Pain, Thoracic
Conditions
Keywords
Rhomboid intercostal block, serratus anterior plane block, Thoracotomy
Brief summary
The objective of the current study is to compare the efficacy of the analgesic effect of ultrasound-guided unilateral Rhomboid intercostal and sub serratus plane block (RISS) versus Serratus anterior plane block (SAPB) in Thoracotomy incision.
Detailed description
Open thoracotomy is commonly considered to be one of the most agonizing surgical operations. Pain following thoracotomy greatly impedes patient recovery and postoperative respiration. The pain experienced after a thoracotomy can originate from various factors, including the surgical incision, injury to the ribs and intercostal nerves, manipulation of the pleura and lung tissue, and the placement of a drainage tube.Recent advances in regional anesthesia techniques have aimed to provide more targeted and effective pain relief. Among these, ultrasound-guided fascial plane blocks, such as the rhomboid intercostal sub-serratus plane (RISS) block and the serratus anterior plane (SAP) block, have emerged as promising options. Both blocks target the thoracic nerves, but they differ in their anatomical approach and potential analgesic effects Postoperative pain was not only related to a comfortable recovery but also related to postoperative complications including pulmonary dysfunction, so the management of postoperative pain is an important part of the care of post operation. Regional anesthesia techniques have been shown to have a good effect on postoperative analgesia and helps patients gain early recovery after operation. Serratus anterior plane block (SAPB) is an easy, and safe method used for blockade of the sensory plane of the lateral cutaneous branch of the intercostal nerve (T2-T9). The Serratus anterior plane block targets the lateral cutaneous branches of the thoracic intercostal nerves, which arise from the anterior rami of the thoracic spinal nerves and run in a neurovascular bundle immediately inferior to each rib. At the midaxillary line, the lateral cutaneous branches of the thoracic intercostal nerve traverse through the internal intercostal, external intercostal, and serratus anterior muscles innervating the musculature of the lateral thorax. These branches of the intercostal nerves travel through the two potential spaces described above. The Rhomboid intercostal and sub serratus plane block (RISS) is a relatively newer block technique whose efficacy was documented in patients undergoing thoracic surgeries. The RISS plane block involves the injection of local anesthetics into fascial planes, theoretically allowing for catheter placement to achieve continuous analgesia. Successful RISS plane blocks have been reported in various procedures, including lung transplantation, radical mastectomy, and nephrectomy, strongly suggesting favorable outcomes in postoperative pain relief. In 2016, Elsharkawy et al. introduced a RA technique known as the rhomboid intercostal block (RIB). Rhomboid intercostal block involves injecting a local anesthetic into the upper intercostal muscle plane beneath the rhomboid muscles, providing analgesia to both the anterior and posterior thorax.Based on past studies, investigators found that RISS and SAPB are effectively decrease total opioid consumption, so investigators hypothesized one of them is the best. Statistical analysis: Statistical analysis will be conducted using IBM SPSS Statistics 22(IBM Corp., Armonk, NY, USA). The normal distribution of data will be assessed by the Kolmogorov-Smirnov and Shapiro-Wilk tests. Mean and standard deviation will be used as descriptive statistics for normally distributed numerical variables, while median and interquartile range (25th to 75th percentiles) will be used as descriptive statistics for non-normally distributed numerical variables. In addition, Chi-square test or fisher exact test will be employed to test the significance between categorical variables as appropriate. Independent t test will be employed for numerical data that exhibited normal distribution, whereas the Mann-Whitney test will be used for numerical data that did not adhere to normal distribution. A significance level of p \< 0.05 will be deemed to be statistically significant.
Interventions
DRUGBupivacain
After the location will be confirmed through hydrodissection of 1 ml on the plane between the rhomboid major and the underlying intercostal muscles after confirming a negative aspiration via a a 22-gauge short bevel sonovisible needle (Spinocan, B. Braun Melsungen AG, Germany) using an in-plane technique then 10 ml of bupivacaine (concentration 0.25%) will be injected. and its spread will be manifested by the hydrodissection and widening of the plane visualized by ultrasound.
DEVICEUltrasound
A linear US transducer (Phillips-Saronno Italy) was placed vertically 3 cm lateral to the midline to visualize back muscles: the trapezius above, the rhomboid major in the middle, and the erector-spinae muscle on the bottom, as well as the TPs with shimmering pleura in between.
Sponsors
Yasser S Mostafa, MD
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Masking description
Triple (Participant, Care Provider, Outcomes Assessor) Apart from the anesthesiologists who performed the blocks, all patients, surgeons, and postoperative nurses remained blinded to randomization throughout the study period.
Intervention model description
After endotracheal intubation, just before the block, the patients were randomly allocated into two groups based on a computerized randomization table created by a researcher who was not involved in the study. The researcher assigned a random ID to each patient, and a blinded anesthesiologist used this ID while collecting the postoperative data in the surgical ward.
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
Yes
Inclusion criteria
* Patients aged 18-70 years. * Patients scheduled for unilateral Thoracotomy. * American Society of Anesthesiologists (ASA) physical status I-III. * Patients who are candidates for general anesthesia. * No history of severe allergies to local anesthetics or other medications used during the procedure.
Exclusion criteria
* ASA PS class ≥ IV patients. * obese (BMI ≥ 35) patients. * Patients with uncontrolled cardiovascular. * patients with neurological deficits, cardiopulmonary, hepatorenal , or metabolic diseases; anticoagulants; any drug allergies. * Patients with emergency surgeries or re-do surgeries. * Systemic infections or infections at the site of injection. * Psychiatric illnesses (schizophrenia, bipolar, uncontrolled anxiety or depression). * Narcotic dependency.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Total opioid consumption | 24 hours postoperatively. | in microgram |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Intraoperative Heart rate | every 30 minutes along operation | Beat / minute |
| Baseline mean arterial blood pressure | 5 minutes before anesthesia | mmHg |
| Intraoperative mean arterial blood pressure | every 30 minutes along operation | mmHg |
| Baseline oxygen saturation | 5 minutes before anesthesia | percentage with pulse oximetry |
| Intraoperative oxygen saturation | every 30 minutes along operation | percentage with pulse oximetry |
| Total length of stay in hospital | 1-2 days | in days |
| Visual analog pain score at rest | Immediately after the procedures | Ranging from 0 indicating no pain to 10 indicating extreme pain |
| Incidence of vomiting | 24 hours postoperative | Yes or no |
| Ramsay sedation score | 24 hours postoperative | From 1 to 5 (1 Awake; agitated or restless or both - 2 Awake; cooperative, oriented, and tranquil - 3 Awake but responds to commands only - 4 Asleep; brisk response to light glabellar tap or loud auditory stimulus - 5 Asleep; sluggish response to light glabellar tap or loud auditory stimulus) Asleep; no response to glabellar tap or loud auditory stimulus |
| Total intraoperative opioid consumption | from begining of operation till 5 minutes after extubation | in microgram |
| Baseline Heart rate | 5 minutes before anesthesia | Beat / minute |
| Visual analog pain score at cough | Immediately after the procedures | Ranging from 0 indicating no pain to 10 indicating extreme pain |
| Time of first rescue analgesic | 5 minutes before first analgesic request | in minutes |
| Patient satisfaction score | 12 hours after end of operation and extubation | 5 degree Likeart scale where 1 Extremely satisfied to 5 Extremely not satisfied |
| Incidence of hematoma | 30 minutes after nerve block | Yes or no |
| Incidence of local anesthetic toxicity | 30 minutes after nerve block | Yes or no |
| Incidence of nausea | 24 hours postoperative | Yes or no |
Other
| Measure | Time frame | Description |
|---|---|---|
| Sex | 5 minutes before entering operation department | Male of female |
| Age | 5 minutes before entering operation department | in years |
Countries
Egypt
Contacts
Primary ContactEmad El Mohamed Abd El-Razek, M.Sc.
Backup ContactYasser S Mostafa, MD
Outcome results
None listed