Thoracic paravertebral block for postoperative pain management after renal surgery: A randomised controlled trial

Analgesic effect of the ultrasound-guided thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy: a randomized controlled trial

BACKGROUND

Paravertebral block has similar effect as epidural anesthesia, and has good somatic and visceral analgesic effect. Paravertebral block is widely used in thoracic surgery, but rarely used in abdominal surgery.

AIMS

This study aimed to evaluate the analgesic effect of thoracolumbar paravertebral block in patients undergoing robot-assisted laparoscopic nephrectomy.

METHODS

One hundred patients undergoing elective robot-assisted laparoscopic nephrectomy were included in this study. Based on whether the thoracolumbar paravertebral block was performed, the patients were randomly divided into the thoracolumbar paravertebral block combined with general anesthesia group (TL-PVB group) and simple general anesthesia group (NO-PVB group). Oxycodone was administered for patient-controlled intravenous analgesia (PCIA). The primary outcomes included the amount of remifentanil used during surgery, the amount of oxycodone used in 24 and 48 h after surgery. Secondary outcomes included the changes of heart rate (HR) and mean arterial pressure (MAP), time for the first analgesia administration, visual analog score (VAS) of pain during rest and movement, and time of postoperative recovery.

RESULTS

Compared to the NO-PVB group, the amount of remifentanil used during surgery in patients with TL-PVB group was significantly reduced (1.78 ± 0.37 mg vs. 3.09 ± 0.48 mg, p < 0.001), the amount of oxycodone used 24 h after surgery was significantly reduced (8.70 ± 1.70 mg vs. 13.79 ± 2.74 mg, p < 0.001), and the amount of oxycodone used 48 h after surgery was remarkably reduced (21.83 ± 4.28 mg vs. 27.27 ± 4.76 mg, p < 0.001). There were significant differences in the changes of HR and MAP between the two groups (p < 0.001). The first analgesic requirement time of TL-PVB group was significantly longer than that of NO-PVB group (468.56 ± 169.60 min vs. 113.48 ± 37.26 min, p < 0.001). The postoperative VAS during rest and movement of TL-PVB group were significantly lower than that of NO-PVB group (p < 0.01). Compared with NO-PVB group, patients in TL-PVB group needed shorter time to awaken from anesthesia, leave the operating room, anal exhaust, get out of bed, and had shorter length of postoperative hospital stay (p < 0.001). The incidence of postoperative adverse reactions were lower in the TL-PVB group than that in the NO-PVB group (p < 0.05).

CONCLUSIONS

Ultrasound-guided thoracolumbar paravertebral block significantly reduces intraoperative and postoperative opioid consumption, and provides better analgesia in patients undergoing robot-assisted laparoscopic nephrectomy, which is a recommendable combined anesthesia technique.

TRIAL REGISTRATION

ChiCTR2200061326, 21/06/2022.

Comparison of the effects of subcostal anterior quadratus lumborum block and thoracic paravertebral block in laparoscopic nephrectomy: a randomized study

BACKGROUND

Thoracic paravertebral block (TPVB) may provide sufficient postoperative analgesia in laparoscopic nephrectomy (LSN) by ensuring ipsilateral somatic and visceral analgesia. However, there are serious reservations due to the complexity of the technique, and various complications thereof. Subcostal anterior quadratus lumborum block (S-QLB3) may be a safe alternative in LSN procedures. Therefore, this study aimed to compare the postoperative analgesic effects of TPVB and S-QLB3.

METHODS

This prospective, randomized, double-blind study included 60 patients aged 18-70 years who were planned to undergo LSN. The patients were randomly assigned to receive either unilateral ultrasound-guided S-QLB3 or TPVB. The primary outcome was postoperative cumulative 24-h morphine consumption. In addition, numeric rating scale (NRS) scores at rest/activity and the American Pain Society Patient Outcome Questionnaire (APS-POQ-R-TR) scores were also evaluated.

RESULTS

While postoperative cumulative 24-h morphine consumption was lower in the TPVB group compared to the other group (mean±SD, 12±3.4 mg vs. 15.4±7.8 mg, P=0.03), NRS pain scores at rest/activity were similar in both groups at all measurement points. Considering the postoperative APS-POQ-R-TR data, only the score related to the pain-daily activity relationship was high in the S-QLB3 group (median [Q1-Q3], 0 [0-1] vs. 2 [0-5], P=0.004), whereas there was no difference between the other scores.

CONCLUSIONS

In this study, NRS and APS-POQ-R-TR scores were similar in the S-QLB3 and TPVB groups, whereas cumulative morphine consumption was modestly lower in the TPVB group. This suggested that S-QLB3 could be an alternative to TPVB in patients undergoing LSN.

Applications of the ultrasound-guided nerve block technique for nonanalgesic effects

The nerve block technique guided by ultrasound has been able to accurately block tiny nerves throughout the body in recent years. It has been increasingly used to treat multisystem diseases or analgesia in surgical patients, but the latter accounted for the vast majority of cases. The nonanalgesic effect of nerve blocks is also in wide demand. After searching ultrasound-guided nerve block works on the PubMed database, we systematically summarized the current clinical application of the nerve block technique and the unique role and related mechanism of nerve block in the prevention and treatment of multi-system diseases or symptoms, including disorders of the circulatory and respiratory systems, postoperative cognitive dysfunction, immune function, posttraumatic stress disorder, and postoperative digestive system, to put forward the potential prospective application in future and serve as a reference for future research of nerve block therapy in these diseases mentioned.

The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials

Background

Paravertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery.

Methods

PubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software.

Results

A total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I² = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I² = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I² = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups.

Conclusion

This study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.

Effect of Preoperative Thoracic Paravertebral Blocks on Emergence Agitation During Tracheal Extubation: A Randomized Controlled Trial

Objective

This study aims to compare the effects of preoperative thoracic paravertebral blocks (TPVB) with intercoastal nerve blocks (ICNB) on emergence agitation (EA) during tracheal extubation in patients who underwent thoracoscopic lobectomy.

Design, Setting, and Participants

A randomized clinical trial was conducted in patients undergoing thoracoscopic lobectomy at Beijing Chest Hospital between June 2019 and December 2020.

Interventions

Patients were randomly assigned 1:1 to receive either ultrasound-guided preoperative TPVB or ICNB.

Main Outcomes and Measures

The primary outcome was the occurrence of emergency agitation, which was evaluated by Aono’s four-point scale (AFPS). Secondary outcomes included hemodynamics [mean arterial pressure (MAP) and heart rate (HR)]; and post-operative pain intensity [visual analog scale (VAS), Ramsay sedation score (RSS), and patient-controlled analgesia (PCA) demand times].

Results

Among the 100 patients aged 55–75 years old, 50 were randomized to each group; 97 patients completed the trial. Compared to the ICNB group, the occurrence of EA in the TPVB group was significantly lower [31.3% (15/48) vs. 12.2% (6/49), relative risk = 1.276, 95% CI: 1.02–1.60, P = 0.028]. For patients in the TPVB group, the MAP and HR at 5, 10, and 30 min after extubation were significantly lower; the intraoperative details including emergence time, extubation time, and consumption of sufentanil were significantly shorter than that in the ICNB group. Additionally, patients in the TPVB group showed significantly lower VAS at rest or coughing and significantly lower RSS at 60 and 240 min after extubation than patients in the ICNB group (all P < 0.05).

Conclusion

Preoperative TPVB was associated with less EA during tracheal extubation when compared with ICNB in patients undergoing thoracoscopic lobectomy.

Clinical Trial Registration

[http://www.chictr.org.cn/index.aspx], identifier [ChiCTR1900023852].

Preoperative Ultrasound-Guided Trigeminal Nerve Block in Orthognathic Surgery: A Prospective Study About Its Efficacy of Intraoperative Anesthetic Dosage and Postoperative Analgesia

PURPOSE

Ultrasound-guided trigeminal nerve block is rarely used in orthognathic surgery, and its impact of postoperative analgesia and the auxiliary effect on hypotensive anesthesia have not been fully reported. The purpose of this study is to measure the efficacy of ultrasound-guided trigeminal nerve block on intraoperative anesthetic dosage and postoperative analgesia.

PATIENTS AND METHODS

In this single-blind, prospective, controlled trial, all patients were randomly assigned to 2 groups (n = 21/group): GEA group (general anesthesia) and TNB group (ultrasound-guided trigeminal nerve block [UGTNB] with general anesthesia). The primary variable was postoperative pain (visual analog scale scores, VAS scores) at postoperative 2, 4, 6, 12, and 24 hours. Satisfaction with postoperative pain management during postoperative 24 hours; the number of patients with moderate-to-severe pain (VAS score: >3) at postoperative 2, 4, 6, 12, 24 hours; and the consumption of opioids and nicardipine intraoperatively, etc. were secondary variables. Data were analyzed using the unpaired t, χ2, and Wilcoxon nonparametric tests.

RESULTS

In this study, 40 patients at the Peking University School and Hospital of Stomatology between January 2019 to March 2019 were included with a mean age of 24.13 ± 5.07 for statistical analysis and 37.5% were male. Compared to GEA group, the TNB group had a significantly lower VAS scores at postoperative 6 hours and 12 hours, which were 2[0,2] and 0[0,2], respectively. Furthermore, patients in TNB group were more satisfied with pain management at postoperative 24 hours than patients in GEA group (5[4,5] vs 4[3,5]; P = .03). Statistically less amount of opioids and nicardipine in TNB group were used intraoperatively (P < .01).

CONCLUSION

UGTNB use in orthognathic surgery may improve analgesia in the 24 hours after the operation, additionally, facilitate hypotensive anesthesia with fewer agents and fewer adverse effects postoperatively.

Ultrasound-guided erector spinae plane block versus thoracic paravertebral block on postoperative analgesia after laparoscopic nephroureterectomy: study protocol of a randomized, double-blinded, non-inferiority design trial

Introduction

Erector spinae plane block (ESPB) is a novel inter-fascial plane block, which is applied more and more in postoperative pain control, especially in chest surgery. Regional block is advocated in order to decrease opioid consumption and improve analgesia in urological surgery. Therefore, we aimed to explore whether ESPB would have similar analgesia compared with thoracic paravertebral block (TPVB) in laparoscopic nephroureterectomy.

Methods and analysis

This prospective, randomized, double-blinded, non-inferiority trial will enroll 166 patients undergoing laparoscopic nephroureterectomy. Participants will be randomly assigned 1:1 into receiving ESPB or TPVB before surgery. Both ultrasound-guided ESPB and TPVB will be performed with an injection of 0.375% ropivacaine 0.4 ml/kg before anesthesia induction. Standardized patients controlled intravenous analgesia (PCIA) will be applied for each patient. The primary endpoint is the joint of cumulative 24 h opioid (sufentanil) consumption and average pain score via numeric rating scale (NRS) at 24 h after surgery. Secondary endpoints include rescued analgesic demand, cumulative opioid consumption, and pain NRS scores at different preset timepoints within 48 h after surgery. Other predefined outcomes include clinical features of blockage, quality of recovery, subjective sleep quality, time to ambulation and diet, and adverse events, as well as length of stay in hospital and anesthesia cost.

Discussion

Previous studies investigating the analgesic efficacy of ESPB only concentrated on a single endpoint for postoperative pain evaluation, while studies focusing on the direct comparison between ESPB and TPVB in urological surgery are still lacking. Our study is the first trial in non-inferiority design of comparing ESPB and TPVB in patient undergoing laparoscopic nephroureterectomy, and the primary outcome is the joint endpoint of opioid consumption and pain NRS score.

Trial registration

Chinese Clinical Trial Registry ChiCTR 2000031916. Registered on 14 April 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05173-0.

Postoperative analgesia and opioid use following hip arthroscopy with ultrasound-guided quadratus lumborum block: a randomized controlled double-blind trial

Objective

To investigate the postoperative analgesic effect of ultrasound-guided quadratus lumborum block (QLB) in patients undergoing arthroscopic hip surgery.

Methods

Patients who were scheduled to undergo elective arthroscopic hip surgery were randomly assigned to the QLB (Q) or control (C) group (n = 40 each). After general anesthesia induction, unilateral QLB was performed under ultrasound guidance in the Q group. The amount of opioid use via patient-controlled analgesia (PCA) and the resting and movement pain visual analog scale (VAS) scores when the patient left the postanesthesia care unit (PACU) and 4, 8, 12, and 24 hours after surgery were recorded. Postoperative complications were recorded for both groups.

Results

At 24 hours post-surgery, opioid consumption amounts via PCA (48.4 [48.1–48.6] mL) in the Q group were significantly lower compared with the C group (52.0 [51.0–53.8] mL). A significant reduction in opioid consumption was observed between the two groups at each time point. Resting and movement VAS scores at each time point were significantly lower in the Q compared with the C group.

Conclusions

Hip arthroscopy patients who received QLB and general anesthesia in combination had less pain and a lower opioid requirement within 24 hours postoperatively.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

Impact of thoracic paravertebral block combined with general anesthesia on postoperative cognitive function and serum adiponectin levels in elderly patients undergoing lobectomy

Introduction

Thoracic paravertebral block (TPVB) can improve postoperative analgesia, inhibiting perioperative stress and the inflammatory response. However, whether it can improve early postoperative cognitive dysfunction (POCD) by altering the secretion and expression of serum ADP remains unclear.

Aim

To investigate the impact of thoracic paravertebral block combined with general anesthesia (TPVB-GA) on postoperative cognitive function and serum adiponectin (ADP) levels in elderly patients undergoing lobectomy.

Material and methods

A total of 120 elderly patients undergoing elective lobectomy were randomly divided into three groups: general anesthesia (GA); TPVB-GA (PG); epidural block combined with general anesthesia (EG). Cognitive function in the three groups was evaluated 1 day before and 7 days after surgery. The serum levels of ADP and S-100β protein were evaluated before anesthesia (T0), 15 min after skin incision (T3), and 7 days after surgery (T5).

Results

Cognitive function scores in the three groups decreased by different extents at T5 (p < 0.05); scores in groups PG and EG were higher than those in group GA (p < 0.05). The serum levels of S-100β protein in the three groups at T3 were higher than those at T0 (p < 0.05); however, serum ADP concentrations were reduced (p < 0.05); the serum levels of S-100β protein in groups PG and EG were lower than those in group GA at T3, while serum ADP levels were higher.

Conclusions

Thoracic paravertebral block or epidural block combined with general anesthesia can improve early postoperative cognitive function in elderly patients undergoing lobectomy. TPVB-GA demonstrated better effects, which may be related to the secretion of ADP.

Efficacy of ultrasound-guided erector spinae plane block on postoperative quality of recovery and analgesia after modified radical mastectomy: randomized controlled trial

BACKGROUND

Erector spinae plane block (ESPB) is a novel regional anesthesia technique that is gaining popularity for postoperative pain management. This randomized controlled trial evaluated the effect of ESPB on quality of recovery (QoR) in patients undergoing modified radical mastectomy.

METHODS

Eighty-two female patients undergoing modified radical mastectomy were included. Patients were randomly assigned to receive preoperative ultrasound-guided ESPB with either 0.5% ropivacaine or saline. The primary outcome was QoR, assessed 24 hours postoperatively using the 15-item QoR questionnaire (QoR-15). Secondary outcomes included postoperative pain scores, postoperative cumulative opioid consumption, postanesthesia care unit (PACU) discharge time, postoperative nausea or vomiting and dizziness.

RESULTS

Global QoR-15 scores 24 hours postoperatively were significantly higher (indicating better quality) in the ESPB group (median 120, IQR 118-124) compared with the control group (median 110, IQR 108.3-112.8), with a median difference of 10 (95% CI 9 to 12, p<0.001). Compared with the control group, ESPB with ropivacaine reduced pain scores up to 8 hours after surgery, as well as reduced postoperative cumulative opioid consumption and PACU discharge time.

CONCLUSIONS

A single preoperative injection of ESPB with ropivacaine may improve QoR postoperatively and acute postoperative analgesia in patients undergoing a modified radical mastectomy.

TRIAL REGISTRATION NUMBER

ChiCTR-1800019599.

Assessment of an ultrasound-guided technique for catheterization of the caudal thoracic paravertebral space in dog cadavers

Background

The caudal thoracic paravertebral (CTPV) block is a regional anesthesia technique currently used in human medicine to provide analgesia in abdominal surgical procedures.

Aim

The objectives of this study are to describe an ultrasound-guided technique to place catheters in CTPV space in canine cadavers and evaluate the distribution of a 50:50 contrast-dye solution administered through them.

Methods

Eight thawed adult beagle cadavers (9.2 ± 2.0 kg body total weight) were used. Thirteen catheters were placed. In the first phase, a volume of 0.3 ml kg^-1 of the contrast-dye was administered in all cases. After the injections, computed tomography (CT) scans were carried out to assess the distribution of the contrast-dye. In the second phase, an extra 0.2 ml kg^-1 of the contrast-dye was administered through eight catheters, followed by a second CT scan. Two cadavers were dissected to assess the distribution of the contrast-dye. The injection site varied between T8-9 and T12-13.

Results

The evaluation of the CT scans showed contrast-dye within the paravertebral space in 92% (12/13) of the injections. The distribution pattern observed after the injections performed within the TPV space was linear and intercostal in all cases. The median (range) linear spread of the contrast was 7 (5-10) spinal nerves and involved 3 (2-8) intercostal spaces. The contrast-dye reached lumbar regions in 42% of the injections (5/12). A larger spread of the contrast-dye was not observed after the administration of a second dose of the injectate. No signs of epidural, intrapleural/intrapulmonary, intravascular, or intraabdominal spread were observed. The dissection of the two cadavers confirmed the spread of the contrast-dye along the sympathetic trunk and intercostal spaces.

Conclusion

The administration of 0.3 ml kg^-1 of the contrast-dye in the CTPV space resulted in a distribution compatible with the block of nerves responsible for the innervation of the majority of the abdominal viscera and cranial abdominal wall.

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.