Thoracic Epidural Block Research Articles

Guides for pain clinicians?

Although there have been debates and different practice guidelines on indication of epidural blocks for pain management [1], there remain patients for whom few alternative options are available, including painless delivery and some postoperative patients. Even though use of fluoroscopy is recommended for correct localization of epidural space, this procedure is not always possible in above mentioned situations. We therefore have to rely solely on loss of resistance technique using our hands. The problem with this method is that there is always a risk of puncturing dura mater even with most experienced hands. Some studies have previously indicated presence of gaps in human ligamentum flavum, causing apprehension in pain clinicians [2,3,4]. In present issue of Korean Journal of Pain, Yoon et al. [5] reports anatomic variations of cervical and high thoracic ligamentum flavum. Having directly examined ligamentum flavum from C3 to T6 in 15 human cadavers, they report that incidence of midline gaps in ligamentum flavum is 87%-100% between C3 and T2. The incidence decreases below this level and is lowest at T4-T5 (8%). The incidences of midline gaps seem to be higher in this study than in prior studies. Among levels presenting gaps, location of a gap in caudal third of ligamentum flavum is more frequent than in middle or cephalic portion of ligamentum flavum. Therefore, authors warn that midline approach for cervical and high thoracic epidural blocks could pose a risk of failure to recognize a loss of resistance. This risk can be further increased when needle is inserted into caudal portion of intervertebral space. Some investigators have tried to solve this problem using ultrasonogram. Lee et al. [6] wrote an article titled, Sonoanatomy of lumbar spine in patients with previously unintentional dural punctures during labor epidurals, and concluded that abnormal sonoanatomy of ligamentum flavum may present anatomical variations of this structure, which may be related to an increased incidence of unintentional dural punctures during epidural placements. Another study looked into sonoanatomy of lumbar spine in pregnant women at term [7], and identified a grossly incomplete or absent ligamentum flavum. However, other authors have contended that ligamentum flavum, epidural space, and posterior dura often appear as a single linear hyperechoic structure, which they have termed the posterior complex, and that posterior epidural space may not always be distinguishable or visible [8]. Yoon et al. [5]'s article contains helpful content reiterating possibility of gaps in ligamentum flavum when performing epidural blocks. Further research, combining this study with radiologic aids, so as to determine whether these gaps in ligamentum flavum could be identified by ultrasonograms or epidurography before dissection, would be of interest to reader. There is also a possibility that defects could change according to posture of patient [9] and this may be another area to investigate. The practice of anesthesia has changed drastically with progress of monitoring devices. Before era of modern monitors, anesthesiologists relied on patients' chest excursions, and precordial stethoscopes. Nowadays, anesthesiologists who were trained after advent of capnogram and pulse oximeter could not imagine practicing anesthesia without them. The practice in field has evolved from stethoscope to capnogram and pulse oximeter - and now ultrasound - improving patients' safety dramatically. As anesthesiologists or pain clinicians, all of us have had an experience of considering whether to push Tuohy needle further in or not, sitting at back of patient. Similar to anesthesiology situations, we should be able to practice more safely with some guide directing us during procedure. In not too distant future, situation will change and practicing an epidural type of block without aid of an ultrasonogram or fluoroscopy will be considered similar to practicing anesthesia without a capnogram or pulse oximeter today.

Celiac plexus block in a patient with upper abdominal pain caused by diabetic gastroparesis.

Celiac plexus block in a patient with upper abdominal pain caused by diabetic gastroparesis.

A case of combined thoracic epidural anesthesia-interscalene block application in high-risk mastectomy patients: a case report

Recent advances in surgical and anesthetic techniques have facilitated general anesthesia and surgical possibilities in the higher-risk patient group. Although general anesthesia is the only preferred approach for breast surgery, there have been many clinical trials about breast surgery that has been achieved with regional anesthesia techniques. It is known that regional anesthesia application decreases the preoperative stress, postoperative morbidity and mortality. Additionally, this application positively affects the early start of feeding and mobilization. Regional anesthesia techniques like high thoracic epidural anesthesia, cervical epidural anesthesia and paravertebral block have been applied successfully in mastectomy operations. Combined thoracic epidural anesthesia-interscalene block technique may also be a good alternative to general or cervical, high thoracic epidural anesthesia. We aimed herein to present a case who underwent successful mastectomy and axillary dissection under combined thoracic epidural anesthesia-interscalene block.

Introduction of ERAS® program into clinical practice: from preoperative management to postoperative evaluation

We, the chairpersons, chose ‘‘Enhanced Recovery After Surgery’’ as a topic of the 2013 Journal of Anesthesia symposium held on May 23, 2013. After reviewing all the manuscripts assigned to the section editor (Y.O.) from 2011 to 2012, we found that a large number of anesthesiologists are interested in preoperative evaluation and intraand postoperative management for improving patient satisfaction and prognosis. Besides providing adequate postoperative analgesia and preventing nausea and vomiting, developing a program targeting enhanced recovery after surgery has been one of the most popular themes among us. The initial idea of enhanced recovery goes back almost half a century, as oral rehydration therapy for the treatment of infectious disease [1]. Based on a long history and cumulated knowledge, the multimodal ERAS protocol has been established and is still under evolution [2]. In this symposium, we aimed at a comprehensive review of the concept of enhanced recovery after surgery, from preoperative management to postoperative evaluation, by four outstanding symposists. Dr. Taniguchi, a co-founder of enhanced recovery programs in our country, elaborated the introduction of the modified ERAS protocol in his institute [3]. He developed this program, originally named ‘‘preoperative oral rehydration therapy,’’ for improving the perioperative safety and satisfaction of the patients. His lecture, describing the modified ERAS protocol according to the current medical system in Japan and improved patient prognosis after its introduction, would have been quite informative to every Japanese anesthesiologist who is starting these programs in their institutes. Dr. Yatabe showed that preoperative oral carbohydrate treatment, in addition to contributing to shortening the preoperative fasting period, improves insulin resistance and prevents a decrease of body temperature during anesthesia in clinical and experimental studies [4]. Adequate control of both blood glucose and body temperature is a part of the ERAS protocol and significantly influences the postoperative outcome. Dr. Kitayama presented the effects of intraoperative analgesia with peripheral nerve block including transversus abdominis plane block and rectus sheath block with local anesthetics as well as thoracic epidural block with opioids. He also validated its safety from the point of plasma concentration of local anesthetics [5]. Dr. Shibata reviewed various kinds of peripheral nerve block, including brachial plexus block, from the point of nerve injury. Anesthesiologists are responsible for neurological complications induced by nerve block. He explained the differential diagnosis of nerve injury for early detection and prompt treatment [6]. Dr. Tanaka [7] developed the Japanese version of the quality of recovery (QoR) 40, a score for evaluating the quality of postoperative recovery originally created by Myles [8]. He translated the original score into Japanese, with modifications according to the Japanese medical system and validated from numerous aspects. The Japanese version of the QoR40 will appear in this manuscript. We believe this symposium was informative and has provided practical knowledge to many anesthesiologists. Y. Oda (&) Department of Anesthesiology, Osaka City General Hospital and Children’s Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan e-mail: odayou@msic.med.osaka-cu.ac.jp

Comparison between Continuous Thoracic Epidural and Paravertebral Blocks for Postoperative Analgesia in Patients Undergoing Thoracotomy: Systematic Review

Background and objective: Thoracotomy is a procedure associated with postoperative severe pain. Epidural block (EB) is considered the gold standard for its control. Paravertebral block (PVB) is an option for the management of postoperative pain. The aim of this study was to evaluate by meta-analyses the effectiveness of continuous thoracic epidural and paravertebral blocks for pain management after thoracotomy and the incidence of adverse effects. MethodThe study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. We analyzed primary (postoperative pain at rest) and secondary outcomes (urinary retention, nausea, vomiting, hypotension). We estimated the weighted mean difference for continuous variables and odds ratios for categorical variables. ResultsWe included eight prospective, randomized, controlled studies. Meta-analysis showed no statistically significant differences between the two techniques regarding the outcomes of postoperative pain at rest at four, eight, 12, 16, 20, 24, 36, and 48hours. Incidence of urinary retention was higher in EP group (OR = 7.19, CI95 = 1.87 to 27.7). The occurrence of hypotension was higher in PVB group (OR = 10.28, 95 = 2.95 to 35.77). There was no statistically significant difference between both groups regarding the outcome nausea/vomiting (OR = 3.00, CI95 = 0.49 to 18.45). ConclusionThere were no statistically significant differences in pain relief after thoracotomy between EB and PVB. PVB showed a lower incidence of side effects with reduced frequency of urinary retention and hypotension.

Educational Exhibit Abstract No. 334 - Regional anesthesia with a subcutaneous catheter for the management of acute pain from multiple rib fractures

Learning Objectives 1. Understand the advantages and complications of regional anesthesia techniques such as epidural, thoracic paravertebral and intercostal nerve blocks. 2. Review the secondary complications of shallow breathing and poor chest physiotherapy due to pain from multiple rib fractures and the importance of prevention with effective pain management. 3. Identify the patient scenarios for utilization of this novel technique. Background Thoracic trauma commonly results in multiple rib fractures with intense associated pain. Regional anesthesia is favored over systemic analgesic use for the management of this pain as it limits pulmonary complications from guarding, shallow breathing and suboptimal chest physiotherapy without the depressive effects of systemic opiates. Thoracic epidural, thoracic paravertebral and intercostal nerve blocks have all demonstrated equal effectiveness in this regard, but all require some degree of patient positioning and careful maneuvering to avoid injury to adjacent nerves. Using a subcutaneous regional approach to delivering local analgesics via a small catheter, we have successfully managed acute pain from multiple rib fractures in several patients. Clinical Findings/Procedure Details A 5 French yueh catheter was modified using an 18-gauge needle, and multiple side-ports were carefully created. After the placement of radio-opaque grids, scout computer tomography (CT) was obtained, and the modified yueh catheter was placed in the subcutaneous tissues overlying the rib fractures and placement was confirmed with CT. The catheter was secured in place using a sterile dressing. 1% lidocaine was then infused through the subcutaneous catheter. At the ICU, long acting analgesics were infused at a rate of 6-7 mL per hour. Conclusion and/or Teaching Points Regional pain management has been established as an effective way to minimize length of hospitalization and secondary complications from pain related to multiple rib fractures. Subcutaneous management of pain from multiple rib fractures appears to be at as least as effective as the established regional techniques. However, this less invasive approach avoids the risk of nerve injury while also circumventing issues related to systemic opiate use.

Newly Developed Urinary Retention and Motor Weakness of Lower Extremities in a Postherpetic Neuralgia Patient

During the early stage of postherpetic neuralgia, an epidural block on the affected segment is helpful in controlling pain and preventing progression to a chronic state. The main neurologic complication following an epidural block is cord compression symptom due to an epidural hematoma. When neurologic complications arise from an epidural block for the treatment of postherpetic neuralgia, it is important to determine whether the complications are due to the procedure or due to the herpes zoster itself. We report a case of a patient who was diagnosed with herpes zoster myelitis during treatment for postherpetic neuralgia. The patient complained of motor weakness in the lower extremities after receiving a thoracic epidural block six times. Although initially, we believed that the complications were due to the epidural block, it was ultimately determined to be from the herpes zoster myelitis.

Asymptomatic pneumomediastinum resulting from air in the epidural space -a case report-

There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.

Sympathetically mediated upper back pain after coronary artery bypass graft surgery

Sympathetically mediated upper back pain after coronary artery bypass graft surgery

ANAESTHESIOLOGY AND INTENSIVE CARE The efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Sagiroglu G, Baysal A, Copuroglu E, et al. ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):139-148. doi:10.5114/kitp.2013.36135. APA Sagiroglu, G., Baysal, A., Copuroglu, E., Karamustafaoglu, Y., Sagiroglu, T., & Yuksel, V. et al. (2013). ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), 139-148. https://doi.org/10.5114/kitp.2013.36135 Chicago Sagiroglu, Gonul, Ayse Baysal, Elif Copuroglu, Yekta Altemur Karamustafaoglu, Tamer Sagiroglu, Volkan Yuksel, and Serhat Huseyin. 2013. "ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 10 (2): 139-148. doi:10.5114/kitp.2013.36135. Harvard Sagiroglu, G., Baysal, A., Copuroglu, E., Karamustafaoglu, Y., Sagiroglu, T., Yuksel, V., and Huseyin, S. (2013). ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), pp.139-148. https://doi.org/10.5114/kitp.2013.36135 MLA Sagiroglu, Gonul et al. "ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 10, no. 2, 2013, pp. 139-148. doi:10.5114/kitp.2013.36135. Vancouver Sagiroglu G, Baysal A, Copuroglu E, Karamustafaoglu Y, Sagiroglu T, Yuksel V et al. ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):139-148. doi:10.5114/kitp.2013.36135.

Pediatric Regional Anesthesia

Two articles in this month’s Anesthesia & Analgesia address safety of regional anesthesia and analgesia in pediatrics.1,2 At first glance, one is very reassuring, the other is frightening. In this Editorial, we will recommend a middle ground. Practitioners of pediatric regional anesthesia should be careful and vigilant but can be confident that many types of complications can be made extremely rare by adopting some recommended practice patterns. Over the past 30 years, pediatric applications of postoperative regional anesthesia and analgesia have expanded rapidly.3 There is now a substantial body of studies regarding techniques, pharmacokinetics, and clinical outcomes. Agerelated trends in local anesthetic pharmacokinetics have been characterized, and safe dosing guidelines have been established.4 Most regional anesthesia in adults is performed awake or with doses of sedatives and analgesics that maintain verbal responsiveness, permitting patient reporting of paresthesias, severe pain with needle movement or injection, immediate symptoms of systemic local anesthetic effect, and progression of sensory and motor blockade over the minutes after injections. Textbooks, review articles, and consensus documents often strongly criticize performing most types of major peripheral or neuraxial blocks in adults under deep sedation or general anesthesia.5 In contrast, most, but not all, regional anesthesia in children is performed under either deep sedation or general anesthesia. Advocates of pediatric regional anesthesia have cited a series of retrospective and prospective safety studies to support their contention that the widespread practice of performing regional anesthesia under general anesthesia is safe.6–8 Polaner et al. report on the first 3 years of prospective registry data from PRAN, the Pediatric Regional Anesthesia Network, a consortium of North American pediatric centers. This report has a number of strengths. The data collection and analysis plan was generally thoughtfully constructed. There is a good degree of detail and new information regarding how procedures are performed and regarding most adverse events. The methodology for data gathering is likely to be fairly complete for intraoperative serious adverse events and for events occurring during patients’ inpatient stay. There are several scenarios that could potentially lead to underreporting of peripheral nerve injuries, most notably partial nerve injuries in nonverbal or nonambulatory children that might evade detection by parents and physicians. For example, a thoracic nerve root or an intercostal nerve injury following thoracic epidural or thoracic paravertebral block might not be detected in a preverbal child. In addition, for a patient in a cast, a deficit might not be apparent until days to weeks postoperatively. The methodology for postoperative surveillance in this registry is likely to omit some cases with delayed detection. Despite these possible sources for underreporting, the PRAN investigators make a good case for the overall very good safety of pediatric neuraxial and peripheral blocks as performed by clinicians in these hospitals. In contrast to the conclusion of the PRAN investigators that “nothing really bad happened,” Meyer et al. showed admirable courage and forthrightness in reporting on 4 cases of neurologic injury following epidural anesthesia in children. All 4 cases involve care by experienced anesthesiologists with extensive experience in pediatric epidural analgesia and acute and chronic pain management. Based on the incomplete information available in this case report, we would tend to agree with the authors’ general contention that there was “absence of proof of medical negligence.” A more important question, which the authors have addressed in their discussion, might be phrased as follows: “Based on these cases and other available knowledge, do we have ways to modify our practice to prevent similar complications in the future?” We consider the 4 cases in this light, taking advantage of “20–20 hindsight.” Among the 4 cases, case 1 was perhaps the most frightening, because the patient was healthy and uncomplicated, the epidural catheter placement proceeded uneventfully at a lumbar level below the terminus of the spinal cord, the duration of general anesthesia was short, and there were no hemodynamic clues intraoperatively to raise concerns. The test dose was appropriate (0.1 mL/kg). E EDITORIAL

Evaluation of Three Anesthesic Techniques in Breast Surgery

INTRODUCTION: The importance of breast surgeries can be observed in the current context in which the increasingly growing number of restorative procedures and plastic surgeries in Brazil. To perform the various surgeries, several anesthesic techniques are used as general anesthesia, thoracic epidural or more recently, thoracic paravertebral block. Thus, it is essential to know about the safety of each anesthesic technique in these surgeries, which led to the realization of this review. OBJECTIVES: Analyze the benefits and complications of general anesthesia, thoracic epidural and paravertebral block in breast surgery. MATERIAL AND METHODS: We used the keywords “breast surgery general anesthesia”, “breast surgery thoracic epidural anesthesia” and “breast surgery thoracic paravertebral block” to draw up this systematic review of literature. The databases searched were PubMed, SciELO, MEDLINE, LILACS and Cochrane Library. The articles were selected using the following inclusion criteria: Medical journals from 1995 to 2011, in the languages English, Spanish and Portuguese, in order of relevance and study design of randomized controlled trials and cohort. The pre-selected articles were assessed individually by two reviewers and evaluated on their methodological quality by the Jadad scale, and were scored according to the criteria of randomization, blinding and accountability of all patients, including withdrawals. RESULTS: Fifteen articles were included in this review. The benefits of thoracic epidural anesthesia were better quality of postoperative analgesia, lower length hospitalization and the consumption of analgesics was also lower than general anesthesia. Hypotension and bradycardia were reported as possible complications. General anesthesia was more frequent reported with nausea, hypertension and vomiting. When associated with thoracic paravertebral block, promoted analgesia and anesthesia with lower complications than when applied as single anesthesic technique, as lower intensity of postoperative pain, less nausea and vomiting and less anesthesic recovery time. There are no studies that prove the effectiveness of paravertebral block when used without general anesthesia association. CONCLUSION: The epidural technique, despite its complications, remains the best option for regional block, and with general anesthesia, are the most commonly anesthesic techniques performed in breast surgeries, since evidence is lacking to prove the effectiveness of using thoracic paravertebral block in a patient who is not sedated. More research on the effectiveness of such techniques not associated with general anesthesia should be performed.

Intercostal nerve block in pediatric minimally invasive thoracic surgery

Background. Very severe postoperative pain is observed after minimal­ ly invasive repair of pectus excavatum (MIRPE), extremely in the early postoperative period. Pain is usually managed by either thoracic epidu­ ral block (TEB) or intravenous patient-controlled analgesia (PCA) with opioids. But the issue of optimal pain management is still controversial. The purpose of our study was to investigate efficiency and side effects of intercostal nerve block (ICNB) in children after MIRPE in comparison with only PCA. Materials and methods. Records of 20 patients, given PCA with mor­ phine (PCA group), were examined retrospectively. 27 patients, given in­ traoperative ICNB (single shot) and PCA with morphine (ICNB group), were examined prospectively. Postoperatively, we recorded morphine consumption, pain scores and side effects every 3 hours. Results. There was no need of the initial dose of morphine in the ICNB group. Pain scores during the first 3 hours, morphine consumption dur­ ing the first 3 hours and during 12 hours after surgery were significantly higher in the PCA group (p

Efficacy of nerve stimulator-guided thoracic paravertebral block in patients undergoing segmental mastectomy

Objective To evaluate the efficacy of nerve stimulator-guided thoracic paravertebral block in patients undergoing segmental mastectomy.Methods Fifty ASA Ⅰ or Ⅱ female patients,aged 18-64 yr,with body mass index ＜ 24 kg/m2,undergoing segmental mastectomy,were randomly divided into 2 groups ( n =25 each):thoracic epidural block group (group A) and nerve stimulator-guided thoracic paravertebral block group (group B).In group A,an epidural catheter was placed at T3,4 interspace and 0.5％ ropivacaine 7-10 ml was administrated via the epidural catheter.In group B,thoracic paravertebral block was performed at T4 under the guide of the nerve stimulator and 0.5％ ropivacaine 25 ml was administrated.The perioperative adverse cardiovascular events (hypotension and bradycardia) were recorded.Shivering,chest distress,and dyspnea during operation and nausea and vomiting after operation were also recorded.The range of block on the operated side was determined by pinprick test.The efficacy of anesthesia was evaluated.Results The incidence of shivering,chest distress,and dyspnea during operation and nausea and vomiting after operation was significantly lower in group B than in group A (P ＜ 0.05).Adverse cardiovascular events and respiratory depression were not found in the two groups.There was no significant difference in the range of block on the operated side in the two groups ( P ＞ 0.05).The satisfactory anesthesia was found in 100％ of cases.Conclusion Nerve stimulator-guided thoracic paravertebral block can be safely and effectively used in patients undergoing segmental mastectomy and the efficacy is better than that of thoracic epidural block. Key words: Nerve block; Thoracic vertebrae; Transcutaneous electric nerve stimulation; Mastectomy,segmental

Post-thoracotomy chronic pain - comparison of two locoregional techniques for postoperative analgesia: thoracic epidural and thoracic paravertebral block

Post-thoracotomy chronic pain - comparison of two locoregional techniques for postoperative analgesia: thoracic epidural and thoracic paravertebral block

Differential Epidural Block Predicts the Success of Visceral Block in Patients with Chronic Visceral Abdominal Pain

Differential thoracic epidural regional block, also known as a differential neural block (DNB), involves the placement of an epidural catheter placed in the thoracic epidural space to achieve appropriate anesthesia in a dermatomal distribution. This is a retrospective case series evaluating how well a DNB may predict success of subsequent visceral blockade in patients with chronic abdominal pain of visceral origin. Of 402 patients who had a DNB performed for unexplained abdominal pain from January 2000 to January 2009, 81 patients were found to have results consistent with visceral pain and thus underwent subsequent visceral blockade. Basic demographic data, years of chronic pain, history of psychosocial issues, initial visual analog scale (VAS) pain score, pain location, and medication usage were documented in our electronic medical record database. Parameters regarding DNB and visceral blocks also were documented. Descriptive statistics were computed for all variables. The positive predictive value (PPV) for DNB for whom visceral block was successful (at least a 50% reduction in VAS) was calculated. Additionally, subjects with successful visceral blocks were compared to those with unsuccessful visceral blocks. All patients with chronic abdominal pain with normal gastrointestinal studies who underwent DNB. Tertiary Outpatient Pain Management Clinic. Retrospective Cohort Study. Mean age of patients was 46 (± 15) years, 73% were female, and median duration of pain was 5 years. 67% of subjects were taking opioid analgesics. PPV of DNB was 70.4%. Only factor found to be statistically significant with visceral block success was baseline VAS with higher scores associated with DNB predictive success (6.8 ± 1.7 vs. 5.5, 1.8; P = 0.004). Use of membrane stabilizing medications was significantly more common in subjects for whom visceral block was not successful (46% vs. 25%; P = 0.058). Area underneath curve (AUC) for VAS was found to be 0.70 (95% CI: 0.57, 0.82), which signifies fair discrimination. Differential neural block is fairly predictive of subsequent visceral block success in patients with chronic abdominal pain of visceral origin. An initial VAS ≥ 5 provides a sensitivity of 93%, which implies that VAS < 5 may predict unsuccessful visceral block. Contrarily, a value of ≥ 8 would provide a specificity of 92% and may be used to predict success of subsequent visceral block.

Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain

Thoracic epidural and paravertebral blocks provide adequate analgesia for postoperative thoracotomy pain. Both procedures are usually performed percutaneously with considerable failure rates. A subpleural catheter placed in the space posterior to the parietal pleura and alongside the paravertebral area may provide superior postoperative pain relief. To compare subpleural analgesia with thoracic epidural analgesia in patients undergoing thoracotomy. Randomised, double-blind study. A tertiary care University Medical Centre between 26 June 2008 and 21 March 2011. Forty-two patients scheduled for elective posterolateral thoracotomy. Patients with American Society of Anesthesiologists physical status ≥4, with a previous history of thoracotomy, on chronic pain medications or with a contraindication to receiving local anaesthetics or thoracic epidural block were excluded from the study. Patients were randomised to receive either subpleural analgesia or thoracic epidural analgesia for 24-h post-thoracotomy pain control. A visual analogue scale was used to assess pain at rest and on coughing during the first 24 h postoperatively and the incidence of hypotension was recorded. Patients who received subpleural analgesia had higher visual analogue scores at rest and on coughing than those who received thoracic epidural analgesia. Seven patients who started with subpleural analgesia were treated with thoracic epidural analgesia at a mean (SD) of 3.9 (4.8) h. The remaining 14 patients had a median (IQR [range]) visual analogue score of 5 cm (4-5 [3-6]) at rest and were maintained on subpleural analgesia until the end of the study. The visual analogue score at rest was <7 cm in all 21 patients who received thoracic epidural analgesia and none was switched to subpleural analgesia during the study. None of the patients in the subpleural analgesia group experienced hypotension compared with five of the 21 patients in the thoracic epidural analgesia group (P=0.047). Thoracic epidural analgesia is superior to subpleural analgesia in relieving post-thoracotomy pain.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n=20), remifentanil and clonidine intravenously (clonidine group, n=20), or ropivacaine epidurally (ropivacaine group, n=20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study

To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

Perioperative Analgesia for Patients Undergoing Open Liver Resection: Epidural or Paravertebral?

Open liver resection is a painful surgery, and patients clearly benefit from regional anesthesia for pain management in the perioperative period. However, it is still unclear which regional block technique is superior in these patients. Epidural Analgesia in Open Liver Resection Although simple liver resection is increasingly done laparoscopically, patients with large liver masses or previous abdominal surgery often undergo an open liver resection. This requires a long right subcostal incision, the associated pain of which may carry significant morbidity in the post-operative period. The best-studied regional technique in abdominal as well as thoracic procedures is thoracic epidural block. Decreasing nociceptive input via epidural analgesia reduces activation of sympathetic outflow, thus reducing surgical stress, which negatively impacts many organ systems (1). Epidural analgesia decreases pain-related tachycardia and hypertension, which could cause perioperative myocardial ischemia. Furthermore, thoracic and upper abdominal nociceptive input activates reflex inhibition of diaphragmatic excursion and increased expiratory intercostal and abdominal muscle tone, leading to increased atelectasis and risk of pneumonia. One study of 915 major abdominal surgical patients revealed that epidural analgesia both decreased pain scores in the first three postoperative days and decreased rates of respiratory failure (2). Interestingly, a handful of studies have also documented a positive impact of epidural analgesia on the coagulation profile, which prevents post-operative thromboembolic complications (1). Other benefits include a decrease in stress-induced gastrointestinal disruption and immunosuppression. Moreover, in patients undergoing open liver resection, epidural technique resulted not only in improved analgesia, but also in decreased postoperative morphine consumption (3), the latter of which is an additional benefit of epidural analgesia, given the potentially deleterious side effects associated with intravenous (IV) opioids (i.e., respiratory depression, decreased gastrointestinal motility). Indeed, epidural analgesia was sufficient for 80% of patients undergoing open liver resection in another study, with only 20% of patients requiring additional analgesia with IV opioids (4).