoperatively, there were fewer patients with moderate to severe pain in the ESPB group compared with those in the SAPB group (adjusted difference, -1.37% [95% CI, -2.29% to -0.45%]. The time to first sufentanil request significantly differed among the three groups (ESPB vs Control P < 0.01, SAPB vs Control P < 0.01, ESPB vs SAPB P = 0.015). CONCLUSIONS: In patients undergoing uniportal thoracoscopic lobectomy, although the differences between the two groups are not statistically significant, both the ESPB and SAPB demonstrate effective reduction in postoperative opioid consumption and the need for rescue analgesics compared to the control group. Moreover, the ESPB group experienced a significantly lower incidence of moderate to severe pain at 6 h postoperatively compared to the SAPB group. TRIAL REGISTRATION: The study was registered in the Chinese Clinical Trial Registry (registration No: ChiCTR1900021695, Date of registration: March 5th, 2019).

Analgesic effectiveness of serratus anterior plane block in patients undergoing video-assisted thoracoscopic surgery: a systematic review and updated meta-analysis of randomized controlled trials.

BACKGROUND: Serratus anterior plane block (SAPB) is a promising regional technique for analgesia in thoracic surgery. Till now, several randomized controlled trials (RCTs) have explored the effectiveness of SAPB for postoperative pain control in patients undergoing video-assisted thoracoscopic surgery (VATS), but the sample sizes were small and conclusions remained in controversy. Therefore, we conducted the present systematic review and meta-analysis. METHODS: RCTs evaluating the analgesic performance of SAPB, comparing to control methods (no block, placebo or local infiltration anesthesia), in patients undergoing VATS were searched in PubMed, EMBASE, Web of Science and Cochrane Library from inception to December 31, 2022. Mean difference (MD) and corresponding 95% confidence interval (95%CI) were calculated for postoperative pain scores at various time points, postoperative opioid consumption and length of hospital stay. Pooled relative risk (RR) with 95%CI were calculated for the risk of postoperative nausea and vomiting (PONV) and dizziness. A random-effect model was applied. RESULTS: A total of 12 RCTs (837 participants) were finally included. Compared to control group, SAPB had significant reductions of postoperative pain scores at 2 h (MD = -1.58, 95%CI: -1.86 to -1.31, P < 0.001), 6 h (MD = -2.06, 95%CI: -2.74 to -1.38, P < 0.001), 12 h (MD = -1.72, 95%CI: -2.30 to -1.14, P < 0.001) and 24 h (MD = -1.03, 95%CI: -1.55 to -0.52, P < 0.001), respectively. Moreover, SAPB conferred a fewer postoperative opioid consumption (MD = -7.3 mg of intravenous morphine equivalent, 95%CI: -10.16 to -4.44, P < 0.001) and lower incidence of PONV (RR = 0.56, 95%CI: 0.41 to 0.77, P < 0.001). There was no difference between both groups regarding length of hospital stay and risk of dizziness. CONCLUSION: SAPB shows an excellent performance in postoperative pain management in patients undergoing VATS by reducing pains scores, postoperative opioid consumption and incidence of PONV. However, due to huge heterogeneity, more well-designed, large-scale RCTs are needed to verify these findings in the future.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study.

OBJECTIVES: The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery. DESIGN: A retrospective observational study. SETTING: A single large teaching hospital. PARTICIPANTS: A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data. INTERVENTIONS: Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications. MEASUREMENTS AND MAIN RESULTS: The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups. CONCLUSIONS: Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

Intraoperative Fascial Plane Blocks Facilitate Earlier Tracheal Extubation and Intensive Care Unit Discharge After Cardiac Surgery: A Retrospective Cohort Analysis.

OBJECTIVES: Novel fascial plane blocks may allow early tracheal extubation and discharge from the intensive care unit (ICU). The present study primarily aimed to determine whether fascial plane blocks, in comparison with intravenous analgesia alone, significantly shortened tracheal extubation times in patients undergoing cardiac surgery. The secondary objectives were to compare each block's performance with that of intravenous analgesia alone in terms of the individual tracheal extubation time and length of ICU stay. DESIGN: Retrospective observational study. SETTING: Single-center study. PARTICIPANTS: Patients who underwent cardiac surgery between 2018 and 2019 were identified from a prospective clinical registry. After obtaining ethics approval, the clinical and electronic records of patients undergoing cardiac surgery in 2018 were analyzed. Data of patients receiving fascial plane blocks (erector spinae plane [ESP], pectoral plane I and II [PECs], and serratus anterior plane [SAP] blocks) with intravenous analgesia were compared with those of patients receiving only intravenous analgesia. A propensity score (PS) model was used to control for differences in the baseline characteristics. Adjusted p < 0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS: Of the 589 patients screened, 532 met the inclusion criteria; 404 received a fascial plane block. After PS matching, weighted linear regression revealed that by receiving a block, the predicted extubation time difference was 9.29 hours (b coefficient; 95% CI: -11.98, -6.60; p = 0.022). Similar results were obtained using PS weighting, with a reduction of 7.82 hours (b coefficient; 95% CI: -11.89, -3.75; p < 0.001) in favor of the block. In the fascial-plane-block group, ESP block achieved the best performance. The length of ICU stay decreased by 1.1 days (b coefficient; 95% CI: -1.43, -0.79; p = 0.0001) in the block group. No complications were reported. CONCLUSIONS: Fascial plane block is associated with reduced extubation times and lengths of ICU stay. ESP block achieved the best performance, followed by PECs and SAP blocks. After PS matching, only ESP block reduced the extubation time.

Ultrasound-guided Serratus Anterior Plane Block, Along with Improved Parasternal Block, is Superior to Serratus Anterior Plane Block Alone in Relieving Pain for Rhinoplasty with Autologous Costal Cartilage.

BACKGROUND: Rhinoplasty with autologous costal cartilage (ACC) is followed by severe pain in the chest. Ultrasound-guided (USG) serratus anterior plane block (SAPB), in combination with parasternal block (PSB), was earlier reported to be highly efficacious in relieving pain associated with thoracic anterior lateral surgery. However, it is unclear whether it is effective for pain relief after ACC harvest. METHODS: Sixty-four patients, aged 18 to 60, who received rhinoplasty with ACC, were randomly separated into a SAPB+PSB or SAPB group. The analyzed parameters of both groups included the rest and coughing numerical rating scale (NRS) pain scores of the chest and the NRS pain scores of the nose at postoperative 2, 4, 8, 12, 24, and 48 hours, oral rescue analgesic usage, side effect incidence and patient satisfaction, etc. RESULTS: Thirty patients per group were recruited for analysis. The rest and coughing NRS scores of the chest and the NRS scores of the nose at postoperative 2, 4, 8, 12 h were lower in the SAPB+PSB group, compared to the SAPB group (all P < 0.05). However, these scores were comparable between the two groups at postoperative 24 and 48 h (all P > 0.05). Additionally, relative to the SAPB group, the oral rescue analgesic usage was drastically lower (P < 0.05), the postoperative nausea and vomiting (PONV) incidence was diminished (P < 0.05), and the patient satisfaction was markedly higher (P < 0.001) in the SAPB+PSB group. CONCLUSION: USG-SAPB, in combination with improved PSB, is superior to SAPB alone in relieving pain after ACC harvest in rhinoplasty. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy of Ice Compress Combined With Serratus Anterior Plane Block in Analgesia After Thoracoscopic Pneumonectomy: A Randomized Controlled Study.

PURPOSE: To explore the analgesic effect of the ice pack combined with serratus anterior plane block after thoracoscopic pulmonary resection. DESIGN: A randomized controlled trial design. METHODS: This prospective randomized controlled trial recruited patients who underwent thoracoscopic pneumonectomy in a grade A tertiary hospital from October 2021 to March 2022. The patients were randomly divided into the control group, the serratus anterior plane block group, the ice pack group, and the ice pack combined with serratus anterior plane block group. The analgesic effect was evaluated by collecting the postoperative visual analog score. FINDINGS: A total of 133 patients agreed to participate in this study, of which 120 patients were eventually included (n = 30/group). The primary outcome was that the pain in SAP block group, ice pack group, and ice pack combined with SAP block group decreased significantly within 24 hours compared with the control group (P < .05). Also, significant differences were noted in other secondary outcomes, such as Prince-Henry pain score within 12 hours, 15-item quality of recovery (QoR-15) score within 24 hours, and fever times within 24 hours. No significant difference was detected in the C-reactive protein value, white blood cell count, and the use of additional analgesics within 24 hours postoperatively (P > .05). CONCLUSIONS: For patients after thoracoscopic pneumonectomy, ice pack, serratus anterior plane block, and ice pack combined with serratus anterior plane block produce better postoperative analgesic effects than intravenous analgesia. The combined group exhibited the best outcomes.

Comparison of ultrasound-guided serratus anterior plane block and thoracic paravertebral block in postoperative analgesia and inflammation control in patients undergoing upper abdominal surgery.

Objective: To compare the effects of ultrasound-guided serratus anterior plane block (SAPB) and thoracic paravertebral block (TPVB) on postoperative analgesia and inflammation control in patients undergoing upper abdominal surgery. Methods: This is a retrospective observational study. The records of patients who underwent upper abdominal surgery in our hospital from June 2019 to January 2021 were selected and retrospectively divided into two groups based on the analgesia method. Fifty-nine patients received ultrasound-guided SAPB analgesia (SAPB-group) and 55 patients received ultrasound-guided TPVB analgesia (TPVB-Group). Patients were matched for age, gender and body-mass index (BMI). The visual analogue scale (VAS) scores of pain at two hours(T1), six hours (T2), 12 hours (T3), 24 hours (T4) and 48 hours (T5) after the operation were compared between the two groups. The levels of interleukin-6 (IL-6), interleukin-10(IL-10) and tumor necrosis factor-α (TNF-α) at the completion of surgery (T0) and T4 were compared between the two groups. Results: The duration of block in SAPB-group was higher than that in TPVB-group (P<0.05). VAS scores of SAPB-groups were significantly lower than those of TPVB-group at all-time points (P<0.05) except at rest 48 hour after the procedure. The levels of IL-6, IL-10 and TNF-α at 24 hours after the operation in both groups were significantly higher than immediately at the end of the operation (P<0.05). Levels of IL-6 and TNF-α 24 hours after the operation were significantly lower in the SAPB-group than in the TPVB-group (P<0.05), while the levels of IL-10 24 hours after the operation were significantly higher in the SAPB-group (P<0.05). Conclusions: SAPB block under ultrasound guidance for patients undergoing upper abdominal surgery has good anesthetic and analgesic effect and can significantly improve the level of postoperative inflammation.

Combined fascial plane blocks as the sole regional anesthesia technique for breast surgery in high-risk patients.

The quest for an effective regional anaesthesia technique in breast surgery has always been eluded by its apparent complexity. Various techniques had been described as anaesthetic techniques for breast cancer surgeries. Fascial plane blocks had been used as analgesic techniques for this procedure. We describe a case series of 12 patients who were given a combination of erector spinae plane block (ESP), Pectoralis I (Pecs I) and serratus anterior plane (SAP) block as sole anaesthetic technique with high risk surgical morbidity. Two patients had discomfort during retraction of axillary apex towards the end of surgery, and one patient had discomfort during medial parasternal incision, which needed a single bolus of low dose ketamine injection. Combined fascial plane blocks could be effectively utilized as a sole regional anesthesia modality for breast cancer surgeries with mild sedation.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain.

PURPOSE OF REVIEW: Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important. RECENT FINDINGS: With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve.  Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS: In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS: Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION: Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION: PROSPERO (CRD42020198244); registered 19 October 2020.

RéSUMé: CONTEXTE: La technique régionale optimale pour contrôler la douleur après une chirurgie de cancer du sein n'a pas encore été clairement établie. Nous avons cherché à synthétiser les données disponibles provenant d'études randomisées contrôlées comparant les issues liées à la douleur à la suite de diverses techniques régionales pour la chirurgie mammaire oncologique majeure. MéTHODE: Dans une revue systématique et une méta-analyse de réseau, nous avons recherché les études portant sur les techniques régionales couramment utilisées dans les bases de données PubMed, Embase Scopus, Medline, Cochrane Central et Google Scholar, de leur création au 31 juillet 2020. Le critère d'évaluation principal était le score de douleur au repos à 24 heures mesuré sur une échelle d'évaluation numérique de 0 à 10. Nous avons utilisé la surface sous la courbe de classement cumulatif (SUCRA) afin d'établir la probabilité qu'une intervention soit cotée plus haut. L'analyse a été réalisée à l'aide d'un modèle bayésien à effets aléatoires, et les tailles d'effet sont rapportées comme intervalle crédible à 95 % (ICr). Nous avons effectué une analyse de classement en grappes en combinant le classement de douleur sur 24 heures avec la consommation d'opioïdes sur 24 heures ou l'incidence des nausées et vomissements postopératoires. RéSULTATS: Soixante-dix-neuf études randomisées contrôlées comportant 11 interventions différentes chez 5686 patientes ont été incluses. Les valeurs SUCRA des interventions pour le score de douleur au repos à 24 heures étaient le bloc paravertébral continu (0,83), le bloc du plan antérieur du serratus (0,76), la perfusion continue de la plaie (0,76), le bloc paravertébral à un seul niveau (0,68), le bloc du plan des muscles érecteurs du rachis (0,59), le bloc pectoral modifié (0,49), le bloc intercostal (0,45), le bloc paravertébral multiniveau (0,41), l'infiltration de plaie (0,33), l'absence d'intervention (0,12) et le placebo (0,08). Par rapport au placebo, le bloc paravertébral continu (différence moyenne, 1,26; ICr 95 %, 0,43 à 2,12) et le bloc du plan antérieur du serratus (différence moyenne, 1,12; ICr 95 %, 0,32 à 1,9) ont affiché la probabilité estimée la plus élevée de diminuer les scores de douleur au repos à 24 heures. L'analyse du classement des grappes combinant les scores de douleur au repos et la consommation d'opioïdes à 24 heures a montré que la plupart des techniques d'analgésie régionale étaient plus efficaces que l'absence d'intervention ou un placebo. Néanmoins, l'infiltration de la plaie et la perfusion continue de la plaie semblaient être les interventions actives les moins efficaces pour réduire les nausées et vomissements postopératoires. CONCLUSION: Le bloc paravertébral continu et le bloc du plan antérieur du serratus ont affiché une forte probabilité de réduire la douleur 24 heures après une chirurgie mammaire oncologique majeure. La fiabilité des données probantes allait de modérée à très faible. Les études futures devraient comparer différentes techniques d'anesthésie régionale, y compris les techniques administrées par le chirurgien telles que l'infiltration de plaie ou les cathéters. Il est peu probable que les études comparant une intervention active à un placebo modifient la pratique clinique. Enregistrement de l'étude : PROSPERO (CRD42020198244); enregistrée le 19 octobre 2020.

The Effect of Erector Spinae Plane Block and Combined Deep and Superficial Serratus Anterior Plane Block on Acute Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study.

OBJECTIVE: The study aimed to compare the analgesic effects of erector spinae plane block (ESPB) and a combination of the deep and superficial serratus anterior plane block (C-SAPB) methods in patients who underwent video-assisted thoracoscopic surgery (VATS). DESIGN: A prospective, randomized study. SETTING: At a single-center, high-volume, tertiary thoracic surgery center. PARTICIPANTS: Adult patients undergoing VATS. INTERVENTIONS: Ultrasound-guided ESPB and C-SAPB. MEASUREMENTS AND MAIN RESULTS: Patients were assigned to ESPB (group 1) or C-SAPB (group 2) groups according to the analgesia protocol. All interventions were performed with single-needle insertion. Multimodal analgesia was achieved via paracetamol, dexketoprofen, and intravenous morphine for both study groups. Pain scores were assessed by the visual analog scale (VAS). Morphine consumption, rescue analgesic requirements, and side effects were recorded postoperatively for 24 hours. The primary outcome was determined as VAS scores at rest and coughing. The secondary outcomes of this study were postoperative morphine consumption and the requirement of rescue analgesics. There was no statistically significant difference between the groups in terms of VAS scores (p > 0.05). The groups also were similar in terms of demographic characteristics, side effects, morphine consumption, additional analgesic use, and duration of block procedures (p > 0.05). There also were comparable results in terms of hemodynamic variables (p > 0.05). CONCLUSIONS: Patients who underwent VATS receiving ESPB or C-SAPB had similar pain scores, opioid consumption, and side effects during the first postoperative 24 hours. At the same time, the fact that the duration of the block procedure was similar in both groups showed that multisite serratus anterior plane block can be an effective alternative method in analgesic treatment after VATS, considering that it easily can be applied. The authors here think that C-SAPB can be a good alternative to ESPB because the outcomes of both applications are similar, and C-SAPB easily can be seen and applied with ultrasound.

Safety of Ultrasound-Guided Serratus Anterior and Erector Spinae Fascial Plane Blocks: A Retrospective Analysis in Patients Undergoing Cardiac Surgery While Receiving Anticoagulant and Antiplatelet Drugs.

OBJECTIVES: Chest wall blocks are an effective strategy for postoperative pain control in minimally invasive cardiac surgery, but, in the absence of clinical trials evaluating their safety in the presence of anticoagulant and antiplatelet drugs, it still is recommended to follow the same guidelines developed for the neuraxial procedures and for peripheral blocks. DESIGN: Retrospective observational study. SETTING: AOU Città della Salute e della Scienza di Torino, University of Turin, Italy. PARTICIPANTS: Between March 28, 2019 and October 19, 2020, 70 patients who underwent mitral valve surgery via right minithoracotomy were enrolled: 35 treated with continuous erector spinae plane block (ESPB) and 35 with continuous serratus anterior plane block (SAPB). INTERVENTIONS: The primary objective was the evaluation of the number of blocks performed or catheters removed while coagulation was abnormal or antithrombotic and anticoagulant therapies were in progress. MEASUREMENTS AND MAIN RESULTS: Eleven patients (15.7%) received fascial plane block with international normalized ratio (INR) > 1.40, four patients (5.71%) with a platelet count <80 × 103, and one patient received ESPB block during dual-antiplatelet therapy. In 16 patients (22.9%), the catheter was removed with an INR > 1.40, in five patients (7.1%) with a platelet count <80 × 103, and in 53 patients (75.71%) despite low-molecular-weight heparin at therapeutic dose. The median antagonist dose of vitamin K at the time of catheter removal was 2.5 mg (range 2.5-3.44 mg) in both groups. No major adverse effects directly attributable to the blocks were observed. CONCLUSIONS: The authors did not find any problems related to the use of continuous ESPB and SAPB, although they were performed in the presence of anticoagulation and in a context with a high risk of bleeding such as cardiac surgery.

Serratus Anterior Plane Block in Pediatric Patients Undergoing Thoracic Surgeries: A Randomized Controlled Trial.

OBJECTIVE(S): This study was designed to evaluate the efficacy and safety of serratus anterior plane block (SAPB) as an analgesic technique for thoracotomies in pediatric patients. DESIGN: Double-blinded randomized controlled trial. SETTING: A single-center study at Aboelrish Pediatric Hospital, one tertiary hospital of Cairo University Hospitals. PARTICIPANTS: Seventy pediatric patients aged six months-to-three years scheduled for thoracotomies. INTERVENTIONS: Patients were randomized into two groups, group SF and group F. Group SF received an ultrasound-guided SAPB (n = 35), whereas group F (n = 35) did not. All groups received an intraoperative fentanyl infusion (at 0.5 µg/kg /h). MEASUREMENTS: The primary outcome was the total dose of postoperatively administrated fentanyl in the first 24 hours. The secondary outcomes included the total dose of intraoperative additional fentanyl boluses; time of the first postoperative rescue analgesia; and postoperative Face, Legs, Activity, Cry, Consolability scale (FLACC) score values. MAIN RESULTS: The main results of this study showed that the administrated fentanyl in the 24 hours postoperatively was significantly lower in SF group than in F group (p value ˂ 0.001). In addition, significant decreases of the postoperative FLACC pain score (p value ˂ 0.001), reduction of intraoperative fentanyl consumption (p value ˂ 0.001), and delay of the first rescue analgesia (p value ˂ 0.001) were recorded in SF group in relation to F group without significant complications in both groups. CONCLUSIONS: Serratus anterior plane block can provide a safe, effective, and easy-to-perform regional technique for children undergoing thoracotomies.

Ultrasound-guided Bilateral Serratus Anterior Plane Block for Postoperative Analgesia in Ear Reconstruction after Costal Cartilage Harvest: A Randomized Controlled Trial.

BACKGROUND: Costal cartilages harvest for ear reconstruction is accompanied by severe pain in chest. However, there is no perfect solution for reducing this chest pain. OBJECTIVE: Evaluate the efficacy and safety of analgesia using ultrasound-guided bilateral serratus anterior plane block (SAPB) in children receiving costal cartilage harvest for ear reconstruction. METHODS: Sixty children undergoing ear reconstruction using costal cartilage were randomized to an SAPB group (SAPB with 3 mg/kg 0.25% ropivacaine) or an incision infiltration (II) group (II with 3 mg/kg 0.75% ropivacaine), and 29 in each group completed the study. All children received patient-controlled intravenous analgesia (PCIA). The primary outcomes were numerical rating scale (NRS) scores of pain while rest and coughing at 1, 6, 12, 24, and 48 h after surgery. The secondary outcomes were sufentanil use within 24 h, duration of analgesia, use of oral rescue analgesics, first time out of bed, and incidence of treatment-related adverse effects. RESULTS: The SAPB group had lower rest and coughing NRS scores at 6 and 12 h after surgery (all P < 0.001), but the scores were similar at other times. The SAPB group used less sufentanil within 24 h, but had a longer duration of analgesia (both P < 0.001). The II group used more oral rescue analgesics within 48 h, had a longer time until first time out of bed, and had more opioid-related side effects (all P < 0.01). There were no SAPB-related complications. CONCLUSION: Ultrasound-guided SAPB can provide safe and effective regional pain relief after costal cartilage harvest for ear reconstruction. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial.

BACKGROUND: Serratus anterior plane block (SAPB) was evaluated that in patients with the complaint of rib fracture pain in terms of total analgesic consumption and pain scores. METHOD: Sixty patients with rib fracture and NRS (Numeric Rating Scala) pain scores equal or greater than four were included in randomized controlled study. Patients were randomized to perform SAPB or control group. Primary outcome was total tramadol consumption in 24 h. Secondary outcomes were NRS scores (after Patient Controlled Analgesia (PCA) application 30 min, first, second, 4 th, 6 th, 12 th, 24 th hour), peripheral oxygen saturation (first and 24 th hour after PCA application), chronic pain. and complications. RESULTS: The total tramadol consumption significantly lower in group S (p = 0.02). NRS scores after 30 min, 1 h, 2 h, 4 h, 6 h, 12 h, and 24 h were significantly lower in group S than in group C (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, p = 0.026). The total number of patients who reported of chronic pain at rest and during effort was significantly lower in group SAPB than in group C (p = 0.006). Nine patients in group C were reported of pain, four of whom had pain at rest and five had pain during effort. One patient in group S was reported of pain during effort. CONCLUSION: This study demonstrated that SAPB, as part of multimodal analgesia in pain management due to rib fractures, is safe and effective in reducing acute pain.