Abstract
Background
The aim of this study was to investigate the analgesic effect and safety of ultrasound‐guided thoracic paravertebral block (UG‐TPVB) in Chinese elderly patients undergoing video‐assisted thoracic lobectomy (VATL) and to study the influence of aging factors on these effects.
Methods
This study was a single‐center, single‐blind, prospective, randomized, controlled trial. A total of 300 patients scheduled for VATL were recruited and randomly divided into the UG‐TPVB group (T group) and conventional anesthesia group (C group) according to the recruitment order, and subgroups were set up according to whether the age was ≥65 years old or not. The postoperative 12, 24, and 48 h static/dynamic visual analog scale (VAS) scores, intraoperative fentanyl consumption, postoperative extubation time, post‐anesthesia care unit (PACU) stay time, hospitalization days, postoperative complications, and other indicators were compared between the two groups.
Results
The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group. The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days were significantly lower than those of the C group. The incidence of postoperative 48 h urinary retention in the T group was significantly lower than that in the C group. These advantages showed no significant difference or slight difference between elderly patients and nonelderly patients, indicating that UG‐TPVB did not influence the analgesic effect and safety of VATL patients by age or age difference.
Conclusion
UG‐TPVB is an effective and safe perioperative analgesia method for elderly VATL patients. Its application improves the quality of life and prognosis of elderly VATL patients.
Keywords: elderly patients, perioperative analgesia, ultrasound‐guided thoracic paravertebral block, video‐assisted thoracic lobectomy
This study rigorously evaluates the analgesic efficacy and safety of ultrasound‐guided thoracic paravertebral block (UG‐TPVB) in elderly Chinese patients undergoing video‐assisted thoracic lobectomy (VATL). Results convincingly demonstrate that UG‐TPVB significantly reduces postoperative VAS scores and other outcome indicators, regardless of age differences, substantiating its role as an effective and safe perioperative analgesic for elderly VATL patients.
INTRODUCTION
Lung cancer is a major global public health problem and one of the diseases with the lowest 5‐year survival rate. According to statistics, there were 2.2 million new cases and more than 1.79 million related deaths worldwide in 2020. 1 In China, the elderly is the main population affected by lung cancer, and their proportion is gradually increasing. From 2005 to 2014, the proportion of elderly lung cancer patients in China increased from 41.2% to 56.2%. 2
Video‐assisted thoracic lobectomy (VATL) is a common treatment method for early or locally advanced non‐small cell lung cancer (NSCLC) patients. However, it is also a highly traumatic surgery that may cause pain, bleeding, respiratory dysfunction, cardiovascular complications, and other adverse consequences. 3 Whether effective perioperative pain management is performed is directly related to the incidence of related complications and the prognosis of patients. 4 , 5 Classic perioperative pain management mainly relies on opioids and nonsteroidal analgesics, but these drugs have their limitations and side effects. 6 Opioids can effectively relieve postoperative pain in patients, but they can also cause respiratory depression, nausea and vomiting, constipation, urinary retention, skin itching, and other adverse reactions. In addition, traditional pain management methods often cannot fully meet the individual needs of patients, resulting in poor analgesia or excessive analgesia. 7
Elderly patients are a special population who have obvious differences from young people in terms of physiology, psychology, tumor condition, and their surgical tolerance and risk: they have multiple chronic diseases such as hypertension, coronary heart disease, heart failure, chronic obstructive pulmonary disease, etc; 8 , 9 , 10 they are more prone to cognitive impairment, depression, anxiety and other psychological problems; their tumor biology behavior is more malignant; all these lead to the need for more safe, effective, accurate, and less traumatic intervention methods for anesthesia and perioperative management process of elderly patients. 2 , 4 , 6 , 11
Ultrasound‐guided thoracic paravertebral block (UG‐TPVB) is a technique that injects local anesthetics to the paravertebral space where the spinal nerves exit from the intervertebral foramen under ultrasound guidance, thereby producing unilateral (ipsilateral), segmental, somatic, and sympathetic nerve block in multiple adjacent thoracic dermatomes. The advantages are that it can provide a more extensive and deeper thoracic nerve block, covering the pain‐sensitive areas of the thorax, reducing drug dosage and adverse reactions; it can also avoid affecting the movement of the diaphragm and cough reflex, reducing the risk of mechanical ventilation time and postoperative pulmonary infection. Previous studies have confirmed the application value of UG‐TPVB in lung cancer radical surgery. 12 , 13 , 14 It can improve the problems existing in traditional anesthesia management of elderly patients, such as excessive and side effects of opioids, respiratory dysfunction, cardiovascular complications, and so on. Some studies have even suggested that paravertebral block can reduce the recurrence rate of breast cancer after surgery compared with using opioid analgesics, 15 but there is no prospective trial to confirm this effect. 16
However, there are still few studies on the effectiveness, safety, and difference between elderly and nonelderly patients of UG‐TPVB in elderly lung cancer patients. For the elderly population, do the mode, dosage and adverse reactions of UG‐TPVB need to be adjusted accordingly? These questions have not been fully explored and answered. 17 Therefore, we designed an interventional clinical randomized controlled trial to compare the analgesic effect, opioid consumption, and postoperative complications of UG‐TPVB and conventional anesthesia methods in elderly VATL patients, and to analyze the difference of UG‐TPVB between elderly and nonelderly patients. We believe that if we can explore these aspects of UG‐TPVB, it will be a powerful improvement in the depth of understanding and mastery of treatment methods for lung cancer, a common and high‐risk disease that mainly affects the elderly population.
METHODS
Subjects
This study was a single‐center, prospective, randomized, controlled trial, approved by the Hospital Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (Ethics No: 2022‐SR‐543), and all patients signed relevant informed consent forms before surgery. Patients scheduled for unilateral, single‐lobar, two‐port VATL at the First Affiliated Hospital of Nanjing Medical University from March 2022 to September 2023 were selected. Inclusion criteria: age >18 years; BMI 18–30 kg/m2; American Society of Anesthesiologists physical status classification of I–III; no obvious liver or kidney dysfunction, no pulmonary disease. Exclusion criteria: history of allergy to local anesthetics; history of thoracic surgery; history of chronic pain; history of drug abuse; combined with uncontrolled asthma or severe chronic obstructive pulmonary disease. Elimination criteria: block failure; change of surgical method during surgery (such as conversion to open surgery); delayed extubation due to bleeding or other reasons.
Methods
Blinding
Patients were numbered according to the recruitment order and randomly assigned to the UG‐TPVB group (T group) and the conventional anesthesia group (C group) using a random number table method. The treatment group consisted of two anesthesiologists and three anesthesia nurses. Before surgery, anesthesia nurse A placed the random group information of each patient into a sealed envelope, which was opened only by anesthesia nurse B who prepared the drugs on the day of surgery, knowing the patient's group result, and informed anesthesiologist A to perform ultrasound‐guided nerve block for U group patients. The rest of the anesthesiologists, surgeons, and anesthesia nurses involved in this study were blinded. Anesthesiologist B was responsible for perioperative management, and anesthesia nurse C collected intraoperative and postoperative follow‐up data.
Intervention measures
The T group underwent UG‐TPVB at T4 and T7 levels on the affected side under ultrasound guidance 30 min before surgery. The patient was placed in a lateral position (consistent with the surgical position), disinfected, and draped. Under low‐frequency convex array probe (Fujifilm Sonosite Inc.) observation, after confirming the paravertebral space, in‐plane needle insertion was performed, and after aspirating to confirm no air or blood, 0.375% ropivacaine 15 mL was injected. The block was considered successful when the sensation of T4–T9 skin on the blocked side disappeared with an ice saline test 20 min after the block. C group had no special treatment before surgery, and 1% lidocaine 10 mL was injected to infiltrate the wound before closing the incision.
Perioperative management
After entering the room, routine monitoring was performed for the patients. Anesthesia induction was given with midazolam 0.05 mg/kg, etomidate 0.2 mg/kg, fentanyl 3‐5 μg/kg, and cisatracurium 0.15 mg/kg. Fentanyl 3–5 ug/kg was added 2 min before skin incision. Anesthesia maintenance: sevoflurane 1–1.5 MAC, propofol 2–3 mg/kg/h, remifentanil 0.1–0.2 μg/kg/min, cisatracurium 2 μg/kg/min, maintaining BIS value at 40–60, adding fentanyl 3–5 ug/kg according to the duration of surgery. Oxycodone 0.1 mg/kg was given 0.5 h before the end of surgery. Postoperative analgesia was performed with an electronic analgesia pump (Renxian Medical), giving 1.0 mg fentanyl (20 mL) in normal saline 80 mL, no background dose, lock time 30 min, single dose 3 mL, started after returning to the ward.
All patients received a two‐port VATL, followed by manual lung inflation and the placement of two drainage tubes postoperatively. After surgery, patients were transferred to the post‐anesthesia care unit (PACU). The endotracheal tube was removed upon meeting the extubation criteria, and patients were returned to their wards upon meeting the discharge criteria from the PACU.
Observation indicators
Pain indicators
Postoperative 12, 24, 48 h static/dynamic visual analog scale (VAS) scores, postoperative 12, 24 and 48 h patients controlled intravenous analgesia (PCIA) press count. The dynamic VAS score was taken after patients performed a deep breath.
Secondary observation indicators
Intraoperative fentanyl consumption; postoperative extubation time, PACU stay time, postoperative hospitalization days.
Safety indicators
Postoperative 24 and 48 h incidence of nausea and vomiting, dizziness, skin itching, and urinary retention.
Statistical analysis
SPSS 27.0 statistical software was used for data analysis. Normally distributed measurement data are expressed as mean ± standard deviation (x ± s), and independent sample t‐test was used for intergroup comparison; non‐normally distributed measurement data are expressed as median (M) and interquartile range (IQR), and Mann–Whitney U test was used for intergroup comparison. Count data comparison was performed using the χ2 test or Fisher exact probability method. p‐values < 0.05 were considered statistically significant.
RESULTS
Patient information
This study recruited a total of 300 patients, of which eight patients refused to participate, and the remaining 292 patients were randomly assigned to T and C groups. A total of 11 patients in the T group were excluded (3 patients had poor exposure of paravertebral space, 3 patients had incomplete UG‐TPVB block, 4 patients were converted to open surgery during surgery). A total of 14 patients in the C group were excluded (1 patient had allergy after anesthesia induction, 3 patients had surgery canceled, 10 patients were converted to open surgery during surgery). The final number of patients enrolled in each group was: 135 in the T group, and according to whether the age was ≥65 years old, subgroups were set up (TO group, age ≥ 65 years old, 64 cases; TY group, age <65 years old, 71 cases); 132 in the C group, (CO group, age ≥ 65 years old, 56 cases; CY group, age <65 years old, 76 cases) (Figure 1). There was no statistical difference in age, sex ratio, body mass index (BMI), ASA classification, and operation time between the T and C groups (all p > 0.05, Table 1). In the T group, all patients safely underwent TPVB, with no instances of puncture‐related complications such as pneumothorax, hemothorax, or pleural reaction.
FIGURE 1.
CONSORT diagram for the trial. A total of 300 patients were allocated, and finally 267 patients (135 patients in group T and 132 patients in group C) who underwent VTAL were analyzed in the present study. VATL, video‐assisted thoracic lobectomy.
TABLE 1.
Comparison between two groups in total cohort.
| hour | Group T (n = 135) | Group C (n = 132) | Statistics | p‐value | |
|---|---|---|---|---|---|
| Demographic variables | |||||
| Age (years) | 59.6 ± 10.7 | 57.3 ± 12.1 | 2.65 | 0.104 | |
| Sex F (%) | 83 (61.4) | 93 (70.4) | 2.90 | 0.089 | |
| BMI (kg/m2) | 24.1 ± 3.1 | 23.4 ± 2.9 | 1.43 | 0.233 | |
| Surgical spot (LU/LL/RU/RM/RL) | 39/15/50/10/21 | 36/13/50/10/23 | 0.32 | 0.988 | |
| Operation time (min) | 100 (75, 126) | 97 (76, 127) | −0.21 | 0.832 | |
| Analgesic variables | |||||
| Static VAS score | 12 h | 1 (0, 1) | 1 (1, 2) | −5.45 | 0.000** |
| 24 h | 1 (0,1) | 1 (1, 2) | −4.81 | 0.000** | |
| 48 h | 1 (0,1) | 1 (1, 2) | −4.53 | 0.000** | |
| Dynamic VAS score | 12 h | 2 (1, 2) | 2 (2, 3) | −5.12 | 0.000** |
| 24 h | 2 (1, 3) | 2 (2, 3) | −4.08 | 0.000** | |
| 48 h | 2 (1, 2.5) | 2 (2, 3) | −3.85 | 0.000** | |
| PCIA press count | 12 h | 1 (0, 2) | 1 (0, 2) | −1.73 | 0.084 |
| 24 h | 1 (0, 2) | 1 (0, 3) | −0.20 | 0.845 | |
| 48 h | 1 (0, 3) | 1 (0, 4) | −0.21 | 0.836 | |
| Perioperative variables | |||||
| Fentanyl consumption (mg) | 0.40 (0.35, 0.50) | 0.40 (0.40, 0.50) | −7.78 | 0.000** | |
| Extubation time (min) | 39.3 (25.0, 52.3) | 33.5 (25.0,44) | −3.75 | 0.000** | |
| PACU stay (min) | 58.5 (45.8, 71.5) | 70 (57, 83.8) | −4.14 | 0.000** | |
| Hospital stay (days) | 5 (3,5) | 7 (5, 7) | −8.79 | 0.000** | |
| Adverse reactions n (%) | |||||
| Nausea and vomiting | 24 h | 8 (5.9) | 8 (6.1) | 0.00 | 0.963 |
| 48 h | 6 (4.4) | 8 (6.1) | 0.35 | 0.554 | |
| Dizziness | 24 h | 15 (11.1) | 14 (10.6) | 0.02 | 0.895 |
| 48 h | 10 (7.4) | 14 (10.6) | 0.84 | 0.361 | |
| Pruritus | 24 h | 0 (0) | 4 (3.0) | — | 2 |
| 48 h | 0 (0) | 4 (3.0) | — | 0.058 | |
| Urinary retention | 24 h | 102 (75.6) | 105 (79.5) | 0.61 | 0.435 |
| 48 h | 33 (24.4) | 104 (78.8) | 78.90 | 0.000** |
Note: Values are mean ± SD, median (IQR) or number (%).
Abbreviations: BMI, body mass index; IQR, interquartile range; LL, left lower lobe; LU, left upper lobe; PACU, post‐anesthesia care unit; PCIA, patient controlled intravenous analgesia; RL, right lower lobe; RM, right middle lobe; RU, right upper lobe; VAS, visual analog scale.
p < 0.01.
Effect of UG‐TPVB on perioperative analgesia, opioid consumption, and postoperative complications in patients
The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group (all p = 0.000, Figure 2), and there was no significant difference in PCIA press count at postoperative 12, 24, and 48 h between the two groups (all p > 0.05). The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days of the T group were significantly lower than those of the C group (all p = 0.000), and the incidence of postoperative 48 h urinary retention in theT group was significantly lower than that in the C group (p = 0.000). There was no statistical difference in the incidence of nausea and vomiting, dizziness, skin itching, and urinary retention at postoperative 24 h and 48 h between the two groups (all p > 0.05) (Table 1).
FIGURE 2.
Comparison of VAS scores between two groups. Data are expressed as median ± IQR, **p < 0.01. (a) The static VAS score at postoperative 12, 24, 48 h were found to be lower than group C (p < 0.01). (b) The dynamic VAS score at postoperative 12, 24, 48 h were found to be lower than group C (p < 0.01). IQR, interquartile range; VAS, visual analog scale.
Effect of UG‐TPVB on perioperative analgesia, opioid consumption, and postoperative complications in the elderly group
In the elderly group, the postoperative 12 h and 24 h static/dynamic VAS scores and the postoperative 48 h static VAS score of TO group were significantly lower than those of the CO group (p = 0.000; p = 0.002; p = 0.01; p = 0.001; p = 0.000, respectively), and there was no significant difference in the postoperative 48 h dynamic VAS score between the TO and CO groups (p = 0.052) (Figure 3). There was no significant difference in PCIA press count at postoperative 12, 24, and 48 h between the TO and CO groups (all p > 0.05). The intraoperative fentanyl consumption, postoperative extubation time, and postoperative hospitalization days of TO group were significantly lower than those of the CO group (p = 0.000; p = 0.006; p = 0.000, respectively), and there was no significant difference in PACU stay time between the TO and CO groups (p = 0.123). The incidence of postoperative 48 h urinary retention in the TO group was significantly lower than that in the CO group (p = 0.000), and there was no statistical difference in the incidence of nausea and vomiting, dizziness, skin itching, and urinary retention at postoperative 24and 48 h between the two groups (all p > 0.05) (Table 2).
FIGURE 3.
Comparison of VAS scores between subgroup TO and subgroup CO. Data are expressed as median ± IQR, *p < 0.05, **p < 0.01. (a) The static VAS score at postoperative 12 and 24 h were found to be lower than subgroup CO (p < 0.01), the static VAS score at postoperative 48 h was found to be lower than subgroup CO (p < 0.05). (b) The dynamic VAS score at postoperative 12 and 24 h were found to be lower than subgroup CO (p < 0.01), the dynamic VAS score at postoperative 48 h was not significantly different between subgroup TO and subgroup CO. IQR, interquartile range; VAS, visual analog scale.
TABLE 2.
Comparison between subgroups.
| hour | Group TO (n = 64) | Group CO (n = 56) | Group TY (n = 71) | |||||
|---|---|---|---|---|---|---|---|---|
| Statistics | p‐value | Statistics | p‐value | |||||
| Demographic | ||||||||
| Age (years) | 69.1 ± 3.5 | 68.8 ± 3.1 | 0.58 | 0.563 | 51.0 ± 7.1 | 18.95 | 0.000⁜ | |
| Sex F (%) | 33 (51.6) | 35 (62.5) | 1.46 | 0.228 | 50 (70.4) | 5.06 | 0.025⁜ | |
| BMI (kg/m2) | 24.7 ± 3.1 | 23.9 ± 2.7 | 0.59 | 0.444 | 23.6 ± 3.0 | 0.24 | 0.627 | |
| Surgical spot (LU/LL/RU/RM/RL) | 18/8/23/5/10 | 18/5/19/3/11 | 1.09 | 0.895 | 21/7/27/5/11 | 0.30 | 0.990 | |
| Operation time (min) | 105 (79, 136) | 101 (84, 144) | −0.21 | 0.835 | 100 (67, 125) | −1.06 | 0.290 | |
| Analgesic variables | ||||||||
| Static VAS score | 12 h | 1 (0, 1) | 1 (1, 2) | −3.95 | 0.000** | 1 (0, 1) | −1.45 | 0.146 |
| 24 h | 1 (0,2) | 1 (1, 2) | −3.07 | 0.002** | 1 (0, 1) | −0.20 | 0.841 | |
| 48 h | 1 (0,1) | 1 (1, 2) | −2.58 | 0.01* | 1 (0, 1) | −0.17 | 0.867 | |
| Dynamic VAS score | 12 h | 2 (1, 2) | 2 (2, 3) | −3.35 | 0.001** | 2 (1, 2) | −0.61 | 0.543 |
| 24 h | 2 (1, 3) | 2 (2, 3) | −3.06 | 0.000** | 2 (1, 2) | −0.71 | 0.476 | |
| 48 h | 2 (1, 3) | 2 (2, 3) | −1.94 | 0.052 | 2 (1, 2) | −0.04 | 0.970 | |
| PCIA press count | 12 h | 1 (0, 2) | 1 (0, 2) | −1.24 | 0.215 | 0 (0, 1) | −0.99 | 0.321 |
| 24 h | 1 (0, 3) | 1 (0, 3) | −0.36 | 0.716 | 1 (0, 2) | −0.99 | 0.325 | |
| 48 h | 1.5 (0, 4) | 1 (0, 3) | −0.64 | 0.523 | 1 (0, 2) | −1.65 | 0.099 | |
| Perioperative variables | ||||||||
| Fentanyl consumption (mg) | 0.40 (0.35, 0.45) | 0.50 (0.41, 0.50) | −4.605 | 0.000** | 0.35 (0.30, 0.45) | −1.35 | 0.178 | |
| Extubation time (min) | 29.0 (19.0, 42.5) | 35 (28.3, 45) | −2.74 | 0.006** | 25 (17.5, 32) | −1.17 | 0.241 | |
| PACU stay (min) | 67.5 (50.0, 79.3) | 70 (57, 83.8) | −1.54 | 0.123 | 55 (45, 70) | −2.47 | 0.013⁜ | |
| Hospital stay (days) | 5 (3,6) | 7 (6, 8.8) | −5.15 | 0.000** | 4 (3, 5) | −2.34 | 0.019⁜ | |
| Adverse reactions (%) | 0.4 (0.35, 0.45) | 0.50 (0.4, 0.5) | −4.61 | 0.000** | 0.35 (0.30, 0.45) | −1.35 | 0.178 | |
| Nausea and vomiting | 24 h | 2 (3.1) | 1 (1.8) | 0.00 | 1 | 6 (8.5) | 0.89 | 0.345 |
| 48 h | 4 (6.3) | 1 (1.8) | 0.58 | 0.445 | 2 (2.8) | 0.30 | 0.583 | |
| Dizziness | 24 h | 5 (11.1) | 2 (3.6) | 0.36 | 0.549 | 10 (14.1) | 1.34 | 0.247 |
| 48 h | 5 (7.8) | 2 (3.6) | 0.36 | 0.549 | 5 (70.4) | 0.03 | 0.865 | |
| Pruritus | 24 h | 0 (0) | 2 (3.6) | — | 0.224 | 4 (5.6) | — | 0.121 |
| 48 h | 0 (0) | 2 (3.6) | — | 0.224 | 4 (5.6) | — | 0.121 | |
| Urinary retention | 24 h | 47 (73.4) | 41 (73.2) | 0.00 | 0.978 | 55 (77.5) | 0.30 | 0.587 |
| 48 h | 15 (23.4) | 41 (73.2) | 29.73 | 0.000** | 18 (25.4) | 0.07 | 0.796 | |
Note: Values are mean ± SD, median (IQR), or number (%).
Abbreviations: BMI, body mass index; IQR, interquartile range; LL, left lower lobe; LU, left upper lobe; PACU, post‐anesthesia care unit; PCIA, patient‐controlled intravenous analgesia; RL, right lower lobe; RM, right middle lobe; RU, right upper lobe; VAS, visual analog scale.
Group CO compared with group TO, p < 0.05.
Group CO compared with group TO, p < 0.01, ⁜Group TY compared with group TO, p < 0.05.
Difference of UG‐TPVB effect between the elderly and young groups
In the UG‐TPVB group, there was no significant difference in postoperative 12, 24, and 48 h static/dynamic VAS scores between the TO and TY groups (all p > 0.05, Figure 4), and there was no significant difference in PCIA press count at postoperative 12, 24 and 48 h between the TO and TY groups (all p > 0.05). The PACU stay time and hospitalization days of the TO group were significantly longer than those of the TY group (p = 0.013; p = 0.019, respectively), and there was no significant difference in intraoperative fentanyl consumption and postoperative extubation time between the TO and TY groups (p > 0.05). There was no statistical difference in the incidence of nausea and vomiting, dizziness, skin itching, and urinary retention at postoperative 24 and 48 h between the two groups (all p > 0.05) (Table 2).
FIGURE 4.
Comparison of VAS scores between subgroup TO and subgroup TY. Data are expressed as median ± IQR. (a) The static VAS score at postoperative 12, 24, and 48 h was not significantly different between subgroup TO and subgroup TY. (b) The dynamic VAS score at postoperative 12, 24, and 48 h was not significantly different between subgroup TO and subgroup TY. VAS, visual analog scale.
DISCUSSION
Ultrasound‐guided thoracic paravertebral block is an emerging perioperative analgesia method, and its application value and safety have not been fully evaluated for the special population of Chinese elderly patients undergoing VATL, especially. This study was a single‐center, prospective, randomized, controlled trial of 300 patients, aiming to explore the analgesic effect, opioid consumption, and postoperative complications of UG‐TPVB in elderly VATL patients, and to compare with nonelderly patients. We discuss and analyze our study results from the following aspects.
Pain is mediated by multiple mechanisms and influenced by surgical methods and patient factors. Postoperative pain may lead to adverse outcomes, such as respiratory complications, prolonged hospital stay, poor quality of life, and chronic post‐thoracotomy pain syndrome in elderly or weak patients. 18 The VAS is widely used to evaluate the degree of postoperative pain in patients, which can effectively quantify the subjective pain felt by patients after surgery. 19 We found that UG‐TPVB can significantly reduce the postoperative 12, 24, and 48 h static/dynamic VAS scores of elderly patients, indicating that it has a positive effect on perioperative analgesia in the Chinese group. This is consistent with several previous studies, which also showed that UG‐TPVB can effectively relieve postoperative pain in patients undergoing lung cancer radical surgery, and improve patient experience and quality of life. 20 UG‐TPVB can achieve such an effect, possibly because it can produce unilateral, segmental, somatic, and sympathetic nerve blocks in multiple adjacent thoracic dermatomes, covering the entire thorax pain‐sensitive area. Such a block mode can better adapt to the postoperative pain pattern of lung cancer radical surgery patients, which is multisource, multilevel, and multiregion pain caused by chest wall incision, chest drainage tube, and pleural stimulation. Second, we found that UG‐TPVB can reduce intraoperative fentanyl consumption, indicating that it has a positive effect on opioid consumption and less drug use. This is consistent with previous studies, which also showed that UG‐TPVB can reduce intra‐ and postoperative opioid use in patients undergoing lung cancer radical surgery. 21
Postoperative complications and drug adverse reactions are important factors affecting patient prognosis and quality of life and should be prevented and reduced as much as possible in perioperative management. Opioids are common but also have many side effects and risks of analgesics, which should be minimized in perioperative management. Other studies have also confirmed that UG‐TPVB can reduce patient demand for opioids through the following mechanisms: blocking thoracic nerve roots and sympathetic nerve fibers, thereby inhibiting the conduction and amplification of postoperative pain signals; reducing intraoperative stress response and postoperative inflammatory response, thereby reducing patient's systemic metabolic burden and immune suppression; increasing the release of endogenous opioid peptides (such as β‐endorphin) in local tissues, thereby enhancing analgesic effect and tolerance. 22 , 23 In addition, UG‐TPVB can also avoid the inhibitory effect of opioids on respiratory function and cough reflexes, thereby facilitating the patient's respiratory recovery. 24 We also found that UG‐TPVB can shorten postoperative extubation time and hospitalization days, and reduce postoperative 48 h urinary retention rate, indicating that it has a positive effect on postoperative complications and drug adverse reactions. This is consistent with several previous studies, which also showed that UG‐TPVB can reduce the incidence of postoperative cardiovascular complications, pulmonary infection, nausea, and vomiting in patients undergoing lung cancer radical surgery. The reason may be related to its ability to reduce intraoperative stress response and postoperative inflammatory response, thereby reducing the patient's systemic metabolic burden and immune suppression. 25 , 26 In addition, UG‐TPVB can also reduce the side effects of opioids, such as respiratory depression, constipation, urinary retention, skin itching, etc., thereby improving patient's comfort and safety. 27 It is noteworthy that none of the study subjects had any puncture‐related complications such as pneumothorax, hemothorax or even pleural reaction. In fact, intercostal block may cause pneumothorax, but the possibility of pneumothorax caused by ultrasound‐guided intercostal block is very low compared with the anatomical landmark method. The incidence of asymptomatic and symptomatic pneumothorax was less than 0.5% and 0.1%, respectively. This is closely related to the application of ultrasound‐guided technique in UG‐TPVB, which can inject local anesthetics in the paravertebral space under ultrasound guidance, more accurate and safer, thus reducing the possibility of intravascular injection and pneumothorax to a low level. The unfavorable position and body shape of elderly patients, which may have caused difficulty in anesthesia and increased complications in the past, are no longer a problem. This feature further enhances its safety.
To verify whether this advantage still exists in the common and high‐risk patient population of Chinese elderly VATL patients, we further analyzed the difference between elderly and nonelderly patients. We found that in elderly patients, the UG‐TPVB group had advantages over the conventional anesthesia group in all main observation indicators except for the difference in 48‐h dynamic VAS score level between the TO and CO groups was not significant. That is, lower main VAS scores after surgery, less opioid consumption, shorter extubation time and hospitalization days, and lower urinary retention rate. This indicates that the analgesic effect and safety of UG‐TPVB for elderly lung cancer surgery patients are not affected by age. This is of great significance for elderly lung cancer radical surgery patients, a group that is more prone to anesthesia complications, surgical complications, and drug adverse reactions. 28 , 29 That is, its analgesic effect and safety advantages also exist in elderly patients. This may be related to UG‐TPVB can be precisely located and dose adjusted according to the individual differences and nerve anatomy of patients. Some relevant studies have also shown that UG‐TPVB has a similar or better analgesic effect and safety than conventional anesthesia methods in lung cancer surgery patients of different age groups. 25 The reason for the lack of significant difference in some indicators (48‐h dynamic VAS score) may be related to factors such as the observation time point being too far from the one‐time administration time of UG‐TPVB, the low level of VAS score at that time, and the limited sample size of this study. However, the measurement value of the TO group was still lower than that of the CO group, and the p‐value was 0.052, which, to some extent, still supports our analysis of the trend and mechanism.
Finally, to verify whether the strength and level of this efficacy and safety advantage are affected by aging, we compared the young subgroup and elderly subgroup of the treatment group. We found that in the UG‐TPVB group, there was no significant difference between elderly patients and nonelderly patients, that is, there was no significant difference in postoperative VAS scores, opioid consumption, extubation time and hospitalization days, urinary retention rate, and other indicators. This indicates that the analgesic effect and safety of UG‐TPVB for lung cancer surgery patients are not only unaffected by age but also unaffected by age difference. That is, the intensity of its analgesic effect and safety is consistent in patients of different age groups. This may also be related to the fact that UG‐TPVB can be refined and individualized according to the differences of patients in various aspects.
This study also had some limitations, which included only involving one center; not optimizing and comparing the dose and mode of UG‐TPVB; not evaluating the impact of UG‐TPVB on lung cancer recurrence and survival rate; not considering other factors that may affect analgesic effect and safety, such as genetic polymorphism, psychological state, and so on; and not using a double‐blind design, which may have introduced observer bias. Based on the valuable findings of this study, we expect to expand the sample size, increase multicenter collaboration, further enhance the understanding level of UG‐TPVB, and explore the best application scheme in future studies.
In conclusion, this study was a single‐center, prospective, randomized, controlled trial of 300 patients, exploring the effect, complications, and safety of UG‐TPVB in elderly lung cancer surgery patients, and comparing with nonelderly patients. We found that UG‐TPVB can significantly improve perioperative analgesia management for elderly patients, reduce opioid use and side effects, shorten extubation time and hospitalization days, and reduce urinary retention rate. These advantages were not significantly different between the TO and CO groups as well as between the TO and TY groups. This indicates that the advantage of the analgesic effect and safety of UG‐TPVB for elderly lung cancer surgery patients is clear, and its existence and intensity are not affected by aging factors. We believe that UG‐TPVB is an effective and safe perioperative analgesia method, which has obvious advantages for elderly lung cancer surgery patients.
AUTHOR CONTRIBUTIONS
(I) Conception and design: Zhengnian Ding, Chanjuan Gong; (II) Administrative support: Rong Ma; (III) Provision of study materials or patients: Rong Ma; Chanjuan Gong; (IV) Collection and assembly of data: Bing Li; (V) Data analysis and interpretation: Li Wen; (VI) Manuscript writing: Li Wen; Chanjuan Gong; (VII) Final approval of manuscript: Zhengnian Ding.
FUNDING INFORMATION
This work was supported by Jiangsu Province Hospital (the First Affiliated Hospital with Nanjing Medical University) Clinical Capacity Enhancement and awarded to the first author, Chanjuan Gong (grant no. JSPH‐MC‐2022‐4).
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ACKNOWLEDGMENTS
We thank all the survey respondents who participated in the study.
Gong C, Ma R, Li B, Wen L, Ding Z. Effect of ultrasound‐guided thoracic paravertebral block on perioperative analgesia in elderly patients undergoing video‐assisted thoracic lobectomy in China: An interventional clinical randomized controlled trial. Thorac Cancer. 2023;14(34):3406–3414. 10.1111/1759-7714.15135
Chanjuan Gong and Rong Ma contributed equally to this study.
Contributor Information
Li Wen, Email: drli1025@163.com.
Zhengnian Ding, Email: zhengnianding@njmu.edu.cn.
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