Optimal postoperative Pain management After Lung surgery

Rationale: Adequate pain control after video-assisted thoracic surgery (VATS) for lung resection is important to improve postoperative mobilisation and recovery, and to prevent postoperative pulmonary complications. Thoracic epidural analgesia (TEA) is the usual care for postoperative pain management following thoracic surgery. Although the analgesic effect of TEA is clear, failure rates are 9-30% and awake placement is stressful for patients. In addition, TEA is associated with patient immobilisation, bladder dysfunction and hypotension. Based on the best available evidence and the recent guidelines by the Enhanced Recovery After Surgery (ERAS) society, the European Society of Thoracic Surgeons (ESTS) includes early mobilisation after surgery as one of their key recommendations.

The disadvantages of the TEA initiated the development of unilateral regional techniques for pain management. Single-shot and continuous paravertebral, intercostal, serratus anterior and erector spinae blocks have shown to be safe and effective. So far, no consensus exists on optimal postoperative pain management after VATS lung resection. The Dutch guideline database and the ESTS guideline on ERATS all address TEA as well as other regional techniques to be valid options for pain control after VATS.

In addition to studying pain, patient satisfaction and postoperative quality of recovery (QoR) are crucial factors in the decision making of patient selected analgesic techniques. Pain assessment continues to be a challenge due to its subjective nature and relation to various outcomes related to QoR, therefore, anaesthesia and pain studies strongly recommend using a patient related outcome measure reporting QoR to assess postoperative pain [14, 15].

Objective: The main objective is to compare regional continuous paravertebral block (PVB), single shot multi-level intercostal nerve block (ICNB) and thoracic epidural analgesia (TEA) as pain relief techniques in order to provide safe, effective and efficient pain management after thoracoscopic lung surgery. This study will provide the evidence for an ERATS protocol to be implemented for the optimal analgesic technique after VATS anatomic lung resection taking into account pain scores and QoR.

Study design: The proposed multi-centre randomised trial is a three-arm trial comparing PVB, single shot ICNB and TEA in a 1:1:1 ratio for pain (non-inferiority) and for QoR (superiority) in patients who have undergone a thoracoscopic anatomical lung resection.

Main study parameters/endpoints: The NRS (0-10; 0= no pain, 10=worst imaginable pain) will be used to measure pain scores. The primary outcome measure for ‘non-inferiority’ is the proportion of NRS ≥4, defined as the number of NRS ≥4 episodes divided by the total amount of NRS pain scores obtained. The primary outcome for ‘superiority’ is QoR measured with the QoR-15 questionnaire on POD 1 and POD 2.

Postoperative pain management by using either regional continuous PVB or single shot ICNB is non-inferior to TEA regarding pain in patients undergoing thoracoscopic anatomical lung resection. Regarding QoR after surgery the unilateral regional techniques are expected to be superior to TEA as scored by the global QoR-15 questionnaire. Signifying faster postoperative mobilisation, reduced morbidity and shorter hospitalization, these techniques may therefore reduce health care costs and improve patient satisfaction.

T-1: Multidisciplinary oncology meeting: indication for VATS anatomical lung resection
T0: Pre-operative appointment with the lung surgeon at the outpatient clinic
T1: Day of the operation
T2: Postoperative day 1
T3: Postoperative day 2
T4: Postoperative day 3
T5: Hospital discharge
T6: Follow-up at the postoperative appointment with the surgeon at the outpatient clinic

Paravertebral block and single shot intercostal nerve block