Thoracic Paravertebral Block: Influence of the Number of Injections (original) (raw)
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Efficacy of single injection unilateral thoracic paravertebral block
Background: Cholecystectomy can be associated with considerable postoperative pain. While the benefits of paravertebral block (PVB) on pain after thoracotomy and mastectomy have been demonstrated, not enough investigations on the effects of PVB on pain after open cholecystectomy have been conducted. We tested the hypothesis that a single-injection thoracic PVB reduces pain scores, decreases opioid consumption, and prolongs analgesic request time after cholecystectomy. Methods: Of 52 patients recruited, 50 completed the study. They were randomly allocated into two groups: the paravertebral group and the control group. The outcome measures were the severity of pain measured on numeric pain rating scale, total opioid consumption, and first analgesic request time during the first postoperative 24 hours. Result: The main outcomes recorded during 24 hours after surgery were Numerical Rating Scale (NRS) pain scores (NRS, 0-10), cumulative opioid consumption, and the first analgesic request time. Twenty four hours after surgery, NRS at rest was 4 (3-6) vs 5 (5-7) and at movement 4 (4-7) vs 6 (5-7.5) for the PVB and control groups, respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four hours after surgery, median (25th-75th percentile) cumulative morphine consumption was 0 (0-2) vs 2.5 (2-4) mg (P<0.0001) and cumulative tramadol consumption was 200 (150-250) mg vs 300 (200-350) mg in the paravertebral and in the control group, respectively (P=0.003). After surgery, the median (25th-75th percentile) first analgesic requirement time was prolonged in the PVB group in statistically significant fashion (P<0.0001). Conclusion and recommendations: Single-shot thoracic PVB as a component of multimodal analgesic regimen provided superior analgesia when compared with the control group up to 24 postoperative hours after cholecystectomy, and we recommend this block for post cholecystectomy pain relief.
Introduction: Thoracic paravertebral block (TPVB) has been employed for post operative analgesia in thoracotomy. Paravertebral block can be given by various techniques, two most commonly used techniques include direct surgical and classic technique yet the relative efficacy of one technique over alternate has not been accessed so far. This study has been intended to look at the performance of both these techniques on different imperative criteria’s. namely analgesic efficacy, technical difficulties and procedure time. Methodology: This study was conducted in a prospective, randomized, double blind fashion. Sixty adult patients of ASA I & II status underwent unilateral thoracotomy. divided into two groups, Group S and Group C and randomly allocated. Paravertebral catheter was placed at an appropriate level just before the closure of thoracotomy either by surgical or classic technique and was activated by 15 ml of ropivacaine 0.3%. Time taken to perform the block was noted down. After recovery from GA, pain was assessed by VAS at pre-fixed intervals. The patients were administered top up dose through paravertebral catheter as soon as VAS score exceeded 4. Total requirement of ropivacaine and rescue analgesia (Morphine) consumption in 24 hours were noted down. Technical problems of both the techniques were documented by the surgeon or anesthetist who performed the block. Result: Out of sixty patients three patients were excluded. Patients in Group C experienced better analgesia compared to Group S. Mean VAS scores at rest were lower at all measured intervals in Group C compared to Group S. Mean total consumption of ropivacaine was (91.72 ± 9.85) mg in Group C and (127.14 ± 9.58) mg in Group S (p<0.0001) over 24 hrs. Rescue analgesia (Morphine) consumption was higher in Group S vs. Group C (Group S 10.75 ± 2.6 vs. Group C 6.56 ± 1.44, p-value = 0.0001) over 24 hrs. Average procedure time in Group S 29.39±5.92 was almost double than Group C 15.90 ± 3. Technique related problems in Group S included difficult pleural stripping, local anesthetic leak, catheter fixation and pleural reattachment while in Group C difficult catheterization was the only problem encountered. Conclusion: Paravertebral block by classic technique provides superior analgesia in thoracotomy, takes less time to execute than direct surgical technique and has fewer technical troubles.
Bilateral thoracic paravertebral block: potential and practice
British Journal of Anaesthesia, 2011
† Paravertebral blocks can provide good intra-and postoperative analgesia. † Large doses may be required, but toxicity has not been reported. † The incidence of complications and side-effect seems low. † The limited evidence available is supportive of their use. Summary. Paravertebral nerve blocks (PVBs) can provide excellent intraoperative anaesthetic and postoperative analgesic conditions with less adverse effects and fewer contraindications than central neural blocks. Most published data are related to unilateral PVB, but its potential as a bilateral technique has been demonstrated. Bilateral PVB has been used successfully in the thoracic, abdominal, and pelvic regions, sometimes obviating the need for general anaesthesia. We have reviewed the use of bilateral PVB in association with surgery and chronic pain therapy. This covers 12 published studies with a total of 538 patients, and with varied methods and outcome measures. Despite the need for relatively large doses of local anaesthetics, there are no reports of systemic toxicity. The incidence of complications such as pneumothorax and hypotension is low. More studies on the use of bilateral PVB are required.
British Journal of Anaesthesia, 2009
Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890 -990 mg per 24 h compared with 325 -472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P¼0.006 at 8 h, P¼0.001 at 24 h, and P,0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV 1 , 95% CI 2.08% -38.07%, P¼0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P¼0.04 at 8 h, P¼0.003 at 24 h, and P,0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.
The Cardiothoracic Surgeon
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.
Place of the paravertebral block in post-operative analgesia in thoracic surgery
E3S Web of Conferences
The thoracic epidural analgesia (TEA) remains the standard gold for analgesic support in thoracic surgery, there is an interesting alternative to epidural analgesia, which is the paravertebral block (PVB). The aim in our study was to assess the value of performing a PVB in the management of postoperative pain in thoracic surgery compared to TEA. Methods: 80 patients were randomized to receive either epidural analgesia (n = 38, 10 cc bupivacaine 0.5% + 10 ϒ Sufentanyl then 10 cc Bupivacain 0.1% + 10 ϒ Sufentanyl via a PCA device) or PVB analgesia loss of resistance technique (n = 40, 10 cc bupivacaine 0.5% + 10 ϒ Sufentanyl via a PCA device). All patients received standard general anesthesia. The peri-operative parameters studied include standard measurement, EVA scale at rest and mobilization, use of morphinics. Results: there is a significant difference between the two groups and the incidents of puncture were significantly more important for the APDT group. The postoperative pain ...
Paravertebral blockade – Underrated method of regional anesthesia
Polish Annals of Medicine, 2014
Anesthesia Post-operative pain Identification a b s t r a c t Introduction: Paravertebral blockade (PVB) is an old, frequently forgotten and underrated method of regional anesthesia, with relatively few possible complications and an easy technique to perform. Aim: The aim is to describe anatomy of paravertebral space (PVS), present history of PVB, its mechanism of action, indications and contraindications, techniques, with particular emphasis on identifying the PVS with the use of ultrasound and advantages of its use in various clinical situations. Material and methods: This work was based on the available literature and the experience of the authors.
One Shot Six Centres: A New Strategy in Ultrasound Guided Paravertebral Block
Journal of Anesthesia & Clinical Research, 2015
The paravertebral block (PVB) is the technique of injecting local anaesthetic alongside the vertebral body close to where the spinal nerves emerge from the intervertebral foramen. This produces unilateral, segmental, somatic, and sympathetic nerve blockade in multiple contiguous thoracic dermatomes which is effective for managing acute and chronic pain. Recently PVB has also been used for surgical anaesthesia in patients undergoing several surgical procedures with improved postoperative outcomes. Unfortunately the spread of local anaesthetic and the anaesthetic effect is sometime unpredictable, even with a standardized ultrasound-guided technique. The aim of this study is to show a new approach for the Paravertebral block ultrasound-guided and confirmed by ENS using a single injection. This new approach allows an easy visualization and accurate puncture of the paravertebral space, ensuring good anaesthesia of reproducibility, productivity and effectiveness. In this study we obtained six dermatomes anaesthesia, with a single shot injection in all patients.
European Journal of Cardio-Thoracic Surgery, 2011
The analgesic scheme combining paravertebral block (PVB) and intravenous non-steroidal anti-inflammatory drug (NSAID) has proven to be effective for postoperative pain control after thoracotomy. The hypothesis tested in this study was that this policy was also suitable to improve pain control after video-assisted thoracic surgery (VATS). Methods: This was a prospective randomized study on 40 patients submitted to three-ports' VATS for pneumothorax or solitary pulmonary nodule. The sample size was calculated to detect one point of minimum pain score difference with 80% statistical power. Patients were randomly assigned to two groups: (1) paravertebral block group (PVB) (n = 20)-At the end of surgery, a catheter was placed in patients in the thoracic paravertebral space under camera control; they received a bolus of 15 ml of local anesthetic (ropivacaine 0.2%) every 6 h, combined with endovenous metamizol (1 g); and (2) alternate NSAIDs group (AN) (n = 20)-They were treated with paracetamol (1 g) combined with metamizol (1 g) every 6 h. Subcutaneous meperidine (synthetic opioid) was employed as rescue drug. Both groups were comparable in terms of age, sex, pathology, and co-morbidity. Pain level was measured with the visual analog scale (VAS) at 1, 6, 24, and 48 h. Results: No side effects related to any of the two analgesic techniques were noted. Two patients needed rescue meperidine in the AN group, and none in the PVB group. VAS scores were the following:
Paravertebral anaesthesia/analgesia for ambulatory surgery
Best Practice & Research Clinical Anaesthesiology, 2002
For many years, paravertebral nerve blockade has been an established technique for providing analgesia to the chest and abdomen. The current emphasis on containment of health care costs has resulted in a rediscovery of anaesthetic techniques, such as paravertebral blocks, that facilitate outpatient surgical management and promote early discharge. Paravertebral nerve blocks (PVB) produce excellent surgical conditions for many procedures of the chest and abdomen while providing profound long-lasting analgesia with few undesirable side-effects that aids in the compassionate early discharge of the patient from the ambulatory setting. This chapter reviews the pertinent anatomy and techniques involved in the successful placement of PVB. Continuous paravertebral catheters, pharmacological agents used in PVB, and single versus multiple injection paravertebral block techniques are also covered. Specific clinical situations that are particularly well suited to the application of PVB as the primary anaesthetic in the ambulatory setting and other clinical situations where analgesia from PVB is efficacious are discussed.