Video assisted thoracic surgery (VATS) has emerged as standard of care for majority of thoracic surgeries. It is less invasive compared to thoracotomy and is associated with improved perioperative outcomes \[1-3\]. Good perioperative analgesia after thoracic surgery will enable pulmonary toilet, early chest physiotherapy and mobilisation, \[4,5,6\]. Thirty-day hospital visits and hospital readmissions at London Health Sciences Centre (LHSC) is around 21% and 9% respectively \[7\]. One of the top five determinant for hospital visit and readmission in 30 days, was persistent post operative pain \[7\].
Several options to analgesia are available for patients undergoing VATS procedure. Systemic opioid based multimodal analgesia, central neuraxial blocks like thoracic epidural and peripheral nerve blocks are different available options, and their practise varies across institution \[4,8,9\]. Thoracic epidural or paravertebral blocks can be challenging to perform with high failure rates \[10-12\].
Fascial plane blocks (SAB; ESP) are in vogue in the present era \[13-16\]. They are easy to perform and do not require similar dexterity as needed to perform thoracic epidural or paravertebral blocks. They have minimal side effects and provide the options for continuous infusion for prolonged analgesia. They have become an effective part of multimodal analgesia and have established their roles in ERAS (enhanced recovery after surgery) protocol for VATS procedures.
SAB has become a common practise at our institution with proved clinical efficacy.
Perioperative Surgical Home is a patient centric team-based approach to improve patient's experiences in the perioperative period and thus improve healthcare \[17\]. Quality of Recovery (QoR) is a key determinant to perioperative surgical home and can be measured using the QoR 40 score \[18\]. This is a well validated score with a minimal important clinical difference (MICD) of 6.3 \[19\]. Quality of recovery combines five dimensions of health: patient support, comfort, emotions, physical independence and pain to achieve a single patient outcome - improved patient care \[18\].
The investigators hypothesize the that patients undergoing VATS lung resections using a combination of intercostal nerve block plus continuous SAB catheter infusion of local anesthetics will have a 20% increase in their QoR-40 score 24hour after the surgery compared to a single shot intercostal nerve block.
Patients undergoing elective VATS lung resections including wedge resection, segmentectomy, bi-lobectomy, or lobectomy.
Age > 18 years.
ASA (American Society of Anesthesiology) Score - 1 to 4.
Gender - all genders
Patient refusal to participate in the study.
Emergency surgery.
Allergies to local anesthetics
BMI>40
Parallel
Serratus Plane Block (Local Anesthetic) and Intercostal Block (Local Anesthetic)
Procedure/SurgeryPatients will receive local anesthetic via serratus plane block as opposed to saline placebo
Serratus Plane Block (Placebo) and Intercostal Block (Local Anesthestic)
Procedure/SurgeryPatients will receive saline placebo via serratus plane block
Quality of Recovery
Measured using the Quality of Recovery 40 (Qor-40) Score and asking patients to complete the questions.
Postoperative pain scores
Pain will be assessed on an 11- point numerical scale of '0' to '10'. Zero signifies no pain whereas 10 signifies maximum pain. Measured by asking patient to rate their pain using this scale. This will be measured every 24 hours following surgery until the patient is discharged, on average one week.
Total opioid consumption
Total opioid consumption will be administered in IV morphine equivalents. This will be assessed daily upon admission to post-anesthesia care unit (postoperative care unit) until day of discharge, on average one week. Measured by evaluating patient's medical record for administered morphine equivalents.
Postoperative complications after thoracic surgery
Any complication that requires assessment and/or treatment postoperatively. This will be recorded by evaluating the patient's medical chart for any noted complication following surgery.
Hospital readmission
Instances that the patient may be re-admitted to the hospital following discharge after surgery. To be measured by evaluating the patient's medical record.
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