Review Note
Last Update: 02/27/2025 04:29 AM
Current Deck: ACG Part 2::Thoracic SSU
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Commit #291082SS_TS 1.15 Identify pain management issues specific to thoracic surgery and critically evaluate analgesic options for patients having thoracic surgery
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Commit #291082Thoracic surgery high risk of postoperative pain and development of chronic pain syndrome (25-60%)
- Increased neurohumoral stress response, impaired mobilisation and deep breathing
Multimodal analgesia strategies
Regional anaesthesia
- Neuraxial blockade - thoracic epidural
- Bilateral procedures, aim for T5/6/7 for anterolateral thoracotomies
- Plane blocks (midway in line of thoracotomy)
- Erector spinae block
- Serratus anterior block
- Paravertebral block
- Intercostal nerve block
- Surgically placed catheters (extrapleural and intrapleural)
ESP
- LA injected deep to erector spinae muscle
- LA spread craniocaudally
- Possible spread of LA to PV space via apertures in fascia
- ESP consistently blocks dorsal (posterior) rami → supplies medial back
- Supply of anterior thoracic area inconsistent
- Tip of needle between ESM and intertransverse tissue complex; visible craniocaudal spread
SAP
- Targets lateral cutaneous branches of intercostal nerve
- Can deposit LA deep or superficial to SA muscle (deep and superficial SAPB)
- Superficial needle target: between lat dorsi and SA
- Deep needle target: between SA and rib or external intercostal muscle
LA dosing for plane blocks:
- Single shot
- Effective for 8-12 hours
- Ropivacaine 0.375% 30mls for single shot ESP or SAP block (or 0.2% depending on patient size)
Catheter infusions
Surgical blocks and catheters
- Open procedures → good visualisation of paravertebral space and intercostals
- Dorsal rami not blocked with ICNB → less effective for posterolateral incisions
- Increased risk of LAST as catheter near highly vascular space (increased systemic absorption)
- Intrapleural not recommended as high risk of LAST due to sporadic spread/absorption