Postoperative pain management after video-assisted thoracoscopic surgery (VATS): Recommendations from PROSPECT (PROcedure-SPECific postoperative pain managemenT)
PROSPECT guidelines are developed by an expert working group of anaesthesiologists and surgeons. They provide practical, evidence-based recommendations for postoperative pain management after different surgical procedures.
Thoracic surgery is increasingly performed using minimally-invasive techniques, such as VATS. Although a benefit of VATS is a reduction in pain compared with open thoracotomy, patients still experience significant acute and chronic postoperative pain. Effectively managing that pain helps patients to recover and reduces the risk of postoperative complications.
The latest PROSPECT guideline aims to provide clinicians with an evidence-based approach for pain management after pulmonary resection under VATS:
PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Feray S, et al. Anaesthesia 2021.
Using PROSPECT’s unique methodology, the working group based their recommendations on a systematic literature review assessing the effects of different analgesic interventions and on the balance of risks and benefits in the context of multimodal, non-opioid analgesic strategies and modern peri-operative care pathways.
The overall recommendations for VATS are shown in Table 1 and on the PROSPECT website.
· Non-steroidal anti-inflammatory drug (Grade D) / cyclooxygenase-2-specific inhibitor (Grade D)
· Dexmedetomidine (Grade B) (excluding patients with severe cardiac disease or conduction and/or rhythm disorders)
· Paravertebral block: single shot (Grade A) / continuous (Grade A)
· Erector spinae plane block: single shot (Grade A) / continuous (Grade B)
· Serratus anterior plane block: single shot (Grade A) / continuous (Grade D)
· Opioid for rescue (Grade D)
Use of a regional analgesic technique as a component of multimodal analgesia is strongly recommended. Paravertebral block is recommended as a first choice, with ESPB considered an effective alternative, based on non-inferiority in two studies. Serratus anterior plane block may be administered as a second-choice option.
The erector spinae plane block and serratus anterior plane block are relatively new techniques, recommended based on recent studies all published since 2017. An accompanying editorial adds further insights regarding the accumulating evidence for these chest wall fascial blocks, and reinforces the need for larger, well-designed trials with appropriate patient-centred endpoints (Shelley, Anderson, Macfarlane. Anaesthesia 2021).
Updates and ongoing PROSPECT work
As well as developing new guidelines, the PROSPECT working group continues to update their recommendations when important new evidence is available. The latest update to be published focuses on pain management after prostatectomy:
PROSPECT guidelines update for evidence-based pain management after prostatectomy for cancer. Lemoine A, et al. Anaesth Crit Care Pain Med 2021;40:100922.
The evidence, recommendations and methodology for VATS, prostatectomy and all the PROSPECT reviews (now 20 surgical procedures) can be found on the website, esraeurope.org/prospect, together with links to all PROSPECT publications (most are open access).
New PROSPECT reviews and updates are underway. Those nearly finalised include total knee arthroplasty (update), open abdominal hysterectomy (update), sternotomy, hip fracture and laparoscopic colectomy.
PROSPECT is supported by an unrestricted grant from the European Society of Regional Anaesthesia and Pain Therapy (ESRA) as an independent Working Group of the society.
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