Paravertebral Block With Ropivacaine 0.5% Versus Systemic Analgesia for Pain Relief After Thoracotomy

Postoperative urinary retention (POUR): A narrative review

Postoperative urinary retention (POUR) is defined as the inability to void in the presence of a full bladder after surgery. Complications include delirium, pain, prolonged hospitalization, and long-term altered bladder contractility. Comorbidities, type of surgery and anesthesia influence the development of POUR. The incidence varies between 5% and 70%. History and clinical examination, the need for bladder catheterization and ultrasonographic evaluation are three methods used to diagnose POUR. The prevention of POUR currently involves identifying patients with pre-operative risk factors and then modifying them where possible. Bladder catheterization is the standard treatment of POUR, however, further studies are necessary to establish patients who need a bladder catheter, bladder volume thresholds and duration of catheterization.

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Feasibility and Efficacy of a Non-Opioid Based Pain Management After Medical Thoracoscopy

BACKGROUND

Prescription opioids are a major cause of the opioid epidemic. Despite the minimally invasive nature of medical thoracoscopy (MT), data on the efficacy of non-opioid-based pain control after MT is lacking. The purpose of this study is to assess the feasibility and efficacy of a non-opioid-based pain management strategy in patients who underwent MT.

METHODS

We performed a retrospective analysis of all patients who underwent MT in the Mayo Clinic (Minnesota and Arizona) outpatient setting. We assessed their pain level and the need for analgesia post-MT from August 1, 2019, to May 24, 2021.

RESULTS

Forty patients were included. In the first 24 hours, 5/40 (12.5%) reported no pain. Twenty-eight patients out of 40 (70%) reported minor pain (pain scale 1-3), and 7/40 (17.5%) reported moderate pain (pain scale 4-6). No patients reported severe pain. Twenty-two out of 35 patients who experienced discomfort (63%) required acetaminophen, 6/35 patients (17%) required nonsteroidal anti-inflammatory drug, and 7/35 patients (20%) did not require analgesia. Of the 7 patients who had moderate pain, 5 (71%) reported that the moderate pain improved to mild at 72 hours post-MT. Zero patients required opioids, and none reported contacting any provider to manage the pain post-MT. Fourteen patients (78%) who had both parietal pleural biopsies and tunneled pleural catheter placed reported minor pain, 3 patients (17%) reported moderate pain, and 1 patient (6%) experienced no discomfort.

CONCLUSION

MT is well-tolerated by patients with non-opioid-based pain management strategy as needed if there is no absolute contraindication.

Combined Programmed Intermittent Bolus Infusion With Continuous Infusion for the Thoracic Paravertebral Block in Patients Undergoing Thoracoscopic Surgery: A Prospective, Randomized, and Double-blinded Study

BACKGROUND

Continuous thoracic paravertebral block (TPVB) connected with patient-controlled analgesia (PCA) pump is an effective modality to reduce postoperative pain following thoracic surgery. For the PCA settings, the programmed intermittent bolus infusion (PIBI) and continuous infusion (CI) are commonly practiced. However, the comparative effectiveness between the 2 approaches has been inconsistent. Thus, the aim of this study was to explore the optimal PCA settings to treat postthoracotomy pain by combing PIBI and CI together.

METHODS

All enrolled patients undergoing thoracoscopic surgery accepted ultrasound-guided TPVB catheterization before the surgery and then were randomly allocated in to 3 groups depending on different settings of the PCA pump connecting to the TPVB catheter: the PIBI+CI, PIBI, and CI groups. Numerical Rating Scales were evaluated for each patient at T1 (1 h after extubation), T2 (12 h after the surgery), T3 (24 h after the surgery), T4 (36 h after the surgery), and T5 (48 h after the surgery). Besides, the consumptions of PCA ropivacaine, the number of blocked dermatomes at T3, and the requirement for extra dezocine for pain relief among the 3 groups were also compared.

RESULTS

First, the Numerical Rating Scale scores in the PIBI+CI group were lower than the CI group at T2 and T3 (P<0.05) when patients were at rest and were also lower than the CI group at T2, T3, and T4 (P<0.01) and the PIBI group at T3 when patients were coughing (P<0.01). Second, the 2-day cumulative dosage of PCA in the PIBI+CI group was lower than both the CI and PIBI groups (P<0.01). Third, the number of blocked dermatomes in the PIBI and PIBI+CI groups were comparable and were both wider than the CI group at T3 (P<0.01). Finally, a smaller proportion (not statistically significant) of patients in the PIBI+CI group (5.26%, 2/38) had required dezocine for pain relief when compared with the PIBI group (19.44%, 7/36) and the CI group (15.79%, 6/38).

CONCLUSIONS

The combination of PIBI and CI provides superior analgesic modality to either PIBI or CI alone in patients undergoing thoracoscopic surgery. Therefore, it should be advocated to improve the management of postoperative pain, clinical outcomes, and ultimately patient satisfaction.

Continuous Unilateral Erector Spinae Plane Block versus Intravenous Analgesia in Minimally Invasive Cardiac Surgery: A Randomized Controlled Trial

Objectives: the study was conducted to assess the safety and efficacy of anesthesia under the erector spinae plane block (ESPB) in minimally invasive cardiac surgery (MICS). Methods: a prospective, randomized controlled trial was carried out in 56 adult patients who underwent MICS via a right thoracic incision at Vietnam National Heart Institute, Bach Mai hospital, Vietnam. Patients were randomly allocated into two groups: ESPB and conventional analgesia (intravenousmorphine patient-controlled analgesia, PCA). Patients in ESPB group received ultrasound-guided unilateral ESPB at the T4/T5 transverse process level, and the tip of the catheter was advanced 5cm beyond the tip of the needle; injected with 20 ml ropivacaine 0.5%. At the cardiac ICU, patients received paracetamol (1g every 6 hours), continuous infusion ropivacaine 0.1% 0.2ml/kg/hour. Patients in the PCA group received paracetamol (1g every 6 hours) and intravenous morphine PCA. All patients were followed for 72 hours after being extubated. Results: the resting VAS score was significantly lower in ESPB group at the time H4, H8, H12, H16, H36, H42, H48, H54, H60, H66 after extubated compared to that of the PCA group (p< 0.05). The dynamic VAS score at was also significantly lower in the ESPB group at all measured time points (p<0.05). Only 4 patients in the ESPB group required intravenous morphine PCA with the mean amount morphine were statistically lower in the ESPB group compared to the PCA group at 24 hours, 48 ​​hours, 72 hours postoperative. No serious adverse events such as neurological complications, bleeding or infection were observed in both groups. Conclusion: ESPB is an effective analgesic for MICS via thoracic incision in reducing the VAS score and the morphine required. It is also a safe method with no severe ESPB-related complications.

Impact on Postoperative Pain and Recovery of a Regional Analgesia Strategy Based on the Surgical Approach for Lung Resection: A Prospective Observational Study

Various regional anesthesia (RA) techniques were shown to reduce pain after lung surgery, but controversies remain regarding the best technique to use to improve recovery. In this observational prospective study, the aim was to assess the efficacy of an RA strategy depending on the surgical approach. Patients who underwent lung surgery were included if an RA was planned following our unit procedure (erector spinae plane block (ESP) for video-assisted thoracic surgery (VATS) and thoracic epidural analgesia (TEA) or intrathecal analgesia (IA) for thoracotomy). Patients were compared according to the RA used. In total, 116 patients were included, 70 (60%), 32 (28%), 14 (12%) in the ESP, TEA and IA groups, respectively. Between Day 1 and Day 3, median NRS values were ≤4 at rest, and <50% patients experienced moderate-to-severe pain in each group. There were no significant differences in opioid consumption and in pain at rest or during chest physiotherapy on Days 1 and 2 between groups. However, patients who received an IA had lower NRS than other groups on Day 0 and 3 and a shorter length of hospital stay in comparison with those who received a TEA. Thus, in our institution, a strategy combining ESP for VATS and TEA, or IA for thoracotomy, allowed for effective analgesia after a lung resection. Interestingly, IA appeared to be more effective than TEA in reducing the length of hospital stay and pain on Day 0 and 3.

Continuous Paravertebral Analgesia versus Continuous Epidural Analgesia after Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial

Background: Whether continuous thoracic epidural analgesia (TEA) and continuous paravertebral block (PVB) have similar analgesic effects in patients undergoing video- assisted thoracic surgery (VATS) lobectomy was compared in this study.

Methods: In all, 86 patients undergoing VATS lobectomy were enrolled in the prospective, randomized clinical trial. Group E received TEA. Group P received PVB. The primary endpoint was postoperative 24-hour visual rating scale (VAS) on coughing. Side effects and postoperative complications were also analyzed.

Results: Pain scores at rest or on coughing at 24 and 48 h postoperatively were significantly lower in group E than in group P (P <0.05). At 24 h postoperatively, more patients in group E suffered from vomiting (32.6% vs 11.6%, P = 0.019), dizziness (55.8% vs 12.9%, P = 0.009), pruritus (27.9% vs 2.3%, P = 0.002), and hypotension (32.6% vs 4.7%, P = 0.002) than those in group P. Patients in group E were more satisfied (P = 0.047). Four patients in group P and two patients in group E suffered from pulmonary complications (P >0.05). The length of hospital and intensive care unit (ICU) stays were not significantly different.

Conclusions: Though TEA has more adverse events than PVB, it may be superior to PVB in patients undergoing VATS lobectomy.

Contrast-enhanced paravertebrogram to confirm paravertebral catheter position in elective thoracic surgery: a proof of concept study

Background

Paravertebral pain catheters have been shown to be equally effective as epidural pain catheters for postoperative analgesia after thoracic surgery with the possible additional benefit of less hemodynamic effect. However, a methodology for verifying correct paravertebral catheter placement has not been tested or objectively confirmed in previous studies. The aim of the current study was to describe a technique to confirm the correct position of a paravertebral pain catheter using a contrast-enhanced paravertebrogram.

Methods

A retrospective cohort proof of concept study was performed including 10 consecutive patients undergoing elective thoracic surgery with radiographic contrast-enhanced confirmation of intraoperative paravertebral catheter placement (paravertebrogram).

Results

The results of the paravertebrograms, which were done in the operating room at the end of the procedure, verified correct paravertebral catheter placement in 10 of 10 patients. The radiographs documented dissemination of local anesthetic within the paravertebral space.

Conclusion

This proof of concept study demonstrated that a contrast-enhanced paravertebrogram could be used in conjunction with standard postoperative chest radiography to add valuable information for the assessment of paravertebral catheter placement. This technique has the potential to increase the accuracy and efficiency of postoperative analgesia, and to set a quality standard for future studies of paravertebral pain catheters.

Complication rate of ultrasound-guided paravertebral block for breast surgery

Background and objectives

Thoracic paravertebral blockade is often used as an anesthetic and/or analgesic technique for breast surgery. With ultrasound guidance, the rate of complications is speculated to be lower than when using landmark-based techniques. This investigation aimed to quantify the incidence of pleural puncture and pneumothorax following non-continuous ultrasound-guided thoracic paravertebral blockade for breast surgery.

Methods

Patients who received thoracic paravertebral blockade for breast surgery were identified by retrospective query of our institution’s electronic database over a 5-year period. Data collected included patient demographics, level of block, type and volume of local anesthetic, occurrence of pleural puncture, occurrence of pneumothorax, evidence of local anesthetic toxicity, and patient vital signs. The incidence of block complications, including pleural puncture, pneumothorax, and local anesthetic toxicity, were ascertained.

Results

529 patients underwent 2163 thoracic paravertebral injections. Zero pleural punctures were identified during block performance; however, two patients were found to have a pneumothorax on postoperative chest X-ray (3.6 per 1000 surgeries, 95% CI 0.5 to 13.6; 0.9 per 1000 levels blocked, 95% CI 0.1 to 3.3). There were no cases of local anesthetic systemic toxicity or associated lipid emulsion therapy administration.

Conclusions

Pneumothorax following non-continuous ultrasound-guided thoracic paravertebral block using a parasagittal approach is an uncommon occurrence, with a similar rate to pneumothorax following breast surgery alone.

Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief

Background

Systemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.

Results

Sixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).

Conclusion

Continuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.

Regional versus systemic analgesia in video-assisted thoracoscopic lobectomy: a retrospective analysis

Background

The optimal perioperative analgesic strategy in video-assisted thoracic surgery (VATS) for anatomic lung resections remains an open issue. Regional analgesic concepts as thoracic paravertebral or epidural analgesia were used as systemic opioid application. We hypothesized that regional anesthesia would provide improved analgesia compared to systemic analgesia with parenteral opioids in VATS lobectomy and would be associated with a lower incidence of pulmonary complications.

Methods

The study was approved by the local ethics committee (AZ 99/15) and registered (germanctr.de; DRKS00007529, 10th June 2015). A retrospective analysis of anesthetic and surgical records between July 2014 und February 2016 in a single university hospital with 103 who underwent VATS lobectomy. Comparison of regional anesthesia (i.e. thoracic paravertebral blockade (group TPVB) or thoracic epidural anesthesia (group TEA)) with a systemic opioid application (i.e. patient controlled analgesia (group PCA)). The primary endpoint was the postoperative pain level measured by Visual Analog Scale (VAS) at rest and during coughing during 120 h. Secondary endpoints were postoperative pulmonary complications (i.e. atelectasis, pneumonia), hemodynamic variables and postoperative nausea and vomiting (PONV).

Results

Mean VAS values in rest or during coughing were measured below 3.5 in all groups showing effective analgesic therapy throughout the observation period. The VAS values at rest were comparable between all groups, VAS level during coughing in patients with PCA was higher but comparable except after 8–16 h postoperatively (PCA vs. TEA; p < 0.004). There were no significant differences on secondary endpoints. Intraoperative Sufentanil consumption was significantly higher for patients without regional anesthesia (p < 0.0001 vs. TPVB and vs. TEA). The morphine equivalence postoperatively applicated until POD 5 was comparable in all groups (mean ± SD in mg: 32 ± 29 (TPVB), 30 ± 27 (TEA), 36 ± 30 (PCA); p = 0.6046).

Conclusions

Analgesia with TEA, TPVB and PCA provided a comparable and effective pain relief after VATS anatomic resection without side effects. Our results indicate that PCA for VATS lobectomy may be a sufficient alternative compared to regional analgesia.

Trial registration

The study was registered (germanctr.de; DRKS00007529; 10th June, 2015).

Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: A randomised controlled trial

BACKGROUND

The benefit of adding opioid to a local anaesthetic for continuous thoracic paravertebral analgesia after video-assisted thoracic surgery (VATS) is unclear.

OBJECTIVES

To analyse the analgesic efficacy of ropivacaine and sufentanil in combination compared with ropivacaine alone after VATS.

DESIGN

A randomised, double-blinded, single-centre clinical trial.

SETTING

A tertiary university hospital between March 2010 and April 2014.

PATIENTS

Ninety patients were recruited, two were not included leaving 88 randomised into two groups. Eighteen patients were excluded from analysis and 70 completed the study.

INTERVENTION

To receive thoracic paravertebral analgesia with either 2 mg ml ropivacaine and 0.25 μg ml sufentanil (ropivacaine + sufentanil group) or 2 mg ml ropivacaine alone (ropivacaine group) for 48 h postoperatively. Infusion rate was set at 0.15 ml kg h in both groups.

MAIN OUTCOME MEASURES

The primary endpoint was the mean total amount of self-administered morphine by the patients in each group at 48 h postoperatively.

RESULTS

The mean ± SD total amount of self-administered morphine was not significantly different between groups (53.1 ± 27.2 mg in the ropivacaine + sufentanil group vs. 58.8 ± 34.3 mg in the ropivacaine group; P = 0.72). No significant differences were found between the two groups in either pain scores at rest or during movement, in opioid-related adverse reactions, in patient satisfaction or length of hospital stay.

CONCLUSION

Adding 0.25 μg ml sufentanil to 2 mg ml ropivacaine in continuous thoracic paravertebral analgesia for VATS did not reduce morphine consumption or pain scores when compared with ropivacaine alone. We cannot recommend its use for routine clinical practice. Further studies analysing different concentrations and infusion rates of sufentanil are needed before a lack of efficacy can be confirmed.

TRIAL REGISTRATION

Clinical trial registrations: EudraCT: 2009-014832-38. ClinicalTrials.gov: NCT 01082744.

The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4-6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24-72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.

Patient-controlled paravertebral analgesia for video-assisted thoracoscopic surgery lobectomy

Background

Paravertebral block has been proven to be an efficient method to provide post-thoracotomy pain management. This study aimed to compare patient-controlled paravertebral analgesia (PCPA) and intravenous patient-controlled analgesia (IVPCA) in terms of analgesic efficiency, respiratory function, and adverse effects after video-assisted thoracoscopic surgery (VATS) lobectomy.

Patients and methods

The prospective randomized trial study was carried out on 60 patients who underwent VATS lobectomy (randomly allocated 30 patients in each group). In the PCPA group, an initial dose of 0.3 mL/kg of 0.125% bupivacaine with fentanyl 2 µg/mL was administered, followed by a 3 mL/h continuous infusion with patient-controlled analgesia (2 mL bolus, 10-minute lockout interval, 25 mL/4 h limit). In the IVPCA group with morphine 1 mg/mL solution, an infusion device was programmed to deliver a 1.0 mL demand bolus with no basal infusion rate, with a 10-minute lockout interval and a maximum of 20 mL/4 h period. Postoperative pain was assessed by visual analog scale at rest and on coughing. Arterial blood gas and spirometry were monitored and recorded for the first 3 postoperative days. Side effects to include were also recorded.

Results

The PCPA group had statistically significant lower pain scores (P<0.0001) at rest at all times. Lower pain scores on coughing were statistically significant in PCPA group in the first 4 hours. Postoperative spirometry showed that both the groups had comparable recovery trajectories for their pulmonary function. Arterial blood gas analysis showed pH and PaCO₂ were in a normal range in both the groups. The incidence of headache was higher in the IVPCA group (13.3% vs 0%; P=0.038).

Conclusion

PCPA effectively managed pain after VATS lobectomy, with lower pain scores, similar respiratory function, and fewer side effects than standard IVPCA treatment.

Efficacy of thoracic paravertebral block versus systemic analgesia for postoperative thoracotomy pain: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of the systematic review is to synthesize the best available evidence on the effectiveness of thoracic paravertebral block compared with the use of systemic analgesia on postoperative pain in patients who have undergone a thoracotomy procedure.

The effects of preoperative single-dose thoracic paravertebral block on acute and chronic pain after thoracotomy: A randomized, controlled, double-blind trial

BACKGROUND

Patients undergoing thoracotomy frequently experience acute pain and chronic post-thoracotomy pain (CPTP). There are few articles relating to the investigations on the effects of preoperative single-dose thoracic paravertebral block (PSTPVB) on acute pain and CPTP. We tested the hypothesis that adding PSTPVB to intravenous (IV) patient-controlled analgesia (PCA) would reduce acute pain scores and decrease the incidence and intensity of CPTP.

METHODS

Fifty-six patients undergoing elective thoracotomy were randomized to receive PSTPVB in addition to IV PCA (group T) or IV PCA alone (group C). A single 20-mL injection of 0.50% ropivacaine plus 10 mg dexamethasone in saline was administered preoperatively under ultrasound guidance; sufentanil was used for IV PCA. The acute pain intensity at rest and at coughing based on verbal rating scale, postoperative sufentanil consumption, and complications were evaluated at 6, 24, 48, and 72 hours after surgery. The incidence and intensity of CPTP were evaluated at 3 months after surgery.

RESULTS

Group T had significantly less acute pain compared with group C at all measurement times both at rest and at coughing (P < .05). The PCA cumulative sufentanil consumption, complications, and the incidence of CPTP between the 2 groups was not statistically significant (P > .05). The intensity of CPTP was significantly higher in group C than in group T (P < .05).

CONCLUSION

This study indicated that adding PSTPVB to IV PCA improved acute postoperative pain and chronic pain in patients undergoing thoracotomy, but did not reduce the incidence of CPTP.

The effect of interscalene block on ipsilateral shoulder pain and pulmonary function in patients undergoing lung lobectomy: A randomized controlled trial

BACKGROUND

Postoperative ipsilateral shoulder pain occurs in 37% to 68% of patients undergoing a thoracotomy. We examined whether interscalene brachial plexus block using a lower concentration of local anesthetic would reduce the incidence of post-thoracotomy ipsilateral shoulder pain with assessment of pulmonary function in patients who underwent a lung lobectomy.

METHODS

Forty-four patients who underwent a lung lobectomy were randomly assigned to either the control or the interscalene block group. Single-shot interscalene block on the surgical site side was performed using ropivacaine 0.25% 10 mL including dexamethasone 5 mg under ultrasound guidance in the interscalene block group. Lobectomy and continuous paravertebral block were performed under general anesthesia. The presence of ipsilateral shoulder pain and postoperative adverse events were assessed. Pulmonary function tests were performed preoperatively, the day after surgery, and the day after removing the chest tube.

RESULTS

The incidence of ipsilateral shoulder pain was significantly lower in the interscalene block group than in the control group (54.5% vs 14.3%, P = .006) with an overall incidence of 34.9%. Postoperative adverse events were similar between the groups, with no patients presenting symptoms of respiratory difficulty. Significant reductions in pulmonary function were observed in all patients after lobectomy; however, no significant difference in any of the pulmonary function test variables was observed postoperatively between the groups.

CONCLUSIONS

Interscalene block using 10 mL of 0.25% ropivacaine including dexamethasone 5 mg reduced the incidence of post-thoracotomy ipsilateral shoulder pain and did not result in additional impairment of pulmonary function.

Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study

Background

Thoracic epidural analgesia (EDA) is the gold standard for pain control after thoracotomy. However, because of its severe side effects, it is contraindicated in patients taking anticoagulant or antiplatelet drugs. In addition, some patients’ anatomy can make epidural catheter insertion challenging. We therefore investigated the safety and efficacy of paravertebral block (PVB) using a thoracoscopic insertion technique, which avoids damage to the parietal pleura, for postoperative pain after thoracotomy.

Methods

Patients who underwent thoracotomy with thoracic PVB in our hospital between March 2013 and March 2014 were examined retrospectively. Prior to creating the thoracotomy incision, a catheter for PVB was inserted percutaneously into the paravertebral space under thoracoscopic guidance. A matched-pair control group was selected at a 1:2 ratio from patients who underwent thoracotomy with thoracic EDA in our hospital from April 2011 to February 2013. Pain control and side effects were compared between groups and the results statistically analyzed.

Results

Thoracic PVB was performed in 56 patients during this period, and 112 patients were selected as matched controls. Numeric Rating Scale scores on postoperative day 2 did not differ significantly between the PVB group (3.25 ± 1.80) and the EDA group (3.56 ± 2.05) (p = 0.334). In terms of side effects, urinary retention occurred less frequently in thoracic PVB patients (p = 0.03).

Conclusion

Under the conditions of the present study, continuous thoracic PVB was at least as effective as epidural analgesia for postoperative pain control after thoracotomy with lung resection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-017-0566-8) contains supplementary material, which is available to authorized users.

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy

BACKGROUND

Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy.

OBJECTIVES

To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness.

SEARCH METHODS

We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis).

MAIN RESULTS

We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs.

AUTHORS' CONCLUSIONS

Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.

Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery

OBJECTIVE

Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function.

DESIGN

Prospective, non-randomized trial from April 2009 to September 2011.

SETTING

Department of Thoracic Surgery, single-center.

PARTICIPANTS

Thoracic surgical patients.

INTERVENTIONS

Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy.

MEASUREMENTS AND MAIN RESULTS

The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups.

CONCLUSIONS

Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.

Comparison Between Intraoperative Two-Space Injection Thoracic Paravertebral Block and Wound Infiltration as a Component of Multimodal Analgesia for Postoperative Pain Management After Video-Assisted Thoracoscopic Lobectomy: A Randomized Controlled Trial

OBJECTIVE

To compare paravertebral block under thoracoscopy with wound infiltration at an early stage after video-assisted thoracic lobectomy surgery.

DESIGN

A prospective, randomized, triple-blinded, placebo-controlled trial.

SETTING

A single-center university hospital.

PARTICIPANTS

Patients scheduled for video-assisted thoracic lobectomy surgery between February 20, 2014 and June 1, 2014 randomly were allocated into paravertebral block (PVB) (n = 35) and infiltration (n = 35) groups.

INTERVENTIONS

In the PVB group, 0.5% ropivacaine was injected into the paravertebral space by the surgeon under direct vision with placebo infiltration of saline in the wounds. In the infiltration group, the wounds were infiltrated with 0.5% ropivacaine by the surgeon with a placebo paravertebral block. Subsequently, patient-controlled intravenous morphine analgesia and paracoxib were administered.

MEASUREMENTS AND MAIN RESULTS

The primary endpoints were visual analog scale (VAS) pain scores at rest and on cough 0, 2, 6, and 24 hours after surgery. The secondary endpoints were the total morphine during postoperative 0 hours to 24 hours, adverse events, and patient satisfaction with the analgesia. Sixty-one patients completed the study. VAS score on cough at each time point was significantly lower (p<0.05) and median (25th, 75th) morphine consumption was lower in the PVB group than in the infiltration group (26 [10, 35] mg and 42 [29, 58] mg, p<0.001, respectively). There was no difference in VAS score at rest. Patients in the PVB group had higher satisfaction with analgesia than in the infiltration group (p = 0.003).

CONCLUSIONS

As part of the multimodal postoperative analgesia, intraoperative paravertebral block provided better dynamic pain relief and reduced morphine consumption compared with local wound infiltration.

Effects of ropivacaine, bupivacaine and sufentanil in colon and pancreatic cancer cells in vitro

The perioperative period is supposed to be a vulnerable period for cancer progression. Results of clinical studies indicate that the use of regional anesthesia can influence and improve oncological outcome of cancer patients. Uncontrolled cell proliferation and resistance to apoptotic cell death are important characteristics of solid tumors. The aim of this study was to investigate the effects of the clinically used local anesthetics ropivacaine or bupivacaine and the opioid analgesic sufentanil on cell proliferation, cell cycle distribution and apoptosis of colon (HT 29 and SW 480) and pancreatic (PaTu 8988t and PANC 1) cancer cell lines in vitro. Cell proliferation was measured by Cell Proliferation ELISA BrdU Assay. Apoptosis was analyzed by annexin V staining and cell cycle distribution was detected by flow cytometry. Ropivacaine, bupivacaine and sufentanil did not change apoptosis rate and cell cycle distribution in clinically concentration. Only high concentrations of ropivacaine or bupivacaine revealed antiproliferative potency. Protective effects of epidural anesthesia observed in clinical studies seem not to be based on direct effects of these drugs on cancer cells.

The importance of pleural integrity for effective and safe thoracic paravertebral block: a retrospective comparative study on postoperative pain control by paravertebral block

OBJECTIVES

Recently, paravertebral block (PVB) has been reported to be an effective analgesic modality for post-thoracotomy pain, but there is no consensus on how thoracic PVB can be more effective. Our hypothesis that intact pleura has a significant impact on the analgesic effectiveness of thoracic PVB was evaluated.

METHODS

Data of patients who underwent general thoracic surgery [thoracotomy or video-assisted thoracic surgery (VATS)] and paravertebral catheterization at Nagara Medical Center between April 2010 and March 2013 were collected. To compare the frequency of non-steroidal anti-inflammatory drugs taken as well as the usage of rescue pain medications between patients with pleural disruption and those without, data were analysed after matching on propensity scores. Covariates for match estimation were age, sex, body mass index, American Society of Anesthesiologists score, diagnosis, operative details and local anaesthesia infused.

RESULTS

There were 278 patients who underwent general thoracic surgery and paravertebral catheterization. The propensity score-matching process created 78 matched patients with pleural disruption and those without. Based on the propensity score matching, a significant increase in the frequency of non-steroidal anti-inflammatory drugs taken on postoperative day 1 and in the usage of rescue drugs was observed in patients with pleural disruption.

CONCLUSIONS

According to our analysis, creating a sub-pleural space without pleural disruption is essential for quality thoracic PVB.

Epidural placement does not result in an increased incidence of venous thromboembolism in combat-wounded patients

BACKGROUND

Patient-controlled epidural analgesia (PCEA) decreases the amount of systemic opioid required for adequate analgesia and decreases the rate of opioid-induced adverse effects. Given the location of catheters required to deliver analgesics and the potential for epidural hematoma, the American Society of Regional Anesthesia and Pain Medicine recommends modification of the standard trauma venous thromboembolism (VTE) prophylaxis regimen of enoxaparin 30 mg twice daily to 40 mg daily. The objective of this retrospective study was to determine if 40-mg daily dosing would increase the incidence of VTE.

METHODS

With institutional review board approval, records of all combat casualties admitted to our institution between November 2010 and November 2012 were reviewed for demographics, VTE prophylaxis regimen, PCEA days, and incidence of VTE. Patients who arrived without VTE were the study cohort. Rates of VTE were compared between PCEA and no-PCEA groups. Variables were analyzed with Mann-Whitney U-test, Pearson's χ test, and Fisher's exact test. A p ≤ 0.05 was considered significant. Data are expressed as median (interquartile range).

RESULTS

A total of 565 records were reviewed; 484 met inclusion criteria; and 181 patients (37.4%) had PCEA for 13 days (6-25 days). Age and sex were similar between the groups. PCEA patients were more often injured by dismounted improvised explosive devices (75.1% vs. 39.3%, p < 0.001), had longer hospital stays (38 days vs. 17 days, p < 0.001), had higher Injury Severity Score (ISS) (14 vs. 12, p = 0.033), and were more likely to have an amputation (66.1% vs. 20.4%, p < 0.001). Twenty-three PCEA patients (12.7%) developed VTE versus 32 no-PCEA patients (10.6%) (p = 0.464). Eleven VTE events (47.8%) occurred with the catheter in place, while 12 VTE events (52.2%) occurred 6 days (2-15 days) after removal.

CONCLUSION

Although PCEA catheters were more often placed in patients prone to VTE, there was no difference in incidence of VTE with their use. These data suggest that enoxaparin 40 mg daily in patients with PCEA is not inferior to 30 mg twice daily for VTE prophylaxis in combat-wounded patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Single-dose, bilateral paravertebral block plus intravenous sufentanil analgesia in patients with esophageal cancer undergoing combined thoracoscopic-laparoscopic esophagectomy: a safe and effective alternative

OBJECTIVE

Paravertebral block (PVB) has been shown to be an ideal aid for analgesia after thoracic or abdominal surgery. The authors studied the safety and efficacy of the single-dose and bilateral ultrasound-guided (USG)-PVB before combined thoracoscopic-laparoscopic esophagectomy (TLE) along with intravenous sufentanil analgesia as a method of pain relief in comparison with intravenous sufentanil as a sole analgesic agent.

DESIGN

Prospective, randomized study.

SETTING

Single university hospital.

PARTICIPANTS

Fifty-two patients undergoing TLE.

INTERVENTIONS

A USG-PVB was performed before surgery using a solution of 30 mL of 0.5% ropivacaine by 3 injections of 10 mL each at the right T5 and bilateral T8 (PVB group, n=26) or the saline injection of 10 mL at every site (control group, n=26).

MEASUREMENTS AND MAIN RESULTS

Successful PVBs were achieved in all patients of the PVB group. Intraoperative mean remifentanil usage and end-tidal sevoflurane concentration were lower in the PVB group (p<0.001). Hemodynamic parameters were stable in both groups. Postoperative pain scores both at rest and on coughing were lower during the first 8 hours in the PVB group than those in the control group (p<0.05). Cumulative sufentanil consumption delivered by patient-controlled analgesia (PCA) was significantly lower in the PVB group at all time points (p<0.05). Postoperative pulmonary function was better at the third postoperative day in the PVB group (p<0.05), with quicker hospital discharge and lower hospital costs (p<0.05).

CONCLUSIONS

The single-dose and bilateral PVB given before TLE combined with sufentanil may provide better postoperative analgesia and early discharge in patients undergoing TLE.

Continuous paravertebral infusion of ropivacaine with or without fentanyl for pain relief in unilateral multiple fractured ribs

Background:

Continuous thoracic paravertebral block (TPVB) provides effective analgesia for unilateral multiple fractured ribs (MFR). However, prolonged infusion of local anaesthetic (LA) in high doses can predispose to risk of LA toxicity, which may be reduced by using safer drugs or drug combinations. This study was conducted to assess efficacy and safety of paravertebral infusion of ropivacaine and adrenaline with or without fentanyl to provide analgesia to patients with unilateral MFR.

Methods:

Thirty adults, having ≥3 unilateral MFR, with no significant trauma outside chest wall, were studied. All received bolus of 0.5% ropivacaine 0.3 ml/kg through paravertebral catheter, followed by either 0.1-0.2 ml/kg/hr infusion of ropivacaine 0.375% with adrenaline 5 μg/ml in group RA or ropivacaine 0.2% with adrenaline 5 μg/ml and fentanyl 2 μg/ml in group RAF. Rescue analgesia was provided by IV morphine.

Results:

Statistical analysis was performed using unpaired Student t-test, Chi-square test and repeated measures ANOVA. After TPVB, VAS scores, respiratory rate and PEFR improved in both groups with no significant inter-group differences. Duration of ropivacaine infusion, morphine requirements, length of ICU and hospital stay, incidence of pulmonary complications and opioid-related side-effects were similar in both groups. Ropivacaine requirement was higher in group RA than group RAF. No patient showed signs of LA toxicity.

Conclusion:

Continuous paravertebral infusion of ropivacaine 0.375% with adrenaline 5 μg/ml at 0.1-0.2 ml/kg/hr provided effective and safe analgesia to patients with unilateral MFR. Addition of fentanyl 2 μg/ml allowed reduction of ropivacaine concentration to 0.2% without decreasing efficacy or increasing opioid-related side-effects.

Postoperative pain relief using intermittent intrapleural analgesia following thoracoscopic anterior correction for progressive adolescent idiopathic scoliosis

Background

Thoracoscopic anterior scoliosis instrumentation is a safe and viable surgical option for corrective fusion of progressive adolescent idiopathic scoliosis (AIS) and has been performed at our centre on 205 patients since 2000. However, there is a paucity of literature reporting on or examining optimum methods of analgesia following this type of surgery. A retrospective study was designed to present the authors’ technique for delivering intermittent local anaesthetic boluses via an intrapleural catheter following thoracoscopic scoliosis surgery; report the pain levels that may be expected and any adverse effects associated with the use of intrapleural analgesia, as part of a combined postoperative analgesia regime.

Methods

Records for 32 patients who underwent thoracoscopic anterior correction for AIS were reviewed. All patients received an intrapleural catheter inserted during surgery, in addition to patient-controlled opiate analgesia and oral analgesia. After surgery, patients received a bolus of 0.25% bupivacaine every four hours via the intrapleural catheter. Patient’s perceptions of their pain control was measured using the visual analogue pain scale scores which were recorded before and after local anaesthetic administration and the quantity and time of day that any other analgesia was taken, were also recorded.

Results

28 female and four male patients (mean age 14.5 ± 1.5 years) had a total of 230 boluses of local anaesthetic administered in the 96 hour period following surgery. Pain scores significantly decreased following the administration of a bolus (p < 0.0001), with the mean pain score decreasing from 3.66 to 1.83. The quantity of opiates via patient-controlled analgesia after surgery decreased steadily between successive 24 hours intervals after an initial increase in the second 24 hour period when patients were mobilised. One intrapleural catheter required early removal due to leakage; there were no other associated complications with the intermittent intrapleural analgesia method.

Conclusions

Local anaesthetic administration via an intrapleural catheter is a safe and effective method of analgesia following thoracoscopic anterior scoliosis correction. Post-operative pain following anterior thoracic scoliosis surgery can be reduced to ‘mild’ levels by combined analgesia regimes.

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.

Comparison between intrathecal morphine with paravertebral patient controlled analgesia using bupivacaine for intraoperative and post-thoracotomy pain relief

Objectives:

This study was designed to compare the intrathecal morphine and paravertebral block with bupivacaine given before induction of anesthesia for intra-operative and post-thoracotomy pain relief for 48 hours using patient controlled paravertebral analgesia in post-operative period.

Methods:

After taken an approval from the ethics committee of the University, 40 patients were randomly assigned to receive either preservative-free intrathecal morphine 0.3 mg in 3 ml normal saline together with paravertebral block (group I) or paravertebral block alone using bupivacaine (group II) before an induction of anesthesia. No continuous infusion of bupivacaine was started in both groups. Primary outcomes were Visual Analogue Score (VAS) at rest and on coughing. Hemodynamic and respiratory effects, bupivacaine consumption, patient's satisfaction, and side effects like nausea, vomiting, urinary retention, and itching were considered as secondary outcomes. All patients in both groups received paracetamol 1 gram (gm) IV every 6 hourly for the 1^st 24 hr. Amount of rescue analgesic (pethidine 0.5 mg/kg IV) in both groups and total bupivacaine cumulative doses in 48 hrs were calculated.

Results:

VAS at rest and on coughing did not differ significantly between the 2 groups at 0, 1, 6, 12, 18, 24, and 48 hours (P= >0.1). At 24 hours, VAS increased in both the groups, but the increase in VAS was comparable in both groups. There were insignificant incidences of nausea, purities, and urinary retention in intrathecal group compared with paravertebral group. The other side effects and patient satisfaction did not show any statistical significant difference between 2 groups.

Conclusion:

Intrathecal morphine 0.3 mg is safe and effective way to improves pain control for thoracic surgery and was comparable to paravertebral patient control analgesia (PPCA) with bupivacaine for the 1^st 48 hours post-thoracotomy.

Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery

BACKGROUND

Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy.

METHODS

Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 μg/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 μg/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 μg/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique.

RESULTS

The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 μg, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group.

CONCLUSIONS

Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).

[Continuous paravertebral block as an analgesic method in thoracotomy]

INTRODUCTION

Open thoracotomy is one of the surgical procedures that is still very painful in the postoperative period, which, in this type of surgery can have on respiratory function and subsequent recovery of the patient.

PATIENTS AND METHOD

The aim of the study is to assess continuous paravertebral thoracic block as an analgesic technique in thoracotomy. A total of 139 patients undergoing pulmonary resection surgery by posterolateral thoracotomy received postoperative analgesia using a 1.5% lidocaine infusion (7-10 ml/h) through a thoracic paravertebral catheter for at least 48 h. Pain intensity measured on the visual analogue scale (VAS) both at rest (passive VAS) and during stimulated cough (active VAS) was recorded at time of discharge from the Recovery Unit, and on the second, third and fourth day post-surgery. Postoperative complications and the need for analgesic rescue were studied.

RESULTS

On discharge from recovery, 98.6% of the patients had mild pain (passive VAS <3), 1.4% had moderate pain (passive VAS 4-6) and none with severe pain (EVA >6); on the 2nd day post-surgery, 97.9% had mild pain, and 1.2% moderate pain; on the third day 98.6% had mild pain and 0.7% moderate pain; and on the 4th day 100% had mild pain. There were no complications arising from the analgesic technique.

CONCLUSIONS

Continuous thoracic paravertebral analgesia is effective and safe in controlling post-thoracotomy pain.

Intraoperative strategy in patients with extended involvement of mediastinal structures

The mediastinum is a virtual space containing several vital organs and structures. Biopsy and resection of lesions located within this region often require several considerations that bear on intraoperative strategy. To optimize outcome, clinicians must be able to predict which patients are at highest risk of anesthetic complications. Superior vena cava involvement, extensive compression of the airway, and pericardial effusion have a clear impact on the decision-making of the anesthetist and surgeon, who should plan together when forming the surgical strategy.

Thoracic paravertebral block (PVB) analgesia

Paravertebral blockade is a safe and effective technique for intraoperative and postoperative management of acute surgical pain. The block may be performed as a single injection or a catheter may be inserted to allow for the continuous or bolus administration of a long acting local anaesthetic. This mode of analgesia is not considered to be a stand alone technique (in contrast to epidural analgesia) and most patients will require additional analgesia (usually parenteral patient controlled analgesia). Compared to epidural analgesia, the paravertebral administration of analgesia is considered to be safer in anti-coagulated patients, but the risk of local anaesthetic toxicity remains. There is little published about the care of patients receiving this form of analgesia. This article provides an overview of the technique of thoracic paravertebral analgesia, the choice of analgesics and side effects together with recommendations for patient care.