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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Ott S, Müller-Wirtz LM, Sertcakacilar G, Tire Y, Turan A. Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review. J Clin Med 2024; 13:1104. [PMID: 38398416 PMCID: PMC10889232 DOI: 10.3390/jcm13041104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/29/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.
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Affiliation(s)
- Sascha Ott
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Deutsches Herzzentrum der Charité-Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center, Saarland University Faculty of Medicine, 66424 Homburg, Germany
| | - Gokhan Sertcakacilar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, 34147 Istanbul, Turkey
| | - Yasin Tire
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, Konya City Hospital, University of Health Science, 42020 Konya, Turkey
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Zhu J, Wei B, Wu L, Li H, Zhang Y, Lu J, Su S, Xi C, Liu W, Wang G. Thoracic paravertebral block for perioperative lung preservation during VATS pulmonary surgery: study protocol of a randomized clinical trial. Trials 2024; 25:74. [PMID: 38254233 PMCID: PMC10801977 DOI: 10.1186/s13063-023-07826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) extend the length of stay of patients and increase the perioperative mortality rate after video-assisted thoracoscopic (VATS) pulmonary surgery. Thoracic paravertebral block (TPVB) provides effective analgesia after VATS surgery; however, little is known about the effect of TPVB on the incidence of PPCs. The aim of this study is to determine whether TPVB combined with GA causes fewer PPCs and provides better perioperative lung protection in patients undergoing VATS pulmonary surgery than simple general anaesthesia. METHODS A total of 302 patients undergoing VATS pulmonary surgery will be randomly divided into two groups: the paravertebral block group (PV group) and the control group (C group). Patients in the PV group will receive TPVB: 15 ml of 0.5% ropivacaine will be administered to the T4 and T7 thoracic paravertebral spaces before general anaesthesia induction. Patients in the C group will not undergo the intervention. Both groups of patients will be subjected to a protective ventilation strategy during the operation. Perioperative protective mechanical ventilation and standard fluid management will be applied in both groups. Patient-controlled intravenous analgesia is used for postoperative analgesia. The primary endpoint is a composite outcome of PPCs within 7 days after surgery. Secondary endpoints include blood gas analysis, postoperative lung ultrasound score, NRS score, QoR-15 score, hospitalization-related indicators and long-term prognosis indicators. DISCUSSION This study will better evaluate the impact of TPVB on the incidence of PPCs and the long-term prognosis in patients undergoing VATS lobectomy/segmentectomy. The results may provide clinical evidence for optimizing perioperative lung protection strategies. TRIAL REGISTRATION ClinicalTrials.gov NCT05922449 . Registered on June 25, 2023.
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Affiliation(s)
- Jiayu Zhu
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Biyu Wei
- Department of Anaesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, 101100, China
| | - Lili Wu
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - He Li
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Yi Zhang
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jinfeng Lu
- Department of Anaesthesiology, Beijing Renhe Hospital, Beijing, 102600, China
| | - Shaofei Su
- Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Chaoyang, Beijing, 100026, China
| | - Chunhua Xi
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Wei Liu
- Department of Anaesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, 101100, China.
| | - Guyan Wang
- Department of Anaesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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Andrade Filho PHD, Pereira VE, Sousa DDEM, Costa LDG, Nunes YP, Taglialegna G, de Paula-Garcia WN, Silva JM. Analgesic efficacy of erector spinae plane block versus paravertebral block in lung surgeries-A non-inferiority randomised controlled trial. Acta Anaesthesiol Scand 2024; 68:71-79. [PMID: 37646584 DOI: 10.1111/aas.14325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/19/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Pain management plays an essential role in postoperative recovery after lung surgeries. The Erector Spinae Plane Block (ESPB) is a widely used regional anaesthesia technique; however, few clinical trials have compared this block to active control in thoracic surgeries. This study evaluated the non-inferiority of the analgesia provided by ESPB when compared to paravertebral block (PVB) in lung surgeries. METHODS Randomised, active-controlled, blinded for patients and assessors, non-inferiority trial. Patients who underwent unilateral lung surgeries were divided into two groups according to the regional anaesthesia technique-continuous ESPB or PVB at the T5 level. The primary outcome was to assess pain using a numerical rating scale (NRS) with a test of the interaction of three measures over 24 h postoperatively. An NRS score ≥ 7 was considered analgesia failure, and the prespecified non-inferiority margin was 10%. RESULTS In the interim analysis that terminated this study, 120 participants were enrolled. ESPB patients reported higher mean NRS general values over 24 h, 4.6 ± 3.2 in the ESPB group versus 3.9 ± 2.9 in the PVB group, with a difference of -0.67 (-15.2%) and 95%CI: -1.29 to -0.05 (p = .02), demonstrating not non-inferiority. In addition, the ESPB group presented higher NRS failure of analgesia over 24 h (p < .01) and required more postoperative opioids (p = .01 over 24 h). There was no difference in patient satisfaction between groups. CONCLUSION This trial demonstrated that a continuous erector spinae plane block was not non-inferior to a continuous paravertebral block for analgesia after lung surgery but resulted in higher levels of postoperative pain and opioid consumption.
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Affiliation(s)
- Pedro Hilton de Andrade Filho
- Department of Anaesthesiology, Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
- Postgraduate Programme in Anaesthesiology, Surgical Sciences, and Perioperative Medicine, University of São Paulo Faculty of Medicine (FMUSP), São Paulo, Brazil
| | - Victor Egypto Pereira
- Orthopedics and Anaesthesiology Department, Ribeirão Preto Medical School, University of Sao Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | | | - Ladyer da Gama Costa
- Department of Anaesthesiology, Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
| | - Yuri Pinto Nunes
- Department of Anaesthesiology, Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
| | - Giovani Taglialegna
- Orthopedics and Anaesthesiology Department, Ribeirão Preto Medical School, University of Sao Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Waynice Neiva de Paula-Garcia
- Orthopedics and Anaesthesiology Department, Ribeirão Preto Medical School, University of Sao Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Joao Manoel Silva
- Department of Anaesthesiology, Hospital do Servidor Publico Estadual de São Paulo, São Paulo, Brazil
- Postgraduate Programme in Anaesthesiology, Surgical Sciences, and Perioperative Medicine, University of São Paulo Faculty of Medicine (FMUSP), São Paulo, Brazil
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Liu W, Wang F, Luo T, Zhang H, Gao G, Liu T, Liu Y, Xu S. The effects of programmed intermittent paravertebral bolus infusion on postoperative analgesia in patients undergoing video-assisted thoracoscopic surgery: A prospective, randomized, controlled study. J Cardiothorac Vasc Anesth 2022; 36:3637-3644. [DOI: 10.1053/j.jvca.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/12/2022]
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Elshal MM, Gamal RM, Ahmed AM, Gouda NM, Abdelhaq MM. Efficacy of adding dexmedetomidine as adjuvant with bupivacaine in ultrasound-guided erector spinae plane block for post thoracotomy pain: Randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1975973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
| | - Reham Mohamed Gamal
- Anesthesia and Pain Relief, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Aya Mohamed Ahmed
- Anesthesia and Pain Relief, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Nevine Mahmoud Gouda
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
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Xu M, Hu J, Yan J, Yan H, Zhang C. Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials. Thorac Cardiovasc Surg 2021; 70:413-421. [PMID: 33477177 DOI: 10.1055/s-0040-1722314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Paravertebral block (PVB) and thoracic epidural analgesia (TEA) are commonly used for postthoracotomy pain management. The purpose of this research is to evaluate the effects of TEA versus PVB for postthoracotomy pain relief. METHODS A systematic literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library (last performed on August 2020) to identify randomized controlled trials comparing PVB and TEA for thoracotomy. The rest and dynamic visual analog scale (VAS) scores, rescue analgesic consumption, the incidences of side effects were pooled. RESULTS Sixteen trials involving 1,000 patients were included in this meta-analysis. The pooled results showed that the rest and dynamic VAS at 12, 24, and rest VAS at 48 hours were similar between PVB and TEA groups. The rescue analgesic consumption (weighted mean differences: 3.81; 95% confidence interval [CI]: 0.982-6.638, p < 0.01) and the incidence of rescue analgesia (relative risk [RR]: 1.963; 95% CI: 1.336-2.884, p < 0.01) were less in TEA group. However, the incidence of hypotension (RR: 0.228; 95% CI: 0.137-0.380, p < 0.001), urinary retention (RR: 0.392; 95% CI: 0.198-0.776, p < 0.01), and vomiting (RR: 0.665; 95% CI: 0.451-0.981, p < 0.05) was less in PVB group. CONCLUSION For thoracotomy, PVB may provide no superior analgesia compared with TEA but PVB can reduce side effects. Thus, individualized treatment is recommended. Further study is still necessary to determine which concentration of local anesthetics can be used for PVB and can provide equal analgesic efficiency to TEA.
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Affiliation(s)
- Mu Xu
- Department of Anesthesiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiajia Hu
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Jianqin Yan
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Hong Yan
- Department of Anesthesiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital Central South University, Changsha, Hunan, China
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Patel A, Kumar V, Garg R, Bhatnagar S, Mishra S, Gupta N, Bharti SJ, Kumar S. Comparison of analgesic efficacy of ultrasound-guided thoracic paravertebral block versus surgeon-guided serratus anterior plane block for acute postoperative pain in patients undergoing thoracotomy for lung surgery-A prospective randomized study. Saudi J Anaesth 2020; 14:423-430. [PMID: 33447181 PMCID: PMC7796745 DOI: 10.4103/sja.sja_143_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/08/2020] [Accepted: 03/11/2020] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Inadequate pain relief after thoracotomy may lead to postoperative respiratory complications. AIMS We have compared total morphine consumption in 24 hours following thoracotomy. SETTINGS AND DESIGN This prospective randomized pilot study involved 50 patients undergoing elective thoracotomy for lung surgery at AIIMS, New Delhi. PATIENTS AND METHODS Fifty patients undergoing elective thoracotomy were randomly allocated into two groups. In Group I patients, ultrasound (USG)-guided paravertebral catheter was inserted preoperatively and in Group II patients, serratus anterior plane (SAP) catheter was inserted by the surgeon before closure. Ropivacaine bolus (group I: 0.2% 0.1 ml/kg and group II: 0.375% 0.4 ml/kg) was given before extubation, followed by its continuous infusion for 24 hours. If the numerical rating scale (NRS) was >3, then patients were given intravenous (i.v.) morphine 3 mg. Total 24-hour morphine consumption, duration of effective analgesia, hemodynamic parameters, side effects, and overall patient satisfaction were recorded. STATISTICAL ANALYSIS USED T-test was used to compare the parametric values in both the groups, whereas the Mann-Whitney U-test was performed to compare the nonparametric values. RESULTS Postoperative morphine requirement in the ParaVertebral Block (PVB) group (8.65 ± 4.27 mg) was less as compared to the SAP group (11.87 ± 6.22 mg) but that was not statistically significant (p 0.052). Postoperative pain scores at rest and on movement, patient satisfaction, and incidence of chronic post-thoracotomy pain were comparable in both the groups. CONCLUSION SAP block with continuous catheter technique seems to be a safe and effective modality for the management of acute postoperative pain after thoracotomy.
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Affiliation(s)
- Anuradha Patel
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
- Address for correspondence: Dr. Vinod Kumar, Room No. 139, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi - 110 029, India. E-mail:
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Sachidanand Jee Bharti
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Sunil Kumar
- Department of Surgical Oncology, Dr B.R.A., Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
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A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study. Adv Ther 2020; 37:4000-4014. [PMID: 32737760 DOI: 10.1007/s12325-020-01446-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION This study aimed to compare the challenge of puncture and catheterization and the effect of postoperative analgesia of ultrasound-guided continuous thoracic paravertebral block and the continuous epidural analgesia in patients receiving thoracoscopic surgery for lung cancer. METHODS One-hundred and fifty patients received elective unilateral thoracoscopic surgery for lung cancer and were randomized into three groups; test group 1 (T group), test group 2 (P group), and the control group (E group). Both of the test groups received ultrasound-guided continuous thoracic paravertebral block (TPVB) while the control group received continuous epidural analgesia. After the operation, all the patients in the test groups received the same postoperative analgesia; loading dose 0.5 mg kg-1, background dose 0.25 mg kg-1 h-1, patient controlled analgesia (PCA) 0.25 mg kg-1, and a locking time of 60 min, while the patients in the control group received a loading dose of 5 ml, a background dose of 5 ml h-1, and a locking time of 20 min. The outcomes of this study were the success rate of the puncture and catheter placement, the blocked segments, numerical rating scale (NRS) scores at rest and during coughing, and the segments with reduced or lost cold and pinpricking sensation. RESULTS The success rates of the puncture and catheterization in group T were the highest. Compared with group P, the failure rate of the puncture in group E was lower (p < 0.05), but the success rate of catheterization was higher (p < 0.05). The puncture time in group T was the shortest; there was no difference between group E and group T. The time of catheterization in group P was the longest, this was followed by group T, and was the fastest in group E. The stable time of the block level in group E was shorter than that in groups P and T, but was similar between groups P and T. The block level of all three groups in the 4 h postoperative period was similar (p > 0.05), while the 4 h postoperative levels of groups P and T were reduced significantly (p < 0.05). CONCLUSION The continuous analgesia technique of paravertebral space catheterization cannot replace the continuous epidural analgesia in thoracoscopic lung cancer surgery as the latter technique is still considered to be the gold standard. TRIAL REGISTRATION China Clinical Trial Registration Center identifier ChiCTR1900020973.
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Choi EK, Kim JI, Park SJ. A Randomized Controlled Trial Comparing Analgesic Efficacies of an Ultrasound-Guided Approach with and without a Combined Pressure Measurement Technique for Thoracic Paravertebral Blocks After Open Thoracotomy. Ther Clin Risk Manag 2020; 16:727-734. [PMID: 32821109 PMCID: PMC7418159 DOI: 10.2147/tcrm.s263353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose Ultrasound-guided thoracic paravertebral block (TPVB) is an established means for providing postoperative analgesia in thoracic surgery. However, there are conflicting results regarding the efficacy of post-thoracotomy pain management of ultrasound-guided TPVB when compared with that using traditional landmark approach. We therefore conducted a comparative study to evaluate the analgesic efficacy of TPVB when pressure measurement during needle advancement is combined with an ultrasound-guided approach. Patients and Methods The patients scheduled for lobectomy through thoracotomy were randomly allocated to receive either the ultrasound-guided approach only group (U group) or the ultrasound-guided approach combined with pressure measurement group (UP group) (n = 36 per group). Before thoracic muscle closure, 0.375% ropivacaine (20 mL) was administered as a bolus, followed by a continuous infusion of 0.2% ropivacaine (0.1 mL/kg/hr) in both groups. Postoperative pain was assessed using the visual analogue scale (VAS) pain score while resting and coughing. Local anesthetics and pethidine usage and sensory block area were also evaluated. Results The UP group showed significantly lower VAS scores, local anesthetics and pethidine usage, and a wider sensory block area than the U group. Conclusion A combined technique with ultrasound guidance and pressure measurement provided a superior analgesic effect over that of an ultrasound-guided approach alone for the management of post-thoracotomy pain.
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Affiliation(s)
- Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ji-Il Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sang-Jin Park
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Deebis A, Elattar H, Saber O, Elfakharany K, Elnahal N. Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-00027-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Systemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.
Results
Sixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).
Conclusion
Continuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.
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Jessula S, Atkinson L, Casey P, Kwofie K, Stewart S, Lee MS, Smith M, Herman CR. Surgically positioned paravertebral catheters and postoperative analgesia after open abdominal aortic aneurysm repair. J Vasc Surg 2019; 70:1479-1487. [PMID: 31153699 DOI: 10.1016/j.jvs.2019.02.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/13/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare postoperative morphine equivalent intake after open abdominal aortic aneurysm (AAA) repair among analgesic modalities: systemic analgesia (SA) only with no regional anesthesia, surgically positioned paravertebral catheter (PVC), and thoracic epidural analgesia (TEA). METHODS This retrospective cohort study included patients undergoing elective open AAA at the Queen Elizabeth II Health Science Center, Halifax, Nova Scotia. Demographics, morphine equivalents, methods of analgesia administration, and outcomes data were collected on all patients from 2005 to 2016. Total morphine equivalent (MEQ) on postoperative days (PODs) 1, 2, and 3 were compared among patients with SA, PVC, and TEA. A multivariable zero-inflated log-linear regression was used to determine the association between analgesic modality and MEQ. Multivariable logistic regression models were used to determine associations between analgesic modality and postoperative pain, rates of discharge from intensive care within 1 day and opioid-related adverse events. RESULTS The study cohort included 355 patients: 177 retroperitoneal and 178 transperitoneal repairs; 173 patients underwent SA, 117 PVC, and 65 TEA. On POD1, median MEQs were 984 (interquartile range [IQR], 342-1525) for SA, 89 (33-246) for PVC, and 49 (0-90) for TEA. On POD2, the median MEQs were 105 (IQR, 57-210) for SA, 45 (15-99) for PVC, and 30 (0-64) for TEA. On POD3, the median MEQs were 45 (IQR, 15-120) for SA, 30 (0-60) for PVC, and 10 (0-45) for TEA. On multivariable log-linear regression, compared with SA, PVC and TEA were associated with increased odds of receiving no opioids on POD1 (odds ratio [OR], 66.85; 95% confidence interval [CI], 17.49-255.57; and OR, 214.68; 95% CI, 60.20-766.38; respectively), POD 2 (OR, 6.97; 95% CI, 3.61-13.46; and OR, 28.73; 95% CI, 15.68-52.62; respectively), and POD 3 (OR, 3.93; 95% CI, 2.72-5.67; and OR, 4.68; 95% CI, 3.20-6.86; respectively). If patients did receive opioids, compared with SA, PVC and TEA were associated with decreased consumption on POD1 (RR, 0.22; 95% CI, 0.18-0.27; and RR, 0.16; 95% CI, 0.12-0.20; respectively), POD2 (RR, 0.50; 95% CI, 0.42-0.58; and RR, 0.46; 95% CI, 0.37-0.56; respectively), and POD3 (RR, 0.78; 95% CI, 0.66-0.93; and RR, 0.76; 95% CI, 0.63-0.93; respectively). Compared with SA, PVC was associated with earlier discharge from intensive care (OR, 2.75; 95% CI, 1.17-6.45) and TEA was not (OR, 1.12; 95% CI, 0.56-2.2). Compared with TEA, PVC was not associated with increased rate of opioid-related adverse events (OR, 0.44; 95% CI, 0.08-2.44). CONCLUSIONS PVC and TEA are associated with decreased MEQ compared with SA. PVC is associated with earlier discharge from intensive care compared with SA and similar rates of opioid-related adverse events compared with TEA. Paravertebral analgesia appears to be a safe and effective analgesic modality in patients undergoing retroperitoneal approach for abdominal aneurysm repair.
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Affiliation(s)
- Samuel Jessula
- Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Logan Atkinson
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patrick Casey
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kwesi Kwofie
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Stewart
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Min S Lee
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Smith
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine R Herman
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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13
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Abstract
Surgical procedure causes tissue damage which activates systemic inflammatory response and leads to changes in endocrine and metabolic system. Anaesthesia and pain can further disrupt immune performance. Regional anaesthesia causes afferent nerve blockade and in this way mediates immune protection. Thoracic epidural analgesia is the cornerstone of pain relief in thoracic and abdominal surgery. Alternatively thoracic paravertebral block can be used with less side effects and good analgesic properties. Drugs that interfere with blood coagulation obstruct the use of central regional blocks. Surgery has also changed recently from open to minimally invasive. Also pain treatment for this procedures has changed to less aggressive, systemic or locoregional techniques. It was shown that transversus abdominis plane block and epidural analgesia have the same effect on postoperative pain, but transversus abdominis plane block was better regarding hemodynamic stability and hospital stay. Multimodal approach combining regional and systemic analgesia is currently the most appropriate perioperative pain management strategy. More studies should be done to give recommendations.
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Affiliation(s)
| | - Jasmina Markovič-Božič
- Clinical department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
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14
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ELdeen HM. Ultrasound-guided thoracic epidural and paravertebral blocks for cholecystectomy in pediatric patients with a cyanotic heart disease: A randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Hala M.S. ELdeen
- Anesthesia Department, Mansoura Children University Hospital, Mansoura University, Egypt
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15
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Abstract
PURPOSE OF REVIEW This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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16
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Stokes SM, Wakeam E, Antonoff MB, Backhus LM, Meguid RA, Odell D, Varghese TK. Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research. J Thorac Dis 2019; 11:S537-S554. [PMID: 31032072 PMCID: PMC6465421 DOI: 10.21037/jtd.2019.01.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022]
Abstract
Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.
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Affiliation(s)
- Sean M. Stokes
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Elliot Wakeam
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson, Cancer Center, Houston, TX, USA
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Robert A. Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - David Odell
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Thomas K. Varghese
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
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17
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Krishnamoorthy B, Critchley WR, Soon SY, Birla R, Begum Z, Nair J, Devan N, Mohan R, Fildes J, Morris J, Fullwood C, Krysiak P, Malagon I, Shah R. A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy. Semin Thorac Cardiovasc Surg 2018; 31:583-592. [PMID: 30529157 DOI: 10.1053/j.semtcvs.2018.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/30/2018] [Indexed: 11/11/2022]
Abstract
Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.
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Affiliation(s)
- B Krishnamoorthy
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK; Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, UK.
| | - W R Critchley
- The Manchester Collaborative Center for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - S Y Soon
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - R Birla
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Z Begum
- The Manchester Collaborative Center for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - J Nair
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - N Devan
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Ram Mohan
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - James Fildes
- The Manchester Collaborative Center for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - J Morris
- Department of Medical Statistics, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - C Fullwood
- Centre of Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre; Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
| | - P Krysiak
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - I Malagon
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - R Shah
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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18
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Khoronenko V, Baskakov D, Leone M, Malanova A, Ryabov A, Pikin O, Golovashchenko M. Influence of Regional Anesthesia on the Rate of Chronic Postthoracotomy Pain Syndrome in Lung Cancer Patients. Ann Thorac Cardiovasc Surg 2018; 24:180-186. [PMID: 29925724 PMCID: PMC6102606 DOI: 10.5761/atcs.oa.18-00044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose: Our study aimed to assess whether the type of regional anesthesia influenced the incidence of chronic postthoracotomy pain syndrome (CPTPS). Methods: This was a prospective, randomized study that included 300 patients undergoing lung cancer resection using thoracotomy. They were randomized into three groups: paravertebral nerve block (PVB), thoracic epidural anesthesia (TEA), and intercostal nerve block (INB). General anesthesia was similar in the groups. A horizontal visual analogue scale (VAS) was used to assess the intensity of the pain syndrome. It was assessed and recorded 7 days, 1 month, and 6 months after surgery. Results: At 6 months after surgery, the incidence (p <0.05) of the CPTPS was higher in the INB group (40%) than in the TEA group (23%). The CPTPS frequency in the PVB group did not differ from the other groups (34%). Conclusion: The use of the TEA in patients who underwent open lung cancer surgery contributed to a significant decline in the CPTPS frequency compared to patients who were administered INB. Using PVB did not decrease the CPTPS frequency.
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Affiliation(s)
| | - Danil Baskakov
- P.A. Herzen Moscow Cancer Research Institute, Moscow, Russia
| | - Marc Leone
- Aix Marseille Université, APHM. Hôpital Nord, Service d'Anesthésie et de Réanimation. Marseille, France
| | - Anna Malanova
- P.A. Herzen Moscow Cancer Research Institute, Moscow, Russia
| | - Andrey Ryabov
- P.A. Herzen Moscow Cancer Research Institute, Moscow, Russia
| | - Oleg Pikin
- P.A. Herzen Moscow Cancer Research Institute, Moscow, Russia
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19
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Jessula S, Herman CR, Kwofie K, Lee MS, Smith M, Casey P. Intraoperative insertion of paravertebral catheter for postoperative analgesia in retroperitoneal aortic aneurysm repair. J Vasc Surg 2018; 67:1308-1310. [PMID: 29579473 DOI: 10.1016/j.jvs.2017.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/01/2017] [Indexed: 11/19/2022]
Abstract
Paravertebral catheters are a well-established analgesic modality in thoracic surgery but have not been described in abdominal aortic surgery. We describe a simple, safe, and effective technique of paravertebral catheter insertion by the operative surgeon after a retroperitoneal abdominal aortic aneurysm repair. Once the aneurysm repair is complete, an extrapleural plane between the parietal pleura and the twelfth rib is created through blunt dissection. A catheter is advanced into the space percutaneously under direct vision, and a continuous infusion of local anesthetic is administered. Paravertebral catheters typically remain in place for 3 to 5 days and provide excellent postoperative non-narcotic analgesia.
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Affiliation(s)
- Samuel Jessula
- Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Christine R Herman
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kwesi Kwofie
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Min S Lee
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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20
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Umari M, Falini S, Segat M, Zuliani M, Crisman M, Comuzzi L, Pagos F, Lovadina S, Lucangelo U. Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice. J Thorac Dis 2018; 10:S542-S554. [PMID: 29629201 PMCID: PMC5880994 DOI: 10.21037/jtd.2017.12.83] [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] [Received: 11/02/2017] [Accepted: 12/11/2017] [Indexed: 12/18/2022]
Abstract
In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.
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Affiliation(s)
- Marzia Umari
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Stefano Falini
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Matteo Segat
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Michele Zuliani
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Marco Crisman
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Lucia Comuzzi
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Francesco Pagos
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
| | - Stefano Lovadina
- Department of General and Thoracic Surgery, Cattinara University Hospital, Trieste, Italy
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care, and Emergency, Cattinara University Hospital, Trieste, Italy
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21
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Župčić M, Graf Župčić S, Duzel V, Šimurina T, Šakić L, Fudurić J, Peršec J, Milošević M, Stanec Z, Korušić A, Barišin S. A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone. Croat Med J 2017; 58:270-280. [PMID: 28857520 PMCID: PMC5577647 DOI: 10.3325/cmj.2017.58.270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.
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Affiliation(s)
- Miroslav Župčić
- Miroslav Župčić, Anesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Dubrava, Av. G. Šuška 6, 10000 Zagreb, Croatia,
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22
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Beltran R, Veneziano G, Bhalla T, Kenney B, Tumin D, Bissonnette B, Tobias JD. Postoperative pain management in patients undergoing thoracoscopic repair of pectus excavatum: A retrospective analysis of opioid consumption and adverse effects in adolescents. Saudi J Anaesth 2017; 11:427-431. [PMID: 29033723 PMCID: PMC5637419 DOI: 10.4103/sja.sja_339_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging. Methods: The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia. Results: The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups. Conclusions: The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.
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Affiliation(s)
- Ralph Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bruno Bissonnette
- Department of Anesthesia and Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
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23
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A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction. Plast Reconstr Surg 2016; 137:660e-666e. [PMID: 27018693 DOI: 10.1097/01.prs.0000481070.79186.0d] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Scarfe AJ, Schuhmann-Hingel S, Duncan JK, Ma N, Atukorale YN, Cameron AL. Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2016; 50:1010-1018. [DOI: 10.1093/ejcts/ezw168] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/28/2016] [Accepted: 04/09/2016] [Indexed: 11/14/2022] Open
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Yeung JHY, Gates S, Naidu BV, Wilson MJA, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; 2:CD009121. [PMID: 26897642 PMCID: PMC7151756 DOI: 10.1002/14651858.cd009121.pub2] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy. OBJECTIVES To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness. SEARCH METHODS We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review. SELECTION CRITERIA We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis). MAIN RESULTS We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs. AUTHORS' CONCLUSIONS Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.
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Affiliation(s)
- Joyce HY Yeung
- Heart of England NHS Foundation Trust, Birmingham Heartlands HospitalAcademic Department of Anaesthesia, Critical Care, Pain and Resuscitation1/F MIDRU Building, Birmingham Heartlands Hospital, Bordersley Green EastBirminghamUKB9 5SS
- University of BirminghamSchool of Clinical and Experimental Medicine, College of Medical and Dental SciencesBirminghamUK
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - Babu V Naidu
- University of BirminghamInstitute of Inflammation and AgeingQueen Elizabeth Hospital Birmingham Edgbaston,BirminghamUKB15 2TT
| | - Matthew JA Wilson
- The University of SheffieldSchool of Health and Related ResearchSheffieldUK
| | - Fang Gao Smith
- Heart of England NHS Foundation Trust, Birmingham Heartlands HospitalAcademic Department of Anaesthesia, Critical Care, Pain and Resuscitation1/F MIDRU Building, Birmingham Heartlands Hospital, Bordersley Green EastBirminghamUKB9 5SS
- College of Medical and Dental Sciences, University of BirminghamSchool of Clinical and Experimental MedicineBirminghamUK
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Krakowski JC, Arora H. Con: Thoracic Epidural Block Is Not Superior to Paravertebral Blocks for Open Thoracic Surgery. J Cardiothorac Vasc Anesth 2015; 29:1720-2. [DOI: 10.1053/j.jvca.2015.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Indexed: 11/11/2022]
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De Pinto M, Dagal A, O'Donnell B, Stogicza A, Chiu S, Edwards WT. Regional anesthesia for management of acute pain in the intensive care unit. Int J Crit Illn Inj Sci 2015; 5:138-43. [PMID: 26557482 PMCID: PMC4613411 DOI: 10.4103/2229-5151.164917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pain is a major problem for Intensive Care Unit (ICU) patients. Despite numerous improvements it is estimated that as many as 70% of the patients experience moderate-to-severe postoperative pain during their stay in the ICU. Effective pain management means not only decreasing pain intensity, but also reducing the opioids’ side effects. Minimizing nausea, vomiting, urinary retention, and sedation may indeed facilitate patient recovery and it is likely to shorten the ICU and hospital stay. Adequate postoperative and post-trauma pain management is also crucial for the achievement of effective rehabilitation. Furthermore, recent studies suggest that effective acute pain management may be helpful in reducing the development of chronic pain. When used appropriately, and in combination with other treatment modalities, regional analgesia techniques (neuraxial and peripheral nerve blocks) have the potential to reduce or eliminate the physiological stress response to surgery and trauma, decreasing the possibility of surgical complications and improving the outcomes. Also they may reduce the total amount of opioid analgesics necessary to achieve adequate pain control and the development of potentially dangerous side effects.
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Affiliation(s)
- Mario De Pinto
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
| | - Armagan Dagal
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
| | - Brendan O'Donnell
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
| | - Agnes Stogicza
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
| | - Sheila Chiu
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
| | - William Thomas Edwards
- Department of Anesthesiology and Pain Medicine, University of Washington, Pain Relief Service, Harborview Medical Center - 325 9 Ave., Seattle, WA 98104, Box 359724, USA
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Ried M, Schilling C, Potzger T, Ittner KP, Rupp A, Szöke T, Hofmann HS, Diez C. Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery. J Cardiothorac Vasc Anesth 2015; 28:973-8. [PMID: 25107716 DOI: 10.1053/j.jvca.2013.12.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function. DESIGN Prospective, non-randomized trial from April 2009 to September 2011. SETTING Department of Thoracic Surgery, single-center. PARTICIPANTS Thoracic surgical patients. INTERVENTIONS Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy. MEASUREMENTS AND MAIN RESULTS The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups. CONCLUSIONS Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Medical Center RegensburgRegensburg, Germany.
| | - Christian Schilling
- Department of Thoracic Surgery, University Medical Center RegensburgRegensburg, Germany
| | - Tobias Potzger
- Department of Thoracic Surgery, University Medical Center RegensburgRegensburg, Germany
| | - Karl-Peter Ittner
- Department of Anesthesiology, University Medical Center RegensburgRegensburg, Germany
| | - Andrea Rupp
- Department of Anaesthesiology, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Tamas Szöke
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center RegensburgRegensburg, Germany; Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Claudius Diez
- Department of Thoracic Surgery, University Medical Center RegensburgRegensburg, Germany
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Chalam KS, Patnaik SS, Sunil C, Bansal T. Comparative study of ultrasound-guided paravertebral block with ropivacaine versus bupivacaine for post-operative pain relief in children undergoing thoracotomy for patent ductus arteriosus ligation surgery. Indian J Anaesth 2015; 59:493-8. [PMID: 26379293 PMCID: PMC4551027 DOI: 10.4103/0019-5049.162988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background and Aims: Thoracotomy incision following patent ductus arteriosus (PDA) ligation surgery is often associated with severe post-operative pain that has deleterious effects on respiratory function. We aimed to assess pain relief with thoracic paravertebral block using either bupivacaine or ropivacaine in these surgeries. Methods: One hundred paediatric patients of age group between 2 and 10 years undergoing PDA ligation surgery were randomised either to bupivacaine or ropivacaine group in this prospective double-blinded study. After induction of general anaesthesia, the ultrasound-guided paravertebral block was carried out using 0.25% bupivacaine 0.4 ml/kg in Group B patients and 0.2% ropivacaine 0.4 ml/kg in Group R patients. Monitoring included minimum mandatory monitoring with pulse rate, pulseoximetry (SpO2), electrocardiogram, blood pressure, temperature during surgery and also in Intensive Care Unit (ICU). Additionally, modified objective pain score (MOPS) was used in ICU for assessment of pain for 12 h after surgery. Incidence of complications was noted. Results: Mean values of MOPSs were comparable in both the groups. The time to rescue analgesic was 8 to 10 h in over 80% of patients in both the groups. More patients had hypotension and bradycardia in bupivacaine group compared to ropivacaine group. Conclusion: Paravertebral injection of 0.4 ml/kg of either 0.2% ropivacaine or 0.25% bupivacaine provided equipotent analgesia, but ropivacaine had a better side effect profile. Ultrasound-guided paravertebral block is a safe and effective mode of analgesia in paediatric patients undergoing thoracotomy.
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Affiliation(s)
- Kolli S Chalam
- Department of Anaesthesiology and Critical Care Medicine, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Sathya Swaroop Patnaik
- Department of Anaesthesiology and Critical Care Medicine, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - C Sunil
- Department of Anaesthesiology and Critical Care Medicine, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Tripti Bansal
- Department of Anaesthesiology and Critical Care Medicine, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
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Neuburger PJ, Ngai JY, Chacon MM, Luria B, Manrique-Espinel AM, Kline RP, Grossi EA, Loulmet DF. A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair. J Cardiothorac Vasc Anesth 2015; 29:930-6. [DOI: 10.1053/j.jvca.2014.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 11/11/2022]
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Esper SA, Bottiger BA, Ginsberg B, Del Rio JM, Glower DD, Gaca JG, Stafford-Smith M, Neuburger PJ, Chaney MA. CASE 8--2015. Paravertebral Catheter-Based Strategy for Primary Analgesia After Minimally Invasive Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1071-80. [PMID: 26070694 DOI: 10.1053/j.jvca.2015.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian Ginsberg
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - J Mauricio Del Rio
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Donald D Glower
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Peter J Neuburger
- Department of Anesthesiology, New York University Medical Center, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis. PLoS One 2014; 9:e96233. [PMID: 24797238 PMCID: PMC4010440 DOI: 10.1371/journal.pone.0096233] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 04/06/2014] [Indexed: 11/19/2022] Open
Abstract
Objective The most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epidural blockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue. Summary of Background Thoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy. Methods Two reviewers independently searched the databases PubMed, EMBASE, and the Cochrane Library (last performed on 1 February, 2013) for reports of studies comparing post-thoracotomy epidural analgesia and paravertebral blockade. The same individuals independently extracted data from the appropriate studies. Result Eighteen trials involving 777 patients were included in the current analysis. There was no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4–8, 24, 48 hours, and the rates of pulmonary complications and morphine usage during the first 24 hours were also similar. However, paravertebral blockade was better than epidural analgesia in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p = 0.01), hypotension (p<0.00001), and rates of failed block were lower in the paravertebral blockade group (p = 0.01). Conclusions This meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.
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Less-invasive off-pump ventricular assist device implantation in regional paravertebral analgesia. J Artif Organs 2014; 17:275-7. [DOI: 10.1007/s10047-014-0764-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
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Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2014; 18:626-35. [DOI: 10.1093/icvts/ivt551] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Yoshida T, Fujiwara T, Furutani K, Ohashi N, Baba H. Effects of ropivacaine concentration on the spread of sensory block produced by continuous thoracic paravertebral block: a prospective, randomised, controlled, double-blind study. Anaesthesia 2014; 69:231-9. [DOI: 10.1111/anae.12531] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2013] [Indexed: 11/30/2022]
Affiliation(s)
- T. Yoshida
- Division of Anesthesiology; Niigata University Graduate School of Medical and Dental Sciences; Niigata-city Japan
| | - T. Fujiwara
- Division of Anesthesiology; Niigata University Graduate School of Medical and Dental Sciences; Niigata-city Japan
| | - K. Furutani
- Division of Anesthesiology; Niigata University Graduate School of Medical and Dental Sciences; Niigata-city Japan
| | - N. Ohashi
- Division of Anesthesiology; Niigata University Graduate School of Medical and Dental Sciences; Niigata-city Japan
| | - H. Baba
- Division of Anesthesiology; Niigata University Graduate School of Medical and Dental Sciences; Niigata-city Japan
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Bottiger BA, Esper SA, Stafford-Smith M. Pain Management Strategies for Thoracotomy and Thoracic Pain Syndromes. Semin Cardiothorac Vasc Anesth 2013; 18:45-56. [DOI: 10.1177/1089253213514484] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pain after thoracic surgery can be severe and, in the acute phase, contribute to perioperative morbidity and mortality. Unfortunately, patients also incur a significant risk of chronic pain. Although there are guidelines for postoperative pain management in these patients, there is no widespread surgical or anesthetic “best practice.” Here, we review the recent literature on techniques specific to perioperative pain control for thoracic patients, including medical management, neuraxial blockade, and other regional techniques, and suggest an algorithm for developing a multimodal pain management strategy.
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Júnior ADPJ, Erdmann TR, Santos TVD, Brunharo GM, Filho CTB, Losso MJ, Filho GRDO. Comparison between continuous thoracic epidural and paravertebral blocks for postoperative analgesia in patients undergoing thoracotomy: Systematic review. Braz J Anesthesiol 2013; 63:433-42. [PMID: 24565302 DOI: 10.1016/j.bjane.2013.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 09/10/2012] [Indexed: 12/13/2022] Open
Abstract
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. METHOD The 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. RESULTS We 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 48 hours. 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). CONCLUSION There 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.
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Affiliation(s)
- Alberto de Pontes Jardim Júnior
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Thomas Rolf Erdmann
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Thiago Viçoso dos Santos
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Guilherme Muriano Brunharo
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Clovis Tadeu Bevilacqua Filho
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Márcio Joaquim Losso
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil
| | - Getúlio R de Oliveira Filho
- Centro de Ensino e Treinamento da Sociedade Brasileira de Anestesiologia Integrado de Anestesiologia da Secretaria de Estado de Saúde de Santa Catarina, Florianópolis, SC, Brasil.
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Morris SA, Izatt MT, Adam CJ, Labrom RD, Askin GN. Postoperative pain relief using intermittent intrapleural analgesia following thoracoscopic anterior correction for progressive adolescent idiopathic scoliosis. SCOLIOSIS 2013; 8:18. [PMID: 24238280 PMCID: PMC3842798 DOI: 10.1186/1748-7161-8-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/07/2013] [Indexed: 12/02/2022]
Abstract
Background Thoracoscopic anterior scoliosis instrumentation is a safe and viable surgical option for corrective fusion of progressive adolescent idiopathic scoliosis (AIS) and has been performed at our centre on 205 patients since 2000. However, there is a paucity of literature reporting on or examining optimum methods of analgesia following this type of surgery. A retrospective study was designed to present the authors’ technique for delivering intermittent local anaesthetic boluses via an intrapleural catheter following thoracoscopic scoliosis surgery; report the pain levels that may be expected and any adverse effects associated with the use of intrapleural analgesia, as part of a combined postoperative analgesia regime. Methods Records for 32 patients who underwent thoracoscopic anterior correction for AIS were reviewed. All patients received an intrapleural catheter inserted during surgery, in addition to patient-controlled opiate analgesia and oral analgesia. After surgery, patients received a bolus of 0.25% bupivacaine every four hours via the intrapleural catheter. Patient’s perceptions of their pain control was measured using the visual analogue pain scale scores which were recorded before and after local anaesthetic administration and the quantity and time of day that any other analgesia was taken, were also recorded. Results 28 female and four male patients (mean age 14.5 ± 1.5 years) had a total of 230 boluses of local anaesthetic administered in the 96 hour period following surgery. Pain scores significantly decreased following the administration of a bolus (p < 0.0001), with the mean pain score decreasing from 3.66 to 1.83. The quantity of opiates via patient-controlled analgesia after surgery decreased steadily between successive 24 hours intervals after an initial increase in the second 24 hour period when patients were mobilised. One intrapleural catheter required early removal due to leakage; there were no other associated complications with the intermittent intrapleural analgesia method. Conclusions Local anaesthetic administration via an intrapleural catheter is a safe and effective method of analgesia following thoracoscopic anterior scoliosis correction. Post-operative pain following anterior thoracic scoliosis surgery can be reduced to ‘mild’ levels by combined analgesia regimes.
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Affiliation(s)
| | - Maree T Izatt
- QUT/Mater Paediatric Spine Research Group, Queensland University of Technology and Mater Research, Level 2, Aubigny Place, Raymond Terrace, South Brisbane, Queensland 4101, Australia.
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Comparação entre Bloqueios Peridural e Paravertebral Torácicos Contínuos para Analgesia Pós-Operatória em Pacientes Submetidos a Toracotomias: Revisão Sistemática. Braz J Anesthesiol 2013. [DOI: 10.1016/j.bjan.2012.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Comparison of intravenous morphine, epidural morphine with/without bupivacaine or ropivacaine in postthoracotomy pain management with patient controlled analgesia technique. Braz J Anesthesiol 2013; 63:213-9. [PMID: 24565129 DOI: 10.1016/j.bjane.2012.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/22/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. METHODS Sixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphine-ropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30(th) and 60(th) minutes and the 2(nd), 4(th), 6(th), 12(th), 24(th), 36(th), 48(th), and 72(nd) hour. RESULTS Diclofenac sodium requirement during the study was lower in Group EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48(th) hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30(th) and 60(th) minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30(th) minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. CONCLUSIONS Morphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.
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Comparison of Intravenous Morphine, Epidural Morphine With/ Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique. Braz J Anesthesiol 2013; 63:213-9. [DOI: 10.1016/s0034-7094(13)70218-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/22/2012] [Indexed: 11/21/2022] Open
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Komatsu T, Sowa T, Takahashi K, Fujinaga T. Paravertebral block as a promising analgesic modality for managing post-thoracotomy pain. Ann Thorac Cardiovasc Surg 2013; 20:113-6. [PMID: 23445804 DOI: 10.5761/atcs.oa.12.01999] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Analgesia following thoracotomy is routinely accomplished using epidural blockage performed by anesthesiologists. More effective pain control can be achieved with continuous paravertebral blockage performed by thoracic surgeons. We aimed to retrospectively analyze the efficacy of paravertebral blockage for managing post-thoracotomy pain. METHODS The study included 125 patients who underwent continuous paravertebral blockage for the following types of thoracic surgery: video-assisted thoracoscopic surgery(n = 87), anterior axillary thoracotomy (n = 21), posterolateral thoracotomy (n = 16), and median sternotomy with additional left thoracotomy (n = 1). We retrospectively evaluated the analgesic effects of continuous paravertebral blockage by assessing whether a good cough effort could be performed and whether an additional painkiller was given as a rescue medication. RESULTS About 115 patients could perform a good cough effort to expectorate sputum immediately after extubation in the operating room. Six patients tolerated postoperative pain well without any oral or rectal non-steroidal anti-inflammatory drugs (NSAIDs). For97 patients postoperative NSAIDs could control thoracotomy pain well. Twenty-two patients were given an additional painkiller stronger than NSAIDs. Three patients complained of nausea postoperatively. CONCLUSION Adequate post-thoracotomy pain control was accomplished by continuous paravertebral blockage, with few complications.
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Affiliation(s)
- Teruya Komatsu
- Department of General Thoracic Surgery, Nagara Medical Center, Gifu, Japan
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Zeid HA, Siddiqui AK, Elmakarem EFA, Ghonaimy Y, Al Nafea A. Comparison between intrathecal morphine with paravertebral patient controlled analgesia using bupivacaine for intraoperative and post-thoracotomy pain relief. Saudi J Anaesth 2012; 6:201-6. [PMID: 23162390 PMCID: PMC3498655 DOI: 10.4103/1658-354x.101204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objectives: This study was designed to compare the intrathecal morphine and paravertebral block with bupivacaine given before induction of anesthesia for intra-operative and post-thoracotomy pain relief for 48 hours using patient controlled paravertebral analgesia in post-operative period. Methods: After taken an approval from the ethics committee of the University, 40 patients were randomly assigned to receive either preservative-free intrathecal morphine 0.3 mg in 3 ml normal saline together with paravertebral block (group I) or paravertebral block alone using bupivacaine (group II) before an induction of anesthesia. No continuous infusion of bupivacaine was started in both groups. Primary outcomes were Visual Analogue Score (VAS) at rest and on coughing. Hemodynamic and respiratory effects, bupivacaine consumption, patient's satisfaction, and side effects like nausea, vomiting, urinary retention, and itching were considered as secondary outcomes. All patients in both groups received paracetamol 1 gram (gm) IV every 6 hourly for the 1st 24 hr. Amount of rescue analgesic (pethidine 0.5 mg/kg IV) in both groups and total bupivacaine cumulative doses in 48 hrs were calculated. Results: VAS at rest and on coughing did not differ significantly between the 2 groups at 0, 1, 6, 12, 18, 24, and 48 hours (P= >0.1). At 24 hours, VAS increased in both the groups, but the increase in VAS was comparable in both groups. There were insignificant incidences of nausea, purities, and urinary retention in intrathecal group compared with paravertebral group. The other side effects and patient satisfaction did not show any statistical significant difference between 2 groups. Conclusion: Intrathecal morphine 0.3 mg is safe and effective way to improves pain control for thoracic surgery and was comparable to paravertebral patient control analgesia (PPCA) with bupivacaine for the 1st 48 hours post-thoracotomy.
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Affiliation(s)
- Haitham Abou Zeid
- Department of Anesthesiology, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
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Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med 2012; 36:256-60. [PMID: 21490523 DOI: 10.1097/aap.0b013e3182176f42] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy. METHODS Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 μg/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 μg/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 μg/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique. RESULTS The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 μg, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group. CONCLUSIONS Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).
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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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Huffmyer J, Tashjian J, Raphael J, Jaeger JM. Management of the Patient for Transcatheter Aortic Valve Implantation in the Perioperative Period. Semin Cardiothorac Vasc Anesth 2012; 16:25-40. [PMID: 22275350 DOI: 10.1177/1089253211434966] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis is a prevalent valvular disease among aging patients, and surgical correction is the most definitive treatment. Yet many elderly patients are deemed to be “inoperable” or at excessive risk to undergo open surgical aortic valve replacement (AVR). Transcatheter aortic valve implantation (TAVI), either through a transfemoral or transapical approach, has become a potential option for these high-risk patients. Although TAVI technology will continue to be developed and perfected, most studies at this time reveal that symptoms are improved and that 1-year morbidity and mortality are similar to those for open surgical AVR. Anesthetic management for patients undergoing TAVI involves maintaining hemodynamic stability during periods of rapidly changing conditions and providing echocardiographic guidance and assessment. Postoperative care includes a variety of challenges such as managing pain control, monitoring for potential complications, and providing hemodynamic management.
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Stopar Pintaric T, Veranic P, Hadzic A, Karmakar M, Cvetko E. Electron-Microscopic Imaging of Endothoracic Fascia in the Thoracic Paravertebral Space in Rats. Reg Anesth Pain Med 2012; 37:215-8. [DOI: 10.1097/aap.0b013e31824451cb] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care 2011; 17:323-7. [PMID: 21716105 DOI: 10.1097/mcc.0b013e328348bf6f] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Thoracic trauma leading to multiple fractured ribs (MFR) remains very common. Good analgesia may help to improve a patient's respiratory mechanics and to avoid intubation of the trachea for ventilatory support and therefore may dramatically alter the course of recovery. We herein review the analgesia options for patients with MFR. RECENT FINDINGS For healthy patients with one to two fractured ribs, systemic analgesics may suffice. For more than three to four fractured ribs, studies and experience have reaffirmed the superior analgesia made possible with thoracic epidural, thoracic paravertebral, and intercostal blocks. From experience, interpleural block has significant drawbacks. Catheterization allows the continuation of analgesia for 2 or more days with just one block. Use of the landmark technique is usually satisfactory for accurate block placement but ultrasound and nerve stimulation are showing promise in further improving needle and catheter placement accuracy, especially in the presence of difficult anatomy. SUMMARY Thoracic epidural, thoracic paravertebral, and intercostal blocks are the top choices for patients with MFR and they are of equivalent efficacy. Each has unique advantages and disadvantages. Our preference tends to be the thoracic paravertebral approach.
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Lucas SD, Higdon T, Boezaart AP. Unintended epidural placement of a thoracic paravertebral catheter in a patient with severe chest trauma. PAIN MEDICINE 2011; 12:1284-9. [PMID: 21714843 DOI: 10.1111/j.1526-4637.2011.01180.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Severe pain can lead to ventilatory compromise in patients with multiple rib fractures. Regional anesthetic techniques, including continuous thoracic paravertebral and thoracic epidural blocks, can be useful in reducing this pain and subsequent morbidity due to respiratory compromise. Thoracic paravertebral block can result in significant complications. Presumed epidural spread of injected medication has been described with thoracic paravertebral block. High-quality radiographic images of an attempted placement of a thoracic paravertebral catheter in the epidural space have not been reported. We present these images to highlight the occurrence of this complication. SETTINGS AND PATIENTS In this case, we report an attempted placement of a thoracic paravertebral catheter that passed into the epidural space. High-fidelity, three-dimensional computer tomography images and the management of the unintended epidural catheterization are presented. RESULTS AND CONCLUSIONS In the setting of severe chest trauma, the potential risk of unintended placement of an intended thoracic paravertebral catheter in the epidural space is graphically illustrated as a potential risk of this procedure.
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Affiliation(s)
- Stephen D Lucas
- Department of Anesthesiology, Division of Regional Anesthesiology and Perioperative Pain Medicine, University of Florida College of Medicine, Gainesville, Florida 32610-0254, USA.
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Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth 2011; 105 Suppl 1:i86-96. [PMID: 21148658 DOI: 10.1093/bja/aeq322] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The indications for continuous nerve blocks for the perioperative pain management in hospitalized and ambulatory patients have extended well beyond orthopaedics. These techniques are not only used to control pain in patients undergoing major upper and lower extremity surgery, but also to provide perioperative analgesia in patients undergoing abdominal, plastic, urological, gynaecological, thoracic, and trauma surgeries. Infusion regimens of local anaesthetics and supplements must take into consideration the condition of the patient before and after surgery, the nature and intensity of the surgical stress associated with the surgery, and the possible need for immediate functional recovery. Continuous nerve blocks have proved safe and effective in reducing opioid consumption and related side-effects, accelerating recovery, and in many patients reducing the length of hospital stay. Continuous nerve blocks provide a safer alternative to epidural analgesia in patients receiving thromboprophylaxis, especially with low molecular-weight heparin.
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Affiliation(s)
- J E Chelly
- Division of Regional Anesthesia and Acute Interventional Perioperative Pain Service, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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