الفهرس 
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Abstract
Thoracotomy is known as one of the most painful surgeries. Inadequate treatment of such pain will lead to immediate impact on both patient comfort and pulmonary function, leading to postoperative pulmonary complications. In addition, it will lead to longer term pain interfering with patients’ returning to regular activities for long time.
Many factors can share in pain after thoracotomy . These include pleural irritation, intercostal nerves injury, costovertebral joints dislocation and resection, retraction or fracture of ribs.
Treatment of acute post thoracotomy pain is particularly important not only to keep the patient comfortable but also to decrease pulmonary complications and prevent post thoracotomy pain syndrome. Enhanced recovery after surgery (ERAS) guidelines for thoracic surgery encourages regional anesthesia and suggests a multimodal approach for pain management with more than one analgesic modality targeting different sites and reducing opioid usage.
Many methods of regional analgesia techniques may be used in acute post thoracotomy pain management, for example, thoracic epidural, thoracic PVB, intrathecal analgesia, intercostal nerve block, SAPB, erector spinae block, interscalene block, intrapleural analgesia, in addition to IV narcotics, NSAID and other systemic medications.
Many studies considered TEA as more effective compared to many other analgesic modalities for treating acute post thoracotomy pain. Still, it is considered the gold standard
Though TEA is sometimes not ideal and it still has its own difficulty and complications as a neuraxial technique, like technique failure and hypotension.
SAPB was presented by Blanco et al. in 2013 as a new ultrasound guided thoracic wall nerve block, that is coming up as a feasible and easy to perform alternative to other standard regional anaesthetic techniques as neuraxial blockade and thoracic PVB, with probable better side effect profile.
Ultrasound guided SAPB can provide analgesia to the anterolateral chest wall between T2 and T9 levels by blocking the lateral branches of the intercostal nerves. This can be achieved by performing the block either deep to the serratus anterior muscle at the region between the serratus anterior muscle and intercostal muscles, or superficial to the serratus anterior muscle to the region between it and latissimus dorsi muscle.
This current prospective comparative randomized double blinded study was conducted at Sohag university hospital and it included 60 patients who were undergoing thoracotomy . They were randomly assigned into 2 groups: group A: In which patients were subjected to Standard anesthesia and Serratus Plane Block. In addition, rescue postoperative IV opioid analgesia was used as needed. group B: In which standard anesthesia was done, and postoperative IV opioid analgesia was used for post thoracotomy pain relief.
The two study groups had comparable demographic data regarding age, gender, weight, height, BMI, ASA status, type of surgery and base line HR and BP.
Total IV opioids used, total intraoperative fentanyl and total postoperative morphine were significantly less in SAPB group than IV analgesia group (all p<0.001). Stratified by time intervals, IV opioids used was significantly less in SAPB group up to 6 hours postoperative (p values were 0.009 and less). The time to first postoperative opioid usage was significantly longer in SAPB group (p<0.001).
Regarding postoperative pain assessment, VAS during rest and with cough were significantly less in SAPB group (group A) than in IV analgesia group (group B) when assessed postoperative immediately after awake and at 1 hour, 3 hours and 6 hours postoperative (p=0.015 and less at rest and p=0.02 and less with cough). Otherwise, there was no significant difference between the two groups regarding VAS during rest and with cough beyond 6 hours postoperative when assessed at 12 hours and 24 hours postoperative.
Performing SAPB did not significantly prolong the overall duration of surgery (p=0.07).
Nausea/vomiting were significantly less in SAPB group (p=0.046), while itching showed no significant difference (p=0.151) between the two groups. No apnea, ileus or urinary retention was reported in any patient in the study population.
HR and systolic BP were significantly less in SABP group (group A) when assessed postoperative immediately after awake and up to 6 hours postoperative (p=0.045 and less for HR and 0.044 and less for systolic BP), while diastolic BP was significantly less in SAPB group when assessed postoperative immediately after awake and up to 3 hours postoperative (p=0.049 and less). These were usually the same time points where VAS was significantly less in SABP group (group A). Otherwise, there was no significant difference between the two groups regarding HR and systolic BP when assessed intraoperative and beyond 6 hours postoperative, while diastolic BP showed no significant difference when assessed intraoperative and beyond 3 hours postoperative.
Both random blood glucose and plasma cortisol levels were significantly less in SAPB group (group A) when assessed postoperative immediately after awake (p=0.033 and 0.02 respectively) and at 6 hours postoperative (p=0.031 and 0.041 respectively). These were the same time points where VAS was significantly less in SABP group (group A) assuming that better pain control may reduce hormonal and metabolic stress responses. Otherwise, no significant difference could be detected between the two groups regarding random blood glucose and plasma cortisol levels beyond 6 hours when assessed at 12 hour and 24 hours postoperative.
We concluded that ultrasound guided SAPB can be an effective technique for postoperative analgesia in patients undergoing thoracotomy with probably better pain control when compared to the use of IV opioid analgesia alone, with significantly less total opioid use and probably less opioid related complications and hormonal and metabolic stress responses.
Conclusions
Ultrasound guided serratus anterior plane block can be an effective technique for postoperative analgesia in patients undergoing thoracotomy with probably better pain control when compared to the use of IV opioid analgesia alone, with significantly less total opioid use and probably less opioid related complications and hormonal and metabolic stress responses.
Recommendations
Further studies are recommended to compare ultrasound guided serratus anterior plane block with other different modalities of regional analgesia used for postoperative analgesia in patients undergoing thoracotomy, especially thoracic epidural analgesia and thoracic paravertebral block.
Further studies are recommended for the efficacy of ultrasound guided serratus anterior plane block with insertion of catheter to the serratus anterior fascial plane for continuous infusion or repeated boluses of local anesthetic as postoperative analgesia, and to use this technique as a sole modality for postoperative analgesia in patients undergoing thoracotomy.
Further studies are recommended to compare the efficacy of different local anesthetic medications and possible beneficial additives to enhance efficacy or increase duration of analgesic effect when using ultrasound guided serratus anterior plane block for postoperative analgesia in patients undergoing thoracotomy.
Further studies on larger population are recommended to study the effect of using ultrasound guided serratus anterior plane block for postoperative analgesia in patients undergoing thoracotomy on reducing opioid related complications.