Catheterization in an ultrasound-guided thoracic paravertebral block using thoracoscopy

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.

A Comparison of Puncture and Continuous Pump Analgesia With Two Different Approaches to Thoracic Paravertebral Block for Thoracic Surgery

Background

This study aims to compare the success rate of thoracic paravertebral block (TPVB) and the effect of postoperative analgesia between two approaches.

Methods

A total of 34 patients with American Society of Anesthesiology (ASA) physical status score II–III, undergoing an optional thoracoscopic surgery, were randomly assigned to a parasagittal approach group (group P, n = 17) and a transverse intercostal approach group (group T, n = 17). The catheterization time, success rate of the puncture and catheterization, block plane and effect at the surgical site were compared between two groups. The mean arterial pressure and heart rate were recorded, as well as the cold tactile block plane and numeric rating scale (NRS) at 0.5, 2, 4, 8, 12, 24, and 48 h after surgery. The study was registered at http://www.chictr.org.cn/showproj.aspx?proj=9624 (Registration number: ChiCTR2100054642).

Results

The catheterization time in group P was significantly longer than that in group T (P < 0.05). The success rate of catheterization in group P was lower than that in group T, but no statistical significance (P = 0.085). There was no significant difference in the success rate of Puncture and blocking effect of the surgical site at 30 min post-injection between two groups (P > 0.05). There was no significant difference in the cold tactile block plane and NRS scores during coughing between two groups at 0.5, 2, 4, 8, 12, 24, and 48 h postoperatively (P > 0.05).

Conclusion

This study suggests that there is no significant difference in postoperative block level or pain score during coughing for thoracoscopic surgery between ultrasound-guided parasagittal and transverse intercostal approach, but the parasagittal approach takes longer and has a higher failure rate.

Distribution of injectates in the thoracic paravertebral space of the dog and cat: A cadaveric study

Background:

Thoracic paravertebral block (TPVB) entails injecting a local anesthetic inside the thoracic paravertebral space (TPVS). Loss of resistance to air injection (air-LOR) was the first technique described in humans to locate the TPVS. To date, no study has investigated the spread of any substance after injection into the TPVS using the air-LOR technique nor has described the cranial and caudal limits of the space.

Aim:

To identify the boundaries of the TPVS, to determine whether the air-LOR technique is reliable for the identification of the TPVS and to examine the relationship between the volume of injectate and its spread.

Methods:

After a preliminary phase, the thorax of five cat and five dog cadavers was accessed and eviscerated. After TPVS probing, the polyurethane foam was injected, and the cranial and caudal borders were recorded after its maximum spread. Different volumes of a mixture of new methylene blue and ioversol were injected in the TPVS after its localization with a Tuohy needle and air-LOR technique in fourteen dog and six cat cadavers. Lateral radiographs of the vertebral column were used to document needle positioning, spread pattern and extension. The thorax of these subjects was then accessed and eviscerated to observe and record the spread of the mixture.

Results:

Injecting a dye into the TPVS, localized by an air-LOR technique, resulted in multi-segmental and often bilateral subpleural staining of paravertebral, intercostal, and dorsal mediastinal structures in dog and cat cadavers. The lateral radiographs most often showed a mixed cloud-like and linear spread pattern, which could be a predictor of the longitudinal spread of the dye. The foam injected into the TPVS at the cranial and the caudal level revealed anatomical communication with the cervical, axillar, and lumbar paravertebral regions.

Conclusion:

TPVS localization by air-LOR technique and injection results in a longitudinal multi-segmental spread in dog and cat cadavers. The communication of the TPVS with the axillary and lumbar regions could be of clinical interest for the brachial plexus and the lumbar intercostal nerve blocks in a clinical setting.

Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial

BACKGROUND

Although several approaches for ultrasound-guided thoracic paravertebral block have been introduced, little is known regarding the differences in analgesic efficacy. We conducted this prospective randomised trial to examine whether the type of approach for ultrasound-guided thoracic paravertebral block could affect analgesic quality in thoracotomy.

METHODS

Patients scheduled for video-assisted thoracotomy were randomly allocated into two groups by block technique: the intercostal approach (group IC) or the paralaminar approach (group PL). At the start and end of surgery, 20 mL of 0.5% ropivacaine was injected, followed by a continuous infusion of 0.2% ropivacaine at 5 mL h^-1 . We also started intravenous fentanyl patient-controlled analgesia at 0.5 μg kg^-1  h^-1 and bolus dose of 15 μg. The main outcome was the number of rescue fentanyl use. We also evaluated postoperative pain scores and number of blocked dermatomes showing a reduced sensation.

RESULTS

Enrolment was ceased because of implementation of a minimally invasive surgical method. Overall, 42 subjects completed the trial for analysis. The number of rescue fentanyl use in group PL was significantly less than that in group IC at 3, 6, 12 and 24 hour postoperatively. The numerical rating scale (NRS) at rest in group PL was significantly lower at 1, 3, 6, and 12 hour postoperatively. Patients in Group PL developed significantly wider sensory block level (median (IQR [range]); 4 (4-5 [2-7])) than those in Group IC (3 (3-3 [2-9])).

CONCLUSIONS

We suggested that paralaminar approach provided superior analgesia for thoracotomy rather than the intercostal approach.

T1 Paravertebral Catheter for Postoperative Pain Management After First Rib Resection for Venous Thoracic Outlet Syndrome: A Case Report

While it has been shown that a paravertebral block provides effective postoperative analgesia for patients undergoing thoracic surgeries, including first rib resection, this is the first reported case of a paravertebral catheter used for perioperative analgesia in a patient undergoing first rib resection. We present the case of a 76-year-old woman with right upper extremity swelling who underwent infraclavicular first rib resection for venous thoracic outlet syndrome. Continuous infusion of ropivacaine through a T1 paravertebral catheter, which was placed before induction of general anesthesia but after T1 and T2 paravertebral blocks, provided effective postoperative pain control. Our experience suggests that paravertebral catheter infusions of local anesthetics may be effective adjuncts to general anesthesia in patients undergoing first rib resection and warrants further investigation.

Comparison of Intrapleural with Paravertebral Levobupivacaine Analgesia for Thoracoscopic Sympathectomy: A Randomized Controlled Study

Background:

Palmar hyperhidrosis is a benign disease of excessive sweating in the palm that exceeds the physiological state. Thoracoscopic sympathectomy is an effective surgical treatment for localized hyperhidrosis.

Aims:

The aim of this study was to compare paravertebral block (PVB) with intrapleural analgesia in thoracoscopic sympathectomy.

Settings and Design:

A total of 90 patients physical status American Society of Anesthesiologists Classes I or II scheduled for arthroscopic thoracoscopic sympathectomy were enrolled in this study.

Subjects and Methods:

Patients were randomly allocated into three groups; in the controlled (C) group, no regional block was performed. In the intrapleural (I) group or paravertebral (P) group using a volume of 20 ml of levobupivacaine 0.5%. The first request for analgesia postoperatively was our primary concern. Secondary outcomes included pain scores, the cumulative consumption of fentanyl during the 1^st postoperative day, pulmonary functions, blood gases, and complications.

Statistical Analysis Used:

Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA).

Results:

First request of analgesia in paravertebral group was statistically significantly longer when compared with either control or intrapleural group. In addition, total fentanyl dose was significantly higher in control group when compared with the other groups. Groups I and P showed statistically significant less pain scores, better pulmonary function, and blood gases when compared with control group.

Conclusion:

We concluded that either intrapleural or paravertebral analgesia compared with control group in thoracoscopic sympathectomy resulted in later request of analgesia, improved pain control, reduced analgesic requirements postoperatively, preservation of lung function and acid-base balance. The PVB, compared to intrapleural, had an advantage of longer and effective analgesia.