Video-Assisted Thoracoscopic Surgery 2021

Video-assisted thoracoscopic surgery-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after VATS

Arguments for…

• One study compared morphine (20 mg), paracetamol (4 g) or ketorolac (120 mg), administered at the end of the surgery and during 24 h postoperatively (Dastan 2020). Mean (SD) VAS pain scores on coughing were significantly higher in the morphine group throughout the study period (morphine: 3.5 ± 2.5; ketorolac: 1.4 ± 1.4; paracetamol: 2.7 ± 2.6).
  • Morphine 0.05–0.1 mg/kg was used as rescue analgesia in the three groups. The number of patients who needed rescue medication was higher in the paracetamol group. However, the mean dose of morphine given as rescue was comparable in the three groups.
  • There was a clinically unimportant difference in the volume of blood loss between the groups (ketorolac: 291 ml; paracetamol: 250 ml; morphine: 169 ml).
• One study compared paracetamol with ketorolac after VATS (Jahangiri 2016), finding no significant difference in pain scores, morphine consumption, and patient satisfaction.
  • Patients received the study drugs at the end of the surgical procedure and postoperatively as a continuous infusion. They did not receive any additional baseline analgesia but had IV morphine as a rescue.
  • The volume of blood in thoracic drains was significantly higher in the ketorolac group (309 ml versus 273 ml; p=0.001) but the difference was not clinically relevant. There was no difference in other side effects.

PROSPECT Recommendations

• Systemic analgesia should include paracetamol, NSAIDs or COX-2 specific inhibitors administered pre-operatively or intra-operatively and continued postoperatively.
  • The benefits of these basic analgesics are well described for other procedures (Ong 2010; Martinez 2017).

Video-assisted thoracoscopic surgery-specific evidence

Data table: IV alpha-2 adrenergic agonists for pain management after VATS

Arguments for…

• One study compared IV dexmedetomidine 1 μg/kg or saline control over 20 minutes before the end of surgery (Lee 2016). Pain NRS scores at rest and on coughing, and opioid consumption, were significantly lower in the dexmedetomidine group compared with the control group during the first 24 h.
  • No basic analgesia (e.g. paracetamol, NSAIDs) was reported. All the patients received a loading dose of fentanyl 1 μg/kg followed by a continuous infusion of 0.4 μg/kg/h. Rescue fentanyl was needed by 58% of patients in the dexmedetomidine group versus 82% of patients in the control group.
  • Baseline QoR (Quality of Recovery)-40 global and dimensional scores were comparable in the two groups. More patients were agitated on emergence from anaesthesia in the control group.
  • FEV1 was significantly greater in the dexmedetomidine group compared with the control group on POD1 and 2.
  • Incidence of nausea and vomiting were more frequent in the control group.
  • There were no differences in the incidence of hypotension or bradycardia between the two groups.
• Another study compared IV dexmedetomidine (1 μg/kg loading dose of dexmedetomidine before induction followed by 0.5 mg/kg infusion until 20 minutes before end of surgery) with saline (Jannu 2020). Dexmedetomidine was associated with a significant reduction in pain scores and rescue medication (72% of patients in the intervention group versus 92% of patients in the control group) during the first 24 h.
  • All patients received IV paracetamol every 8 h for the first 72 h after surgery. Tramadol was used as rescue and there was no additional baseline analgesia.
  • Patients in the intervention group had better FEV1 and shorter hospital stay compared with those in the control group.
  • Hypotension and bradycardia were not reported in this study.
• Kweon 2019 compared a postoperative IV infusion of low dose (0.15 µg/kg/day) dexmedetomidine versus saline. Sufentanil requirement and pain scores at rest and on movement were lower in the dexmedetomidine group during the first 24 h.
  • The use of basic analgesia (paracetamol, NSAIDs) was not reported. Patients in both groups received IV sufentanil PCA.
  • Postoperative nausea and vomiting were lower in the dexmedetomidine group than the control group.
  • There was no difference between the two groups for the occurrence of bradycardia at 1, 4, 8 and 24 h postoperatively.
  • Mean arterial blood pressure was lower in the dexmedetomidine group, at 8 h postoperatively, but the difference was not clinically relevant.
• Another study compared a loading dose of dexmedetomidine intraoperatively followed by an IV dexmedetomidine PCA (0.1 µg/kg/h) versus a loading dose of saline intraoperatively followed by an IV sufentanil PCA (Miao 2020). There was no significant difference between the two groups in pain scores or rescue medication.
  • All patients received NSAIDs and an ICNB performed by the surgeon at the end of the surgical procedure.
  • The incidence of nausea and vomiting was significantly lower in the dexmedetomidine group.
  • A significant reduction in median arterial blood pressure, heart rate and sufentanil consumption was observed within 48 h after surgery in the dexmedetomidine group compared with the sufentanil group.
• One study compared a loading dose of dexmedetomidine administered at the end of surgery followed by dexmedetomidine PCA versus a loading dose of saline followed by saline PCA (Wang 2016). Pain scores and oxycodone consumption were significantly lower in the dexmedetomidine group versus saline group until 24 h after the surgery.
  • Median VAS pain scores were 2 in the dexmedetomidine group versus 4 in the saline group.
  • Oxycodone was provided to all patients. Oxycodone consumption was 13 mg in the dexmedetomidine group versus 16 mg in the saline group. The use of basic analgesia (paracetamol, NSAIDs) was not reported. No additional baseline analgesia was used.
  • The incidence of nausea and vomiting was reduced in the dexmedetomidine group.
  • There was no difference between the two groups in the occurrence of bradycardia at the different time points assessed.

Arguments against…

• No study concerning the use of clonidine in VATS was identified during the literature search period.

PROSPECT Recommendations

• Intraoperative administration of IV dexmedetomidine is recommended, especially when basic analgesics cannot be given.
  • Several studies have documented that IV dexmedetomidine reduces pain scores and opioid demand (Lee 2016; Jannu 2020).
  • Dexmedetomidine also decreases the incidence of postoperative agitation and cognitive dysfunction, and postoperative nausea and vomiting (Lee 2016; Jannu 2020; Kweon 2018). Improvement in lung function, with an increase in FEV1 and vital capacity, has also been demonstrated (Lee 2016; Jannu 2020; Kweon 2018).
  • Patients with severe cardiac disease, conduction and/or rhythm disorders were excluded from these studies and dexmedetomidine should not be used in those patients.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Corticosteroids for pain management after VATS

Arguments for…

• One study compared high-dose methylprednisolone (125 mg) before surgery with placebo (Bjerregaard 2017). On the day of surgery, pain scores at rest and during mobilisation were significantly reduced in the methylprednisolone group (1.7 versus 2.5) but not during arm abduction or coughing. Pain scores on the first and second days after surgery and opioid consumption were comparable.
  • Baseline analgesia included paracetamol, ibuprofen and gabapentin, supplemented by a PVB and an ICNB, with morphine or a bolus of bupivacaine in the ICNB given as rescue.
  • Side effects were comparable in the two groups, except that patients in the methylprednisolone group needed more insulin for high blood glucose levels.

PROSPECT Recommendations

• Corticosteroids are not recommended for management of postoperative pain after VATS due to lack of procedure-specific evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: NMDA antagonists for pain management after VATS

Arguments for…

• One study compared the administration of an IV bolus of magnesium sulphate of 50 mg/kg for 10 min, followed by a continuous infusion of 50 mg/kg/h during surgery after tracheal intubation, until the end of surgery, versus saline control (Sohn 2017). Mean opioid demand was significantly lower in the magnesium sulphate group compared with the control group (35.1 mg versus 44.7 mg at 24 h). Pain scores and rescue analgesics were comparable in both groups.
  • A fentanyl PCA associated with a basal IV infusion was started at the end of surgery. Basic analgesia (NSAIDs) was used at the discretion of the physicians.
  • Postoperative FEV1 and FVC were higher in the magnesium group compared with the control group.

Arguments against…

• No study concerning the use of ketamine in VATS was identified during the literature search period. One study aiming to assess both dexmedetomidine and ketamine has been registered in ClinicalTrials.gov (NCT03596424).

PROSPECT Recommendations

• Magnesium sulphate is not recommended for management of postoperative pain after VATS due to limited procedure-specific evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Gabapentinoids for pain management after VATS

Arguments for…

• One study documented that a single administration of pregabalin before surgery decreased postoperative pain scores up to 24 h and the need for additional rescue analgesics without an increase in the incidence of side effects (Kim 2017).
  • Patients did not receive any additional baseline analgesia in this study.
• In one study, pregabalin administered for three months from POD2 was compared with control (Homma 2019). The number of patients who experienced postoperative neuropathic pain was significantly lower in the pregabalin group compared with the control group (19.6 % versus 41.3%). However, the delay between surgery and the occurrence of postoperative neuropathic pain was comparable between groups.
  • All patients received NSAIDs and had TEA for 2 days after surgery.

Arguments against…

• One study reported that the administration of pregabalin before surgery and for 5 days after surgery had no significant effect on pain scores and postoperative opioid consumption (Konstantatos 2016).
  • All patients received paracetamol and the port sites were infiltrated with a ropivacaine solution.

PROSPECT Recommendations

• Gabapentinoids are not recommended for management of postoperative pain after VATS due to inconsistent evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: IV lidocaine for pain management after VATS

Arguments against…

• One study compared IV lidocaine (bolus after induction of anaesthesia followed by continuous infusion until the end of surgery) with placebo (Slovack 2015), finding no significant difference in pain scores and opioid consumption. Basic analgesia was not reported.

PROSPECT Recommendations

• IV lidocaine is not recommended for management of postoperative pain after VATS due to lack of procedure-specific evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Paravertebral block (PVB) for pain management after VATS

Arguments for…

• Three studies investigated continuous PVB with a catheter placement performed intraoperatively by surgeons (Giang 2018; Lee 2018; Wu 2018); all reported a reduction in opioid consumption with PVB versus IV PCA opioid.
  • One of these studies compared continuous PVB with IV morphine PCA and noted significantly lower pain scores only during the first 4 h postoperatively (Giang 2018). Opioid consumption was higher in the IV PCA group. Baseline analgesia was not reported. There was no difference in side effects.
  • In a similar study, continuous PVB was compared with IV fentanyl PCA (Lee 2018). All patients received tramadol and paracetamol as basic analgesia. This study documented lower opioid consumption in the PVB group with no difference in pain scores between groups. There was a higher incidence of PONV and discontinuation of IV fentanyl PCA in the PCA group.
  • A further study compared PVB catheter to systemic analgesia with IV sufentanil PCA (Wu 2018). All the patients received systemic NSAIDs. Mean VAS pain scores were not significantly different between groups but morphine consumption was significantly higher in the sufentanil PCA group. There was significantly more PONV and more rescue analgesia in the sufentanil PCA group.
• Four studies focused on the PVB single-shot technique (Zhang 2015; Chu 2020; Chu 2019; Kang 2020); all four found a reduction in analgesic consumption and two studies found a reduction in pain scores compared with controls.
  • One study documented a lower VAS pain score on coughing and lower opioid consumption in the PVB single shot group compared with the local wound infiltration group (Zhang 2015). PVB was performed by the surgeon under direct vision. All patients received NSAIDs and IV morphine PCA as a rescue.
  • One study found lower pain scores and lower opioid consumption in the single-shot PVB group compared with the control group with no block (Chu 2020). PVB was performed by an anaesthetist. All patients received NSAIDs and IV sufentanil PCA as a rescue.
  • Another study compared three different groups: pre- and postoperative PVB injection using ropivacaine 2 mg/ml versus postoperative PVB injection versus sham block with saline (Chu 2019). PVB was performed by an anaesthetist. No significant difference in pain scores was documented between the three groups but there was a significant decrease in opioid use in the pre- and postoperative PVB group compared to the other groups. The basic analgesia protocol was not reported.
  • One study examined the effect of ultra-sound-guided, single-shot PVB versus control on rehabilitation using the decline rate of 6MWT (six-minute walking test) on POD1 as the primary outcome (Kang 2020). PVB was performed by an anaesthetist with an ultrasound-guided technique. There was a lower decline rate of 6MWT on POD1 and POD2 in the PVB group compared to the control group. Postoperative analgesic consumption was also lower in the PVB group than the control group. Basic analgesia use was not reported.
• Two studies compared continuous PVB with ICNB (Hutchins 2017; Kadomatsu 2018), with inconsistent results.
  • Continuous PVB (ropivacaine 2 mg/ml infused at 10–14 ml/h through a catheter placed by the anaesthetist) was compared with single-shot ICNB (ropivacaine 2.5–5.0 mg/ml, performed by the surgeon) (Hutchins 2017). This study found lower pain scores in the PVB catheter group but no difference in opioid use. Basic and baseline analgesia were not reported.
  • In a second study, continuous PVB was compared with ICNB, with a catheter placed by a surgeon in both instances (Kadomatsu 2018). Basic analgesia was provided with NSAIDs. This study found no significant difference between the two groups.
• There are several studies regarding the addition of dexmedetomidine to PVB (Xu 2017; Hong 2019; Abd-Elshafy 2019; Ding 2018), showing benefits for reduction of pain scores.
  • One study looked at multilevel PVBs with ropivacaine plus dexmedetomidine versus plain ropivacaine (Xu 2017). Basic analgesia was provided with NSAIDs. Lower pain scores were observed in the dexmedetomidine group but there was similar opioid consumption.
  • Using a similar protocol, another study found lower pain scores and reduced opioid consumption in the dexmedetomidine plus ropivacaine group (Hong 2019). Baseline analgesia was nefopam; NSAIDs were used as rescue analgesia.
  • One study compared PVB with bupivacaine 5 mg/ml plus dexmedetomidine versus plain bupivacaine (Abd-Elshafy 2019). This study observed a significant decrease in pain only within the first 2 h. Opioid consumption was not reported. There was a reduction of chronic pain at three months but not at six months in the dexmedetomidine group, as a secondary outcome.
  • Another study compared three groups: TEA plus a single dose of epidural morphine versus single-shot PVB versus single-shot PVB with dexmedetomidine (Ding 2018). Patients in the dexmedetomidine PVB group and those in the TEA group had significantly lower pain scores.
• Different modalities of administration of LA by a paravertebral catheter have been studied (Taketa 2019; Chen 2019; Kamalanathan 2018; Kaya 2012; Bauer 2018; Taketa 2018).
  • One study looked at programmed intermittent bolus (PIBI) versus continuous infusion for postoperative analgesia (Taketa 2019). There was no significant difference regarding analgesic effect, opioid consumption and PONV. There were, however, a larger number of dermatomes anaesthetised in the PIBI group.
  • A similar study with a smaller number of patients (Chen 2019) found lower pain scores at rest and with coughing in the PIBI group and also lower consumption of LA.
  • In a study looking specifically at the timing of the block, either after incision or at the end of the procedure (Kamalanathan 2018), there was no significant difference between the two groups in terms of pain score and opioid consumption. Basic analgesia was supplied by NSAIDs and paracetamol.
  • One study looked at multiple injections (five injections from T4 to T8) versus a single injection at T6 (Kaya 2012). Multiple injections were more painful and took longer to be performed but the analgesic effect and opioid consumption were similar between groups.
  • One study compared a continuous PVB with ropivacaine plus sufentanil versus ropivacaine alone (Bauer 2018). There was no significant difference between the two groups for pain scores and opioid consumption.
  • One study compared the intercostal approach versus the paralaminar approach to PVB (Taketa 2018). This study suggested that the paralaminar approach provided superior analgesia; the number of postoperative fentanyl rescue doses was smaller than with the intercostal approach at 3, 6, 12 and 24 h postoperatively.

PROSPECT Recommendations

• Regional analgesic techniques such as PVB and ESPB are recommended, using either a single shot or preferably a catheter with a continuous infusion of local anaesthetics.
• A PVB is recommended because of its efficacy on pain control and limited side effects compared to TEA. The use of a catheter instead of single-shot analgesia prolongs the analgesic effect.
• The block should be performed, whatever the technique, at a thoracic level adapted to the location of the port sites.
• Addition of preservative-free dexmedetomidine in perineural analgesia could be recommended. However, it remains to be demonstrated that a comparable effect could be achieved with IV administration of dexmedetomidine making it more appropriate for clinical use.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Erector spinae plane block (ESPB) for pain management after VATS

Arguments for…

• Two studies compared ESPB single shot performed with 20 ml bupivacaine 5 mg/ml versus a control group with no block (Cifti 2019; Liu 2020), finding lower pain scores and opioid consumption with ESPB.
  • One study concluded that patients having ESPB single shot had lower active and passive pain scores and lower opioid consumption during the first 24 h (Cifti 2019). There was significantly less PONV in the ESPB group. NSAIDs were given for basic analgesia.
  • Results were similar in another study, with lower pain scores and lower opioid consumption associated with single-shot ESPB (Liu 2020). A secondary outcome was a faster postoperative out-of-bed activity. No basic analgesia (NSAIDs, paracetamol) was reported.
• Two other studies compared ESPB with ropivacaine versus placebo block with saline (Yao 2020; Shim 2020), and reported lower pain scores with ESPB.
  • One study found that ESPB with ropivacaine reduced pain scores at rest and during coughing for the first 8 h after surgery (Yao 2020). NSAIDs were used as basic analgesia. Postoperative sufentanil use was lower in the ESPB ropivacaine group in the first 24 h. QoR-40 scores were higher on the first and second postoperative days and patients were discharged earlier. Patient satisfaction was also higher in the ESPB group with ropivacaine.
  • A similar study reported lower pain scores with ESPB in the first 6 h only (Shim 2020). No basic analgesia was reported. Rescue opioid use, however, was lower in the placebo group. The length of stay was significantly shorter in the ESPB group.
• Two studies compared ESPB and PVB (Zhao 2020; Taketa 2020), finding ESPB to be non-inferior to PVB in terms of analgesic effect.
  • Zhao 2020 found no significant difference in pain scores, quality of recovery or opioid consumption during the first 48 h between single-shot ESPB and single-shot PVB. Continuous infusion of NSAIDs was used as basic analgesia.
  • Taketa 2020 found no difference in pain scores or opioid consumption during the first 48 h between continuous ESPB and PVB. No basic analgesia was reported.
• Gao 2020 studied three groups with different adjuvants combined with ropivacaine in ultrasound-guided ESPB: plain ropivacaine versus ropivacaine plus dexamethasone versus ropivacaine plus dexmedetomidine. NSAIDs were used as basic analgesia. The dexmedetomidine group had reduced pain scores, lower need for rescue analgesia and shorter hospital stay compared to the other two groups.

Arguments against…

• Two studies compared ESPB, PVB and ICNB (Chen 2020; Turhan 2020), finding lower pain scores with PVB.
  • In one study, opioid consumption and pain scores at rest and while coughing were significantly lower in the PVB group compared to the ESPB and ICNB groups up to 8 h postoperatively (Chen 2020). There was no significant difference in pain scores between the ESPB and ICNB groups during the first 48 h. Additional baseline and basic analgesia were not reported.
  • In the other study, pain scores were lower in the PVB group compared to the INCB group and lower in the ICNB group compared to the ESPB group (Turhan 2020). Patients all received basic analgesia with paracetamol and NSAID. Morphine consumption was lower in the ICNB and the PVB groups compared to the ESPB group. There was no difference in morphine consumption between the PVB and the ICNB groups. There was no difference between the three groups in mobilisation times.

PROSPECT Recommendations

• Regional analgesic techniques such as PVB and ESPB are recommended, using either a single shot or preferably a catheter with a continuous infusion of local anaesthetics.
• An ESPB is recommended as several studies have shown efficacy of ropivacaine ESPB versus sham block (Yao 2020; Shim 2020). Two studies have shown non-inferiority of ESPB compared with PVB (Zhao 2020; Taketa 2020). ESPB should therefore be considered as an alternative.
• The block should be performed, whatever the technique, at a thoracic level adapted to the location of the port sites.
• Addition of preservative-free dexmedetomidine in perineural analgesia could be recommended. However, it remains to be demonstrated that a comparable effect could be achieved with IV administration of dexmedetomidine making it more appropriate for clinical use.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Serratus anterior plane block (SAPB) for pain management after VATS

• To perform SAPB, local anaesthetic can be injected above the serratus anterior muscle, between it and the latissimus dorsi muscle (superficial SAPB) or below the serratus muscle, between it and the intercostal muscles (deep SAPB).

Arguments for…

• Four studies compared SAPB versus no block and found reduced pain scores with SAPB (Ökmen 2017; Park 2018; Viti 2019; Semyonov 2019).
  • One study concluded that pain scores were lower in the deep SAPB group, and patients used less tramadol as rescue medication in this group (Ökmen 2017). NSAIDs were given in both groups as routine analgesia.
  • Another study found lower pain scores and opioid consumption in the first 24 h with deep SAPB compared with no block (Park 2018). Routine analgesia was used, with paracetamol and NSAIDs.
  • A third study reported better pain control with deep SAPB, using baseline analgesia with tramadol and NSAIDs (Viti 2019). Opioid consumption was not reported in this study.
  • A further study documented lower pain scores in the first 8 h and significantly lower opioid consumption among patients who received SAPB (either a deep or a superficial injection at the operator’s discretion) (Semyonov 2019). PONV was lower in the SAPB group. Paracetamol and NSAIDs were given to both groups as basic analgesia.
• One study compared superficial SAPB with ropivacaine versus saline (Kim 2018). Pain scores at rest and opioid consumption were lower with SAPB, and PONV was less frequent. Basic analgesia was applied with paracetamol, codeine and NSAIDs.
• Two studies compared SAPB with LA infiltration (Chen 2019; Shang 2020), and results favoured SAPB.
  • One study compared superficial SAPB versus local anaesthetic infiltration before the surgical incision (Chen 2019). There was a difference in pain scores favouring SAPB at 2 and 8 h after surgery, but not later. During the first 8 h, opioid consumption was lower in the SAPB group. No basic analgesia was reported in any group.
  • Another study also compared superficial SAPB versus local anaesthetic infiltration of the surgical incision (Shang 2020). Basic analgesia included NSAIDs. The estimated median time to the first VAS pain score ≥4 was significantly longer in the SAPB group.
• Two studies compared SAPB with ICNB, finding no difference in pain scores and analgesic consumption (Kim 2020; Lee 2020).
  • One study compared deep SAPB with ICNB but found no significant difference in opioid consumption and pain scores (Kim 2020). Paracetamol was used as basic analgesia.
  • Another study also compared ultrasound-guided superficial SAPB with ICNB performed by the surgeon (under direct vision) (Lee 2020). No basic analgesia was reported. This study also found no significant difference in pain scores and postoperative analgesic consumption.
• Comparisons were made between SAPB and ESPB in three studies (Ekinci 2020; Gaballah 2019; Finnerty 2020); two of the studies found no difference in analgesic effect.
  • One study found lower pain scores and lower opioid consumption with ESPB compared with deep SAPB (Ekinci 2020). Basic analgesia was provided with NSAIDs only.
  • Another study performed a superficial SAPB and found comparable results (Gaballah 2019). This study used both NSAIDs and paracetamol as rescue medication.
  • A third study found no difference between deep SAPB and ESPB, both in analgesic effect and opioid consumption (Finnerty 2020). Paracetamol and NSAIDs were given to both groups.
• Li 2020 studied the use of different doses of dexmedetomidine (0.5 μg/kg or 1 μg/kg) as an adjuvant to ropivacaine in superficial SAPB. Basic analgesia was delivered with paracetamol and NSAIDs. Significantly lower pain scores were reported in the highest dose dexmedetomidine group (1 μg/kg), with reduced opioid consumption when compared with the lower dose.
• A systematic review and meta-analysis investigated whether perioperative ultrasound-guided SAPB combined with GA is more effective and safer than systemic analgesia after VATS (Zhang 2020). The review included three RCTs and one retrospective trial, and found that perioperative SAPB reduced postoperative pain scores and analgesic consumption after GA. Moreover, SAPB provided better patient satisfaction. No significant difference was found in duration of surgery, time to chest tube removal, length of stay or side effects.

PROSPECT Recommendations

• Regional analgesic techniques such as PVB and ESPB are recommended, using either a single shot or preferably a catheter with a continuous infusion of local anaesthetics.
• Serratus anterior plane block can be used as a second choice. The studies retrieved considered a single injection and documented a benefit in terms of pain and opioid consumption compared with systemic basic analgesia or compared with infiltration of the incision site.
• The block should be performed, whatever the technique, at a thoracic level adapted to the location of the port sites.
• Addition of preservative-free dexmedetomidine in perineural analgesia could be recommended. However, it remains to be demonstrated that a comparable effect could be achieved with IV administration of dexmedetomidine making it more appropriate for clinical use.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Thoracic epidural analgesia (TEA) for pain management after VATS

Arguments against…

• Two studies compared TEA with systemic analgesia (Zejun 2018; Tseng 2019), with mixed results.
  • One study compared TEA versus IV sufentanil PCA in patients receiving NSAIDs as basic analgesia (Zejun 2018). In the TEA group a bolus of 5 ml ropivacaine 2.5 mg/ml solution was administered after catheter placement before surgery, followed by a 5 ml/h infusion of the same solution. Postoperatively, patients in the TEA group received ropivacaine 1.5 mg/ml and sufentanil 0.2 μg/ml at a rate of 5–10 ml/h with a bolus of 5 ml allowed every 40 minutes. The study found superiority in pain control at rest and mobilisation in the TEA group. TEA was also associated with a decrease in the incidence of PONV and a shorter duration of postoperative ileus.
  • Another study compared TEA versus IV fentanyl PCA and low-dose ketamine (Tseng 2019). Basic analgesia was provided by ICNB performed by surgeons. All patients received ketorolac. The authors did not find any difference in the pain scores at rest and during mobilisation at 48 h. There was no difference in the occurrence of PONV.
• Three studies compared TEA with PVB, with mixed results.
  • One study compared TEA to PVB catheter and found no difference in pain scores and opioid consumption (Okajima 2014). All patients received NSAIDs. There was more hypotension in patients who received TEA.
  • Another study compared TEA with single-shot PVB and with continuous infusion PVB (Yeap 2020), reporting that TEA was more effective to reduce pain scores and opioid consumption. There was no difference in chronic pain at 6 months between the groups. In the TEA group, an infusion of bupivacaine 1.25 mg/ml with hydromorphone 0.05 mg/ml was commenced postoperatively. In the first PVB group, a single shot of 30 ml of ropivacaine 5.0 mg/ml was injected through the catheter inserted before surgery. In the second PVB group, 10 ml/h of ropivacaine 2.0 mg/ml was administered continuously through the catheter. Basic analgesia consisted of preoperative pregabalin and paracetamol followed by postoperative paracetamol.
  • A third study compared TEA versus ultrasound-guided continuous PVB performed either by a parasagittal or a transverse approach (Huang 2020). All patients received NSAIDs. Pain scores were lower in the TEA group and a larger sensory block extension was obtained. There was a high ratio of failure to identify the epidural space (14.6%) and hypotension in the TEA group and an even higher rate of failure of catheter placement in the parasagittal paravertebral group (27.1%).
• A review by Harky 2019 sought to compare PVB and TEA for analgesia and postoperative complications. They included three small RCTs and one small cohort study. From a pain perspective, there was no conclusive evidence to recommend either PVB or TEA: one study by Kashiwagi 2015 demonstrated significantly lower levels of pain with TEA, one study by Kosinski 2016 showed better pain control with PVB and the third study by Okajima 2014 found no difference between the two techniques. PVB was associated with lower rates of urinary retention and hypotension compared to TEA.
• One study compared TEA with extrapleural blocks (Hotta 2011). Basic analgesia was provided with flurbiprofen. The authors found no significant difference in analgesic effect and opioid consumption.
• One study found that addition of magnesium 100 mg to epidural injection of ropivacaine did not improve postoperative pain within the first 48 h and did not reduce opioid consumption (Lee 2012). The primary outcome, chronic postoperative pain, did not differ between the two groups.

PROSPECT Recommendations

• TEA is not recommended due to non-inferiority of less invasive techniques with fewer side effects.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Intercostal nerve block (ICNB) for pain management after VATS

Arguments for…

• One study compared the effect of single-shot ICNB performed at the end of the surgical procedure by the anaesthetist versus no block (Ahmed 2017). They reported significantly lower pain scores in the ICNB group, with less rescue analgesics required. Basic analgesia was not reported.
• Zhang 2019 studied four different groups, with different LA mixtures for ICNB: ropivacaine plus perineural dexamethasone; ropivacaine plus perineural dexmedetomidine; ropivacaine plus perineural dexmedetomidine and dexamethasone; plain ropivacaine (control). The duration of analgesia was significantly longer in the dexmedetomidine and dexamethasone group compared to the other three groups, and significantly shorter in the control group compared to the other three groups. There was no difference between the dexmedetomidine group and the dexamethasone group.
• Maher 2016 compared an ICNB with ropivacaine plus dexamethasone versus plain ropivacaine. They reported a prolonged duration of analgesia in the dexamethasone group, with lower pain scores and reduced opioid requirements at 24 h. Paracetamol was given in both groups.

PROSPECT Recommendations

• ICNB is not recommended due to lack of procedure-specific evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Subpleural block with catheter for pain management after VATS

Arguments against…

• Ghee 2017 compared subpleural catheter with a bupivacaine infusion, inserted intraoperatively by the surgeon, versus intraoperative infiltration of the incision site with bupivacaine. There was no difference in analgesic effect or use of narcotics. Basic analgesia was achieved with paracetamol and NSAIDs.

PROSPECT Recommendations

• Subpleural block is not recommended due to limited procedure-specific evidence.

Video-assisted thoracoscopic surgery-specific evidence

Data table: Surgical site infiltration for pain management after VATS

Arguments against…

• One study compared pre-emptive bupivacaine injection around the surgical incision versus no block (Yang 2015). No basic analgesia was reported. There was no difference in analgesic effect between groups and a higher need for rescue analgesia in the intervention group.

PROSPECT Recommendations

• Surgical site infiltration is not recommended due to limited procedure-specific evidence.