Continuous Paravertebral Blockade Research Articles

A Retrospective Study Comparing Outcomes of Paravertebral Clonidine Infusion for Pediatric Patients Undergoing Nuss Procedure

The continuous paravertebral blockade as part of the multimodal pain protocol is an effective regional technique to control pain after the Nuss procedure. We investigated the effectiveness of clonidine as an adjunct to paravertebral ropivacaine infusion. We conducted a retrospective study of 63 patients who underwent Nuss procedures and received bilateral paravertebral catheters. Data on demographics, surgical, anesthesia, and block characteristics, numeric rating pain scores (NRS), opioids consumption, hospital length of stay, complications, and side effects from medication administration were collected in children who received paravertebral ropivacaine 0.2% infusion without (N = 45) and with clonidine (1 mcg/mL) (N = 18). The two groups had similar demographics, although the clonidine group had higher Haller indices (6.5 (4.8, 9.4) vs. 4.8 (4.1, 6.6), p = 0.013). The clonidine group required less morphine equivalent/kg on postoperative day 2 (median, interquartile range 0.24 (0.22, 0.31) vs. 0.47 (0.29, 0.61) p = 0.002). There was no difference in median NRS pain scores. Both groups had similar catheter infusion durations, hospital length of stay, and complication rates. A postoperative pain management plan that includes paravertebral analgesia, including clonidine as an adjunct, may be considered to minimize opioid administration for patients undergoing primary Nuss repair.

Ultrasound-guided blocks for cardiovascular surgery: which block for which patient?

Regional anesthesia blocks may benefit patients undergoing cardiovascular surgery. This review coincides with the evolution of ultrasound-guided fascial plane blocks, societal concerns regarding opioid misuse and changing expectations regarding surgical recovery. Paravertebral block and thoracic epidural analgesia have comparable postoperative analgesic profiles following thoracotomy; however, the former has a more favorable complication profile. Limited trials have compared these modalities in cardiac surgery. The mechanism of action of continuous paravertebral blockade may be systemic. Bilateral continuous paravertebral (and other continuous peripheral nerve blocks) should be used with caution in adult patients having cardiac surgery because of the risk of systemic local anesthetic toxicity and bleeding. Novel ultrasound-guided blocks: erector spinae, serratus anterior, pectoral, transversus thoracic muscle and pecto-intercostal fascial plane blocks potentially reduce postoperative opioid requirements; however, they require further investigation before their routine use can be recommended in adult cardiovascular surgical practice. The mechanism of action of erector spinae block is not fully elucidated. Ultrasound-guided fascial plane blocks may reduce postoperative opioid requirements. Investigation into the safety and efficacy of bilateral continuous ultrasound-guided blockade for cardiac surgery is required. Trial protocols should be embedded into enhanced recovery after surgery programs. Patient-reported and long-term outcomes are recommended.

Impact of continuous paravertebral blockade infusion type on pain management over time for video-assisted thoracoscopic surgery: a pilot study

This pilot study was designed to examine the impact of two different (PVB) infusion types compared to a control (no PVB) on pain management in video-assisted thoracoscopic surgery. Acute and chronic pain over time, perioperative oral morphine milligram equivalent (MME) consumption and patient satisfaction were measured. A protracted enrollment period and participant attrition precluded target enrollment and subsequent power analysis. Further, there was no increased efficacy of the intervention groups over the control group. In fact, the patient-controlled analgesia only group (control) had lower mean and median MME consumption postoperatively. Pain and patient satisfaction scores were similar among all treatment groups at all time points assessed. We characterize our study population, report our results for each treatment group and highlight challenges encountered and lessons learned to aid in the development of future research.

Randomised controlled pilot study to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: TOPIC feasibility study protocol

IntroductionOpen chest surgery (thoracotomy) is considered the most painful of surgical procedures. Forceful wound retraction, costochondral dislocation, posterior costovertebral ligament disruption, intercostal nerve trauma and wound movement during respiration combine...

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study

Effective postoperative pain management has been shown to be a positive predictive factor for postoperative recovery following a thoracotomy. The primary objective of this study was to examine the efficacy and safety of continuous paravertebral blockade in managing acute postsurgical pain following unilateral and bilateral single-lung transplantation. The authors conducted a prospective observational trial of patients. The study was conducted in an academic university hospital. Patients (≥18 years of age) who underwent either unilateral or bilateral single-lung transplantation and received a postoperative paravertebral catheter. Paravertebral catheters were placed via an ultrasound-guided technique on either postoperative day 1 or 2. After placement, a continuous infusion of 0.2% ropivacaine was run at 0.2 to 0.25 mL/kg/h with maximum dose of 7 mL/h per side in bilateral lung transplant patients, and 14 mL/h in unilateral lung transplant patients. Patients were followed up to 120 hours after placement of catheters, and pain scores, opioid use, and adverse events were recorded. There were 35 patients who completed the study from October 2013 to December 2014 (21 bilateral transplants and 14 unilateral transplants). The mean time to paravertebral catheter placement was 1.14 days in the overall group, with median time to extubation occurring 543 minutes after placement (range, 23-2,985 minutes). Catheters remained in place for a mean of 7.18 days. The mean maximal pain scores for both groups was 5.94 (day 1), 6.26 (day 2), 6.20 (day 3), 5.12 (day 4), and 5.60 (day 5). There were no adverse events related to the paravertebral catheters in either group. Paravertebral catheters provide a feasible option for postoperative pain control following unilateral or bilateral single-lung transplant in adult patients. Future research should focus on randomized trials of thoracic epidurals compared to paravertebral catheters.

Perioperative pain management after thoracotomy

Perioperative acute pain and the development of persistent pain after thoracotomy are major problems severely affecting health-related quality of life. This review examines and highlights recent strategies and advances in perioperative pain management in this field. Despite the fact that thoracic epidural analgesia (TEA) is considered the 'gold standard' of perioperative care after thoracotomy, other local and regional techniques have emerged within recent years and seem to become valid alternatives to TEA. The use of continuous paravertebral blockade, in particular, may provide similar analgesia and fewer adverse effects than TEA. Multimodal systemic approaches, including the use of ketamine and gabapentinoids are being investigated as well as the effect of surgical techniques and adjuvant therapies such as transcutaneous electrical nerve stimulation on post-thoracotomy pain. Even though thoracotomy is associated with significant postoperative complications, a growing understanding of the underlying pathophysiology and advances in multimodal pain therapy concepts in this specific group of patients are promising improved postoperative outcomes and potential reduction of the incidence of persistent pain.

Regional anaesthesia – the bride at last?

Regional anaesthesia – the bride at last?

Intercostally Placed Paravertebral Catheterization: An Alternative Approach to Continuous Paravertebral Blockade

Continuous paravertebral nerve blocks can provide effective postoperative analgesia after abdominal and thoracic surgery. While offering a number of advantages compared with thoracic epidural analgesia, access to the paravertebral space using a classic approach is not always easily accomplished and/or possible. In this regard, continuous paravertebral blockade via a percutaneous intercostal approach may theoretically serve as an alternative approach to the paravertebral space. One hundred ten patients undergoing major abdominal, thoracic, or retroperitoneal procedures had preoperative placement of unilateral or bilateral paravertebral catheter(s) via an intercostal approach. At a point 8 cm lateral to the midline a 5 cm, 18 G Tuohy needle was advanced with the needle tip angled 45 degrees cephalad and 60 degrees medial to the sagittal plane to come in contact with the lower third of the rib. The needle was "walked-off" the inferior border of the rib while maintaining its orientation and advanced a further 5 to 6 mm under the rib to lie in the subcostal groove. After injection of 5 mL ropivacaine 0.5%, a catheter was advanced medially the estimated distance to the paravertebral space. Postoperatively 0.2% ropivacaine was continuously infused at 10 mL/h in each catheter with hourly boluses of 5 mL available for breakthrough pain. Median pain scores averaged 2 on a scale of 0-10 and patient-controlled analgesia hydromorphone consumption averaged only 1.69 mg for the first 24 h postoperatively. There were no clinically significant complications of the technique. The intercostally placed paravertebral catheter provides postoperative analgesia after major surgery of the chest, abdomen, or retroperitoneum.

Paravertebral Ropivacaine, 0.3%, and Bupivacaine, 0.25%, Provide Similar Pain Relief After Thoracotomy

This study was designed to determine whether ropivacaine plus fentanyl was as effective as bupivacaine plus fentanyl in a continuous thoracic paravertebral block after posterolateral thoracotomy. Patients were randomly assigned in a blinded fashion to receive 1 of 2 solutions for paravertebral analgesia. Multi-institutional university hospital. Sixty patients undergoing elective thoracotomy. A continuous paravertebral infusion of 0.1 mL/kg/h of either 0.3% ropivacaine/fentanyl, 3 microg/mL, or 0.25% bupivacaine/fentanyl, 3 microg/mL, was started on admission to the intensive care unit. Pain scores (rest, deep breathing, and coughing), spirometry, subcutaneous opioids, or nonsteroidal anti-inflammatory drug consumption and adverse events were assessed for 48 hours. Both techniques provided adequate pain relief for the first 2 days after posterolateral thoracotomy. There were no differences between groups in pain scores at rest, coughing, or movement. There was an improvement of spirometry values between the first and second day in both groups. There were no differences in the requirements for rescue analgesia and side effects between groups. It is concluded that both bupivacaine, 0.25%, and ropivacaine, 0.3%, with fentanyl are equally effective for post-thoracotomy pain control when used via continuous paravertebral blockade.