Daily Anesthesiology Research Analysis
A multicenter RCT found thoracic paravertebral block superior to erector spinae plane block for major breast surgery analgesia, challenging the use of ESPB as a primary technique. A meta-analysis of 58 RCTs confirmed opioid-sparing strategies reduce morphine consumption, pain scores, and PONV. An RCT of esophageal pressure–guided individualized ventilation in severe pancreatitis–associated ARDS improved mechanics, oxygenation, and reduced 28-day mortality, supporting precision ventilation at the
Summary
A multicenter RCT found thoracic paravertebral block superior to erector spinae plane block for major breast surgery analgesia, challenging the use of ESPB as a primary technique. A meta-analysis of 58 RCTs confirmed opioid-sparing strategies reduce morphine consumption, pain scores, and PONV. An RCT of esophageal pressure–guided individualized ventilation in severe pancreatitis–associated ARDS improved mechanics, oxygenation, and reduced 28-day mortality, supporting precision ventilation at the bedside.
Research Themes
- Comparative effectiveness of regional anesthesia for breast surgery
- Opioid-sparing multimodal analgesia in postoperative pain
- Personalized mechanical ventilation using esophageal pressure monitoring
Selected Articles
1. Erector spinae plane block versus paravertebral block for major oncological breast surgery: a multicentre randomised controlled trial.
In a multicenter double-blind RCT (n=292), ESPB failed noninferiority to PVB for early morphine rescue after major breast surgery, showed higher pain scores (notably on mobilization), and less reliable dermatomal coverage. No major complications occurred; patient satisfaction was high in both arms.
Impact: This high-quality comparative RCT directly informs regional anesthesia choices for breast cancer surgery and challenges routine use of ESPB as a primary technique.
Clinical Implications: For major oncological breast surgery, PVB should remain the preferred regional technique when feasible, while ESPB may be considered when PVB is contraindicated or expertise is limited, with counseling on potentially higher pain and incomplete coverage.
Key Findings
- ESPB group had a higher percentage requiring morphine within 2 hours postoperatively (75.2% vs 50.3%), failing noninferiority.
- Pain scores were higher with ESPB, particularly during mobilization.
- Dermatomal coverage was incomplete more often with ESPB (55.9% not covering required area vs 20.4% with PVB).
- Morphine consumption and patient satisfaction were similar; no major complications were observed.
Methodological Strengths
- Prospective multicenter randomised double-blind design
- Clear primary endpoint with clinically meaningful rescue morphine requirement
Limitations
- Focus on early postoperative period; chronic pain outcomes not assessed
- Block performance and spread may vary by operator and anatomy, affecting generalizability
Future Directions: Evaluate long-term pain, opioid use, and chronic pain syndromes; define subgroups where ESPB may be noninferior; standardize ESPB techniques to improve dermatomal coverage.
BACKGROUND: Breast cancer is the most common cancer in women, and oncological breast surgery often results in significant postoperative pain. Regional analgesia techniques such as thoracic paravertebral block (PVB) are effective but carry risks, whereas the erector spinae plane block (ESPB) is a newer, potentially safer alternative. We compared the efficacy of ESPB and PVB for managing acute pain after major breast cancer surgery. METHODS: This prospective, multicentre, randomised, double-blind trial involved 292 women who underwent major breast surgery. Patients were randomised to receive either ESPB or PVB. The primary outcome was the percentage of participants requiring morphine within the first 2 h after surgery, and the secondary outcomes included pain scores, morphine consumption, complications, and participants satisfaction. RESULTS: A total of 75.2% and 50.3% of the participants in the ESPB and PVB groups, respectively, required morphine, and the noninferiority criterion for ESPB was not met. However, morphine consumption was similar between the groups. Pain scores were greater in the ESPB group, especially during mobilisation, and ESPB provided less reliable dermatomal coverage than PVB, with the required area was not covered in 55.9% of participants in the ESPB group compared with 20.4% of participants in the PVB group. Satisfaction was similar between groups, with participants in both groups reporting high satisfaction. No major complications were observed. CONCLUSIONS: Compared with thoracic paravertebral block, erector spinae plane block did not meet the noninferiority criteria and was less effective for complete analgesia. Thoracic paravertebral block remains the preferred technique for major breast surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT04827030).
2. Individualized Lung-Protective Ventilation Strategy Based on Esophageal Pressure Monitoring in Patients With ARDS Associated With Severe Acute Pancreatitis-A Randomized Controlled Trial.
In SAP-related ARDS (n=124), esophageal pressure–guided individualized lung-protective ventilation reduced transpulmonary driving pressure, improved compliance and oxygenation, shortened ventilation and ICU stay, lowered VAP, and reduced 28-day mortality versus conventional lung-protective ventilation. ΔPL at 72 h independently predicted mortality.
Impact: Provides randomized evidence that precision ventilation using esophageal pressure monitoring can improve hard clinical outcomes, including mortality, in a high-risk ARDS subgroup.
Clinical Implications: Consider implementing esophageal pressure monitoring to guide individualized PEEP and tidal strategies in SAP-related ARDS; monitor ΔPL (72 h) as a prognostic marker and target to optimize.
Key Findings
- EPM-guided ventilation lowered transpulmonary pressure and transpulmonary driving pressure compared with conventional lung-protective ventilation.
- Static compliance and PaO2/FiO2 were significantly higher in the EPM group.
- EPM-guided strategy reduced duration of mechanical ventilation and ICU length of stay, decreased VAP incidence, and lowered 28-day mortality (19.35% vs 32.26%).
- ΔPL at 72 h was an independent predictor of 28-day mortality (AUC 0.832).
Methodological Strengths
- Randomized controlled design with pragmatic clinical outcomes including mortality
- Comprehensive physiologic measurements linking mechanism (ΔPL) to outcomes
Limitations
- Single-center trial; blinding not reported and may be impractical for EPM
- Results specific to SAP-related ARDS; external validity to other ARDS etiologies requires testing
Future Directions: Multicenter RCTs to validate mortality benefit; assess protocolized ΔPL targets; evaluate cost-effectiveness and training requirements for broader implementation.
BACKGROUND AND OBJECTIVE: Acute respiratory distress syndrome (ARDS) secondary to severe acute pancreatitis (SAP) presents significant management challenges with high mortality rates. This study aimed to investigate the application value of an individualized lung-protective ventilation strategy guided by esophageal pressure (Pes) monitoring in patients with ARDS associated with SAP. METHODS: This randomized controlled trial included 124 patients with SAP-related ARDS admitted to our hospital from January 2023 to December 2023, and they were randomized to a conventional lung protective ventilation group (conventional group, n = 62) and an esophageal pressure monitoring-guided group (EPM-guided group, n = 62). The conventional group adopted a conventional lung protective ventilation strategy; whereas, the EPM-guided group received the individualized ventilation strategy based on EPM. The EPM indicators, respiratory mechanics parameters, oxygenation indicators, and clinical outcomes were compared between the two groups. RESULTS: After treatment, the EPM-guided group showed significantly lower transpulmonary pressure (PL) [(16.82 ± 2.46) versus. (22.41 ± 3.23) cmH2O, p = 0.006], transpulmonary driving pressure (ΔPL) [(12.36 ± 1.83) versus. (16.52 ± 2.37) cmH2O, p = 0.007], and driving pressure (ΔP) [(11.43 ± 1.83) versus. (14.52 ± 2.24) cmH2O, p = 0.008] than the conventional group, whereas static compliance (Cst) [(37.82 ± 4.46) versus. (29.41 ± 5.23) mL/cmH2O, p = 0.009] and the PaO2/FiO2 ratio [(268.82 ± 32.46) versus. (195.41 ± 28.23) mmHg, p = 0.008] were significantly higher. The EPM-guided group had shorter mechanical ventilation duration [(12.32 ± 3.24) versus. (16.83 ± 4.52) d, p = 0.013] and intensive care nit (ICU) length of stay [(18.53 ± 4.62) versus. (23.72 ± 5.83) d, p = 0.018] compared to the conventional group, along with a lower VAP incidence (14.52% vs. 25.81% and p = 0.038) and a 28-day mortality rate (19.35% vs. 32.26% and p = 0.042). Multivariate logistic regression analysis showed that ΔPL at 72 h (OR 1.56, 95% CI 1.25-2.01, p < 0.001) was an independent predictor of a 28-day mortality rate. ROC curve analysis showed that ΔPL had a good diagnostic value for predicting a 28-day mortality rate (AUC = 0.832 and 95% CI 0.760-0.904). Correlation analysis showed that ΔPL at 72 h was significantly negatively correlated with the PaO2/FiO2 ratio (r = -0.71 and p < 0.001) and static compliance (r = -0.69 and p < 0.001). CONCLUSION: Individualized lung protective ventilation strategy guided by EPM can more accurately assess the actual lung inflation pressure, optimize the setting of ventilation parameters, and improve clinical outcomes of patients with SAP-related ARDS.
3. The Impact of Opioid-Sparing Analgesia on Postoperative Pain and Recovery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Across 58 RCTs (n=5614), opioid-sparing strategies reduced 24-hour morphine use (MD -9.47 mg), lowered 24-hour pain scores, decreased PONV and pruritus, and improved patient satisfaction, without changes in length of stay or overall recovery quality.
Impact: Provides broad, aggregated evidence supporting multimodal, opioid-sparing perioperative analgesia with tangible benefits in pain, opioid exposure, and PONV.
Clinical Implications: Adopt opioid-sparing multimodal regimens (e.g., NSAIDs, acetaminophen, regional techniques, adjuncts) as standard postoperative analgesia to reduce opioid exposure and PONV while maintaining recovery metrics.
Key Findings
- Opioid-sparing strategies reduced 24-hour morphine consumption (MD -9.47 mg; 95% CI -13 to -5.95).
- 24-hour pain scores decreased (MD -0.72) and patient satisfaction improved (MD 0.88).
- PONV (OR 0.73) and pruritus (OR 0.64) were reduced; no differences in length of stay or quality of recovery.
Methodological Strengths
- Systematic review and meta-analysis of randomized controlled trials with PROSPERO registration
- Comprehensive assessment of efficacy and adverse effects across multiple outcomes
Limitations
- Heterogeneity in surgical procedures, analgesic protocols, and outcome definitions
- Potential publication bias and limited data on long-term outcomes
Future Directions: Head-to-head RCTs of specific multimodal bundles, standardized outcome reporting, and evaluation of long-term opioid use and chronic pain.
INTRODUCTION: Opioids are commonly used for postoperative pain management but are associated with adverse effects and risk of dependence, potentially hindering recovery. This systematic review evaluates the impact of opioid-sparing analgesic strategies on postoperative pain and functional recovery to provide evidence-based guidance for clinical practice and future research. METHODS: A comprehensive systematic review and meta-analysis was conducted by searching PubMed, Embase, Web of Science, and the Cochrane Library for randomized controlled trials on adult surgical patients from the inception of each database to July 10, 2024. The primary outcome was the total morphine consumption within 24 h postoperatively. Secondary outcomes included postoperative pain scores at 24 h, patient satisfaction, length of stay, quality of recovery, and opioid-related adverse effects, such as postoperative nausea and vomiting (PONV), sedation, dizziness, drowsiness, pruritus, urinary retention, and hypotension. RESULTS: A total of 58 studies (5614 patients) were included. The total morphine consumption was reduced, with a mean difference (MD) of -9.47, 95% confidence interval (95% CI) [-13, -5.95]. The postoperative pain score at 24 h was lower than in the control group, with an MD of -0.72 (95% CI [-0.97, -0.47]). Patient satisfaction was higher than in the control group, with an MD of 0.88 (95% CI [0.36, 1.40]). There were no significant differences in length of stay or recovery quality compared to the control group (P = 0.7, P = 0.48). The incidence of PONV was lower than the control group, with an odds ratio (OR) of 0.73 (95% CI [0.59, 0.90]), and the incidence of pruritus was also lower than in the control group, with an OR of 0.64 (95% CI [0.41, 0.98]). There were no differences in other adverse reactions compared to the control group. CONCLUSION: The results of this meta-analysis indicate that, compared to opioid-based analgesia, opioid-sparing analgesia is associated with reduced morphine consumption within 24 h postoperatively, lower pain scores, and a decreased incidence of PONV and pruritus. Patient satisfaction was also improved. The findings will help clinicians make evidence-based decisions for postoperative pain management. TRIAL REGISTRATION: The protocol for this meta-analysis: PROSPERO CRD42024579882.