The evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

Thoracic Erector Spinae Plane (T-ESP) Block Together With Intertransverse Process (ITP) Block for Laparoscopic Abdominal Surgery: A Case Report

Laparoscopy has become a milestone with reduced surgical stress and postoperative pain. Evidence promotes erector spinae block for laparoscopic abdominal surgery, in particular for cholecystectomy. The thoracic paravertebral space block is the administration of local anesthetic into a wedge-shaped space on the antero-lateral thoracic spine and provides abdominal analgesia. We hypothesized that a combination of two paravertebral by proxy blocks (erector spinae and intertransverse process (ITP)) with multi-dermatomeric coverage and visceral pain control, with evidence for intra- and postoperative analgesia in thoracic and abdominal surgeries, may be a surgical anesthesia option for laparoscopy. A 42-year-old patient with gastroesophageal reflux disease (GERD) was scheduled for a laparoscopic Nissen fundoplication. He was 173 cm in height and weighed 90 kg (BMI 30 kg.m-2) and was classified in the American Society of Anesthesiologists Physical Status Classification System (ASA-PS) as 2. He had a history of difficult airway and refused general anesthesia. With the patient's informed written consent, we performed a bilateral thoracic erector spinae plane (T-ESP)/ITP blocks at the T4-8 level. Surgery was performed with the patient spontaneously breathing under sedation without complications. Hence, the combination of ESP-ITP blocks was a good anesthesia option for the planned surgery without side effects and optimal postoperative pain control.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial

Background

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively.

Objectives

We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption.

Methods

This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours.

Results

Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively).

Conclusions

A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Paravertebral block using levobupivacaine or dexmedetomidine-levobupivacaine for analgesia after cholecystectomy: a randomized double-blind trial

Background

Thoracic paravertebral block (TPVB) has emerged as an effective and feasible mode of providing analgesia in laparoscopic cholecystectomy. Though a variety of local anaesthetic combinations are used for providing TPVB, literature is sparse on use of dexmedetomidine in TPVB. We aimed to compare levobupivacaine and levobupivacaine-dexmedetomidine combination in ultrasound guided TPVB in patients undergoing laparoscopic cholecystectomy.

Methodology

70 ASA I/II patients, aged 18–60 years, scheduled to undergo laparoscopic cholecystectomy under general anaesthesia were enrolled and divided into two groups. Before anaesthesia induction, group A patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml normal saline while group B patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml solution containing dexmedetomidine 1 μg.kg^-1. Patients were monitored for pain using Numeric Rating Scale (NRS) at rest, on movement, coughing and comfort scores post surgery. Total analgesic consumption in first 48 hour postoperative period, time to first request analgesic and pain scores were recorded.

Results

Total amount of rescue analgesia (injection tramadol plus injection tramadol intravenous equivalent dose) consumed during 48 hours postoperatively in group A was 146.55 mg while in group B was 111.30 mg (p = 0.026). Mean time for demanding rescue analgesia was 273 minutes in group A while in group B was 340 minutes (p = 0.00).

Conclusion

TPVB using dexmedetomidine 1 μg.kg^-1 added to levobupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy significantly reduced total analgesic consumption in first 48 hours and provided longer duration of analgesia postoperatively compared to levobupivacaine 0.25% alone.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

THE ROLE OF PARAVERTEBRAL BLOCKS IN AMBULATORY SURGERY: REVIEW OF THE LITERATURE

Ambulatory surgery often involves surgical procedures on the thorax, abdomen and limbs, which can be associated with substantial postoperative pain. The aim of this narrative review is to provide an analysis of the effectiveness of paravertebral block (PVB) alone or in combination with general anaesthesia, in this setting, with an emphasis on satisfactory postoperative analgesia in comparison to other modalities. We have conducted a search of current medical literature written in English through PubMed, Google Scholar and Ovid Medline®. Peer-reviewed professional articles, review articles, retrospective and prospective studies, case reports and case series were systematically searched for during the time period between November 2003 and February 2019. The literature used for the purpose of creating this review showed that utilisation of paravertebral block either alone or in combination with general anaesthesia, has a positive effect on satisfactory analgesia in ambulatory surgery. With a multimodal analgesic approach of PVB and other techniques of anaesthesia and analgesia there is a reduction in postoperative opioid consumption, fewer side effects, lower pain scores, decreased mortality, earlier mobilisation of patients and reduced hospital stay.

Out-of-plane ultrasound-guided paravertebral blocks improve analgesic outcomes in patients undergoing video-assisted thoracoscopic surgery

Purpose

Paravertebral blocks (PVBs) are a method of limiting postoperative pain for patients undergoing video-assisted thoracoscopic surgery (VATS). We began providing ultrasound-guided PVBs for patients undergoing VATS in the spring of 2011, using an out-of-plane approach. The aim of this study was to evaluate this practice change.

Methods

Following institutional review board approval, we reviewed the charts of 114 patients undergoing VATS by one surgeon at our institution between January 2011 and July 2012. Of the 78 eligible patients, 49 patients received a PVB prior to surgery. We evaluated opioids administered in the perioperative period, pain scores, and side effects from pain medications.

Results

Patients who received a preoperative PVB required fewer narcotics intraoperatively and during their hospital stay (P=0.001 and 0.011, respectively). Pain scores on initial assessment and in recovery were lower in patients who received a PVB (P=0.005), as were dynamic and resting pain scores at 24 hours after surgery (P=0.003 and P<0.001, respectively). Patients receiving a PVB had fewer episodes of treated nausea both in the postanesthesia care unit (P=0.004) and for the first 24 hours after surgery (P=0.001). These patients also spent less time in recovery (P=0.025) than the patients who did not receive a block.

Conclusion

The current study suggests improved outcomes in patients who underwent VATS with a preoperative PVB. All variables showed a trend toward improved results in patients who obtained a preoperative PVB.