Thoracic Paravertebral Analgesia Research Articles

A Randomized Comparison of Plasma Levobupivacaine Concentrations Following Thoracic Epidural Analgesia and Subpleural Paravertebral Analgesia in Open Thoracic Surgery.

Background: The aim of this study was to compare plasma levobupivacaine concentrations in thoracic epidural and subpleural paravertebral analgesia. Methods: Forty-four patients indicated for open lung resection had an epidural catheter inserted preoperatively or a subpleural catheter surgically. A bolus of 0.25% levobupivacaine at a dosage of 0.5 mg × kg−1 was given after the thoracotomy closure. Plasma levobupivacaine level at 30 min was the primary outcome. Pharmacokinetic modeling was performed subsequently. Secondary outcomes included the quality of analgesia, complications, and patients’mobility. Results: Plasma concentrations were similar 30 min after application—0.389 mg × L−1 in the epidural and 0.318 mg × L−1 in the subpleural group (p = 0.33) and lower in the subpleural group at 120 min (p = 0.03). The areas under the curve but not maximum concentrations were lower in the subpleural group. The time to reach maximum plasma level was similar in both groups—27.6 vs. 24.2 min. No clinical symptoms of local anesthetic toxicity were recorded. Conclusions: Levobupivacaine systemic concentrations were low in both groups without the symptoms of toxicity. This dosage should be safe for postoperative analgesia after thoracotomy.

Arts on tailored postoperative analgesia after video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery (VATS) has been widely used in recent decades. However, VATS, although different from an open thoracotomy, causes intense pain (1,2). In some individuals, it remains one of the most painful surgical procedures possible. Poor postoperative pain control after VATS may prolong hospitalization duration and result in the development of chronic persistent pain after surgery (3) However, for different pain sensations after VATS, multimodal analgesia, with or without conventional thoracic epidural or paravertebral analgesia, has become the mainstay for achieving adequate analgesia.

Postoperative Pain Management Strategies and Delirium After Transapical Aortic Valve Replacement: A Randomized Controlled Trial

This study was designed to compare 2 different perioperative analgesia strategies with respect to the incidence of postoperative delirium after a transapical approach for transcatheter aortic valve replacement (TAVR). The authors hypothesized that perioperative thoracic paravertebral analgesia with a local anesthetic would decrease opioid consumption and in turn reduce the incidence of postoperative delirium when compared with systemic opioid-based analgesia after a transapical TAVR procedure. Prospective, randomized controlled clinical trial. Tertiary referral center, university hospital. The study comprised 44 patients undergoing a transapical TAVR procedure. Patients with a history of serious mental illness, delirium, and severe dementia and/or patients with contraindications to regional anesthesia were excluded. Patients were randomly assigned to either the paravertebral group (perioperative continuous thoracic paravertebral block with local anesthetic) or the patient-controlled analgesia group (systemically administered opioids) using a computer-generated randomization code in blocks of four patients. Assessment of postoperative delirium was performed by trained research staff using the confusion assessment method for intensive care unit preoperatively and postoperatively every 12 hours or more often if needed according to the patient's condition during the first 7 postoperative days or until discharge. Pain was assessed with a 10 cm Visual Analog Scale pain score system during the 48 hours postoperatively. The sedation level was assessed using the Sedation Agitation Scale during the same period. Overall postoperative delirium was detected in 12/44 (27%) patients, with 7/22 (32%) in the patient-controlled analgesia and 5/22 (23%) in the paravertebral groups, respectively (p = 0.73). Both groups were similar with respect to demographic data, preoperative medications, and comorbidities. Paravertebral analgesia was associated with an opioid-sparing effect during surgery and during the 48-hour postoperative period. Sedation and pain scores were similar between the 2 groups. In addition, paravertebral analgesia was associated with earlier extubation times; however, the overall morbidity and mortality were similar between the 2 groups. Paravertebral analgesia in patients undergoing transapical TAVR procedures appears to have an opioid-sparing effect. However, it did not translate into a statistically significant decrease in the rate of postoperative delirium.

Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: A randomised controlled trial.

The benefit of adding opioid to a local anaesthetic for continuous thoracic paravertebral analgesia after video-assisted thoracic surgery (VATS) is unclear. To analyse the analgesic efficacy of ropivacaine and sufentanil in combination compared with ropivacaine alone after VATS. A randomised, double-blinded, single-centre clinical trial. A tertiary university hospital between March 2010 and April 2014. Ninety patients were recruited, two were not included leaving 88 randomised into two groups. Eighteen patients were excluded from analysis and 70 completed the study. To receive thoracic paravertebral analgesia with either 2 mg ml ropivacaine and 0.25 μg ml sufentanil (ropivacaine + sufentanil group) or 2 mg ml ropivacaine alone (ropivacaine group) for 48 h postoperatively. Infusion rate was set at 0.15 ml kg h in both groups. The primary endpoint was the mean total amount of self-administered morphine by the patients in each group at 48 h postoperatively. The mean ± SD total amount of self-administered morphine was not significantly different between groups (53.1 ± 27.2 mg in the ropivacaine + sufentanil group vs. 58.8 ± 34.3 mg in the ropivacaine group; P = 0.72). No significant differences were found between the two groups in either pain scores at rest or during movement, in opioid-related adverse reactions, in patient satisfaction or length of hospital stay. Adding 0.25 μg ml sufentanil to 2 mg ml ropivacaine in continuous thoracic paravertebral analgesia for VATS did not reduce morphine consumption or pain scores when compared with ropivacaine alone. We cannot recommend its use for routine clinical practice. Further studies analysing different concentrations and infusion rates of sufentanil are needed before a lack of efficacy can be confirmed. Clinical trial registrations: EudraCT: 2009-014832-38. ClinicalTrials.gov: NCT 01082744.

Investigation of single-dose thoracic paravertebral analgesia for postoperative pain control after thoracoscopic lobectomy – A randomized controlled trial

BackgroundThoracoscopic lobectomy is less painful than normal thoracotomy, but pain management is still an issue in the postoperative period. Thoracic epidural analgesia (TEA) is considered as the gold standard for post-thoracotomy pain control, but is associated with numerous risks. MethodsA total of 114 patients undergoing thoracoscopic lobectomy were randomly divided into three groups. Patients in the PVB-R group received a single-dose 0.5% ropivacaine paravertebral block (PVB), combined with patient-controlled intravenous analgesia (PCIA) after extubation during the 48-h postoperative period; those in the PVB-RD group received a single-dose 0.5% ropivacaine and dexmedetomidine (1 μg/kg) PVB, combined with the same PCIA scheme; and those in the TEA group received intraoperative thoracic epidural anesthesia with 0.5% ropivacaine, and a single dose of epidural morphine (0.03 mg/kg) after extubation combined with the same PCIA scheme. The dose and first time of postoperative analgesia, verbal rating score (VRS), change in catecholamine, cortisol and cytokine levels, change in hemodynamic parameters, and side effects during the postoperative period were recorded. ResultsCompared to the PVB-R group, the dose of postoperative analgesia and VRS were lower and the first time of postoperative analgesia were longer in the PVB-RD and TEA group. Patients in the PVB-RD group had a lower incidence of side effects compared to those in the TEA group. ConclusionsSingle-dose 0.5% ropivacaine combined with dexmedetomidine (1 μg/kg) PVB provides satisfactory postoperative pain control after thoracoscopic lobectomy, and can reduce the incidence of postoperative side effects.

Efficacy of dexmedetomidine applied with ropivacaine for thoracic paravertebral blockade in thoracotomy

Objective To explore the analgesic efficacy of dexmedetomidine(Dex) applied with ropivacaine for thoracic paravertebral nerve blockade(TPVB) in thoracotomy. Methods Thirty patients undergoing thoracotomy were randomly divided into two groups(15 patients in each). Patients in one group (group TL) received 0.35% ropivacaine 30 ml for TPVB, while the other group ( group TDL) received 1 μg/kg Dex added into 0.35% ropivacaine 30 ml for TPVB. Thoracic paravertebral patient-controlled analgesia(PCA) was carried out up till 36 h after surgery. The tenderness thresholds on 1 day before surgery, and 12, 24, 48 h and 72 h after surgery were recorded. The consumption of general anesthetics(propofol and remifentanil) during the surgery were also recorded. The incidence of side-effects related to analgesia in the first 3 d after surgery were analyzed. Results The tenderness threshold 24 h and 48 h after surgery in group TDL were significantly higher than in group TL (P<0.05) . Additionally, the intraoperative consumption of Propofol[ (251±13) mg/h vs (211±18) mg/h]and remifentanil[ (0.49±0.05) mg/h vs (0.42±0.04) mg/h]were less than that in group TDL(P<0.05). Conclusions Application of Dex with ropivacaine for continuous TPVB in thoracotomy can relieve postoperative pain. Key words: Dexmedetomidine; Ropivacaine; Field block; Thoracic vertebra; Perioperative; Analgesia

Propensity score‐matched outcomes after thoracic epidural or paravertebral analgesia for thoracotomy

It is not known which regional analgesic technique is most effective or safest after open lung resection. We retrospectively examined outcomes in 828 patients who received thoracic epidural analgesia and 791 patients who received paravertebral block after lung resection between 2008 and 2012. We analysed outcomes for 648 patients, 324 who had each analgesic technique, matched by propensity scores generated with peri-operative data. There were 22 out of 324 (7%) postoperative respiratory complications after thoracic epidural and 23 out of 324 (7%) after paravertebral block, p = 0.88. For any postoperative complication, there were 80 out of 324 (25%) and 78 out of 324 (24%) complications, respectively, p = 0.85. There were 17 out of 324 (5%) re-admissions to intensive care after thoracic epidural and 17 out of 324 (5%) after paravertebral block, p > 0.99, and the number of deaths before discharge were 6 out of 324 (2%) and 4 out of 324 (1%), respectively, p = 0.53. There was no significant difference in median (IQR [range]) hospital stay after thoracic epidural or paravertebral block, 6 (5-9 [2-94]) days vs. 6 (5-9 [2-122]), respectively, p = 0.83. Our study suggests that rates of complications as well as length of hospital stay after thoracic epidural analgesia and paravertebral blockade are similar. We were unable to compare analgesic efficacy due to incomplete data.

Ultrasound-guided continuous thoracic paravertebral analgesia with bupivacaine versus continuous intravenous morphine infusion for unilateral multiple fracture ribs

Background Rib fractures are common, and pain from rib fractures can be difficult to control, particularly in first few days. This pain may affect the pulmonary functions, morbidity, and mortality. Objective The aim of this study was to compare and evaluate the efficacy of ultrasound-guided continuous thoracic paravertebral block (USG-TVPB) using bupivacaine versus continuous intravenous morphine infusion (IVMI) in pain relief for patients with unilateral multiple fractured ribs (UMFRs) and on pulmonary function improvement. Patients and methods The study included 70 ICU patients of both sexes, aged 18–60 years with ASA physical status class I to III who had unilateral three or more ribs fracture. According to the conducted method for relief of fracture rib pain, these patients were assigned into two equal groups with 35 patients in each. The first group patients (USG-TPVB) received ultrasound-guided thoracic paravertebral analgesia using bupivacaine. The second group patients (IVMI group) received intravenous morphine infusion. The recorded data included patients demographic variables, pain severity, pulmonary mechanics, arterial blood gases, hemodynamic changes, analgesic request/day, total rescue morphine analgesic dose, and total ketorolac dose over 4 days of ICU stay, and hospital stay durations, and adverse effects. Results After the start of analgesic regimen, the patients who received continuous thoracic paravertebral bupivacaine infusion (USG-TPVB group) were significantly better than those received continuous IV morphine infusion (IVMI group), where the forced vital capacity was significantly higher in USG-TPVB group than in IVMI group at 30 min, 24 h, and 48 h (P Conclusion Ultrasound-guided continuous thoracic paravertebral analgesia with bupivacaine provided better pain control with improved pulmonary functions than continuous systemic intravenous morphine analgesia in unilateral multiple rib fractures with less rescue analgesic requests, shorter length of ICU stay, and less adverse effects.

Intravenous versus Ultrasound Guided Thoracic Paravertebral Morphine-Dexmedetomidine Combination in Patients with Multiple Rib Fractures

Background: Severe pain caused by multiple rib fractures (MRF) can compromise oxygenation, ventilation and pulmonary functions so can affect patient outcome. Adequate pain control helps to avoid these complications. Thoracic paravertebral analgesia is comparable to thoracic epidural with fewer side effects. Methods: Seventy-five patients were randomly allocated into three groups, (n=25 each). Group (GM) received intravenous morphine with a loading dose of 0.1-0.2 mg/kg followed by PCA bolus of 1mg with a six min lockout. Group (GMD) received also intravenous morphine with a loading dose of 0.1-0.2 mg/kg then PCA bolus of 1 mg morphine plus 5 μg dexmedetomidine with a six min lockout. Group (GPV) received paravertebral morphine loading dose of 0.2 mg/kg then PCA bolus of 0.1 ml/kg of a solution with a concentration of 0.5 mg/ml morphine mixed with 1 μg/ml dexmedetomidine and 60 min lockout. Any patient with VAS score more than 4, a top-up dose was given until VAS ≤ 4 Results: No significant difference between the three groups as regards age, BMI, sex, and ASA. Road traffic accident was the main cause of blunt chest trauma (64%, 76% and 68% in GM, GMD, and GPV respectively). Total morphine requirements were significantly lower in GMD and GPV than GM and in GPV than GMD (GM=190.9 ± 45.26, GMD=117.1 ± 31.9 and GPV=86.2 ± 21.7). There was a significant decrease in nausea and vomiting in GMD and GPV than GM. No significant difference in RR between the three groups although 8 patients in GM developed respiratory depression which was significantly higher than in GMD (2 patients) and GPV (0 patient). No significant difference in HR, MAP, and SpO2 between the groups. VAS scores at rest and with cough were significantly lower in both GMD and GPV than GM. FVC, FEV1 and PaO2/FiO2 ratio were significantly increased and PaCO2 significantly decrease in GMD and GPV than GM. Conclusion: Adding dexmedetomidine to morphine either TPV or IV PCA significantly decreases VAS scores, improves pulmonary functions and also decrease morphine consumption with fewer side effects in patients with MRF.

Thoracic Paravertebral Analgesia for Treatment Blunt Chest Trauma with Multiple Rib Fractures

Multiple rib fracture (MRF) causes severe pain that compromise respiratory mechanics. We evaluated the efficacy of thoracic paravertebral block with bupivacaine -fentanyl mixture in patients with unilateral MRF. The study was carried out on 172 blunt chest trauma patients in prospective nonrandomized case series. An initial bolus dose of 0.3 ml/kg of bupivacaine 0.25% plus fentanyl 2 μg/ml was used following by continuous infusion with 0.1 ml/kg/h of bupivacaine 0.125% plus fentanyl 2 μg/ml. Pain severity was assessed by visual analogue scale (VAS) at rest and during coughing; bedside spirometry was measured 5 times in 3 consecutive days after paravertebral block. Traffic accidents (69.1%) was major reason for blunt chest trauma; the number of ribs fracture ranged from 3-5 (76.1%) and 6-8 (23.9%). The rate of hemothorax, pneumothorax and the combination hemothorax-pneumothorax were 64.5%, 7.6% and 27.9% respectively. There was significant improvement in pain score at rest and during coughing, respiratory rate, FVC and FEV1 (p<0.05) 30 min after initial bolus dose, which were sustained during continuous thoracic paravertebral infusion 72 h (p<0.05). The rate of analgesic rescue by paracetamol infusion was 6.4%. No patient had respiratory depression or respiratory failure or signs of local anesthetic toxicity. The result shows that thoracic paravertebral analgesia with bupivacaine and fentanyl provided a good efficacy for pain management in patients with unilateral MRF.

Intraoperative haemodynamic stability and stress response to surgery in patients undergoing thoracotomy: comparison between ultrasound-assisted thoracic paravertebral and epidural block

Objectives and aim Thoracotomy is a procedure usually associated with severe postoperative pain. This study aimed to evaluate intraoperative haemodynamics and stress response to thoracotomy in patients receiving thoracic epidural or thoracic paravertebral block. Patients and methods Sixty patients undergoing elective thoracotomy were randomly allocated into two equal groups: the thoracic paravertebral analgesia (TPVA) group, which received ultrasound-assisted thoracic paravertebral catheter, and the thoracic epidural analgesia (TEA) group, which received ultrasound-assisted thoracic epidural catheter. The primary outcome was the measuring of stress response to surgery using plasma cortisol level. The secondary outcomes included intraoperative haemodynamic parameters, visual analogue pain score and postoperative complications. Results Heart rate showed significantly lower values in the TEA group compared with the TPVA group. The mean arterial blood pressure showed significantly lower values in the TEA group compared with the TPVA group. In both groups, there was a significant increase in plasma cortisol level after surgical stress compared with basal values. Moreover, there were significantly lower values in the TPVA group compared with the TEA group at 2 h after surgical incision, 2 h postoperatively and 24 h postoperatively. Visual analogue pain score was noncomparable in both groups at all measurement timepoints. As regards complications, group TPVA had less complications compared with group TEA. Conclusion Thoracic paravertebral block is an effective analgesic technique showing greater haemodynamic stability and less stress response to surgery compared with epidural analgesia in patients undergoing thoracotomy.

Comparison of thoracic epidural and paravertebral analgesia for postoperative pain control after thoracotomy

In the present randomized, controlled, and blinded study, the effects of thoracic paravertebral analgesia were compared to those of epidural analgesia on postoperative pain, hemodynamics, and respiration rate following thoracotomy. Patients scheduled for elective open-lung surgery were included. One hour prior to surgery, thoracic epidural catheters were used in 18 patients (ED group), and ultrasound-guided paravertebral catheters were used in 17 patients (PV group). Standard general anesthesia was administered to all. Following anesthesia, postoperative analgesia of levobupivacaine 0.1% and morphine 0.1 mg mL-1 was administered via catheter. Patient-controlled analgesia (PCA) regime with tramadol was initiated, and amounts of local anesthetics and tramadol demanded and delivered within the first 24 hours were recorded. Visual analog scale (VAS) pain score, sedation score, side effects, and vital signs (blood pressure, heart rate, and respiratory rate) were assessed by an observer blinded to patient data at 1, 2, 3, 4, 6, 12, and 24 hours. Differences in PCA bolus demands and deliveries were not statistically significant between the PV group (26.8±1.3 and 33.1±4.5) and the ED group (25.1±3.5 and 32.5±4.3). Neither were differences in VAS scores statistically significant (p=0.3). Rates of sedation among the PV group were lower than those of the ED group at 1 hour (p=0.001). Five patients in the ED (%28) group experienced hypotension (p=0.02). Paravertebral block with levobupivacaine 0.1% and morphine 0.1 mg mL-1 may be an alternative form of pain relief following thoracotomy.

Thoracic Paravertebral Block for Postoperative Analgesia in Pediatric Oncology

Objective: to enhance the efficiency and safety of anesthesia during thoracic surgical interventions in pediatric cancer surgery, by using general anesthesia in combination with thoracic paravertebral analgesia. Subjects and methods. A prospective, randomized trial was conducted. Intra- and postoperative data were analyzed in 90 patients who had been operated on for lung and thoracic malignancies. There were two patient groups: 1) 50 children who used continuous thoracic paravertebral block (PVB) with ropivacaine 0.3% as part of combined balanced anesthesia and 2) 40 children who received epidural block with ropivacaine 0.2% as an analgesic component of combined anesthesia. All the patients underwent hemodynamic monitoring; postoperative pain assessment were carried out by a visual analogue scale (VAS) in children above 3 years of age and by the modified Douleur Aigue du Nouveau-ne (DAN) scale in those below the age of 3 years. Results. The trial has demonstrated that the analgesic effect during continuous PVB in the intra- and postoperative periods is comparable with that of epidural block with ropivacaine 0.2%; however, it has a higher hemodynamic stability. Ultrasound guided PVB has sufficient safety. The postoperative complications were pneumonia in 2 (4%) patients in the PVB group; these were associated with the baseline patient status in 5 (12.5%) children in the epidural analgesia group. Postoperative nausea was found in only 6% of the patients in the PVB group. Conclusion. The proposed modification of ropivacaine 0.3% injection into the paravertebral space under ultrasound guidance can increase the extent of the local anesthetic, thus enhancing the efficiency of PVB. The efficiency of the block is 98.1% versus 86% of the given by foreign authors.

The comparative estimation of the efficiency of the intrapleural and thoracic paravertebral analgesia at the thoracoscopic surgeries

The comparative estimation of the efficiency of the intrapleural and thoracic paravertebral analgesia at the thoracoscopic surgeries

Eficacia del bloqueo paravertebral continuo como método analgésico en la toracotomía

Introduction Open thoracotomy is one of the surgical procedures that is still very painful in the postoperative period, which, in this type of surgery can have on respiratory function and subsequent recovery of the patient. Patients and method The aim of the study is to assess continuous paravertebral thoracic block as an analgesic technique in thoracotomy. A total of 139 patients undergoing pulmonary resection surgery by posterolateral thoracotomy received postoperative analgesia using a 1.5% lidocaine infusion (7–10 ml/h) through a thoracic paravertebral catheter for at least 48 h. Pain intensity measured on the visual analogue scale (VAS) both at rest (passive VAS) and during stimulated cough (active VAS) was recorded at time of discharge from the Recovery Unit, and on the second, third and fourth day post-surgery. Postoperative complications and the need for analgesic rescue were studied. Results On discharge from recovery, 98.6% of the patients had mild pain (passive VAS <3), 1.4% had moderate pain (passive VAS 4–6) and none with severe pain (EVA >6); on the 2nd day post-surgery, 97.9% had mild pain, and 1.2% moderate pain; on the third day 98.6% had mild pain and 0.7% moderate pain; and on the 4th day 100% had mild pain. There were no complications arising from the analgesic technique. Conclusions Continuous thoracic paravertebral analgesia is effective and safe in controlling post-thoracotomy pain.

Continuous paravertebral block as an analgesic method in thoracotomy

IntroductionOpen thoracotomy is one of the surgical procedures that is still very painful in the postoperative period, which, in this type of surgery can have on respiratory function and subsequent recovery of the patient. Patients and methodThe aim of the study is to assess continuous paravertebral thoracic block as an analgesic technique in thoracotomy. A total of 139 patients undergoing pulmonary resection surgery by posterolateral thoracotomy received postoperative analgesia using a 1.5% lidocaine infusion (7–10ml/h) through a thoracic paravertebral catheter for at least 48h. Pain intensity measured on the visual analogue scale (VAS) both at rest (passive VAS) and during stimulated cough (active VAS) was recorded at time of discharge from the Recovery Unit, and on the second, third and fourth day post-surgery. Postoperative complications and the need for analgesic rescue were studied. ResultsOn discharge from recovery, 98.6% of the patients had mild pain (passive VAS <3), 1.4% had moderate pain (passive VAS 4–6) and none with severe pain (EVA >6); on the 2nd day post-surgery, 97.9% had mild pain, and 1.2% moderate pain; on the third day 98.6% had mild pain and 0.7% moderate pain; and on the 4th day 100% had mild pain. There were no complications arising from the analgesic technique. ConclusionsContinuous thoracic paravertebral analgesia is effective and safe in controlling post-thoracotomy pain.

Thorakale Paravertebralblockade

Thoracic paravertebral block for postoperative pain control has been introduced more than a century ago. It is currently gaining increasing popularity. This simple and safe technique can be used for postoperative analgesia, as well as sole anesthetic technique. When compared to epidural analgesia for postthoracotomy pain control, thoracic paravertebral analgesia provides comparable analgesic efficacy, but less side-effects. Regarding concomitant use of anticoagulants and antiplatelet drugs, paravertebral blockade is considered a central nerve block.

Thoracic Paravertebral Block (Pvb) Analgesia

Paravertebral blockade is a safe and effective technique for intraoperative and postoperative management of acute surgical pain. The block may be performed as a single injection or a catheter may be inserted to allow for the continuous or bolus administration of a long acting local anaesthetic. This mode of analgesia is not considered to be a stand alone technique (in contrast to epidural analgesia) and most patients will require additional analgesia (usually parenteral patient controlled analgesia). Compared to epidural analgesia, the paravertebral administration of analgesia is considered to be safer in anti-coagulated patients, but the risk of local anaesthetic toxicity remains. There is little published about the care of patients receiving this form of analgesia. This article provides an overview of the technique of thoracic paravertebral analgesia, the choice of analgesics and side effects together with recommendations for patient care.

Transient Horner’s syndrome in an infant after continuous upper thoracic paravertebral analgesia

Transient Horner’s syndrome in an infant after continuous upper thoracic paravertebral analgesia

Intraoperative Harlequin Syndrome

To the Editor: Recently, Mashour et al. (1) described a patient who developed an intraoperative Harlequin syndrome after an asymmetric epidural anesthetic. We (2) reported a similar case of a patient who developed postoperative ipsilateral Horner’s syndrome with contralateral facial flushing and sweating after high thoracic paravertebral analgesia. We believe that upward migration of local anesthetic in the paravertebral space was followed by an interruption of the sympathetic outflow at the level of preganglionic fibers originating from T1–3 spinal segments which impaired the oculomotor, vasomotor, and sudomotor response to the face on to the blocked side. Consequently, the contralateral side appeared excessively flushed and sweaty in special environmental circumstances such as exposure to heat. A similar Harlequin appearance after low thoracic epidural analgesia was described recently by Crawley (3) and thought to be related to the rostral unilateral migration of the local anesthetic to the upper spinal segments after Trendelenburg’s positioning during surgery. The explanation for perioperative Harlequin syndrome (with or without Horner’s syndrome) after regional anesthesia in the vicinity of sympathetic outflow track appears, therefore, logical. The mystery resides in the rarity of this condition. Crina L. Burlacu, MSc, FCARCSI Donal J. Buggy, MD, MSc, FRCPI, FCARCSI, FRCA Department of Anaesthesia, Intensive Care and Pain Medicine Mater Misericordiae University Hospital Ireland [email protected]