Blocs du tronc : indications, techniques, avantages et risque

Comparison between systemic analgesia, continuous wound catheter analgesia and continuous thoracic paravertebral block: a randomised, controlled trial of postthoracotomy pain management

CONTEXT

Thoracotomy is the surgical procedure that creates the greatest demand for postoperative analgesia.

OBJECTIVE

We aimed to compare the efficacy of systemic analgesia, continuous wound catheter (CWC) analgesia and thoracic paravertebral block (TPVB) for pain management after thoracotomy, assessed by Visual Analogue Scale (VAS) pain score and morphine consumption.

DESIGN

Prospective, randomised study.

SETTING

University teaching hospital. Inclusions from April 2007 to February 2010.

PATIENTS

153 adult patients scheduled for pulmonary surgery.

INTERVENTIONS

All three groups received systemic analgesia with paracetamol and morphine (patient-controlled analgesia, PCA). The PCA group received systemic analgesia only. The TPVB group underwent insertion of a paravertebral catheter and the CWC group underwent CWC catheter insertion at the end of the intervention.

MAIN OUTCOME MEASURES

Pain score at rest as assessed by VAS.

RESULTS

One hundred and fifty-three patients were included, of whom 140 were included in the final analysis (50 PCA, 44 TPVB, 46 CWC). Baseline and surgical characteristics were comparable in the three groups. VAS scores were statistically different between the TPVB and PCA groups at rest (at 0, 1, 3, 6 h; P < 0.0026) and after coughing (0, 1, 3, 6, 12 h; P < 0.003). In recovery room care, titrated morphine doses were significantly lower (P = 0.00001) in the TPVB group than in the other two. Morphine consumption was statistically lower in the TPVB group than in the PCA group at 24 h (P = 0.0036). There was no difference between CWC and PCA groups in terms of VAS scores or morphine consumption. No signs of toxicity or local complications were observed.

CONCLUSION

Our results support the efficacy of TPVB for pain management after thoracotomy, at rest and after coughing. These results confirm the preference for TPVB over epidural analgesia in postthoracotomy pain care. CWC failed to decrease pain and morphine consumption and performed no better than placebo.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]

INTRODUCTION

Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements.

MATERIAL AND METHODS

An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block.

RESULTS

In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II.

CONCLUSIONS

Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.