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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.
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*"

Search 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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kim JA, et al. 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
Hill SE, et al. 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
Vogt A, et al. 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
Fernandez MI, et al. 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.

Comment(s)

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.

Clinical 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

1. 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? J Korean Med Sci 2009 Oct;24(5):930-935.
2. 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. Anaesthesiology 2006 May;104(5):1047-1053.
3. Vogt A, Steiger DS, Theurillat C, Curatolo M. Single-injection thoracic paraverteral block for postoperative pain treatment after thoracoscopic surgery. Br J Anaesth 2005 Dec;95(6):816-821.
4. 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? European Journal of Cardiothoracic Surgery 2550 Apr;27(4):671-4.