Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial

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

BACKGROUND/IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSION

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

Comparing Continuous and Intermittent Infusion Effects on Serratus Anterior Plane Blocks in Video-Assisted Thoracoscopic Surgery: A Randomized Clinical Trial

Objective

The programmed intermittent bolus infusion (PIBI) of local anesthetic produces wider sensory blockade and better analgesia than continuous infusion (CI). We designed this trial to compare the effects of these two different infusion methods combined with Serratus Anterior Plane Blocks (cSAPBs) on postoperative pain relief in patients undergoing video-assisted thoracoscopic surgery.

Methods

We randomly allocated 66 patients under going elective video-assisted thoracoscopic unilateral lung resection surgery to two groups (PIBI group and CI group, n=33 per group). After the surgical operation, the patients received ultrasound-guided ipsilateral SAPB, we randomized them to receive either automated intermittent boluses or continuous infusion of 0.3% ropivacaine. Tramadol consumption during the 48 hours following surgery was the primary outcome. Secondary outcomes included cumulative tramadol consumption during the first 24-h and the second 24-h periods after surgery, pain scores, patient satisfaction, blocked dermatomes, and adverse events.

Results

During 48h, tramadol consumption in the PIBI group was significantly lower than in the CI group (190 mg [125, 305] vs 220 mg [170, 480], p= 0.034). As compared to the CI group, the PIBI group consumed less tramadol during the first 24 hours (145 mg [87.5, 210] vs 190 mg [140, 400], p=0.012). The dermatomes anesthetized to the pinprick and cold test were significantly more abundant in the PIBI group than in the CI group (3 [3,4] vs. 5 [4,5], p<0.001). Both groups had similar VAS scores at rest and when moving (p>0.05). Additionally, the PIBI group showed greater patient satisfaction. Both groups experienced similar adverse events (p>0.05).

Conclusion

Compared with CI, PIBI administration regimen (0.3% ropivacaine 5 mL/h) for cSAPBs resulted in lower tramadol consumption, superior analgesia during the initial 12 h after the operation, and higher patient satisfaction. PIBI combined with cSAPBs was a better choice for postoperative analgesia in patients undergoing video-assisted thoracoscopic surgery.

Comparison of Edge of Lamina Block with Thoracic Paravertebral Block and Retrolaminar Block for Analgesic Efficacy in Adult Patients Undergoing Video-Assisted Thoracic Surgery: A Prospective Randomized Study

Background

A novel ultrasound-guided paravertebral block, the edge laminar block (ELB) was reported recently. However, it was unclear how effective ELB was in comparison with traditional blocking methods. We conducted a trial to compare the analgesic efficacy of ELB with the thoracic paravertebral block (TPVB) and the retrolaminar block (RLB) in patients undergoing video-assisted thoracic surgery (VATS).

Methods

We identified 90 patients who were scheduled for VATS and randomly assigned them to three groups: ELB group (Group E), TPVB group (Group T), and RLB group (Group R). Each group underwent ELB, TPVB, and RLB, respectively, under ultrasound guidance before general anesthesia induction. All patients received post-operative routine analgesia protocol. Our primary outcome was the extent of dermatomal sensory loss on the midclavicular, midaxillary, and scapular lines, measured using a pinprick 15 minutes after the nerve block. Secondary outcomes included the intraoperative dose of sufentanil, the numerical rating scale (NRS) scores assessed in the post-anesthesia care unit (PACU) and at 6, 12, and 24 hours post-operatively, and pethidine administrated as analgesic rescue dose.

Results

The percentages of nerve block range reaching the midclavicular line, midaxillary line, and scapular line in Group E were 96.7%, 93.3%, 93.3%, and 60% in Group T and 30%, 56.7%, and 96.7% in Group R, respectively. Group E had wider dermatomal sensory loss on the midclavicular line and midaxillary line compared to Group R (P < 0.001) and had a wider range compared to Group T on the scapular line (P < 0.001). There was no significant difference in the intraoperative use of sufentanil in the three groups. Post-operative NRS scores at each time point were significantly lower in Group E than those in the other two groups (P < 0.01).

Conclusion

ELB had a wider nerve block range and applied better post-operative analgesia in comparison with TPVB and RLB.

Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study

Background and Aims

Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery.

Material and Methods

This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block.

Results

The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable.

Conclusion

Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.

The effect of peripheral regional analgesia in thoracic surgery: a systematic review and a meta-analysis of randomized-controlled trials

BACKGROUND

Several peripheral regional anaesthesia (RA) techniques are commonly used in thoracic surgery even in the absence of precise indications regarding their effectiveness on postoperative pain management.

OBJECTIVE

This systematic review and meta-analysis aims to describe and evaluate the relative effectiveness of different peripheral regional blocks and systemic analgesia in the context of video-assisted thoracoscopic surgery (VATS) or thoracotomy.

DESIGN

Systematic review of randomized controlled clinical trials (RCTs) with meta-analyses.

DATA SOURCES

We searched PubMed and Embase for all RCTs comparing the 24 hour morphine equivalents (MMEs) consumption following peripheral regional blocks and systemic analgesia (SA).

ELIGIBILITY CRITERIA

We selected only RCTs including adult participants undergoing thoracic surgery, including esophagectomy and reporting on postoperative pain outcomes including 24 hour MMEs consumption.

RESULTS

Among the 28 randomized studies including adult participants undergoing thoracic surgery and reporting on 24 hour opioid consumption, 11 reporting a comparison of individual blocks with systemic analgesia were meta-analyzed. RA was effective for almost all peripheral blocks. Regarding intercostal block, its antalgic effect was not well evaluated SMD -1.57 (CI -3.88, 0.73). RA in VATS was more effective in reducing MMEs than thoracotomy SMD -1.10 (CI -1.78, -0.41).

CONCLUSIONS

RA is a useful choice in thoracic surgery. However, it is still not possible to determine the most appropriate block in the individual surgical settings to be performed due to RCTs paucity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is It Useful and Necessary to Add a T2 Paravertebral Block to the Regional Anesthesia During Proximal Humeral Fracture Surgery in Elderly Patients? A Prospective and Randomized Controlled Trial

Objective

This study was designed to investigate whether it is useful and necessary to add a T2 level thoracic paravertebral block (TPVB) based on brachial-cervical plexus block to avoid incomplete anesthesia in elderly patients undergoing deltopectoral approach proximal humeral fracture (PHF) surgery.

Materials and Methods

This study involved 80 patients scheduled for PHF surgery who were randomized to receive either IC block (combined interscalene brachial plexus with superficial cervical plexus block) or ICTP block (T2 TPVB supplemented with IC block). The primary outcome was the success rate of regional anesthesia. The patient who experienced incomplete block was administered with intravenous remifentanil for rescue, or conversion to general anesthesia (GA) if remifentanil was still ineffective. Secondary outcomes included requirements of rescue anesthesia, sensory block of the surgical region, the incidence of adverse reactions, and block procedure-related complications.

Results

The success rate of regional anesthesia in the ICTP group was higher compared with the IC group (77.5 vs. 52.5%, p = 0.019). Intravenous remifentanil was required in 32.5% of patients in the IC group and 17.5% in the ICTP group, respectively. Conversion to GA was performed in 15% of patients in the IC group and 5% in the ICTP group. Sensory block at the medial proximal upper arm was achieved in 85% of patients in the ICTP group, whereas 10% in the IC group (p &lt; 0.001). There was no difference between the groups with respect to the incidence of intraoperative adverse reactions. No block-related complications occurred in either group.

Conclusion

Adding a T2 TPVB is helpful to decrease, but not absolutely avoid the occurrence of incomplete regional anesthesia during PHF surgery in elderly patients. However, considering the potential risks, it is not an ideal option while a minor dose of remifentanil can provide a satisfactory rescue effect.

Clinical Trial Registration

ClinicalTrials.gov, identifier: NCT03919422.

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations

Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

Comparison of single-injection ultrasound-guided thoracic paravertebral block with transversus abdominis plane block in peritoneal dialysis catheter implantation: a randomized controlled trial

Background

Previous study indicated that transversus abdominis plane (TAP) block could be the principal anesthetic technique for peritoneal dialysis catheter (PDC) implantations. However, a TAP block could not provide an optimal anesthetic effect on catheter exit site during PDC implantation. We hypothesized that single-injection ultrasound-guided thoracic paravertebral block (US-TPVB) could be the principal anesthetic technique with better pain relief at catheter exit site during PDC implantation, compared to a TAP block. And anesthesia quality of a single-injection US-TPVB was compared with that of a TAP block and local anesthetic infiltration (LAI).

Methods

Patients undergoing PDC implantations were randomized into groups TPVB or TAP or LAI. In group TPVB, single-injection US-TPVB at T10-T11 level was performed with 20 ml of 0.25% ropivacaine. In group TAP, oblique subcostal TAP block was performed with 20 ml of 0.25% ropivacaine. In group LAI, 40 ml of 0.25% ropivacaine was used. Anesthesia quality was compared among the three groups, including general anesthesia conversion rate, cumulative rescuing sufentanil consumption, and satisfaction rate by nephrologists and patients.

Results

Eighty-eight eligible patients were enrolled. Visual analogue scale (VAS) at most time points (except for the catheter exit site) were lower in group TAP, compared with group TPVB. VAS at parietal peritoneum manipulation was 6 (5, 7), 3 (0, 6), and 7 (4.75, 9) in groups TPVB, TAP, and LAI, respectively (P < 0.001). VAS at catheter exit site was 4 (3, 4), 5.5 (4, 8), and 5 (3, 7.25) in groups TPVB, TAP, and LAI, respectively (P = 0.005). Lower general anesthesia conversion rate, less cumulative rescuing sufentanil consumption, and higher satisfaction rates by nephrologists and patients were recorded in group TAP, compared with groups TPVB and LAI.

Conclusions

Single-injection US-TPVB provided a better pain relief at catheter exit site. The quality and reliability of anesthesia after a single-injection US-TPVB was comparable to that of LAI, but not better than that of an oblique subcostal TAP block for PDC implantation.

Trial registration

TCTR20160911002. Registered on 8 September 2016.

Postoperative pain control with continuous paravertebral nerve block and intercostal nerve block after two-port video-assisted thoracic surgery

INTRODUCTION

Effective pain control after video-assisted thoracic surgery (VATS) is critical because of the correlation between postoperative pain and recovery after surgery. Due to the limitations of traditional analgesic modalities, in this study, we present a method of placing a paravertebral catheter (PVC) or an intercostal catheter (ICC) in the sub-pleural space, followed by continuous ropivacaine injection by an infusion pump after surgery.

AIM

To investigate the impact of continuous paravertebral nerve block and intercostal nerve block on postoperative pain control in patients who underwent two-port thoracic surgery.

MATERIAL AND METHODS

A total of 269 patients underwent various types of two-port VATS at Hwa Mei Hospital. Among them, we retrospectively compared paravertebral block versus intercostal nerve block to intravenous patient-controlled analgesia after VATS. Data regarding postoperative pain score on postoperative day 0, 1, 2, 3, and discharge day pain score, tramadol requirements, drainage duration, postoperative hospital stay, postoperative complications, and chronic pain 3 months after surgery were collected and analyzed.

RESULTS

Compared with the control group, patients who received a continuous nerve block, including the PVC group and ICC group, had a lower postoperative pain score (p < 0.001), shorter drainage duration (4.63 ±2.84 to 5.61 ±2.66 days, p = 0.004), reduced postoperative hospital stay (6.04 ±3.01 to 7.69 ±3.26 days, p < 0.001), and a reduced frequency of tramadol (0.95 ±1.27 1.79 ±2.13 times, p < 0.001). Additionally, there was no significant difference in chronic pain between groups.

CONCLUSIONS

In our study, PVC and ICC appeared to be safe and effective analgesic techniques to reduce postoperative pain, thus shortening the duration of postoperative hospital stay and improving the satisfaction of patients.

Effect of thoracic paravertebral nerve block on the early postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery

Objective

To evaluate the effect of thoracic paravertebral nerve block on early postoperative rehabilitation in patients undergoing radical thoracoscopic surgery for lung cancer.

Methods

Ninety patients scheduled for elective video-assisted thoracoscopic lobectomy of lung cancer were divided into 2 groups: the general anesthesia group (GA group, n = 45) and the TPVB group (TP group, n = 45). The primary outcome was the decline rate of the 6-min walking test (6MWT); the second outcomes were as follows: absolute value and the completion rate of 6MWT, postoperative analgesia deficiency and pain scores, oxycodone consumption, sleep quality, the incidence of postoperative pulmonary complications, and the hospital stay.

Results

Compared with the GA group, the TP group had a lower decline rate of the 6MWT on POD1 and POD2. The walking distance on POD1 and POD2 in the TP group was significantly longer than that in the GA group; the completion rate at POD1 in the TP group was higher than that in the GA group. The pain scores and oxycodone consumption at POD1 in the TP group were lower than the GA group. The sleep quality in the TP group was higher than the GA group.

Conclusions

TPVB can significantly improve postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery, which is helpful for promoting the early recovery of patients.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1900026213. Registered 26 Sept. 2019, http://www.chictr.org.cn/showproj.aspx?proj=43733.

A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study

INTRODUCTION

This study aimed to compare the challenge of puncture and catheterization and the effect of postoperative analgesia of ultrasound-guided continuous thoracic paravertebral block and the continuous epidural analgesia in patients receiving thoracoscopic surgery for lung cancer.

METHODS

One-hundred and fifty patients received elective unilateral thoracoscopic surgery for lung cancer and were randomized into three groups; test group 1 (T group), test group 2 (P group), and the control group (E group). Both of the test groups received ultrasound-guided continuous thoracic paravertebral block (TPVB) while the control group received continuous epidural analgesia. After the operation, all the patients in the test groups received the same postoperative analgesia; loading dose 0.5 mg kg^-1, background dose 0.25 mg kg^-1 h^-1, patient controlled analgesia (PCA) 0.25 mg kg^-1, and a locking time of 60 min, while the patients in the control group received a loading dose of 5 ml, a background dose of 5 ml h^-1, and a locking time of 20 min. The outcomes of this study were the success rate of the puncture and catheter placement, the blocked segments, numerical rating scale (NRS) scores at rest and during coughing, and the segments with reduced or lost cold and pinpricking sensation.

RESULTS

The success rates of the puncture and catheterization in group T were the highest. Compared with group P, the failure rate of the puncture in group E was lower (p < 0.05), but the success rate of catheterization was higher (p < 0.05). The puncture time in group T was the shortest; there was no difference between group E and group T. The time of catheterization in group P was the longest, this was followed by group T, and was the fastest in group E. The stable time of the block level in group E was shorter than that in groups P and T, but was similar between groups P and T. The block level of all three groups in the 4 h postoperative period was similar (p > 0.05), while the 4 h postoperative levels of groups P and T were reduced significantly (p < 0.05).

CONCLUSION

The continuous analgesia technique of paravertebral space catheterization cannot replace the continuous epidural analgesia in thoracoscopic lung cancer surgery as the latter technique is still considered to be the gold standard.

TRIAL REGISTRATION

China Clinical Trial Registration Center identifier ChiCTR1900020973.

Distribution of injectate administered through a catheter inserted by three different approaches to ultrasound-guided thoracic paravertebral block: a prospective observational study

Background

Despite the popularity of continuous thoracic paravertebral block (TPVB), there is a paucity of information on catheter tip position and distribution of injectate through the catheter. We observed, in real time, the spread of dye, the catheter tip position and sensory block levels produced with three different (intercostal (IC), transverse process sagittal (TS) and paralaminar (PL)) approaches to ultrasound-guided TPVB in patients undergoing video-assisted thoracoscopic surgery.

Methods

After the induction of general anesthesia, ultrasound-guided TPVB was conducted with a patient in the lateral decubitus position. During surgery, 10 mL of dye was injected through a catheter to observe the catheter tip and the dye distribution under thoracoscopy. Dermatomal sensory block levels were measured postoperatively.

Results

Ten patients for each of three different approaches completed the study. There were a variety of dye spreading patterns. The median (range) number of segmental levels stained with dye was 1.5 (1–4), 3 (1–4) and 3 (1–5) with the IC, TS and PL approaches, respectively. We observed that a catheter tip was present at the same segmental paravertebral space as intended in 50%–90% of patients using these approaches. The median (range) number of dermatomes with sensory blockade at 6 hours after block was 2.5 (1–4), 3 (2–8) and 3 (1–8) with the IC, TS and PL approaches, respectively.

Conclusions

Although a bolus injection through a catheter for ultrasound-guided TPVB produced multiple levels of spread and sensory blockade in more than half the patients, considerable differences existed in the spread regardless of approach.

Feasibility of laryngeal mask anesthesia combined with nerve block in adult patients undergoing internal fixation of rib fractures: a prospective observational study

BACKGROUND

The laryngeal mask airway (LMA) is occasionally used in internal fixation of rib fractures. We evaluated the feasibility of general anesthesia with an LMA associated to a thoracic paravertebral block (TPB) and/or an erector spinae plane block (ESPB) for internal fixation of rib fractures.

METHODS

Twenty patients undergoing unilateral rib fracture fixation surgery were enrolled. Each patient received general anesthesia with an LMA combined with TPB and/or ESPB, which provided a successful blocking effect. All patients received postoperative continuous analgesia (PCA) with 500 mg of tramadol and 16 mg of lornoxicam, and intravenous injection of 50 mg of flurbiprofen twice a day. Our primary outcomes including the partial pressure of arterial oxygen (PaO₂) and arterial carbon dioxide (PaCO₂) were measured preoperatively and on the first day after surgery. Secondary outcomes including the vital signs, ventilation parameters, postoperative numerical rating scale (NRS) pain scores, the incidence of postoperative nausea and vomiting (PONV), perioperative reflux and aspiration, and nerve block-related complications were also evaluated.

RESULTS

Thirteen men and seven women (age 35-70 years) were enrolled. Six (30%) had a flail chest, nine (45%) had hemothorax and/or pneumothorax, and two (10%) had pulmonary contusions. The postoperative PaO₂ was higher than the preoperative value (91.2 ± 16.0 vs. 83.7 ± 15.9 mmHg, p = 0.004). The preoperative and postoperative PaCO₂ were 42.1 ± 3.7 and 43.2 ± 3.7 mmHg (p = 0.165), respectively. Vital signs and spontaneous breathing were stable during the surgery. The end-tidal carbon dioxide concentrations (EtCO₂) remained within an acceptable range (≤ 63 mmHg in all cases). NRS at T1, T2, and T3 were 3(2,4), 1(1,3), and 0(0,1), respectively. None had PONV, regurgitation, aspiration, and nerve block-related complications.

CONCLUSIONS

The technique of laryngeal mask anesthesia combined with a nerve block was feasible for internal fixation of rib fractures.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR1900023763 . Registrated on June 11, 2019.

The effectiveness of additional thoracic paravertebral block in improving the anesthetic effects of regional anesthesia for proximal humeral fracture surgery in elderly patients: study protocol for a randomized controlled trial

BACKGROUND

The innervation of the shoulder-upper-extremity area is complicated and unclear. Regional anesthesia with a brachial plexus and cervical plexus block is probably inadequate for the proximal humeral surgery. Missing blockade of the T1-T2 nerves may be the reason. We conduct this prospective randomized controlled trial (RCT) to explore whether an additional T2 thoracic paravertebral block (TPVB) can improve the success rate of regional anesthesia for elderly patients in proximal humeral fracture surgery.

METHODS/DESIGN

The patients aged 65 years or older, referred for anterior-approach proximal humeral fracture surgery, will be enrolled. Each patient will be randomly assigned 1:1 to receive a combined interscalene brachial plexus with superficial cervical plexus block (IC) (combined interscalene brachial plexus with superficial cervical plexus block) or an IC block combined with thoracic paravertebral block (ICTP) block (combined thoracic paravertebral block with brachial plexus and superficial cervical plexus block). The primary outcome is the success rate of regional anesthesia without rescue analgesic methods. The secondary outcomes are as follows: sensory block at the surgical area, proportion of patients who need rescue anesthesia (intravenously administered remifentanil or conversion to general anesthesia), cumulative doses of intraoperative vasoactive medications and adverse events. The total sample size is estimated to be 80 patients.

DISCUSSION

This RCT aims to confirm whether an additional T2 TPVB can provide better anesthetic effects of regional anesthesia with brachial and cervical plexus block in elderly patients undergoing proximal humeral surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03919422. Registered on 19 April 2019.

Programmed intermittent bolus infusion versus continuous infusion of 0.2% levobupivacaine after ultrasound-guided thoracic paravertebral block for video-assisted thoracoscopic surgery: A randomised controlled trial

BACKGROUND

The analgesic benefits of programmed intermittent bolus infusion for thoracic paravertebral block remain unknown.

OBJECTIVE

The aim of this study was to compare the analgesia from intermittent bolus infusion with that of a continuous infusion after thoracic paravertebral block.

DESIGN

A randomised controlled study.

SETTING

A single centre between December 2016 and November 2017. Seventy patients scheduled for video-assisted thoracoscopic surgery were included in the study.

INTERVENTION(S)

Patients were randomly assigned to receive 0.2% levobupivacaine via continuous infusion (5 ml h, continuous group) or programmed intermittent bolus infusion (15 ml every 3 h, bolus group) after an initial 15-ml bolus injection of 0.2% levobupivacaine.

MAIN OUTCOME MEASURES

The main outcome was the amount of rescue fentanyl (per kg of body weight) consumed within 24 h after surgery. Secondary outcomes were postoperative pain scores, plasma levobupivacaine concentrations and the number of dermatomes anaesthetised.

RESULTS

There was no significant difference between the continuous and bolus groups in the postoperative consumption of fentanyl (median [interquartile range] 5.5 [4 to 9.5] μg kg versus 6 [3.5 to 9] μg kg respectively, P = 0.45) and postoperative pain scores within 24 h. At 20 h after initiating the infusions, there was no statistically significant difference between the two groups in terms of the plasma levobupivacaine concentration. The number of dermatomes anaesthetised to pinprick and cold testing was significantly greater in the bolus group.

CONCLUSION

Our findings suggest that postoperative pain and opioid usage are similar with either programmed intermittent bolus infusion or continuous infusion after thoracic paravertebral block. Programmed intermittent bolus infusion provides a wider sensory blockade and could benefit patients requiring a wider extent of anaesthesia.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN-CTR; URL: http://umin.ac.jp/ctr/, ID: UMIN000023378).

Effects of Catheter Tip Location on the Spread of Sensory Block Caused by a Continuous Thoracic Paravertebral Block: A Prospective, Randomized, Controlled, Double-Blind Study

Single injections in the anterior region of the thoracic paravertebral space (TPVS) have been reported to generate a multisegmental longitudinal spreading pattern more frequently than those in the posterior region of the TPVS. In this trial, we examined the hypothesis that a continuous thoracic paravertebral block (TPVB) administered through a catheter inserted into the anterior region of the TPVS allows a wider sensory block dispersion. Fifty consecutive patients undergoing video-assisted thoracic surgery were enrolled. Before the surgery, an infusion catheter was inserted into the TPVS through a needle placed adjacent to either the parietal pleura (group A) or internal intercostal membrane (group P) using an ultrasound-guided intercostal transverse approach according to a randomized allocation schedule. A chest radiograph was obtained postoperatively after injection of 10 mL of radiopaque dye through the catheter. Thereafter, 20 mL of 0.375% levobupivacaine was injected via the catheter, followed by commencement of continuous TPVB with 0.25% levobupivacaine at 8 mL/h. The primary outcome was the number of blocked dermatomes at 24 h after surgery. The secondary outcomes included radiopaque dye spreading patterns, the number of segments reached by the radiopaque dye, the number of blocked dermatomes at 2 h after surgery, and pain scores. The median (interquartile range [range]) number of blocked dermatomes 24 h after surgery was 3 (2.75–4 [1–6]) in group A (n = 22) and 2 (1.5–3 [0–7]) in group P (n = 25; p = 0.037). No significant differences in the other outcomes were found between the groups. In conclusion, a continuous TPVB administered using a catheter supposedly inserted into the anterior region of the TPVS allows a wider sensory block dispersion than a catheter inserted into the posterior region of the TPVS. This trial is registered with the UMIN Clinical Trials Registry (UMIN000018578).

Thoracic paravertebral block: comparison of different approaches and techniques. A study on 27 human cadavers

BACKGROUND AND OBJECTIVES

The success rate and spread of thoracic paravertebral block (TPVB) are variable and difficult to predict. It is now recommended that an ultrasound guidance technique should replace the traditional landmark technique. The objective was to compare anatomical outcomes of both techniques on cadavers.

METHODS

A landmark technique (loss of resistance technique [LOR]) and a USG technique (three approaches: sagittal, transversal in-plane, transverse out-of-plane) were performed on 27 thawed non-embalmed cadavers. Each of the four approaches was performed in each body (T3-T5 and T9-T11 × right and left). A coloured solution (13 mL, saline 0.9%) was injected in the targeted thoracic paravertebral space (TPVS). A successful thoracic paravertebral injection (TPVI) was defined by the presence of dye in at least one TPVS during anatomical dissection.

RESULTS

In 104 TPVIs analysed, the overall success rate was 78%. Factors associated with success were: USG versus LOR technique (85% vs. 52%, P < 0.0007), sagittal versus both transversal approaches (93%/81%/83%, P < 0.0007) and right side (86% vs. 66%). The median spread was 2 TPVS (min - max 1-5) with a median cephalad-caudal spread of 5 cm (min - max 1-18). By multivariate analysis, the sagittal approach was an independent factor of success (OR 2.75). Dye spread and pleural entry were influenced by neither the approach nor the site of injection.

CONCLUSIONS

Paravertebral spread of TPVI is variable. USG technique has higher anatomical success rates than the LOR technique, the sagittal USG approach being the most successful.