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Naja Z, Kanawati S, Khatib ZE, Ziade F, Nasreddine R, Naja AS. Three versus five lumbar paravertebral injections for inguinal hernia repair in the elderly: a randomized double-blind clinical trial. J Anesth 2018; 33:50-57. [PMID: 30446826 DOI: 10.1007/s00540-018-2582-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/01/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of the study was to compare three nerve stimulator-guided paravertebral injections versus five injections for elderly patients undergoing inguinal hernia repair in terms of the amount of intraoperative fentanyl and propofol consumption and conversion to general anesthesia. The secondary objective was postoperative pain. METHODS A prospective, randomized, double-blind clinical trial was performed. 200 elderly patients undergoing unilateral herniorrhaphy were randomized into two groups. Group III received three PVB injections from T12 to L2 and placebo at T11 and L3. Group V received five PVB injections from T11 to L3. RESULTS The mean intraoperative fentanyl and propofol consumption were significantly lower in group V (4.9 ± 7.2 µg versus 20.0 ± 12.9 µg and 5.7 ± 11.6 mg versus 34.6 ± 22.9 mg, respectively, p value < 0.0001). Five patients (5.0%) in group III had failed block and were converted to general anesthesia (p value = 0.024). Group V had significantly lower pain scores compared to group III during the first three postoperative days (p value < 0.0001). CONCLUSION The five PVB injection technique is more suitable as a sole anesthetic technique for elderly patients undergoing herniorrhaphy, since it required less intraoperative supplemental analgesia and provided lower postoperative pain scores compared to the three PVB injection technique. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02537860.
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Affiliation(s)
- Zoher Naja
- Anesthesia and Pain Management Department, Makassed General Hospital, P.O. Box: 11-6301, Riad EI-Solh, Beirut, 11072210, Lebanon.
| | - Saleh Kanawati
- Anesthesia and Pain Management Department, Makassed General Hospital, P.O. Box: 11-6301, Riad EI-Solh, Beirut, 11072210, Lebanon
| | - Ziad El Khatib
- Surgery Department, Makassed General Hospital, Beirut, Lebanon
| | - Fouad Ziade
- Faculty of Public Health, Lebanese University, Beirut, Lebanon
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Thompson C, French DG, Costache I. Pain management within an enhanced recovery program after thoracic surgery. J Thorac Dis 2018; 10:S3773-S3780. [PMID: 30505564 DOI: 10.21037/jtd.2018.09.112] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Evidence for ERAS within thoracic surgery (ERATS) is building. The key to enabling early recovery and ambulation is ensuring that postoperative pain is well controlled. Surgery on the chest is considered to be one of the most painful of surgical procedures for both open and minimally invasive surgery (MIS) approaches. Increasing use of MIS and improved perioperative care pathways has resulted in shorter length of stay (LOS), requiring patients to achieve optimal pain control earlier and meet discharge criteria sooner, sometimes on the same day as surgery. This requires optimizing pain control earlier in the postoperative recovery phase in order to enable ambulation and a better recovery profile, as well as to minimize the risk for development of chronic persistent postoperative pain (CPPP). This review will focus on the options for pain management protocols within an ERAS program for thoracic surgery patients (ERATS).
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Affiliation(s)
- Calvin Thompson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel G French
- Division Thoracic Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ioana Costache
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Khetarpal R, Chatrath V, Kaur A, Jassi R, Verma R. Comparison of Spinal Anesthesia and Paravertebral Block in Inguinal Hernia Repair. Anesth Essays Res 2017; 11:724-729. [PMID: 28928578 PMCID: PMC5594797 DOI: 10.4103/aer.aer_251_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Inguinal hernia repair (IHR) is a common surgical procedure which can be performed under general, regional, or peripheral nerve block anesthesia. Aim: The aim of our study was to compare the efficacy of paravertebral block (PVB) with spinal anesthesia (SA) for IHR with respect to postoperative analgesia, ambulation, and adverse effects. Settings and Design: This was a prospective, single-blind randomized controlled trial. Materials and Methods: Sixty American Society of Anesthesiologists Class I–II patients of 20–60 years scheduled for IHR were randomized by a computer-generated list into two groups of thirty each, to receive either PVB (Group PVB: at T12–L2 levels, 10 ml of 0.5% levobupivacaine at each level) or SA (Group SA: at L3–L4/L2–L3 level, 2.5 ml of 0.5% levobupivacaine). Primary outcome was duration of postoperative analgesia and time to reach discharge criteria. Secondary outcome was time to ambulation, time to perform the block, time to surgical anesthesia, total rescue analgesic consumption, adverse effects, hemodynamic changes, patient, and surgeon satisfaction. Statistical Analysis Used: Student's t-test, Chi-square test as applicable, and Statistical Package for Social Sciences (version 14.0, SPSS Inc., Chicago, IL, USA) were used. Results: Time to the first analgesic requirement was 15.17 ± 3.35 h in Group PVB and 4.67 ± 1.03 h in Group SA (P < 0.001). Time to reach the discharge criteria was significantly shorter in Group PVB than Group SA (P < 0.001). Conclusion: PVB is advantageous in terms of prolonged postoperative analgesia and encourages early ambulation compared to SA.
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Affiliation(s)
- Ranjana Khetarpal
- Department of Anesthesiology and ICU, Government Medical College, Amritsar, Punjab, India
| | - Veena Chatrath
- Department of Anesthesiology and ICU, Government Medical College, Amritsar, Punjab, India
| | - Arminder Kaur
- Department of Anesthesiology and ICU, Government Medical College, Amritsar, Punjab, India
| | - Reeta Jassi
- Department of Anesthesiology and ICU, Government Medical College, Amritsar, Punjab, India
| | - Renu Verma
- Department of Anesthesiology and ICU, Government Medical College, Amritsar, Punjab, India
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Agarwal A, Batra RK, Chhabra A, Subramaniam R, Misra MC. The evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy. Saudi J Anaesth 2013; 6:344-9. [PMID: 23493523 PMCID: PMC3591552 DOI: 10.4103/1658-354x.105860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. METHODS FIFTY PATIENTS WERE INCLUDED IN THIS PROSPECTIVE RANDOMIZED STUDY AND ALLOCATED TO TWO GROUPS: Group A (25 patients) receiving general anesthesia alone and Group B (25 patients) receiving nerve-stimulator-guided bilateral thoracic Paravertebral Block (PVB) at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl (0.5 μg/kg) based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia (PCA) morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. RESULTS Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A (17.6 μg and 38.6 μg, respectively, P =0.001). PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A (4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P <0.0001 at all intervals). CONCLUSION Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects.
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Affiliation(s)
- Anil Agarwal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Abstract
Paravertebral blocks have been demonstrated to represent an interesting alternative to epidural, especially for the management of perioperative and trauma pain. Initially performed mostly as single-shot blocks for breast surgery, thoracotomy, and hernia repairs in adults and children, presently these blocks are also used for placement of a paravertebral catheter, either unilateral or bilateral. Although complications associated with the performance of these blocks are infrequent, the use of ultrasound-guided approaches, which allow performing the block under direct vision, is becoming the standard in most groups performing these blocks routinely.
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Affiliation(s)
- Jacques E Chelly
- Division of Acute Interventional Perioperative Pain and Regional Anesthesia, Department of Anesthesiology, University of Pittsburgh Medical Center, Presbyterian-Shadyside Hospital, PA 15232, USA.
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Cheung Ning M, Karmakar MK. Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours. Br J Radiol 2010; 84:785-9. [PMID: 21081575 DOI: 10.1259/bjr/28983063] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Percutaneous radiofrequency ablation (PRFA) of liver tumours performed under local anaesthesia and intravenous sedation can cause severe pain to patients. This prospective study evaluated the efficacy of a right thoracic paravertebral block (TPVB) for anaesthesia and analgesia during PRFA of liver tumours. METHODS 20 patients, aged 44-74 years, with liver malignancies received a multiple injection TPVB at the T6-10 levels 30 min before the PRFA. An intravenous infusion of propofol (3-5 mg kg(-1) h(-1)) was administered to patients who requested to be sedated and intravenous fentanyl (25 µg bolus) was administered as rescue analgesia. Pain during the TPVB and PRFA was assessed using a numerical rating scale (NRS; 0, no pain; 10, worst imaginable pain). Patients were also assessed for residual pain and analgesic consumption during the 24 h after the intervention. RESULTS The TPVB was well tolerated and produced ipsilateral sensory anaesthesia with satisfactory spread (median (range); 8 (6-11) dermatomes). The PRFA procedure caused mild pain (mean (standard deviation, SD); NRS 1.4 (1.9)) during the insertion of the ablation needle and the peak pain intensity during the therapeutic burn was moderate (mean (SD); NRS 5.0 (3.3)) in severity. During the 24 h after the PRFA, patients reported minimal pain and consumed very few analgesics. The mean (SD) satisfaction score (0, totally dissatisfied; 10, very satisfied) of the patients was 8.9 (1.1) and that of the radiologists was 8.8 (1.4). CONCLUSION A right TPVB is safe and effective for anaesthesia and analgesia during PRFA of malignant liver tumours.
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Affiliation(s)
- M Cheung Ning
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, People's Republic of China.
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Berta E, Spanhel J, Smakal O, Smolka V, Gabrhelik T, Lönnqvist PA. Single injection paravertebral block for renal surgery in children. Paediatr Anaesth 2008; 18:593-7. [PMID: 18482238 DOI: 10.1111/j.1460-9592.2008.02592.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous paravertebral block (PVB) has been successfully used for postoperative analgesia in children. However, data regarding the efficacy of a single injection technique for major renal surgery are still lacking. METHODS Following the ethics committee approval and parent informed consent, 24 children (median 10.3 months; range: 2.9-26.8) undergoing major renal surgery were included in a prospective observational pilot study. Following a standardized general anesthetic the patients were administered a single injection low thoracic PVB (loss-of-resistance technique; 0.5 ml.kg(-1) of levobupivacaine 2.5 mg.ml(-1) with epinephrine 5 mug.ml(-1)) at the end of surgery. Postoperative pain was assessed by Face, Legs, Activity, Cry, Consolability (FLACC) score at predetermined time points and in case of apparent patients' discomfort during the first 12 postoperative hours. The duration of postoperative analgesia was defined as the interval between PVB and the first supplemental administration of a rescue opioid analgesic. The incidence of complications and postoperative vomiting (POV) was also recorded. RESULTS A successful PVB was achieved in 23/24 patients (95.8%). The median duration of the block was 600 min (range: 180-720 min) with 10 children not requiring any supplemental analgesia during the 12-h observation period. Vascular puncture was observed in 2/24 children (8.3%) and POV occurred in 4/24 children (16.7%). All complications were considered minor and did not influence recovery. CONCLUSIONS Single injection PVB provided clinically relevant postoperative analgesia in children undergoing major renal surgery.
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Affiliation(s)
- Emil Berta
- Department of Anaesthesia and Intensive Care, University Hospital Olomouc, Olomouc, Czech Republic.
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Naja ZM, Raf M, El-Rajab M, Daoud N, Ziade FM, Al-Tannir MA, Lönnqvist PA. A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children. Anaesthesia 2006; 61:1064-8. [PMID: 17042844 DOI: 10.1111/j.1365-2044.2006.04833.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93%vs 69%) and surgeon satisfaction (93%vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.
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Affiliation(s)
- Z M Naja
- Department of Anaesthesia, Makassed General Hospital, Beirut, Lebanon
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Evans H, Steele SM, Nielsen KC, Tucker MS, Klein SM. Peripheral Nerve Blocks and Continuous Catheter Techniques. ACTA ACUST UNITED AC 2005; 23:141-62. [PMID: 15763416 DOI: 10.1016/j.atc.2004.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.
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Affiliation(s)
- Holly Evans
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA
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Carré P, Mollet J, Le Poultel S, Costey G, Ecoffey C. [Ilio-inguinal Ilio-hypogastic nerve block with a single puncture: an alterantive for anesthesia in emergency inguinal surgery]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:643-6. [PMID: 11530753 DOI: 10.1016/s0750-7658(01)00425-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The authors describe the anaesthetic procedure for a strangulated hernia repair needing resection and anastomosis of the small bowel in an adult patient. This procedure was performed with an ilio-inguinal/ilio-hypogastric nerve block according to a paediatrical simplified technique with a single puncture. For this patient who had relative contraindications for central blocks, this regional technique allowed to avoid general anaesthesia with its gastric aspiration and predictible difficult intubation risks. This block associated with a very light sedation was sufficient for all the surgical procedure, and postoperative analgesia was efficient over 3 hours. This simplified nerve block, better than the conventional approach for the clinical practice, represents a recommended alternative for hernia repair in emergency for high risk patients who could have a general anaesthesia or a central block.
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Affiliation(s)
- P Carré
- Service d'anesthésie réanimation chirurgicale 2, centre hospitalier universitaire Pontchaillou, 35033 Rennes, France.
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Greengrass RA. Regional anesthesia for ambulatory surgery. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2000; 18:341-53, vii. [PMID: 10935014 DOI: 10.1016/s0889-8537(05)70167-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ambulatory surgery is increasing at unprecedented rates with more complex procedures being performed. This article reviews the benefits of the use of regional anesthesia during ambulatory surgeries. Regional anesthesia, by putting the anesthetic at the surgical site, provides ideal conditions for ambulatory surgery and provides a smooth, predictable post-operative course.
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Affiliation(s)
- R A Greengrass
- Department of Anesthesiology, Duke Medical Center, Durham, North Carolina, USA
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Abstract
Local and regional block provides an effective means for the control of postoperative pain. In surgery involving the trunk, it serves as a useful alternative to epidural analgesia. With the increasing use of low molecular weight heparin, the use of peripheral nerve block is increasingly popular for patients undergoing lower limb surgery.
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Affiliation(s)
- P W Peng
- Department of Anaesthesia, University of Toronto, Ontario, Canada.
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