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Ramjit S, Davey MG, Loo C, Moran B, Ryan EJ, Arumugasamy M, Robb WB, Donlon NE. Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials. Dis Esophagus 2024; 37:doad074. [PMID: 38221857 DOI: 10.1093/dote/doad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 01/16/2024]
Abstract
Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.
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Affiliation(s)
- Sinead Ramjit
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitlyn Loo
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brendan Moran
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eanna J Ryan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - William B Robb
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel E Donlon
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:59-66. [PMID: 37429620 PMCID: PMC10850837 DOI: 10.1136/rapm-2023-104666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND/IMPORTANCE Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. OBJECTIVE We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). EVIDENCE REVIEW We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. CONCLUSIONS Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.
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Affiliation(s)
- Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Boretsky
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Childrens Hospital, Boston, Massachusetts, USA
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Terauchi M, Okutani H, Ishimoto D, Shimode N, Takao Y, Hirose M. Imaging evaluation of continuous extrapleural intercostal nerve block for minimally invasive cardiac surgery: a case report. JA Clin Rep 2021; 7:48. [PMID: 34109465 PMCID: PMC8190210 DOI: 10.1186/s40981-021-00450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/15/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Spinal nerve block is difficult with minimally invasive cardiac surgery (MICS), because of the risk of serious bleeding complications due to full heparinization. Continuous extrapleural intercostal nerve block (CEINB) is a postoperative pain treatment for intercostal thoracotomy, with fewer complications. Here, we report a case in which imaging evaluation of CEINB with contrast medium was conducted to anatomically confirm the spread of local anesthetics after MICS. Case presentation A 65-year-old woman with severe mitral regurgitation underwent mitral valve plasty under general anesthesia via right-sided mini-thoracotomy. A CEINB catheter was placed before the incision was closed, without creating a conventional extrapleural pocket. We conducted an imaging evaluation with a contrast medium via the inserted catheter and confirmed sufficient spread around the intercostal nerve area. In addition, postoperative pain was well controlled by the nerve block. Conclusions Imaging evaluation of CEINB with contrast medium could increase analgesic quality and decrease complications post-MICS.
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Affiliation(s)
- Misa Terauchi
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan
| | - Hiroai Okutani
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan.
| | - Daisuke Ishimoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan
| | - Noriko Shimode
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan
| | - Yumiko Takao
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 6638501, Japan
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Deebis A, Elattar H, Saber O, Elfakharany K, Elnahal N. Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-00027-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Vilvanathan S, Kuppuswamy B, Sahajanandan R. A randomized control trial to compare thoracic epidural with intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy. Ann Card Anaesth 2020; 23:127-133. [PMID: 32275024 PMCID: PMC7336962 DOI: 10.4103/aca.aca_167_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective The objective of the study is to compare the efficacy of Thoracic epidural with Intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy. Methodology and Design This study is designed as a prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India. Participants Patients undergoing elective thoracic surgery through posterolateral thoracotomy. Intervention In Group A (TEA) patients epidural catheter was inserted at T5-6 level before induction of GA and analgesia was activated using 0.25% of bupivacaine towards the end of the surgery, before chest closure and infusion of 0.1% bupivacaine with 2 mcg/ml of fentanyl was started. In Group B (ICN) patients, an intercostal blockade of the 5 intercostal spaces was performed by the surgeon just before chest closure using 0.25% bupivacaine and a continuous intravenous morphine infusion of 0.015-0.02 mg/kg/hr was started. Measurements Assessment of resting and dynamic pain intensity using Numerical rating scale and sedation using Ramsay sedation scale was done and recorded at 1, 6,12,18,24 hours during the first postoperative day. The other parameters that were measured include side effects and the requirement of rescue analgesia. Results: Resting and Dynamic (NRS) pain scores were less in Group A (TEA) than Group B (ICN). In the first 12 hours, the differences in both the resting (P = 0.0505) and dynamic (P = 0.0307) pain scores were statistically significant. By the end of the first postoperative day, sedation scores were more or less similar in both groups. The incidence of side effects and requirement of rescue analgesia were found to be similar in both the groups. Conclusion To summarize, though the results show a slightly better quality of analgesia with the thoracic epidural, the difference being clinically insignificant intercostal blockade could be considered as a valid alternative.
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Affiliation(s)
- Santhosh Vilvanathan
- Department of Cardiothoracic Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences, Trivandrum, Kerala, India
| | - Balaji Kuppuswamy
- Department of Anaesthesiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Raj Sahajanandan
- Department of Anaesthesiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
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van den Berg JW, Tabrett K, Cheong E. Paravertebral catheter analgesia for minimally invasive Ivor Lewis oesophagectomy. J Thorac Dis 2019; 11:S786-S793. [PMID: 31080659 DOI: 10.21037/jtd.2019.03.47] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO). Methods Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, high-dependency unit (HDU) stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed. Results One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve (ICN) block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively. Conclusions Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
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Affiliation(s)
- Jan Willem van den Berg
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Kate Tabrett
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Edward Cheong
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
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Bhatnagar S, Mishra S, Madhurima S, Gurjar M, Mondal AS. Clonidine as an Analgesic Adjuvant to Continuous Paravertebral Bupivacaine for Post-thoracotomy Pain. Anaesth Intensive Care 2019; 34:586-91. [PMID: 17061632 DOI: 10.1177/0310057x0603400507] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We prospectively evaluated the effect of Clonidine as an adjuvant to bupivacaine for continuous paravertebral intercostal nerve block, measuring pain and sedation scores and pulmonary function tests. Thirty patients scheduled to undergo thoracotomy were randomized to receive either a bolus of 0.125% bupivacaine 2 mg/kg (group BUP) or 0.125% bupivacaine 2 mg/kg with Clonidine 2 μg/kg (group BUP+CLO), followed by an infusion of 0.125% bupivacaine at 0.5 mg/kg/h, or 0.125% bupivacaine at 0.5 mg/kg/h with Clonidine at 2 μg/kg/h, in respective groups, through a paravertebral intercostal catheter. Haemodynamic parameters, pain and sedation scores and pulmonary function tests were recorded at 6, 12, 24 and 48 hours after arrival in postoperative care unit. There were significantly lower pain scores at rest and on coughing in group BUP+CLO compared with group BUP (P<0.01). Multiple comparisons revealed a significant reduction in pain score at each time point (P<0.01), except at 12h to 24h, in group BUP+CLO. Sedation scores were significantly higher in group BUP+CLO compared with group BUP at each time point (all P<0.01). There was a linear effect of time on sedation score in group BUP whereas in group BUP+CLO, the effect was quadratic. Patients in the Clonidine group had a higher incidence of hypotension (P<0.01). There was no significant difference in pulmonary function between the groups. We conclude that using Clonidine as an adjunct to bupivacaine for continuous paravertebral intercostal nerve block improves pain relief after thoracotomy, but hypotension and sedation are adverse effects interfering with its clinical application.
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Affiliation(s)
- S Bhatnagar
- Department of Anaesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
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Comparison of the analgesic effects of modified continuous intercostal block and paravertebral block under surgeon’s direct vision after video-assisted thoracic surgery: a randomized clinical trial. Gen Thorac Cardiovasc Surg 2018; 66:425-431. [DOI: 10.1007/s11748-018-0936-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/05/2018] [Indexed: 10/17/2022]
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D’Ercole F, Arora H, Kumar PA. Paravertebral Block for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 32:915-927. [DOI: 10.1053/j.jvca.2017.10.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 01/23/2023]
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11
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Affiliation(s)
- Taichiro Goto
- Department of General Thoracic Surgery, Yamanashi Central Hospital, Yamanashi, Japan
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12
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Yokoyama Y, Nakagomi T, Shikata D, Goto T. Combined analgesic treatment of epidural and paravertebral block after thoracic surgery. J Thorac Dis 2017; 9:1651-1657. [PMID: 28740682 DOI: 10.21037/jtd.2017.05.27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In pulmonary surgical practice, appropriate pain management after thoracotomy is essential for patient recovery and the prevention of complications. Although epidural analgesia (EPI) has been established for chest surgery, it has some limitations and contraindications. Recently, paravertebral block (PVB) was reported as a good alternative method with fewer side effects. Despite the significant effects of these two treatments, postoperative pain remains among the greatest patient burdens. In our institution, we apply a combination of epidural and PVBs after thoracic surgery to reduce pain more effectively. The purpose of this study was to demonstrate the safety and feasibility of our method. This study included patients who underwent thoracic surgery and analgesic treatment in our institution between November 2014 and December 2016. Per our method of PVB induction, the parietal pleura was peeled off with a metal suction tube and an extrapleural pocket was created. An epidural catheter was inserted into this pocket and used to inject local anesthetics continuously after surgery. The catheters for analgesia were removed on the 4th postoperative day. In total, 368 patients received the combined epidural and PVBs. No severe complication was observed. The rate of rescue medication use in this study was lower than that in the historical control before adoption of this combination method; the incidence of pneumonia and length of hospital stay after surgery were not significantly different in this study from those in the historical control. In conclusion, our study demonstrated the safety and feasibility of the combination method of EPI and PVB. Acute pain after thoracic surgery may be adequately controlled using double analgesic regimens, including EPI and PVBs, suggesting an alternative to conventional modalities of EPI alone or PVB alone.
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Affiliation(s)
- Yujiro Yokoyama
- Department of General Thoracic Surgery, Yamanashi Central Hospital, Yamanashi, Japan
| | - Takahiro Nakagomi
- Department of General Thoracic Surgery, Yamanashi Central Hospital, Yamanashi, Japan
| | - Daichi Shikata
- Department of General Thoracic Surgery, Yamanashi Central Hospital, Yamanashi, Japan
| | - Taichiro Goto
- Department of General Thoracic Surgery, Yamanashi Central Hospital, Yamanashi, Japan
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Khalil KG, Boutrous ML, Irani AD, Miller CC, Pawelek TR, Estrera AL, Safi HJ. Operative Intercostal Nerve Blocks With Long-Acting Bupivacaine Liposome for Pain Control After Thoracotomy. Ann Thorac Surg 2015; 100:2013-8. [DOI: 10.1016/j.athoracsur.2015.08.017] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 08/07/2015] [Accepted: 08/14/2015] [Indexed: 11/16/2022]
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Komatsu T, Sowa T, Kino A, Fujinaga T. The importance of pleural integrity for effective and safe thoracic paravertebral block: a retrospective comparative study on postoperative pain control by paravertebral block. Interact Cardiovasc Thorac Surg 2014; 20:296-9. [PMID: 25422276 DOI: 10.1093/icvts/ivu395] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Teruya Komatsu
- Department of General Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Terumasa Sowa
- Department of General Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Atsunari Kino
- Department of Anesthesiology, Nagara Medical Center, Gifu, Japan
| | - Takuji Fujinaga
- Department of General Thoracic Surgery, Nagara Medical Center, Gifu, Japan
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15
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A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis. PLoS One 2014; 9:e96233. [PMID: 24797238 PMCID: PMC4010440 DOI: 10.1371/journal.pone.0096233] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 04/06/2014] [Indexed: 11/19/2022] Open
Abstract
Objective The most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epidural blockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue. Summary of Background Thoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy. Methods Two reviewers independently searched the databases PubMed, EMBASE, and the Cochrane Library (last performed on 1 February, 2013) for reports of studies comparing post-thoracotomy epidural analgesia and paravertebral blockade. The same individuals independently extracted data from the appropriate studies. Result Eighteen trials involving 777 patients were included in the current analysis. There was no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4–8, 24, 48 hours, and the rates of pulmonary complications and morphine usage during the first 24 hours were also similar. However, paravertebral blockade was better than epidural analgesia in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p = 0.01), hypotension (p<0.00001), and rates of failed block were lower in the paravertebral blockade group (p = 0.01). Conclusions This meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.
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Vogt A. Paravertebral block – A new standard for perioperative analgesia. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Comparison between systemic analgesia, continuous wound catheter analgesia and continuous thoracic paravertebral block: a randomised, controlled trial of postthoracotomy pain management. Eur J Anaesthesiol 2013; 29:524-30. [PMID: 22914044 DOI: 10.1097/eja.0b013e328357e5a1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Komatsu T, Sowa T, Takahashi K, Fujinaga T. Paravertebral block as a promising analgesic modality for managing post-thoracotomy pain. Ann Thorac Cardiovasc Surg 2013; 20:113-6. [PMID: 23445804 DOI: 10.5761/atcs.oa.12.01999] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Analgesia following thoracotomy is routinely accomplished using epidural blockage performed by anesthesiologists. More effective pain control can be achieved with continuous paravertebral blockage performed by thoracic surgeons. We aimed to retrospectively analyze the efficacy of paravertebral blockage for managing post-thoracotomy pain. METHODS The study included 125 patients who underwent continuous paravertebral blockage for the following types of thoracic surgery: video-assisted thoracoscopic surgery(n = 87), anterior axillary thoracotomy (n = 21), posterolateral thoracotomy (n = 16), and median sternotomy with additional left thoracotomy (n = 1). We retrospectively evaluated the analgesic effects of continuous paravertebral blockage by assessing whether a good cough effort could be performed and whether an additional painkiller was given as a rescue medication. RESULTS About 115 patients could perform a good cough effort to expectorate sputum immediately after extubation in the operating room. Six patients tolerated postoperative pain well without any oral or rectal non-steroidal anti-inflammatory drugs (NSAIDs). For97 patients postoperative NSAIDs could control thoracotomy pain well. Twenty-two patients were given an additional painkiller stronger than NSAIDs. Three patients complained of nausea postoperatively. CONCLUSION Adequate post-thoracotomy pain control was accomplished by continuous paravertebral blockage, with few complications.
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Affiliation(s)
- Teruya Komatsu
- Department of General Thoracic Surgery, Nagara Medical Center, Gifu, Japan
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Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain. Eur J Anaesthesiol 2012; 29:186-91. [DOI: 10.1097/eja.0b013e32834fcef7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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D'Souza D, Sondergaard K, Detterbeck FC. Transient brachial plexus palsy: an unusual complication of paravertebral infusion of local anesthetic. Ann Thorac Surg 2010; 90:e75-6. [PMID: 20971226 DOI: 10.1016/j.athoracsur.2010.07.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 06/21/2010] [Accepted: 07/19/2010] [Indexed: 11/16/2022]
Abstract
A continuous infusion of 0.25% bupivaciane into the parevertebral space was used for postoperative pain relief after a lung resection. On postoperative day 1, a brachial plexus palsy developed, which resolved on discontinuation of the infusion. We believe this rare complication has not been reported previously. Awareness of this possibility may avoid unnecessary investigations.
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Affiliation(s)
- Desmond D'Souza
- Department of General Surgery, Hospital of Saint Raphael, New Haven, Connecticut, USA
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Invited Commentary. Ann Thorac Surg 2010; 89:386. [DOI: 10.1016/j.athoracsur.2009.11.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 11/27/2009] [Accepted: 11/30/2009] [Indexed: 11/22/2022]
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Norum HM, Breivik H. A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy. Scand J Pain 2010; 1:12-23. [DOI: 10.1016/j.sjpain.2009.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.
Methods
A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.
Results
Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.
Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (<T7). TEA was superior to PVB in 1/10, during first 1.5 days. PVB and TEA were equally effective in 8/10. 5/10 trials found PVB had less hypotension or urinary retention. None of the studies used appropriate and optimal TEA: TEA was started after end of surgery in half, catheters placed too low (2/10), too high (1/10), not reported in (1/10). 7/10 infused local anaesthetic only, 2/10 added fentanyl, 1/10 added morphine, and none added adrenaline. PVB infusions had higher concentration of bupivacaine (5 mg/ml) in 2/10, 1/10 added fentanyl, 1/10 added ornipressin. Loading doses were higher in 5/10, and with more concentrated solutions in 5/10 of PVB than in the TEA group.
Conclusions
10 heterogeneous, mostly small, studies comparing TEA and PVB for post-thoracotomy analgesia do not allow conclusions on which method has superior analgesic efficacy and safety. The main methodological problem was that none of the studies use optimal thoracic epidural analgesia, with siting of catheters inappropriate in some and the epidural infusion containing too concentrated local anaesthetic because opioid and adrenaline were not added. Anatomical considerations (the paravertebral space comprises parts of the epidural space and contains spinal cord arteries) and personally experienced complications with PVB (paraplegia) convince us that PVB must have higher risk of, infrequent but serious, spinal cord complications than TEA. Percutaneous PVB may puncture pleura and lung.
Some surgeons expressed satisfaction with PVB because the method omits costly acute pain services for monitoring on surgical wards and saves time in the operating room. They are, however, bound to experience serious complications from PVB, sooner or later.
To our knowledge, optimally conducted epidural analgesia has not been compared with PVB. Current literature and our experience with both techniques for up to four decades, indicate that PVB may be an alternative for post-thoracotomy pain when TEA is infeasible for various patient-related reasons (Breivik et al., 2009). Severely disturbed haemostasis is a contraindication for PVB and TEA. Higher concentrations of local anaesthetics are needed to obtain intercostal nerve blocks and epidural analgesia with PVB, risking local anaesthetic intoxication. Robust monitoring regimen for effects and adverse effects is as important for PVB as for TEA.
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Affiliation(s)
- Hilde M. Norum
- Division of Anaesthesia and Intensive Care Medicine , Medical Faculty , Rikshospitalet, 0027 Oslo , Norway
| | - Harald Breivik
- Division of Anaesthesia and Intensive Care Medicine , Medical Faculty , Rikshospitalet, 0027 Oslo , Norway
- University of Oslo , Medical Faculty , Oslo , Norway
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Sullivan EA. The Role of the Anesthesiologist in Thoracic Surgery: We Can Make A Difference! J Cardiothorac Vasc Anesth 2009; 23:761-5. [DOI: 10.1053/j.jvca.2009.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Indexed: 11/11/2022]
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Update on the role of paravertebral blocks for thoracic surgery: are they worth it? Curr Opin Anaesthesiol 2009; 22:38-43. [PMID: 19237975 DOI: 10.1097/aco.0b013e32831a4074] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To consider optimal analgesic strategies for thoracic surgical patients. RECENT FINDINGS Recent studies have consistently suggested analgesic equivalence between paravertebral and thoracic epidural analgesia. Complications appear to be significantly less common with paravertebral analgesia. SUMMARY There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.
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Ouerghi S, Frikha N, Mestiri T, Smati B, Mebazaa MS, Kilani T, Ben Ammar MS. A prospective, randomised comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2008. [DOI: 10.1080/22201173.2008.10872572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Maurer K, Blumenthal S, Rentsch KM, Schmid ER. Continuous extrapleural infusion of ropivacaine 0.2% after cardiovascular surgery via the lateral thoracotomy approach. J Cardiothorac Vasc Anesth 2007; 22:249-54. [PMID: 18375328 DOI: 10.1053/j.jvca.2007.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The pharmacokinetics of ropivacaine 0.2% were evaluated during a 48-hour continuous extrapleural infusion with 2 different infusion rates in patients undergoing cardiovascular surgery. The hypotheses that no toxic plasma concentrations of ropivacaine would be reached and that proportionality exists among plasma concentrations and dosage used were tested. DESIGN A prospective, randomized, nonblinded study. SETTING The investigation was performed as a single-center study in the Division of Cardiovascular Anesthesia, University Hospital of Zurich, in Switzerland. PARTICIPANTS Seventeen consenting adults scheduled for elective cardiovascular surgery, with or without extracorporeal bypass, via the lateral thoracotomy approach were enrolled. INTERVENTIONS For postoperative pain relief, patients were randomly assigned to receive continuous extrapleural infusion of ropivacaine 0.2% at a rate of either 6 or 9 mL/h over 48 hours. MEASUREMENTS AND MAIN RESULTS Plasma concentrations of ropivacaine reached toxic levels (>2.2 mg/L) in 25% of cases. No proportionality of plasma concentrations of ropivacaine existed when the 2 dosing regimens were compared. CONCLUSIONS Plasma concentrations of ropivacaine, administered at the given dose and rates during continuous extrapleural infusion, are unpredictable and may reach toxic levels in patients undergoing major cardiothoracic surgery.
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Affiliation(s)
- Konrad Maurer
- Division of Cardiovascular Anesthesia, University Hospital of Zurich, Zurich, Switzerland
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Jin HC, Choi SG, Kim SH, Choi WS, Lee JS, Kim YI. The Comparison of the Concentration of Bupivacaine for Continuous Paravertebral Block Used for Pain Control after Thoracotomy. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.2.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hee Cheol Jin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Sang Gu Choi
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Sang Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Won Seok Choi
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Jeong Seok Lee
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Yong Ik Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
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Myles PS, Bain C. Underutilization of Paravertebral Block in Thoracic Surgery. J Cardiothorac Vasc Anesth 2006; 20:635-8. [PMID: 17023278 DOI: 10.1053/j.jvca.2006.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Indexed: 11/11/2022]
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Detterbeck FC. Subpleural Catheter Placement for Pain Relief After Thoracoscopic Resection. Ann Thorac Surg 2006; 81:1522-3. [PMID: 16564317 DOI: 10.1016/j.athoracsur.2005.01.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Revised: 01/18/2005] [Accepted: 01/20/2005] [Indexed: 11/24/2022]
Abstract
Infusion of local anesthetics into an extrapleural pocket results in excellent postoperative pain relief through a multilevel intercostal nerve blockade. This report describes a simple, rapid technique of subpleural catheter placement that lends itself well to thoracoscopic procedures.
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Affiliation(s)
- Frank C Detterbeck
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina 27599-7065, USA.
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Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006; 96:418-26. [PMID: 16476698 DOI: 10.1093/bja/ael020] [Citation(s) in RCA: 427] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI. We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4-8, 24 or 48 h, WMD 0.37 (95% CI: -0.5, 121), 0.05 (-0.6, 0.7), -0.04 (-0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery.
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Affiliation(s)
- R G Davies
- Department of Anaesthesia and Pain Management, Alfred Hospital Commercial Road, Melbourne, Victoria 3004, Australia
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Patel AN, Finlay KU, Schyra KC, Jones CC, Black RE, Dullye LJ, Jennings LW, Hein HAT, Urschel HC, Ramsay MAE. Use of general anesthetic only vs general anesthetic combined with paravertebral block for perioperative pain management after first rib resection. Proc (Bayl Univ Med Cent) 2006; 15:374-5. [PMID: 16333467 PMCID: PMC1276640 DOI: 10.1080/08998280.2002.11927868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amit N Patel
- Department of Surgery, Baylor University Medical Center, Dallas, Texas 75246, USA
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Detterbeck FC. Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy. Ann Thorac Surg 2005; 80:1550-9. [PMID: 16181921 DOI: 10.1016/j.athoracsur.2004.11.051] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Revised: 11/22/2004] [Accepted: 11/24/2004] [Indexed: 10/25/2022]
Abstract
Intercostal nerve blockade for postthoracotomy pain relief can be accomplished by continuous infusion of local anesthetics through a catheter in the subpleural space or through an interpleural catheter, by cryoanalgesia, and by a direct intercostal nerve block. A systematic review of randomized studies indicates that an extrapleural infusion is at least as effective as an epidural and significantly better than narcotics alone. The other techniques of intercostal blockade do not offer an advantage over narcotics alone.
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Affiliation(s)
- Frank C Detterbeck
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina 27599-7065, USA.
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Plasma Concentrations and Analgesic Effects of Ropivacaine 3.75 mg/mL During Long-Term Extrapleural Analgesia After Thoracotomy. Reg Anesth Pain Med 2005. [DOI: 10.1097/00115550-200507000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Luketich JD, Land SR, Sullivan EA, Alvelo-Rivera M, Ward J, Buenaventura PO, Landreneau RJ, Hart LA, Fernando HC. Thoracic Epidural Versus Intercostal Nerve Catheter Plus Patient-Controlled Analgesia: A Randomized Study. Ann Thorac Surg 2005; 79:1845-9; discussion 1849-50. [PMID: 15919269 DOI: 10.1016/j.athoracsur.2004.10.055] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Revised: 10/26/2004] [Accepted: 10/28/2004] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pain control is an important issue after thoracotomy. Ideal methods should have a high success rate, with easy implementation and minimal complications. Debate exists over the optimal pain control method. This randomized trial was designed to compare epidural (EPI) and intercostal nerve catheter with patient-controlled analgesia (ICN-PCA) for pain control after thoracotomy. METHODS The study included 124 randomized patients; 91 had sufficient data for analysis (44 EPI, 47 ICN-PCA). The primary endpoint was pain measurement using a composite of a visual analogue scale, numerical rating, and categorical rating. A second endpoint was the success rate of each method. Pulmonary function tests, antibiotics, intensive care unit (ICU), and hospital days, and use of nonprotocol pain medications were also compared. RESULTS There were 12 pain observations per patient (90% completed on days 1 to 5). The pain composite revealed an average postoperative pain score of 2.4 on a scale from 0 (no pain) to 10 (worst pain). There was no difference between the groups. Failures of the planned method of analgesia included 9 in the EPI group and 4 in the ICN group (p = 0.23). Another 20 patients were excluded (no difference between groups) due to unsuspected mediastinal metastases precluding thoracotomy (n = 13), and other miscellaneous factors precluding follow-up (n = 7). The EPI group had an increased number of urinary catheter days (2.5 days vs 1.7, p = 0.002) and increased narcotic supplements (p = 0.03) compared with ICN. Mean ICU days (0.9) and hospital days (6.2) were similar for both groups, and there were no differences in arrhythmias, pneumonias, transfusions, and antibiotic use. Significant differences were seen (p = 0.001) between preoperative and postoperative pulmonary function tests in both groups. However, there were no differences in pulmonary function when the groups were compared with each other. CONCLUSIONS Satisfactory pain control was achieved after thoracotomy using either EPI or ICN-PCA. The ICN-PCA achieved equivalent pain control compared with EPI, and was placed by the surgeon with no delays in surgery, and demonstrated a decreased requirement for Foley catheter duration.
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Affiliation(s)
- James D Luketich
- Division of Thoracic and Foregut Surgery, Cancer Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Affiliation(s)
- Sugantha Ganapathy
- Department of Anesthesiology and Perioperative Medicine, St. Joseph's Health Care, London, Ontario
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Bilgin M, Akcali Y, Oguzkaya F. Extrapleural regional versus systemic analgesia for relieving postthoracotomy pain: a clinical study of bupivacaine compared with metamizol. J Thorac Cardiovasc Surg 2003; 126:1580-3. [PMID: 14666036 DOI: 10.1016/s0022-5223(03)00701-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The effects of a local anesthetic delivered through a catheter inserted in the extrapleural region by a surgeon and an analgesic agent given systemically on pain after thoracotomy were assessed. METHODS The patients in group I (n = 25) had a catheter inserted between the parietal pleura and the endothoracic fascia by a surgeon, and 0.5% bupivacaine was given through this catheter. Another 25 patients (group II) had metamizol given intravenously. Respiratory function tests, arterial blood gases, range of shoulder motion, and postoperative pain were evaluated for each group. Bupivacaine and metamizol were given just before finishing the thoracotomy and then repeated every 4 hours for 3 days. RESULTS There was no statistical difference in arterial blood gases between the groups (P >.05). There were statistically significant differences in the respiratory function tests, range of shoulder motion, and visual analogue scale (P <.05) between the groups. Group I had fewer complications than group II. There was no mortality in either group. CONCLUSIONS Bupivacaine given through a catheter to the extrapleural region before finishing thoracotomy is substantially beneficial for the prevention of postoperative pain and reduction of postoperative complications.
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Affiliation(s)
- Mehmet Bilgin
- Department of Thoracic Surgery, Erciyes University Medical Facility, Kayseri, Turkey.
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Intercostal nerve blockade versus thoracic epidural analgesia for post thoracotomy pain relief. Indian J Thorac Cardiovasc Surg 2003. [DOI: 10.1007/s12055-003-0003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.
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Affiliation(s)
- Roy G Soto
- Department of Anesthesiology, University of South Florida College of Medicine, Tampa, Florida 33612, USA.
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Takamori S, Yoshida S, Hayashi A, Matsuo T, Mitsuoka M, Shirouzu K. Intraoperative intercostal nerve blockade for postthoracotomy pain. Ann Thorac Surg 2002; 74:338-41. [PMID: 12173810 DOI: 10.1016/s0003-4975(02)03710-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Epidural analgesia is widely employed as a means to control postthoracotomy pain, but is sometimes inadequate. The purpose of this study is to evaluate the effectiveness of intraoperative, temporary, intercostal nerve blockade in addition to epidural analgesia for control of postthoracotomy pain. METHODS Forty patients undergoing elective lobectomy through antero-axillary thoracotomy were randomized to receive epidural analgesia only (group A, n = 20) or epidural analgesia plus temporary, intraoperative intercostal nerve blockade using 0.25% bupivacaine (group B, n = 20). Postoperative pain was assessed using a subjective analogue visual scale, and with the Prince Henry pain scale. Food intake and nonsteroidal analgesic consumption were also investigated. Serum ACTH and cortisol in each group were measured before and after the operation. RESULTS The analogue visual scale scores were significantly higher in group A than group B (p < 0.001), and were significantly higher on the day of operation and postoperative days 1, 2, and 3 (p < 0.001, p < 0.005, p < 0.005, p < 0.05, respectively). Prince Henry pain scale scores were significantly higher on the day of operation and postoperative day 1 (p < 0.05, p < 0.005, respectively). Food intake was significantly lower in group A than in group B (p < 0.05), and nonsteroidal analgesic consumption was not significantly different between groups. There was no significant difference between group A and group B in serum ACTH or in cortisol levels. CONCLUSIONS Additional intraoperative intercostal nerve blockade provides an additive benefit for postthoracotomy pain relief, especially early after operation.
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Affiliation(s)
- Shinzo Takamori
- Department of Surgery, Kurume University School of Medicine, Japan.
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Hazelrigg SR, Cetindag IB, Fullerton J. Acute and chronic pain syndromes after thoracic surgery. Surg Clin North Am 2002; 82:849-65. [PMID: 12472133 DOI: 10.1016/s0039-6109(02)00031-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pain is one of the most important considerations in the care of thoracic surgical patients. Failure in pain management is associated with increased mortality and morbidity. Acute pain management aspires to stop the painful stimuli before it is transferred to the CNS. The authors recommend (1) a thorough explanation of the operation and the expected outcome to the patient, (2) preoperative pulmonary rehabilitation for those with marginal lung function, (3) choosing the least painful surgical approach with acceptable exposure, (4) minimizing tissue trauma during surgery, (5) preemptive analgesia, and (6) early ambulation as prophylactic measures that should be employed during hospitalization. Good acute pain control should reduce the incidence of chronic pain. Mediansternotomy and VATS seem to be less acutely painful approaches than thoracotomy for most thoracic surgery. One should rule out recurrent malignancy as the etiology for chronic or recurrent pain. Opioids and NSAIDs are sufficient to produce optimal pain control in patients who undergo VATS and sternotomv. TEA is typically reserved for patients who have a thoracotomy. Opioid PCA can be used instead of-or after the discontinuation of-the epidural catheter. Chronic pain can be treated in many ways, and input from a pain clinic might be beneficial. The single best approach to chronic pain is to prevent it. This can be achieved by selecting the right incisional approach, instituting early physical therapy, and achieving optimal postoperative pain control.
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Affiliation(s)
- Stephen R Hazelrigg
- Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, 800 North Rutledge, Room D314, P.O. Box 19638, Springfield, IL 62794-9638, USA.
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Greengrass R, Buckenmaier CC. Paravertebral anaesthesia/analgesia for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2002; 16:271-83. [PMID: 12491557 DOI: 10.1053/bean.2002.0238] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
For many years, paravertebral nerve blockade has been an established technique for providing analgesia to the chest and abdomen. The current emphasis on containment of health care costs has resulted in a rediscovery of anaesthetic techniques, such as paravertebral blocks, that facilitate outpatient surgical management and promote early discharge. Paravertebral nerve blocks (PVB) produce excellent surgical conditions for many procedures of the chest and abdomen while providing profound long-lasting analgesia with few undesirable side-effects that aids in the compassionate early discharge of the patient from the ambulatory setting. This chapter reviews the pertinent anatomy and techniques involved in the successful placement of PVB. Continuous paravertebral catheters, pharmacological agents used in PVB, and single versus multiple injection paravertebral block techniques are also covered. Specific clinical situations that are particularly well suited to the application of PVB as the primary anaesthetic in the ambulatory setting and other clinical situations where analgesia from PVB is efficacious are discussed.
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Affiliation(s)
- Roy Greengrass
- Department of Anesthesia, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Yin W. A posterior parasagittal approach to thoracic paravertebral neural structures with curved cannulae. ACTA ACUST UNITED AC 2001. [DOI: 10.1053/trap.2001.25286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Nociception is a complicated process, and only in recent years have the neural pathways and mediators of pain transmission been unraveled. Several regional anesthetic interventions, most notably epidural drug delivery, can interrupt nociception and provide safe and effective pain control in critically ill patients while substantially reducing the need for systemic medications. This article discusses the possibilities for regional control of the neurobiology of nociception and describes the arsenal of regional anesthetic techniques available to the intensivist. Used wisely, regional techniques can provide excellent pain control and may have a significant role in improving overall patient outcome. Regional analgesia offers the best opportunity to provide substantial analgesia without significant central opioid effects. Well-conducted regional analgesia can reduce many of the unpleasant or potentially problematic side effects observed when traditional intravenous medications are used exclusively for pain control.
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Affiliation(s)
- F Clark
- Department of Anesthesiology, Northwestern University, Evanston Northwestern Healthcare, Evanston, Illinois, USA.
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