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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 8  |  Page : 213-217

Applications of nerve stimulator-guided thoracic paravertebral nerve block plus general anesthesia in small-incision lung cancer surgery


Department of Anesthesiology, Xinxiang Centre Hospital of China, Xinxiang, China

Date of Web Publication26-Mar-2018

Correspondence Address:
Peishan Wang
Department of Anesthesiology, Xinxiang Centre Hospital of China, Xinxiang 453000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.188031

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 > Abstract 


Objective: The aim of the study was to investigate the application of nerve stimulator-guided thoracic paravertebral nerve block (TPVB) plus general anesthesia (GA) in small-incision lung cancer surgery.
Methods: Forty patients scheduled for small-incision lung cancer surgery, the American Society of Anesthesiologists Grade I-II, were randomized into a TPVB-GA group (Group P) and a GA group (Group G), with 20 cases in each group. The dosage of general anesthetic, mean arterial pressure (MAP) at each time point, and heart rate (HR) of the two groups were recorded. The postoperative respiration recovery time, extubation time, incidence of adverse reactions, and postoperative visual analog scale (VAS) scores of the two groups were also observed.
Results: Group P showed stable hemodynamics, and lower MAP and HR at each time point than Group G (P < 0.05). The intraoperative dosage of general anesthetic in Group P was lower than that in Group G (P < 0.05). The respiration recovery time and extubation time in Group P were significantly shorter than those in Group G (P < 0.05); the incidence of agitation was significantly lower than that in Group G (P < 0.05). The VAS scores of Group P under quiet and cough status were also better than Group G (P < 0.05).
Conclusions: Nerve stimulator-guided TPVB-GA is suitable for small-incision lung cancer surgery.

Keywords: General anesthesia, nerve stimulator, small-incision lung cancer surgery, thoracic paravertebral nerve block


How to cite this article:
Lei P, Gao S, Wang P, Fan J, Ai X. Applications of nerve stimulator-guided thoracic paravertebral nerve block plus general anesthesia in small-incision lung cancer surgery. J Can Res Ther 2018;14, Suppl S1:213-7

How to cite this URL:
Lei P, Gao S, Wang P, Fan J, Ai X. Applications of nerve stimulator-guided thoracic paravertebral nerve block plus general anesthesia in small-incision lung cancer surgery. J Can Res Ther [serial online] 2018 [cited 2019 Jun 16];14:213-7. Available from: http://www.cancerjournal.net/text.asp?2018/14/8/213/188031




 > Introduction Top


According to the GLOBOCAN World Cancer Report issued by the International Agency for Research on Cancer (IARC), lung cancer affects more than 1 million people worldwide each year, and among cancers in men, it is first in incidence and mortality; in women, it is first in mortality.[1] Treatment for lung cancer depends on tumor histology, tumor extent, and other patient-specific factors; however, surgery remains the cornerstone in treating this disease, and it offers the only chance for long-term survival. In recent years, there has been tremendous progress in the development of surgical techniques and anesthetic methods for lung surgery.[2] Minimally invasive surgery has become more and more popular: For example, video-assisted thoracoscopic surgery (VATS), which is performed under thoracoscopic monitoring with the aid of three to four holes, is a well-known small-incision surgery.[3] The Da Vinci Surgical System for cancer treatment has also generated excitement, and the benefits of robotic surgery are seen in shorter hospitalization times and a few blood loss which indicates the clinical effectiveness regarding reduced morbidity and increased safety.[4]

The postoperative pain resulting from small-incision lung cancer surgery wounds inhibits patients' effective breathing and coughing and reduces lung function, leading to CO2 accumulation, pneumonia, and atelectasis. Since one goal of preoperative risk stratification is to identify the patient's risks for perioperative pulmonary complications and long-term pulmonary disability,[5] recovering coughing, expectoration, and respiratory functions in the early stage after thoracic surgery is particularly important. Meanwhile, thoracic surgeries, including thoracotomy and VATS, are very high-risk procedures which often lead to chronic postsurgery pain (CPSP).[6],[7] It has been demonstrated that nearly 1 out of 4 patients who undergo thoracic surgery will develop CPSP, and one-third of those cases would be accompanied by a neuropathic component.[8] With the development of positioning techniques of nerve stimulator, a nerve block is now being widely used in clinical practice.

In the operating room, with the induction and maintenance of anesthesia and the requirements of surgery, respiratory physiology, and lung mechanics present a diverse and dynamic set of challenges for the anesthesiologist.[9] Regional anesthesia for thoracic surgery was used extensively in the past.[10],[11],[12] For patients undergoing thoracotomy, preserving the intercostal nerve during surgery may minimize pain during in-hospital recovery.[13] A large number of studies have shown that thoracic paravertebral nerve block (TPVB) could produce analgesic effects equivalent to epidural anesthesia.[14],[15]


 > Methods Top


General information

For this study, we selected 40 patients (American Society of Anesthesiologists Grade I-II) hospitalized in our department and scheduled for small-incision lung cancer surgery between June 2012 and October 2013. No patient had TPVB contraindications or other serious organic diseases and was randomized into Groups P and G based on random number table, with 20 cases per group. The sample size was 37 or more (confidence level: 95%, confidence interval: 5%, population size: 40), and we have exceed it in the study. This study was approved by the ethics committee of our hospital, and all patients provided informed consent.

Anesthesia

After the patient was moved into the operation room, intravenous access was established, and blood pressure (BP), electrocardiography, SpO2, and PET CO2 were routinely monitored. The patients in Group P were placed in the lateral position, with the operating side upward, hunched at the waist, and knee were held. The intercostal area of the incision was selected as the center, and the intercostal area was marked at the same time. We set the paravertebral area 3.0 cm away from the spinal midline as the puncture point and placed an AgCl electrode pad onto the patient's anterolateral chest wall. The skin was routinely disinfected, paved with towels, and l% lidocaine was used to infiltrate and anesthetize the skin and subcutaneous tissues. A needle (22-gauge, 10 cm, B. Braun, Germany) was connected to a nerve stimulator, with the initial current set at 1.2 mA and 2 Hz. The needle perpendicularly punctured the skin and was withdrawn when exposed to the transverse process, extended the needle intero-inferiorly to pass over the transverse process until passed through the superior costotransverse ligament and the intercostal muscles at the corresponding segments appeared to contract. The needle was stopped, and the current of the stimulator was adjusted to 0.4 mA. If strong contraction of the intercostal muscles still occurred, it indicated that the needle had entered the paravertebral space. A total of 5 ml of 0.5% ropivacaine were injected when no blood or gas appeared during withdrawal of the needle. The anesthetic method between the two adjacent intercostal areas was as described above. The total local anesthetic amount administered to each patient was 15 ml 0.5% ropivacaine. The patients in Group P underwent GA induction (the induction regimen was the same in the two groups) after we had completed TPVB. They received intravenous injections of midazolam 0.05 mg/kg, sufentanil 0.3 μg/kg, cisatracurium 0.1 mg/kg, and etomidate 0.3 mg/kg for anesthesia induction. A double-lumen endotracheal tube was inserted along with a flexible bronchofiberscope, each connected to the anesthesia machine for mechanical ventilation. Anesthesia maintenance was performed as follows: Propofol 4–8 mg/kg/h, cisatracurium 0.1 mg/kg/h, and remifentanil 6–10 μg/kg/h. Group P was not administered supplemental sufentanil during skin incision while Group G was intravenously injected with sufentanil 0.2 μg/kg 5 min before the skin incision, and the amount of anesthetic was adjusted according to intraoperative changes of bispectral index (BIS), mean arterial pressure (MAP), and heart rate (HR) as needed. After surgery, all patients were sent to the postanesthesia care unit (PACU) and administrated postoperative intravenous analgesia pump. The formula was sufentanil 2 μg/kg, ondansetron (8 mg diluted to 100 ml), 2 ml/h intravenous continuous infusion, single dose 0.5 ml, and a locking time of 15 min.

Observation indexes

We recorded MAP and HR in both groups a total of six times: Before anesthesia induction (T0), after intubation (T1), immediately after making the incision (T2), immediately after opening the chest (T3), 30 min after one-lung ventilation (T4), immediately after closing the chest (T5), and at the end of surgery (T6). We also recorded the amount of general anesthetic (propofol, remifentanil, and sufentanil), spontaneous respiration recovery time, extubation time, and the incidence of agitation, nausea and vomiting after reanimation. Nausea was defined as a subjectively unpleasant sensation associated with an urge to vomit. Vomiting was defined as the forceful expulsion of gastric contents in the study. Postoperative pain was assessed using 10 cm visual analog scale (VAS). VAS was performed by nursing staff who were blinded to the protocol. VAS scores at the postoperative 2nd, 6th, and 24th h under static and coughing status were also recorded.

Statistical methods

We used SPSS version 13.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis. All measurement data were expressed as mean ± standard deviation (x

± s), and the t-test was used to estimate the difference between two groups, ANOVA analysis was used to estimate the difference for repeated measurement data (among multiple groups), the counting data were performed using the Chi-square test, with P < 0.05 considered as statistically significant.


 > Results Top


General characteristics

The comparison of the general information between two groups had no significant difference (P > 0.05) [Table 1].
Table 1: General information

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Hemodynamics

Group P showed stable hemodynamics, with MAP and HR lower than Group G at each time point after incision (T2–T6) (P < 0.05). The hemodynamic changes between the two groups at T2–T6 had significant differences. Group G showed bigger hemodynamic fluctuations, and the intragroup comparison showed a statistically significant difference (vs. T0) (P < 0.05) [Table 2].
Table 2: Hemodynamic changes at each time point during anesthesia (x̄±s, n=20)

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Anesthetic amounts and postoperative postanesthesia care unit indexes

The comparisons of anesthetic amounts and postoperative PACU indexes between the two groups were found to have statistically significant differences (P < 0.05) [Table 3].
Table 3: Comparisons of anesthetic amounts and postoperative postanesthesia care unit indexes between the two groups (x̄±s, n=20)

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Visual analog scale scores

Comparison of the VAS scores at the postoperative 2nd, 6th, and 24th h under static and coughing status showed a statistically significant difference at the 6th h (P < 0.05) [Table 4].
Table 4: Comparisons of the visual analog scale scores at the postoperative 2nd, 6th, and 24th h under static and coughing status (x̄±s, n=20)

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 > Discussion Top


When performing TPVB, the local anesthetic is firstly localized in the puncture space, and then it diffuses along the intercostal nerves, followed by diffusing toward the superior and inferior grooves of paravertebral space. Thereby, the motor, feeling and sympathetic nerves are blocked, leading to ipsilateral somatic anesthesia.[16] This provides an effective anesthesia and analgesia for unilateral thoracic and abdominal surgery.[17] In recent years, because positioning techniques in the nerve stimulator have improved the success rate of nerve blocks and reduced their risks,[18] the application of nerve stimulators has become increasingly widespread in a variety of nerve block fields.

TPVB has been widely applied in breast cancer surgery. Many studies have shown that TPVB reduces postoperative pain and opioid consumption and that it has a beneficial (if limited) effect on the quality of recovery. Among all the techniques evaluated, only the addition of fentanyl and performing multilevel blocks were associated with improved acute analgesia. TPVB may even reduce CPSP for 6 months.[19]

An intercostal nerve block is a recognized method of providing analgesia in thoracotomy. There is a small association between intercostal nerve block and complications from total spinal anesthesia,[20] thus it could provide the same effective intraoperative and postoperative analgesia, and an internal intercostal nerve block was technically feasible and safe in the surgical treatment of selected lung cancer patients.[21] TPVB could reduce the stress response as well as inhibit surgery stimulation-increased BP and HR. In this study, Group P showed more stable hemodynamics, and at each time point after the skin incision (T2–T6) MAP and HR were lower than they were in Group G (P < 0.05). In addition, the incidence of agitation after reanimation in Group P was lower.

TPVB-GA could significantly reduce the amount of inhaled anesthetic and analgesic compared to pure GA.[22] In this study, under the detection of anesthesia depth by BIS, the total amounts of propofol, remifentanil, and sufentanil were significantly lower than Group G; furthermore, Group P exhibited shorter spontaneous respiration recovery times and extubation times after entering PACU while Group G used larger amount of analgesics and exhibited longer postoperative respiratory depression time. This may be a result of substantial amounts of sufentanil.

Good postoperative analgesia would be helpful for expectoration among patients with small-incision lung cancer and very useful for preventing the occurrence of postoperative pneumonia and atelectasis and in promoting patient rehabilitation. Richardson et al.[23],[24] observed that TPVB postoperative analgesia did not affect the diaphragmatic movements and had only a minimal influence on breathing, suggesting that postoperative pulmonary function would be better than an epidural and pleural block. One study collected 14 cases and found that the induction of a temporary diaphragmatic palsy did not significantly influence the dynamic lung volumes in mid-to-long-term pneumonectomy patients, suggesting that preserving the phrenic nerve was of greater importance in the immediate postoperative period after pneumonectomy.[25] The VAS scores of Group P at the postoperative 2nd and 6th h under coughing status were lower than Group G, a finding largely consistent with the above reports.

One prospective study divided 120 patients into two groups, and found that intercostal nerve block was associated with mini-thoracotomy, could reduce postoperative pain, and may contribute to improving postoperative outcomes after major pulmonary resections.[26]

In summary, we showed that nerve-stimulator-guided TPVB-GA was superior to GA in that it required less medication, promoted a more rapid recovery, and caused fewer complications when applied in small-incision lung cancer surgery.


 > Conclusion Top


Epidural anesthesia plus general anesthesia (GA) have been widely used clinically. However, the application of TPVB plus GA (TPVB-GA) to small-incision lung cancer surgery is seldom reported. The aim of this study was to explore the feasibility, safety, and effectiveness of TPVB-GA to small-incision lung cancer surgery, and to provide a reference for it further clinical application.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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