Paracetamol did not improve the analgesic efficacy with regional block after video assisted thoracoscopic surgery: a randomized controlled trial

What if a commonly used analgesic isn’t as effective as we think? A new study shows that 1 gram of IV paracetamol (acetaminophen) may not improve pain management when paired with regional nerve blocks in patients undergoing video-assisted thoracoscopic surgery (VATS).

The Emerging Evidence

"Intravenous administration of one gram of paracetamol adjunctive to a regional block did not result in an improvement in analgesic efficacy after VATS or reduce the pain scores or the dose of rescue analgesics."

Key Takeaways

No Additional Pain Relief

1. Pain Scores: No significant reduction in postoperative pain when paracetamol was added to a regional block.
2. Opioid Use: Paracetamol didn’t reduce the total dose of rescue opioids required after VATS.

Study Highlights

1. Design: A prospective, double-blind, randomized controlled trial with 101 patients aged 19–80 (ASA 1–4).
2. Intervention: Erector Spinae Plane Block (ESPB) and Intercostal Nerve Block (ICNB) with or without IV paracetamol.

Patient Outcomes

1. No difference in pain scores, satisfaction levels, or incidence of postoperative nausea and vomiting (PONV).
2. Patients receiving regional blocks alone had similar pain relief without the added paracetamol.

Study Fast Facts

Dose: 1 g IV administered postoperatively.

Pain Scores: No significant differences between groups at any time point (PACU, 6, 12, 24, or 48 hours post-op).

Opioid Use: Morphine milligram equivalents (MME) did not differ between groups.

Adverse Events: Similar rates of PONV, bradycardia, and hypotension.

What This Means for VATS Pain Management

Enhanced Recovery After Surgery (ERAS) Guidelines: Recommend regional techniques like ESPB or ICNB and non-opioid analgesics to reduce opioid use. However, this study challenges the role of paracetamol in this strategy.

Persistent Pain: Up to 30% of VATS patients still report moderate-to-severe pain despite advanced analgesia, emphasizing the need for alternative approaches.

Multimodal Analgesia: While paracetamol is widely used, its efficacy alongside regional techniques may be limited in VATS, suggesting that resources may be better allocated to other adjuvants.

Excerpts

The Enhanced Recovery After Surgery guidelines for lung surgery recommend the use of regional techniques and non-opioid analgesics to reduce opioid use during the postoperative period.

Paravertebral block or erector spinae plane block (ESPB) with intercostal nerve block (ICNB) is performed after VATS; nevertheless, moderate to severe pain has been reported by up to 30% of patients, necessitating the use of high-dose opioids

No significant differences were observed in the total dose of opioids administered or the incidence of postoperative nausea and vomiting.

No differences were observed between the pain scores and satisfaction scores at any time point during the first 48 huors and moderate to severe pain was reported at a similar rate.

patients receiving both regional techniques were less painful after VATS regardless of paracetamol

Abstract

Background: Various analgesic techniques have been applied, the pain after video assisted thoracic surgery (VATS) is still challenging for anesthesiologists. Paracetamol provide analgesic efficacy in many surgeries. However, clinical evidence in the lung surgery with regional block remain limited. This monocentric double-blind randomized controlled trial investigates the efficacy of paracetamol after VATS with regional block.

Methods: A total of 90 patients were randomized to receive paracetamol (1 g) or normal saline. Erector Spinae Plane Block and Intercostal Nerve block were applied during the surgery. The Visual Analogue Scales (VAS) pain score was measured in the PACU as well as 6, 12, 24, and 48 h postoperatively. And the total dose of rescue analgesics administered to patients in morphine milligram equivalents (MME), satisfaction score, length of hospital stays, and incidence of nausea and vomiting were also recorded.

Results: The VAS pain score at each time point, the primary endpoint, did not differ between the groups (3.09 ± 2.14 vs. 2.53 ± 1.67, p = 0.174 at PACU; 4.56 ± 2.80 vs. 4.06 ± 2.46, p = 0.368 at 6 h; 3.07 ± 1.98 vs. 3.44 ± 2.48, p = 0.427 at 12 h; 2.10 ± 2.00 vs. 2.49 ± 2.07, p = 0.368 at 24 h; and 1.93 ± 1.76 vs. 2.39 ± 1.97, p = 0.251 at 48 h postoperatively). Satisfaction scores (4.37 ± 0.76 vs. 4.14 ± 0.88, p = 0.201), nausea (35.6% vs. 37.8%, p = 0.827), hypotension (2.2% vs. 0.0%, p = 0.317), and bradycardia (6.7% vs. 2.2%, p = 0.309) were also reported at similar rates.

Conclusions: The analgesic efficacy of one gram of paracetamol with ESPB and ICNB after VATS was not proven. Thus, caution should be exercised when prescribing paracetamol for pain control during VATS.

Citation

Kim S, Song SW, Lee H, Byun CS, Park JH. Paracetamol did not improve the analgesic efficacy with regional block after video assisted thoracoscopic surgery: a randomized controlled trial. BMC Anesthesiol. 2025 Jan 7;25(1):11. doi: 10.1186/s12871-025-02888-4. PMID: 39773335; PMCID: PMC11706059.

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