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- Title
Effectiveness of Surgeon-Performed Paravertebral Block Analgesia for Minimally Invasive Thoracic Surgery: A Randomized Clinical Trial.
- Authors
Chenesseau, Josephine; Fourdrain, Alex; Pastene, Bruno; Charvet, Aude; Rivory, Adrien; Baumstarck, Karine; Bouabdallah, Ilies; Trousse, Delphine; Boulate, David; Brioude, Geoffrey; Gust, Lucile; Vasse, Matthieu; Braggio, Cesare; Mora, Pierre; Labarriere, Ambroise; Zieleskiewicz, Laurent; Leone, Marc; Thomas, Pascal Alexandre; D'Journo, Xavier-Benoit
- Abstract
This randomized clinical trial investigates if paravertebral block (PVB) performed under video-assisted thoracoscopic surgery by a surgeon is noninferior to PVB performed by an anesthesiologist using an ultrasound-guided technique. Key Points: Question: In minimally invasive thoracic surgery, is paravertebral block (PVB) undertaken by a surgeon under video-assisted thoracoscopic surgery (VATS) noninferior to PVB performed by an anesthesiologist using an ultrasound (US)–guided technique? Findings: In this noninferiority randomized clinical trial, 196 patients were assigned to PVB-VATS or PVB-US. Results showed the noninferiority of PVB-VATS to PVB-US in the mean difference in total 48-hour opioid consumption. Meanings: Results suggest that in cases of local resource or human limitations, an effective and easy postoperative analgesia can be provided by the surgeon under thoracoscopic vision. Importance: In minimally invasive thoracic surgery, paravertebral block (PVB) using ultrasound (US)–guided technique is an efficient postoperative analgesia. However, it is an operator-dependent process depending on experience and local resources. Because pain-control failure is highly detrimental, surgeons may consider other locoregional analgesic options. Objective: To demonstrate the noninferiority of PVB performed by surgeons under video-assisted thoracoscopic surgery (VATS), hereafter referred to as PVB-VATS, as the experimental group compared with PVB performed by anesthesiologists using US-guided technique (PVB-US) as the control group. Design, Setting, and Participants: In this single-center, noninferiority, patient-blinded, randomized clinical trial conducted from September 8, 2020, to December 8, 2021, patients older than 18 years who were undergoing a scheduled minimally invasive thoracic surgery with lung resection including video-assisted or robotic approaches were included. Exclusion criteria included scheduled open surgery, any antalgic World Health Organization level greater than 2 before surgery, or a medical history of homolateral thoracic surgery. Patients were randomly assigned (1:1) to an intervention group after general anesthesia. They received single-injection PVB before the first incision was made in the control group (PVB-US) or after 1 incision was made under thoracoscopic vision in the experimental group (PVB-VATS). Interventions: PVB-VATS or PVB-US. Main Outcomes and Measures: The primary end point was mean 48-hour post-PVB opioid consumption considering a noninferiority range of less than 7.5 mg of opioid consumption between groups. Secondary outcomes included time of anesthesia, surgery, and operating room occupancy; 48-hour pain visual analog scale score at rest and while coughing; and 30-day postoperative complications. Results: A total of 196 patients were randomly assigned to intervention groups: 98 in the PVB-VATS group (mean [SD] age, 64.6 [9.5] years; 53 female [54.1%]) and 98 in the PVB-US group (mean [SD] age, 65.8 [11.5] years; 62 male [63.3%]). The mean (SD) of 48-hour opioid consumption in the PVB-VATS group (33.9 [19.8] mg; 95% CI, 30.0-37.9 mg) was noninferior to that measured in the PVB-US group (28.5 [18.2] mg; 95% CI, 24.8-32.2 mg; difference: −5.4 mg; 95% CI, −∞ to −0.93; noninferiority Welsh test, P ≤.001). Pain score at rest and while coughing after surgery, overall time, and postoperative complications did not differ between groups. Conclusions and Relevance: PVB placed by a surgeon during thoracoscopy was noninferior to PVB placed by an anesthesiologist using ultrasonography before incision in terms of opioid consumption during the first 48 hours. Trial Registration: ClinicalTrials.gov Identifier: NCT04579276
- Publication
JAMA Surgery, 2023, Vol 158, Issue 12, p1255
- ISSN
2168-6254
- Publication type
Article
- DOI
10.1001/jamasurg.2023.5228