Continuous Thoracic Paravertebral Block Research Articles

Continuous thoracic epidural versus continuous paravertebral analgesia in patients undergoing open renal surgery: Evaluation of pulmonary function; randomized double-blinded clinical trial

ABSTRACT Background This study aimed to assess pulmonary functions after either continuous thoracic paravertebral block (cTPVB) or thoracic epidural block (cTEB) in open renal surgeries. Methodsː The double-blinded, randomized clinical trial included 40 patients scheduled for open renal surgeries at Urology Hospital-Assiut University, equally assigned into group E (n = 20) and group P (n = 20), both at the level of 7th-8th thoracic vertebra. Initially, 7.5–12 mL of bupivacaine 0.25% was started before the induction of general anesthesia, followed by bupivacaine 0.125% continuously at a rate of 5–15 ml/h. Forced vital capacity (FVC) measured every 6 hours postoperatively within the first 24 hours was the primary outcome. Secondary outcomes were peak expiratory flow rate (PEFR), forced expiratory volume in the first second (FEV1), diaphragmatic excursion (DE), postoperative analgesia, total opioid consumption, total local anesthetic dose, hemodynamics and complications. Resultsː FVC, FEV1 and DE were better preserved in cTPVB where the lowest postoperative readings as a fraction of preoperative control were 0.7 ± 0.11 vs 0.65 ± 0.11 L, 0.74 ± 0.11 vs 0.64 ± 0.10 L and 0.73 ± 0.1 vs 0.58 ± 0.1 cm, respectively. The lowest postoperative PEFR was reported in cTEB (p-value = 0.128). Analysis of numeric rating pain scale, total opioid consumption and time of first rescue analgesic request revealed a statistical nonsignificant difference. The total infused dose of local anesthetic was significantly higher in cTPVB group. Incidence of sympatholytic complications was higher in cTEB. Conclusion cTEB and cTPVB had convergent effect on respiratory function and diaphragmatic motility and equivalent analgesic efficacy after open renal surgeries. Although cTPVB was technically easier and less time-consuming than cTEB, higher dose of local anaesthetic was required in cTPVB.

Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block

Abstract Background and Aims: Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Material and Methods: Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. Results: The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Conclusion: Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.

Comparison of continuous erector spinae plane block and thoracic paravertebral block for postoperative analgaesia in patients undergoing modified radical mastectomy: A randomised controlled non-inferiority trial.

Modified radical mastectomy (MRM) is associated with significant postoperative pain for which many blocks including thoracic paravertebral (TPV) block are being used. Erector spinae plane (ESP) block is a recently described technique. We planned to compare the efficacy and safety of ultrasound-guided continuous ESP and TPV blocks for postoperative analgaesia following MRM. Sixty-six patients belonging to American Society of Anaesthesiologists physical status I and II, aged 25-85 years, undergoing MRM were enrolled and randomly allocated into two groups. Ipsilateral block was given preoperatively at T3 or T4 level with 20 ml of 0.5% ropivacaine and 50 μg fentanyl. Infusion of 0.5% and 0.2% ropivacaine with fentanyl 2 μg/ml at a rate of 5 ml/hr was continued during intraoperative and postoperative period, respectively. Pain was assessed using visual analogue scale (VAS) till 24 hours. Block performance time, time to first rescue analgaesia, total amount of rescue analgaesic consumed, the incidence of procedure-related and postoperative complications, failure rate and patient satisfaction score were also recorded. Data collected were analysed using the Chi-square test or Student's t-test with the help of SPSS 22.0. Demographics, baseline vitals, VAS scores both at rest and on movement, block performance time, time to first rescue analgaesia, the total amount of rescue analgaesia and patient satisfaction score were comparable in both groups (P value > 0.05). No complications were observed in either group. In patients undergoing MRM, continuous catheter technique ESP block is as efficacious and safe as TPV block for providing prolonged postoperative analgaesia.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Analgesic Efficacy of Intravenous Dexamethasone as an Adjunct to Ultrasound-Guided Paravertebral Block with Bupivacaine in Video-Assisted Thoracoscopic Surgery.

PurposeThoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS.Patients and MethodsIn this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed.ResultsAfter excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) (P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups.ConclusionIntravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.

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.

Comparison of continuous thoracic epidural block and continuous thoracic paravertebral block for management of post thoracotomy pain: a randomised trial

Aim: Pain after thoracotomy is one of the most severe in clinical practice and more effective analgesia can be achieved by combining systemic and regional techniques. Though thoracic epidural analgesia (TEA) is the gold standard in the treatment, its application can be restricted due to side effects and contraindications. We investigated the hypothesis that thoracic paravertebral block (TPVB) reduced morphine consumption, pain scores, and side effects as much as TEA after thoracotomy.&#x0D; Material and Method: Fifty patients who underwent elective posterolateral thoracotomy were included in this study. Patients were randomly allocated into two groups as TEA (group I, n = 25) and TPVB (group II, n = 25). Postoperative consumption of patient-controlled morphine, visual analog scores (VAS), hemodynamic parameters, and side effects were collected in 72 hours. Additionally, pulmonary function tests (PFT) values were recorded.&#x0D; Results: Postoperative VAS values during rest were comparable between the groups (p &gt; 0.005) and they did not have significantly difference postoperative VAS values during coughing (p &gt; 0.005). The cumulative morphine consumption was higher in Group 2 (p &lt; 0.05). Side effects were comparable between the groups II (p &gt; 0.05).&#x0D; Conclusion: We conclude that TEA provided more effective analgesia than TPVB in thoracotomy patients in the early postoperative period with comparable side effects.

Continuous Thoracic Paravertebral Block to Treat Electrical Storm.

Continuous ganglion block is increasingly being used to help manage ventricular tachyarrhythmias. We present the cases of 2 patients in whom we used continuous left thoracic paravertebral block to achieve sympathetic denervation and improvement in drug-refractory ventricular tachyarrhythmias. Whether as destination therapy or bridging therapy, we conclude that the block is safe, improves patients' comfort, and is superior in several ways to stellate ganglion block and other single-injection techniques.

Ultrasound-Guided Continuous Thoracic Paravertebral Block Improves Patient's Quality of Recovery After Open Hepatectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

BackgroundUltrasound-guided continuous thoracic paravertebral block can provide pain-relieving and opioid-sparing effects in patients receiving open hepatectomy. We hypothesize that these effects may improve the quality of recovery (QoR) after open hepatectomy. MethodsSeventy-six patients undergoing open hepatectomy were randomized to receive a continuous thoracic paravertebral block with ropivacaine (CTPVB group) or normal saline (control group). All patients received patient-controlled intravenous analgesia with morphine postoperatively for 48 hours. The primary outcome was the global Chinese 15-item Quality of Recovery score on postoperative day 7, which was statistically analyzed using Student's t-test. ResultsThirty-six patients in the CTPVB group and 37 in the control group completed the study. Compared to the control group, the CTPVB group had significantly increased global Chinese 15-item Quality of Recovery scores (133.14 ± 12.97 vs. 122.62 ± 14.89, P = 0.002) on postoperative day 7. Postoperative pain scores and cumulative morphine consumption were significantly lower for up to 8 and 48 hours (P < 0.05; P = 0.002), respectively, in the CTPVB group. ConclusionPerioperative CTPVB markably promotes patient's QoR after open hepatectomy with a profound analgesic effect in the early postoperative period.

Randomized Trial of Poloxamer 407-Based Ropivacaine Hydrogel After Thoracoscopic Pulmonary Resection

BackgroundWe conducted a comparative study to evaluate the efficacy of poloxamer 407-based ropivacaine hydrogel at the wound site (Gel) and continuous thoracic paravertebral block using On-Q PainBuster (On-Q; B. Braun Medical) for postoperative pain after thoracoscopic pulmonary resection. MethodsThis prospective, randomized, noninferiority study included 89 patients randomized to the Gel group (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) or the On-Q group (0.2% ropivacaine, 4 mg/h for 48 hours). The primary outcome measure was total fentanyl consumption, and secondary outcome measures were the need for rescue analgesia and pain intensity using the numeric rating scale (NRS). ResultsThere was no significant difference in total fentanyl consumption between the Gel group and the On-Q group (1504.29 ± 315.72 μg vs 1560.32 ± 274.81 μg, P = .374). Pain intensity using the NRS between the Gel group and the On-Q group demonstrated no statistical differences at 6 hours (3.56 vs 3.55, P = .958), 24 hours (3.21 vs 3.00, P = .25), 48 hours (2.75 vs 2.49, P = .233), and 72 hours (2.39 vs 2.33, P = .811), and there was no significant difference in the frequency of analgesic rescue medication use (3.70 vs 3.33, P = .417). ConclusionsWe confirm the noninferiority of Gel compared with On-Q for acute postoperative pain after thoracoscopic pulmonary resection. Considering a technical simplicity and low systemic toxicity of the local injection of Gel, this analgesic modality may be worthy of further research and is thus considered to have potential as a viable alternative to On-Q for regional analgesia.

Thoracic Paravertebral Block Ameliorates Postoperative Delirium in Geriatric Patients.

Thoracic surgery often causes postoperative delirium (POD) in geriatric patients. This study aimed to explore the effect of ultrasound-guided continuous thoracic paravertebral block (UG-TPVB) on POD in geriatric patients undergoing pulmonary resection. Total 128 patients who underwent pulmonary resection were randomly allocated to either the conventional patient-controlled analgesia (PCA) group or the UG-TPVB group (n = 64 per group). The consumption of opioid agents (propofol and remifentanil), postoperative hospital stay, postoperative pulmonary atelectasis, postoperative nausea/vomiting, and postoperative itchiness were recorded. The diagnosis of delirium was dependent on the Nursing Delirium Screening Scale. The postoperative pain was assessed by visual analogue scale (VAS) score. The serum levels of interleukin (IL)-1β, IL-6, and tumor necrosis factor-α were used to evaluate the postoperative neuroinflammation. The consumption of propofol and remifentanil, postoperative hospital stay, postoperative pulmonary atelectasis, postoperative nausea/vomiting, and postoperative itchiness in the UG-TPVB group were lower than that in the PCA group. Compared with the PCA group, the prevalence of POD was decreased in the UG-TPVB group. In addition, use of UG-TPVB not only reduced postoperative pain (VAS score) but also decreased postoperative neuroinflammation compared with PCA in geriatric patients undergoing pulmonary resection. This study determined the benefits of UG-TPVB over PCA, providing an effectiveness approach to alleviate POD in geriatric patients undergoing pulmonary resection.

The comparison of analgesic efficacy between ultrasound-guided continuous thoracic paravertebral block and continuous thoracic epidural block using bupivacaine - fentanyl in patients undergoing lung surgery: A prospective, randomized, controlled trial.

This study aimed to compare the efficacy and the safety of ultrasound-guided continuous thoracic paravertebral block (CTPB) to the continuous thoracic epidural block (CTEB) for pain relief in patients undergoing lung surgery. Our study included 102 patients after lung surgery at the 74 Central Hospital from 9/2013 to 12/2017. Patients were divided into 2 groups: CTPB group (n= 51) and CTEB group (n= 51). The primary outcomes were the Visual Analogue Scale (VAS) scores when patients were at rest (VR) and movement (VM), the total used dosage of bupivacaine - fentanyl after surgery, plasma glucose, and cortisol levels, additional doses of morphine. Adverse reactions were recorded during the study. The study was approved by the Ethics Committee of the 74 Central Hospital. All participants provided their informed consent. There were no significant differences between CTPB and CTEB groups in terms of the VR and the VM, total used doses of bupivacaine - fentanyl after 72-hours of surgery (p> 0.05), the increased plasma glucose, and plasma cortisol (p> 0.05), and the additional doses of morphine. The percent of patients in the CTPB group undergoing adverse reactions in the circular system and the respiratory system was lower than in the CTEB group. Adverse reactions included vascular puncture, urinary retention, and itch. Ultrasound-guided CTPB is an effective intervention of pain relief after lung surgery. Its analgesic efficacy is comparable to CTEB. Also, this method had fewer adverse reactions in circulation and respiration compared to the CTEB.

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy: A Prospective Randomized Trial.

Postoperative pain following mastectomy is often severe and pain management is necessary. We evaluated the analgesic efficacy of continuous pectoral nerve block (PEC) in comparison with that of the continuous thoracic paravertebral block (TPVB) and the intravenous opioid analgesia in patients scheduled for modified radical mastectomy (MRM). A total of 90 female patients aged 20 to 70 years, American Society of Anesthesiologists (ASA) I to III, undergoing unilateral MRM were randomly allocated into 3 groups. All patients received postoperative morphine patient-controlled analgesia (PCA). Continuous TPVB and continuous PECs were added in group II and group III, respectively. Postoperative morphine consumption during the first 48 hours and postoperative visual analog scale were recorded. The cumulative morphine consumption in the first 24 hours postoperative was higher in the PCA-M group (27.47±4.95 mg) than that of the TPVB group (8.43±2.67 mg) and PEC group (13.47±3.89 mg) (P<0.001, confidence interval: 16.6-21.5 and 11.6-16.4, respectively). It was significantly higher in the PEC group as compared with the TPVB group (P<0.001, confidence interval: 2.6-7.5). On admission to postanesthesia care unit till 2 hours postoperative, the median visual analog scale score at rest was higher in the PCA-M group than that of the TPVB group (P<0.05) and PEC group (P<0.05) without statistical difference between the TPVB group and PEC group. Continuous PEC and continuous TPVB reduced the postoperative morphine consumptions as compared with the intravenous opioid analgesia in patients undergoing MRM with greater reduction in TPVB and without increased adverse effects.

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.

Effects of different postoperative analgesic strategies on postoperative neurocognitive function and quality of recovery in elderly patients undergoing one lung ventilation

To evaluate the effects of different postoperative analgesic strategies on neurocognitive function and quality of recovery in elderly patients at 7 days after thoracic surgery with one lung ventilation. Ninety elderly patients undergoing video-assisted thoracic surgery were randomized into 3 groups (n=30) to receive postoperative analgesia with thoracic paravertebral block analgesia (TA), epidural analgesia (EA) and intravenous analgesia (GA). Before and at 7 days after the surgery, the patients' cognitive function was assessed using Mini-Mental State Examination (MMSE), and their early recovery at 7 days postoperatively was evaluated using Quality of Recovery-40 items (QoR-40). The patients in TA and EA groups had significantly higher MMSE scores and lower incidence of postoperative neurocognitive dysfunction (PNCD) than those in GA group without significant difference between the former two groups. At 7 days after the surgery, serum levels of S100-β and MMP-9 were significantly higher in GA group than in TA and EA group, and did not differ significantly between the latter two groups. QoR-40 scores were significantly higher in TA and EA groups than in GA group, and were higher in TA group than in EA group. The chest intubation time and length of hospital stay were significantly shorter in TA and EA groups than in GA group. In elderly patients undergoing surgeries with one lung ventilation, general anesthesia combined with either postoperative continuous thoracic paravertebral block or epidural analgesia can significantly improve postoperative neurocognitive function and quality of recovery, but continuous thoracic paravertebral block analgesia can be more advantageous for improving postoperative quality of recovery.

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.

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

BackgroundDespite 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...

Transverse vs. parasagittal in-plane approaches in ultrasound-guided paravertebral block using a microconvex probe: A randomised controlled trial.

Several approaches have been proposed for ultrasound-guided thoracic paravertebral block, but the best approach remains unclear. We compared two ultrasound-guided in-plane approaches using a microconvex probe, transverse and parasagittal. We assessed whether either approach would facilitate successful catheter placement in the paravertebral space. Randomised controlled trial. University hospital, July 2015 to March 2016. Sixty patients scheduled to undergo thoracotomy were randomly allocated into two groups. A microconvex probe was placed transversely between adjacent ribs (transverse) or sagittally between adjacent transverse processes (parasagittal). When the Tuohy needle reached the paravertebral space, a catheter was inserted to a depth of 4 cm. Then, 0.5-ml radiocontrast was injected through the catheter under fluoroscopy. The primary outcome was successful catheter placement in the paravertebral space; secondary outcomes were 0 to 100 mm visual analogue scale pain score and morphine consumption in the first 24 h. All patients received the allocated paravertebral block. Correct catheter placement occurred in 23 (77%) and 24 patients (80%) using the transverse (n=30) and parasagittal approaches (n=30), respectively (P = 1.00). Five patients were excluded due to changes in surgical procedure. Postoperative pain, represented by median [IQR] visual analogue scale score, was 19.5 [12 to 25] at rest and 55 [44 to 77] on movement with the transverse approach (n=28) vs. 22 [12 to 33.5] at rest and 59 [41.5 to 75] on movement with the parasagittal approach (n=27) (P = 0.57 at rest, P = 0.76 on movement). Median morphine consumption was 11.5 [5 to 21] and 11 [5 to 18] mg in the transverse and parasagittal approaches, respectively (P = 0.99). There were no clinically significant differences between approaches for continuous ultrasound-guided thoracic paravertebral block using a microconvex probe, and both approaches achieved a high rate of correct catheter placement. UMIN Clinical Trials Registry identifier: UMIN000015988.

Ultrasound-guided continuous thoracic paravertebral block alleviates postoperative delirium in elderly patients undergoing esophagectomy: A randomized controlled trial.

Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy. A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1β, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method. The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1β, IL-6, and TNF-α levels and less pain when coughing after surgery. Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Ultrasound-guided continuous deep serratus anterior plane block versus continuous thoracic paravertebral block for perioperative analgesia in videoscopic-assisted thoracic surgery.

The deep serratus anterior plane block (SAPB) is a promising novel regional anaesthesia technique for blockade of the anterolateral chest wall. Evidence for the efficacy of SAPB versus other analgesic techniques in thoracic surgery remains inadequate. This study compared ultrasound-guided continuous SAPB with a surgically placed continuous thoracic paravertebral block (SPVB) technique in patients undergoing videoscopic-assisted thoracic surgery (VATS). In a single-centre, double-blinded, randomized, non-inferiority study, we allocated 40 patients undergoing VATS to either SAPB or SPVB, with both groups receiving otherwise standardized treatment, including multimodal analgesia. The primary outcome was 48-hr opioid consumption. Secondary outcomes included numerical rating scale (NRS) for postoperative pain, patient-reported worst pain score (WPS) as well as functional measures (including mobilization distance and cough strength). A 48-hr opioid consumption for the SAPB group was non-inferior compared with SPVB. SAPB was associated with improved NRS pain scores at rest, with cough and with movement at 24hr postoperatively (p=.007, p=.001 and p=.012, respectively). SAPB was also associated with a lower WPS (p=.008). Day 1 walking distance was improved in the SAPB group (p=.012), whereas the difference in cough strength did not reach statistical significance (p=.071). There was no difference in haemodynamics, opioid side effects, length of hospital stay or patient satisfaction between the two groups. The SAPB, as part of a multimodal analgesia regimen, is non-inferior in terms of 48-hr opioid consumption compared to SPVB and is associated with improved functional measures in thoracic surgical patients. ClinicalTrials.gov Identifier: NCT03768193. The SAPB interfascial plane block is an efficacious alternative method of opioid-sparing analgesia in high-risk thoracic surgical patients as part of an enhanced recovery programme.