Continuous Paravertebral Block Research Articles

Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis

Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.

Utility of Continuous Paravertebral Block After Retroperitoneal Abdominal Aortic Aneurysm Repair

Open abdominal aortic aneurysm (AAA) repairs can be associated with significant pain and morbidity. Previous studies have demonstrated utility of adjunctive epidural analgesia (EA) in addition to general anesthesia (GA) to reduce pain and blunt the maladaptive surgical stress response. However, EA may be complicated by epidural hematomas and severe hypotension. Recently, we started using continuous paravertebral block (PVB) for perioperative analgesia after retroperitoneal AAA repair. PVB has some distinct advantages over EA such as unilateral localization, reduced risk of hypotension, and minimal risk of epidural hematoma in the setting of systemic heparinization. This study aimed to examine the utility of PVB by comparing total opioid consumption in the postoperative period among patients who received GA+PVB and those who received GA alone. This retrospective matched cohort study included 62 patients who underwent elective retroperitoneal AAA repair between January 2019 and August 2022. Thirty-one subjects managed with GA+PVB were compared with 31 control subjects treated with GA alone, matched on following criteria: age, sex, and cross-clamp location. Outcome measures included total opioid analgesics administered during their inhospital postoperative course, time to extubation, time to return to baseline activity, time to normal bowel function, and length of stay. Opioid doses were converted to morphine milligram equivalents (MMEs). The GA+PVB group required significantly less opioid analgesics (81±53 MME) than the GA group (171±121 MME) (P<0.001). Compared to GA alone, GA+PVB was superior in every clinical metric examined: time to extubation (3 vs. 1hr, P<0.001), recovery of bowel function (3 vs. 2days, P=0.002), recovery of baseline physical activity (4 vs. 2days, P=0.019), and length of stay (5 vs. 3days, P<0.001). Continuous paravertebral block provides better pain management with significantly decreased opioid requirements in the postoperative period compared to GA-alone for patients undergoing elective retroperitoneal AAA repair.

This Month in Anesthesiology

This Month in Anesthesiology

0.125% 8ml/h v.s. 0.25% 8ml/h of levobupivacaine in continuous paravertebral block for postoperative analgesia in video-assisted thoracoscopic surgery: a randomized, controlled, double-blind study.

Research has shown that a higher dose of bupivacaine administered in continuous paravertebral block (CPVB) provides a greater analgesic effect after video-assisted thoracoscopic surgery (VATS). In this randomized, controlled, double-blind study, we hypothesized that 0.25% 8ml/h of levobupivacaine administered in CPVB after VATS provides a greater analgesic effect than 0.125% 8ml/h. Fifty patients who underwent unilateral VATS were randomized to receive a postoperative continuous infusion of 0.125% (low group, n = 25) or 0.25% (high group, n = 25) levobupivacaine at 8mL/h for CPVB. The primary outcome was the visual analog scale (VAS) score during coughing on the morning of postoperative day (POD) 1. The secondary outcomes were the VAS scores at rest and during coughing on POD 2, the number of anesthetized dermatomes, the frequency of rescue analgesics, postoperative nausea and vomiting, patient satisfaction, and adverse events and complications. There was no significant difference in the VAS score during coughing on the morning of POD 1 between the low and high groups [median, 37.5 (interquartile range 21-50) vs. 40.0 (interquartile range 21-50), respectively; p = 0.79]. Similarly, there were no significant differences in any secondary outcomes between the two groups. Levobupivacaine at 0.25% 8ml/h in CPVB did not provide better analgesia after VATS over 0.125% 8ml/h. UMIN000037930.

Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery—comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial

BackgroundMinimally invasive thoracic surgery (MITS) has been shown to reduce postoperative pain and contribute to better postoperative quality of life as compared to open thoracic surgery (Bendixen et al., Lancet Oncol 17:836–44, 2016). However, it still causes significant post-operative pain. Regional anaesthesia techniques including fascial plane blocks such as the erector spinae plane block (ESP) have been shown to contribute to post-operative pain control after MITS (Finnerty et al., Br J Anaesth 125:802–10, 2020). Case reports relating to ESP catheters have described improved quality of pain relief using programmed intermittent boluses (PIB) instead of continuous infusion (Bendixen et al., Lancet Oncol 17:836–44, 2016). It is suggested that larger, repeated bolus dose may provide superior pain relief, possibly because of improved spread of the local anaesthetic medications (Ilfeld and Gabriel, Reg Anesth Pain Med 44:285–86, 2019). Evidence for improved spread of local anaesthetic may be found in one study which demonstrated that PIB increased the spread of local anaesthetic medication compared to continuous infusions for continuous paravertebral blocks, which are another type of regional anaesthesia technique for the chest wall (Hida et al., Reg Anesth Pain Med 44:326–32, 2019). Similarly, regarding labour epidural analgesia, the weight of evidence is in favour of PIB providing better pain relief compared with continuous infusion (Onuoha, Anesthesiol Clin 35:1–14, 2017).Since fascial plane blocks, such as ESP, rely on the spread of local anaesthetic medication between muscle layers of the chest wall, intermittent boluses may be particularly useful for this group of blocks. However, until recently, pumps capable of providing automated boluses in addition to patient-controlled boluses were not widely available. To best of our knowledge, there are no randomised controlled trials comparing continuous infusion versus intermittent bolus strategies for erector spinae plane block for MITS in terms of patient centred outcomes such as quality of recovery.MethodsThis trial will be a prospective, double-blinded, randomised controlled superiority trial. A total of 60 eligible patients will be randomly assigned to receive an intermittent bolus regime of local anaesthetic vs a continuous infusion of local anaesthetic. The medication will be delivered via an ultrasound-guided erector spinae plane block catheter which will be inserted by an anaesthesiologist while the patient is under general anaesthetic before their MITS surgery begins. The primary outcome being measured is the Quality of Recovery (QoR-15) score between the two groups 24 h after surgery. Secondary outcomes include respiratory testing of maximal inspiratory volume measured with a calibrated incentive spirometer, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 score at 48 h and time to first mobilisation.DiscussionDespite surgical advancements in thoracic surgery, severe acute post-operative pain following MITS is still prevalent. This study will provide new knowledge and possible recommendations about the efficacy of programmed intermittent bolus regimen of local anaesthetic vs a continuous infusion of local anaesthetic via an ultrasound-guided erector spinae plane catheter for patients undergoing MITS.Trial registrationThis trial was pre-registered on ClinicalTrials.gov Identifier: NCT05181371. Registered on 6 January 2022. All item from the World Health Organization Trial Registration Data set have been included.

Optimal postoperative pain management after VATS lung resection by thoracic epidural analgesia, continuous paravertebral block or single-shot intercostal nerve block (OPtriAL): study protocol of a three-arm multicentre randomised controlled trial

BackgroundAdequate pain control after video-assisted thoracoscopic surgery (VATS) for lung resection is important to improve postoperative mobilisation, recovery, and to prevent pulmonary complications. So far, no consensus exists on optimal postoperative pain management after VATS anatomic lung resection. Thoracic epidural analgesia (TEA) is the reference standard for postoperative pain management following VATS. Although the analgesic effect of TEA is clear, it is associated with patient immobilisation, bladder dysfunction and hypotension which may result in delayed recovery and longer hospitalisation. These disadvantages of TEA initiated the development of unilateral regional techniques for pain management. The most frequently used techniques are continuous paravertebral block (PVB) and single-shot intercostal nerve block (ICNB). We hypothesize that using either PVB or ICNB is non-inferior to TEA regarding postoperative pain and superior regarding quality of recovery (QoR). Signifying faster postoperative mobilisation, reduced morbidity and shorter hospitalisation, these techniques may therefore reduce health care costs and improve patient satisfaction.MethodsThis multi-centre randomised study is a three-arm clinical trial comparing PVB, ICNB and TEA in a 1:1:1 ratio for pain (non-inferiority) and QoR (superiority) in 450 adult patients undergoing VATS anatomic lung resection. Patients will not be eligible for inclusion in case of contraindications for TEA, PVB or ICNB, chronic opioid use or if the lung surgeon estimates a high probability that the operation will be performed by thoracotomy. Primary outcomes: (1) the proportion of pain scores ≥ 4 as assessed by the numerical rating scale (NRS) measured during postoperative days (POD) 0–2; and (2) the QoR measured with the QoR-15 questionnaire on POD 1 and 2. Secondary outcome measures are cumulative use of opioids and analgesics, postoperative complications, hospitalisation, patient satisfaction and degree of mobility.DiscussionThe results of this trial will impact international guidelines with respect to perioperative care optimization after anatomic lung resection performed through VATS, and will determine the most cost-effective pain strategy and may reduce variability in postoperative pain management.Trial registration The trial is registered at the Netherlands Trial Register (NTR) on February 1st, 2021 (NL9243). The NTR is no longer available since June 24th, 2022 and therefore a revised protocol has been registered at ClinicalTrials.gov on August 5th, 2022 (NCT05491239). Protocol version: version 3 (date 06-05-2022), ethical approval through an amendment (see ethical proof in the Study protocol proof).

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials.

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. In a systematic review and network meta-analysis, we searched trials in PubMed,Embase Scopus, Medline,Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. PROSPERO (CRD42020198244); registered 19 October 2020.

Study of ultrasound-guided ropivacaine combined with butorphanol continuous paravertebral block to prevent pain syndrome by evaluating ccl2 gene expression after radical mastectomy

This study aimed to investigate the clinical effect of ultrasound-guided ropivacaine combined with butorphanol continuous paravertebral block in preventing postoperative pain syndrome of breast cancer. For this purpose, 100 women treated for breast cancer from April 2018 to July 2019 were enrolled as research objects. Surgical procedures included local sentinel lymph node biopsy, mastectomy, sentinel lymph node biopsy for mastectomy, modified radical mastectomy, and implantation. The selected patients were randomly divided into two groups: control group (routine operation anesthesia; n = 50) and observation group (ultrasound-guided thoracic paravertebral block before induction of ropivacaine+butorphanol anesthesia; n = 50). The Real-time PCR technique was performed to evaluate CCL2 gene expression. VAS scores were recorded during the postoperative period. Compared with the control group, the observation group had lower VAS scores at six h, 24h, and 48h (P&lt;0.05). The pain effect of the observation group was less than that of the control group. The observation group had better analgesic effects after anesthesia. The observation group had a lower incidence of pain syndrome at the 6th, 8th, and 12th months (P&lt;0.05), and the incidence of pain syndrome in the two groups decreased with the extension of time. The observation group had lower levels of related factors (P&lt;0.05), and the observation group had lower traumatic stress responses. The protein expression of IL-6, IL-17, and CRP in the observation group was lower than that in the control group (P&lt;0.05). The results of CCL2 gene expression also showed that gene expression in the control group increased significantly (P=0.0047). Since the expression of this gene is one of the factors that stimulate pain signals in the body, the method used in the present study was able to reduce the amount of pain significantly. Therefore, the combination of ropivacaine combined with butorphanol ultrasound-assisted paravertebral block can reduce the intensity of postoperative pain in patients with breast cancer surgery, decrease the incidence of pain syndrome, and increase pain tolerance.

Retrospective Case Series Comparing the Efficacy of Thoracic Epidural With Continuous Paravertebral and Erector Spinae Plane Blocks for Postoperative Analgesia After Thoracic Surgery.

Perioperative pain management for thoracic surgery plays a vital role in recovery and improved outcomes. In this retrospective study we compare three different regional anesthesia techniques utilized at one institute to provide postoperative analgesia for thoracic surgery. Continuous thoracic epidural analgesia (TEA), thoracic paravertebral block (PVB) and erector spinae plane (ESP) block are compared for postoperative pain management, opioid requirements, postoperative nausea and vomiting (PONV), respiratory events and length of stay. In this study, pairwise comparisons were also performed among the regional techniques with respect to mentioned outcomes.

A systematic review and meta-analysis of the effects of general anesthesia combined with continuous paravertebral block in breast cancer surgery and postoperative analgesia.

This study aimed to compare the effects of general anesthesia (GA) combined with continuous paravertebral block (CPVB) in breast cancer surgery via systematic review and meta-analysis, in order to provide a theoretical basis for the clinical use of CPVB surgical analgesia. A search of the PubMed, Embase, Medline, Ovid, Springer, and Web of Science databases was conducted to screen clinical trials on GA + CPVB for breast cancer surgery published before December 31, 2020. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was adopted for bias risk assessment, and Review Manager 5.3 software (RevMan, The Cochrane Collaboration, http://tech.cochrane.org/revman) was applied for meta-analysis of the literature. A total of 15 studies that satisfied the requirements were included, involving a total of 1,435 research subjects. The results of our meta-analysis showed the following: the visual analogue scale (VAS) score of the observation group (group A) was significantly reduced [mean difference (MD) =-0.68; 95% confidential interval (CI): -1.04 - -0.33; Z=3.80; P=0.0001]; the level of monocyte chemoattractant protein -1 (MCP-1) was notably decreased (MD =-18.64; 95% CI: -29.68 - -7.61; Z=3.31; P=0.0009); the level of tumor necrosis factor-α (TNF-α) was markedly lower (MD =-1.89; 95% CI: -2.66 - -1.13; Z=4.87; P<0.00001); the interleukin-6 (IL-6) level was obviously reduced (MD =-12.10; 95% CI: -19.22 - -4.99; Z=3.33; P=0.0009); and the incidence of postoperative adverse reactions was substantially decreased (MD = 0.16; 95% CI: 0.07-0.36; Z=4.47; P<0.00001). Compared with group B, the differences of the above five indicators showed statistical significance. In addition, the heart rate (HR) (MD =-1.56; 95% CI: -6.20 - 3.08; Z=0.66; P=0.51), mean arterial pressure (MAP) (MD = 4.66; 95% CI: -0.12 -9.43; Z=1.91; P=0.06), Ramsay score (MD =0.44; 95% CI: -0.06-0.93; Z=1.73; P=0.08) of patients in group A showed no statistical differences compared to group B. GA + CPVB applied to breast cancer surgery for analgesia can reduce the levels of MCP-1, TNF-α, and IL-6 in patients, thereby providing good postoperative analgesia. Therefore, GA + CPVB could effectively reduce the incidence of pain and adverse reactions in patients, and is effective for analgesia in breast cancer surgery.

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

Background: Whether continuous thoracic epidural analgesia (TEA) and continuous paravertebral block (PVB) have similar analgesic effects in patients undergoing video- assisted thoracic surgery (VATS) lobectomy was compared in this study.Methods: In all, 86 patients undergoing VATS lobectomy were enrolled in the prospective, randomized clinical trial. Group E received TEA. Group P received PVB. The primary endpoint was postoperative 24-hour visual rating scale (VAS) on coughing. Side effects and postoperative complications were also analyzed.Results: Pain scores at rest or on coughing at 24 and 48 h postoperatively were significantly lower in group E than in group P (P <0.05). At 24 h postoperatively, more patients in group E suffered from vomiting (32.6% vs 11.6%, P = 0.019), dizziness (55.8% vs 12.9%, P = 0.009), pruritus (27.9% vs 2.3%, P = 0.002), and hypotension (32.6% vs 4.7%, P = 0.002) than those in group P. Patients in group E were more satisfied (P = 0.047). Four patients in group P and two patients in group E suffered from pulmonary complications (P >0.05). The length of hospital and intensive care unit (ICU) stays were not significantly different.Conclusions: Though TEA has more adverse events than PVB, it may be superior to PVB in patients undergoing VATS lobectomy.

Analgesic efficacy of ultrasound-guided continuous quadratus lumborum block versus continuous paravertebral block in radical cystectomy: a randomized study

Background Various techniques of regional anesthesia have been used in abdominal surgery including thoracic epidural, thoracic paravertebral block (TPVB), and transversus abdominis plane block. However, new techniques such as quadratus lumborum (QL) block are tested to detect its efficacy.Purpose To compare between intraoperative and postoperative analgesic effects of ultrasound-guided continuous QL block and continuous TPVB in patients operated for radical cystectomy (primary outcome). Side effects, length of hospital stay, and patient satisfaction are the secondary outcome.Patients and methods Sixty patients admitted to the Urosurgery Department at Alexandria Main University Hospital for radical cystectomy were randomly assigned into two groups, 30 patients for each group: group I received ultrasound-guided QL block with 0.3 ml/kg bupivacaine 0.25% on each side with catheter insertion for maintenance doses of 0.1 ml/kg/h on each side while group II received ultrasound-guided TPVB with 0.3 ml/kg bupivacaine 0.25% on each side with catheter insertion for maintenance doses of 0.1 ml/kg/h on each side.Results There was no statistically significant difference between the two groups regarding postoperative visual analog scale score, first request of analgesia, and length of hospital stay; however, there was statistically significant difference between the two groups as regards heart rate and mean blood pressure at the 1st, 4th, 6th, and 7th hours during the intraoperative periods.Conclusion It can be concluded that there is no difference in analgesic efficacy, opioid consumption, and hospital stay between continuous bilateral QL block and continuous bilateral TPVB after radical cystectomy. These data suggest that QL block is a viable alternative for delivering multimodal analgesia in radical cystectomy.

Comparative randomized study of continuous serratus anterior plane block versus continuous paravertebral block in post-mastectomy pain

BackgroundMany analgesic methods have been used to control post-mastectomy pain. Both thoracic paravertebral and serratus anterior blocks are recent regional techniques with promising results. The aim of this study was to compare safety and analgesic efficacy of both techniques in controlling post-mastectomy pain.MethodsThe study was conducted from January 1, 2019, till January 10, 2019, on 60 female patients ASA class ≤ 2 undergoing modified radical mastectomy. After induction of balanced general anesthesia patients received either continuous thoracic paravertebral block (group P) or continuous serratus anterior block (group S). Twenty milliliters of levobupivacaine 0.25% were injected in each technique under ultrasound guidance followed by continuous infusion of 5 ml/h levobupivacaine 0.125% through a 22-gage catheter. IV morphine was given postoperatively by patient-controlled analgesia. In both groups, we measured time to first dose morphine, total 24 and 48 h morphine consumption, vital signs, visual analog scale, and side effects of each technique.ResultsThe demographic data (age, body mass index, and duration of surgery) were comparable in both groups. The time for first dose of morphine was significantly longer in group P (368 ± 36 min) than group S (270 ± 37.65 min) with P value < 0.001. Total morphine consumption in milligram at both 24 and 48 h were significantly less in group P (8.1 ± 0.8, and 11.5 ± 1 respectively) than in group S (10.1 ± 1.3 and 14.2 ± 1.4), with limited side effects in both groups.ConclusionBoth continuous paravertebral and serratus anterior plane blocks are safe good alternatives to control post-mastectomy pain. However continuous paravertebral block provides better analgesic profile.

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

IntroductionEffective 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.AimTo 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 methodsA 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.ResultsCompared 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.ConclusionsIn 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.

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

BackgroundSystemic 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.ResultsSixty-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).ConclusionContinuous 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.

Efficacy and Safety of Continuous Paravertebral Block after Minimally Invasive Radical Esophagectomy for Esophageal Cancer.

Objective To compare the effects of continuous paravertebral block analgesia and patient-controlled intravenous analgesia after minimally invasive radical esophagectomy for esophageal cancer and their effects on postoperative recovery. Methods A retrospective analysis was performed among 233 patients who underwent minimally invasive esophageal cancer radical operation and met the requirements, including 87 patients (group C) who were successfully placed with a continuous paravertebral block device under direct vision and 146 patients (group P) who used a patient-controlled intravenous analgesia device. Visual analogue pain score (VAS) at rest and in motion for 1, 3, 6, 12, 24, 36, and 48 hours after awakening, incidence of adverse reactions of the two analgesic methods, occurrence of pulmonary complications after operation, use of emergency analgesics, and hospital stay after operation was recorded. Results The VAS scores of group C in resting and active state at 1, 3, 6, 12, 24, 36, and 48 hours after operation were significantly lower than those of group P (P < 0.001). The incidence of adverse reactions, pulmonary complications, and the use of emergency analgesics in group C were lower than those in group P (P < 0.05). The hospitalization time of group C was significantly shortened, and the satisfaction degree of group C was significantly higher than that of group P (P < 0.05). Conclusion Paravertebral block is safe and effective for patients undergoing minimally invasive radical esophagectomy. The incidence of adverse reactions and complications is lower, and the satisfaction of postoperative analgesia is higher, which is beneficial to the rapid recovery of patients after operation.

Paravertebral Block Versus Preemptive Ketamine Effect on Pain Intensity after Posterolateral Thoracotomies: A Randomized Controlled Trial.

Severe postoperative pain affects most patients after thoracotomy and is a risk factor for post-thoracotomy pain syndrome (PTPS). This randomized controlled trial compared preemptively administered ketamine versus continuous paravertebral block (PVB) versus control in patients undergoing posterolateral thoracotomy. The primary outcome was acute pain intensity on the visual analog scale (VAS) on the first postoperative day. Secondary outcomes included morphine consumption, patient satisfaction, and PTPS assessment with Neuropathic Pain Syndrome Inventory (NPSI). Acute pain intensity was significantly lower with PVB compared to other groups at four out of six time points. Patients in the PVB group used significantly less morphine via a patient-controlled analgesia pump than participants in other groups. Moreover, patients were more satisfied with postoperative pain management after PVB. PVB, but not ketamine, decreased PTPS intensity at 1, 3, and 6 months after posterolateral thoracotomy. Acute pain intensity at hour 8 and PTPS intensity at month 3 correlated positively with PTPS at month 6. Bodyweight was negatively associated with chronic pain at month 6. Thus, PVB but not preemptively administered ketamine decreases both acute and chronic pain intensity following posterolateral thoracotomies.

Bloqueo epidural alto por migración de un catéter paravertebral colocado mediante visión directa del cirujano para control analgésico tras toracotomía

La técnica analgésica de elección para el control del dolor postoperatorio tras una cirugía de tórax sigue siendo la analgesia epidural. En los últimos 10 años, varios estudios han presentado al bloqueo paravertebral continuo como igualmente efectivo e incluso más seguro con pocas complicaciones graves asociadas. Presentamos el caso de una paciente de 73 años, ASA III, sometida a cirugía de resección pulmonar con colocación de un catéter paravertebral por visión directa del cirujano para analgesia postoperatoria. 5 horas más tarde la paciente presentó clínica de bloqueo epidural alto (sensitivo hasta T1, motor hasta T4). Se detuvo la infusión de anestésico local, y se confirmó la localización de la punta del catéter mediante imagen radiológica con contraste. En este caso, la migración del catéter cuestiona la sensación de mayor seguridad de esta técnica y hace énfasis en la necesidad de mantener una monitorización estricta de cualquier procedimiento que realicemos. ABSTRACT High epidural block after migration of paravertebral catheter placed by surgeon’s direct vision for post-thoracotomy analgesia The analgesic technique of choice for postoperative pain control after thoracic surgery remains a thoracic epidural analgesia. In the last 10 years, many studies have shown continuous paravertebral block as equally effective and even safer, with few cases of serious associated complications. We present the case of a 73-year-old female, ASA III, undergoing a left atypical pulmonary resection with intraoperative placement of a paravertebral catheter by surgeon’s direct vision for postoperative analgesia. 5 hours later she presented a high epidural block (T1 sensitive, T4 motor). Local anaesthetic infusion was stopped, and the epidural catheter’s tip location was confirmed by contrast radiological image. In our case, catheter’s migration questions the sense of greater safety of this technique and emphasizes the mandatory need of strict monitoring in any performed procedure.

Effects of different anesthesia methods on cardiac function and postoperative complications in elderly patients undergoing thoracotomy

Objective To investigate the effects of ultrasound-guided continuous thoracic paravertebral nerve block combined with general anesthesia on cardiac function and postoperative complications in elderly patients undergoing thoracotomy. Methods A total of 108 elderly patients who underwent thoracotomy in our hospital from January 2017 to December 2018 were randomly divided into the general anesthesia group(receiving general anesthesia)and the combination group(receiving ultrasound-guided continuous thoracic paravertebral nerve block combined with general anesthesia)(n=54, each group). The anesthesia effect was compared between the two groups. Results The excellence rate of anesthesia was higher in the combination group than in the general anesthesia group(90.7% vs.72.2%, χ2=4.267, P=0.039). Stroke volume variability(SVV), stroke volume(SV), heart rate(HR)and mean artery pressure(MAP)had no significant difference between the two groups at T0(pre-anesthesia)(P>0.05). At T1(anesthesia), T2(intraoperative tissue traction), and T3(postoperative suture), there were significant differences in SVV, SV, HR and MAP between the two groups(P<0.05). The incidence of postoperative complications was lower in the combination group than in the general anesthesia group(7.4% vs.22.2%, χ2=4.696, P=0.000). Conclusions Ultrasound-guided continuous thoracic paravertebral nerve block combined with general anesthesia has good anesthetic effects, minor influence on cardiac function and a low incidence of postoperative complications in elderly patients undergoing thoracotomy. Key words: Anesthesia, general; Thoracotomy

Comparison of several methods for pain management after video-assisted thoracic surgery for pneumothorax: an observational study

BackgroundThere is no defined gold standard for pain management after video-assisted thoracic surgery (VATS) for pneumothorax. In addition to systemic analgesia, various loco-regional analgesic techniques have been proposed but remain poorly evaluated in this context. We aimed to assess the analgesic efficacy of several of these techniques for the management of postoperative pain.MethodsWe conducted a monocentric prospective observational cohort study from February 2017 to April 2018 in patients suffering from spontaneous pneumothorax and scheduled for VATS (n = 59). Patients received systemic analgesia (i) alone (n = 15); (ii) combined with a continuous paravertebral block (n = 9); (iii) combined with a continuous serratus plane block (n = 19); or (iv) single-shot serratus plane block (n = 16) as decided by the attending physician. Pain scores and analgesic-related side effects were prospectively collected by an independent observer during the first postoperative 72 h. The primary endpoint criterion was the cumulative oral morphine consumption at the end of the third postoperative day. Statistical analysis used univariate and multivariate step-by-step forward logistic regression models to determine risk factors associated with the main criteria.ResultsMean pain scores and morphine consumption were not significantly different between the 4 groups. In the multivariate analysis, the use of a continuous serratus plane block through a catheter was the only technique associated with a reduced incidence of high-dose oral morphine consumption (OR 0.09–95%CI [0.01–0.79], p = 0.03).ConclusionThis study suggests that serratus plane block combined with continuous infusion through a catheter may have some benefits, although further studies are needed to confirm these results and determine the true place of the serratus plane block in pain management after VATS for pneumothorax.