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Continuous thoracic paravertebral analgesia after minimally invasive atrial septal defect closure surgery in pediatric population: Effectiveness and safety analysis
Analgesia paravertebral torácica continua tras cirugía mínimamente invasiva de cierre de comunicación interauricular en población pediátrica: análisis de eficacia y seguridad
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Álvarez-Baena, M. Hervías, S. Ramos, J. Cebrián, A. Pita, I. Hidalgo" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Álvarez-Baena" "email" => array:1 [ 0 => "lucia.alvarezbaena@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Hervías" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Cebrián" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Pita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "I." "apellidos" => "Hidalgo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Sección de Anestesiología Pediátrica, Hospital General Universitario Gregorio Marañón. Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Sección de Cirugía Cardiaca infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Analgesia paravertebral torácica continua tras cirugía mínimamente invasiva de cierre de comunicación interauricular en población pediátrica: análisis de eficacia y seguridad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1184 "Ancho" => 2088 "Tamanyo" => 113313 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mean scores on the adapted pain scale by age subgroup. The <span class="elsevierStyleItalic">Face-Legs-Activity-Cry-Consolability</span> (FLACC) was used in patients aged ≤ 3 years; the Faces scale was used in patients aged between 3 and 7 years; and in patients aged over 7 years the colour scale was used.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Median sternotomy is the most common approach in cardiac surgery. In the case of simple heart defects, however, it is increasingly being replaced by less invasive techniques, such as minimally invasive lateral thoracotomy for atrial septal defect (ASD) closure. This approach gives better cosmetic outcomes, which in turn minimise the risk of lasting psychological scars. Minimally invasive thoracotomy provides excellent outcomes because it minimises surgical trauma and chest instability, decreases length of stay, and the small scar greatly improves patient satisfaction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For the anaesthesiologist, however, this approach is more complex than sternotomy both during and after surgery, because it requires one-lung ventilation to facilitate surgical manoeuvring, and is associated with greater postoperative pain - thoracotomy is one of the most painful surgical incisions. Anaesthesia management is further complicated by the need to adhere to fast track protocols, including extubation in the operating room, and early mobilization and discharge.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Inadequate control of post-thoracotomy pain can compromise respiratory mechanics and lead to serious postoperative complications; therefore, good postoperative pain control is one of the focal points of the anaesthesia plan in paediatric patients undergoing thoracotomy instead of sternotomy for ASD closure.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Continuous paravertebral block has been described as an effective and safe technique for post-thoracotomy pain control in both adults and children.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In paediatric patients, an effective paravertebral nerve block will reduce postoperative consumption of opioids, which in turn reduces the risk of postoperative nausea and vomiting, urine retention, pulmonary complications, and the systemic stress response.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thoracic paravertebral block is believed to be as effective as thoracic epidural for post-thoracotomy pain control<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and its good safety profile is evidenced by the low incidence of complications reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Potential complications of paravertebral block include pneumothorax, vascular puncture, nerve injury, inadvertent total spinal block, epidural block, local anaesthetic toxicity, hypotension, and technique failure.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the paediatric population, both nerve blocks are performed under general anaesthesia; therefore, the consequences of a complication arising in connection with one of these techniques, though rare, is more likely to affect the spinal cord than the thoracic spinal nerves. This is why the paravertebral block is considered the pain management technique of choice in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study, we aimed to: 1) assess the continuous perfusion of a local anaesthetic (LA) through a thoracic paravertebral catheter (continuous thoracic paravertebral block [TPVB]) for postoperative pain control after thoracotomy for ASD closure in a series of paediatric patients, and 2) assess the effectiveness of this analgesic technique in the context of an ultra-fast track paediatric cardiac surgery programme.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was an observational, descriptive, retrospective study. After obtaining informed consent from the parents or legal guardians, all paediatric patients diagnosed with ASD requiring surgical repair involving right posterolateral thoracotomy followed by right sided (T4 -T5) continuous TPVB for postoperative pain control treated consecutively at our paediatric hospital between 1 January 2016 and 31 December 2018 were included.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion criteria were: 1) indication for median sternotomy, 2) patients not receiving continuous TPVB 3) patients whose medical charts were missing data required for this study.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical histories of all study patients were reviewed retrospectively and the following data were collected and analysed: 1) demographics (age, sex, weight, comorbidities); 2) perioperative data (time on cardiopulmonary bypass [CPB], time to extubation); 3) effectiveness of analgesia measured in the paediatric intensive care unit (PICU) (pain scale validated for the patient's age, opioid consumption, length of stay (hours) in the PICU, time to removal of the TPVB catheter) and 4) patient safety (LA toxicity, technique-related complications).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following validated, age-specific pain scales were used: the multifactorial Face-Legs-Activity-Cry-Consolability (FLACC) in patients from 2 month to 3 years; the Faces scale in patients aged between 3 and 7 years, and for patients aged over 7 years the colour scale was used.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> The 3 scales used measure pain on a scale of 0 to 10 points: 0 = no pain, 1-2 = mild pain, 3-5 = moderate pain, 6-8 = severe pain, 9-10 = excruciating pain.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> The FLACC scale is not validated for Spanish.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Pain management with continuous TPVB was evaluated on the basis of the individual pain scale scores collected during each PICU nursing shift. These scores were then used to calculate each patient’s mean score during their PICU stay. The patients were followed up by staff from the Paediatric Acute Pain Unit (PADU) until removal of the chest drain and the TPVB catheter. PADU staff consulted the pain scores recorded during each PICU shift, the patient's history, and the findings from a physical examination, and on this basis rated the effectiveness of the analgesic technique and evaluated the need to make changes in analgesic treatment. PADU staff were also responsible for recording any technique-related complications, their evolution, and the need for treatment, if any.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The same anaesthesia technique was used in all patients. After standard anaesthesia induction with incremental doses of sevoflurane, an intravenous line was placed and 2-3 mg/kg propofol, 2-3 μg/kg fentanyl, and 1 mg/kg rocuronium were administered. Following this, the patient was intubated using a cuffed tube containing a bronquial blocker (Univent®, Fuji Systems Corporation, Tokyo, Japan) for one-lung ventilation. Fibreoptic bronchoscopy was performed to confirm correct placement of the bronchial blocker. General anaesthesia was maintained with sevoflurane, remifentanil perfusion, and boluses of fentanyl and rocuronium as required. A standard right lateral thoracotomy was performed through which the patient was cannulated and connected to CPB. Hypothermia was induced, and the ASD was either sewn shut or covered with an autologous pericardium patch, depending on the size of the defect.</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the end of surgery, once haemostasis had been confirmed, a right thoracic paravertebral catheter was inserted at T4-T5 following the same technique described in adults, but using a thinner, shorter epidural needle and catheter (20 G, 5 cm Tuohy needle [Perifix®, B. Braun, Melsungen, Germany]) due to the shorter anatomical distances encountered in paediatric patients. With the patient in left lateral decubitus, the spinous processes were identified as the midline reference for the target block level. The distance between spinous processes was used to calculate the distance from midline for the lateral puncture. After locating the puncture point, the needle was inserted perpendicular to the skin until contact was made with the transverse process. Once this had been identified, the needle was withdrawn slightly, tilted at an angle of 10-15 °, and then slid along the upper edge of the transverse process and advanced using the loss of resistance to saline technique for up to 0.5 cm, depending on the age and weight of the patient, until it penetrated the paravertebral space. Once in the space, the catheter was inserted through the needle with the bevel oriented cranially and advanced 2-3 cm into the paravertebral space. If aspiration was negative for blood and craniosacral fluid, the needle was removed and the catheter was taped to the skin. Prior to extubation, a 0.5 ml/kg bolus of 0.25% bupivacaine was administered through the catheter. Following this, the patients were transferred to the PICU.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Pain management during the first 72 h in the PICU consisted of continuous catheter perfusion of 0.2 ml/kg/h bupivacaine 0.125% and fentanyl (1 μg/ml) combined with continuous intravenous infusion of 6.6 mg/kg/min metamizole and 15 mg/kg intravenous paracetamol every 6 h. If the TPVB failed or the catheter was accidentally dislodged, 0.5-1 μg/kg/h intravenous fentanyl was administered. All patients underwent a postoperative chest X-ray after injection of 1.5-2 ml iodinated contrast medium through the catheter to check correct catheter placement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Patients underwent close neurological follow-up and continuous haemodynamic and electrocardiographic monitoring by the medical and nursing staff of the PICU and staff from the PADU to detect possible bupivacaine toxicity.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The study data were analysed using descriptive statistics, and normally distributed variables were presented as median (± interquartile range)</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 21 patients underwent thoracotomy for ASD closure with continuous TPVB over the study period. Four patients were excluded due to data missing from the clinical history, leaving a final total of 17 study patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The group included 9 girls and 8 boys, with a median age of 5 years (P25-P75: 4-6) and a median weight of 17 kg (P25-P75: 15-19). None presented significant comorbidities, except for 1 diagnosed with frontotemporal epilepsy.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Median duration of CPB was 53 min (P25-P75: 45-57). All patients were extubated in the operating room.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The median of the mean pain scale scores for each patient was 1.5 (P25-P75: 1-2). <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the mean pain scale scores in each patient. The median pain score by age subgroups were: 1.45 in children ≤ 3 years, 2 in children aged 3-7 years, and 1 in children aged > 7 years. Pain management was considered effective, since a pain score of between 1 and 2 on the scales used both overall and in each age subgroup is defined as mild.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">No patient receiving continuous catheter analgesia in the PICU required intravenous opioid rescue for wound pain. Two patients (11.76%) required additional intravenous boluses of 0.5 μg/kg fentanyl for routine procedures performed during their stay in the PICU, such as removal of the bladder catheter. The fentanyl dose administered through the catheter was 4.8 μg/kg/day.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The median length of stay in the PICU was 48 h (P25-P75: 48-56), with a mode of 48 h. Continuous TPVB was maintained for a median of 72 h (P25-P75: 48-96), with a mode of 48 h.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Adverse catheter-related events were observed in 3 patients (17.64%): in 1 case (5.88%) the catheter was removed due to incorrect positioning, and in 2 patients (11.76%) the catheter was accidentally dislodged. All 3 patients required continuous infusion of 0.5 μg/kg/h fentanyl for pain management during their stay in the PICU.</p><p id="par0100" class="elsevierStylePara elsevierViewall">No other complications associated with catheter insertion or maintenance were recorded, and no cases of bupivacaine toxicity were recorded.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Post-thoracotomy pain is associated with postoperative atelectasis, pneumonia, pulmonary thromboembolism, and cardiac arrhythmias,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> complications that have limited the widespread implementation of minimally invasive cardiac surgery in the paediatric population. This is why effective treatment of postoperative pain will improve the efficacy of thoracotomy for ASD closure.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In terms of analgesia, the thoracic paravertebral block is similar to thoracic epidural, but the incidence of failure is lower and the technique is associated with only minor side effects, such as hypotension, nausea, vomiting, pruritus, and urine retention.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The use of continuous TPVB is used extensively in adults undergoing thoracic surgery, and was first described in children in 1992, when Lönnqvist et al. reported that the technique performed in 5 children undergoing abdominal surgery provided good intra- and postoperative analgesia.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This report was followed by further descriptions of continuous TPVB in paediatric patients undergoing different abdominal and thoracic surgeries.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our study, overall pain was mild, with a median of mean pain scores of 1.5 for each patient, showing that continuous TPVB is an effective technique for pain control in children undergoing thoracotomy for ASD closure. Postoperative pain in each age subgroup was also mild. We observed that the pain scores measured during each nursing shift in the PICU gave the staff of our PADU a good picture of each patient’s pain, and this in turn improved follow-up and pain management.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The FLACC scale has not been validated in Spanish, so its use in a different linguistic setting could be affected by translation quality and cultural differences. Although a composite pain scale in Spanish - Llanto-Actitud-Normorrespiración-Tono postural-Observación facial (LLANTO) - has been validated for the measurement of acute pain in children under 6 years of age,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> we used the FLACC scale to assess pain in patients aged under 3 years, since it is the scale included in the protocol used in our PADU.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Another indication of the effectiveness of the analgesic technique used is that none of our patients with correct catheter positioning required opioid rescue for wound pain.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The sympathetic response is accentuated in surgeries requiring CPB due to the magnitude of the inflammatory response, so the gold standard for intraoperative management involves high doses of opioids to minimize inflammation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However, one of the main aims of current fast track protocols is to reduce the perioperative use of opioids, thereby reducing the risk of opioid-related side effects and speeding up postoperative recovery. Hence the importance of implementing an opioid-sparing postoperative pain management technique. Evidence has shown that the paravertebral block can reduce consumption of opioids in the postoperative period in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In our study population, the need for anticoagulation in procedures requiring CPB ruled out the possibility of starting TPVB before surgery to reduce intraoperative opioid consumption in the context of a fast track protocol. Despite this, we were able to extubate all our patients in the operating room, probably due to our use of ultra-short-acting opioids (remifentanil) during anaesthesia maintenance,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> short CPB time (median 53 min), and bolus administration of LA through the TPVB catheter prior to extubation.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Our protocol calls for continuous instead of single shot catheter infusion, because the former prolongs postoperative analgesia and therefore reduces opioid requirements. This effect is evidenced in our results, since none of the patients in whom TPVB was successful required rescue opioids for wound pain. This is the advantage of using continuous TPVB in a fast-track protocol. Bear in mind that we used low-dose fentanyl in combination with continuous infusion of LA during the postoperative period; however, the analgesic effect of fentanyl administered by this route may also be due to a local peripheral mechanism unrelated to systemic absorption, and presumably allowed us to reduce the LA dose and, therefore, its toxicity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Our technique did not prolong the PICU stay of patients undergoing ASD closure in our hospital (median length of stay 48 h). Few studies similar to ours have been published, and all use different methodologies, procedures and anaesthetic techniques that make it impossible to compare our PICU length of stay with that reported in other centres.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The paravertebral blockade is associated with a low incidence of major neurological complications. Walker et al. performed a multicentre study in which they analysed the complications and adverse effects of more than 100,000 locoregional blocks performed in children, of which 535 were paravertebral blocks. They observed no cases of permanent neurological damage secondary to paravertebral block, and only 1 case of haematoma associated with bilateral paravertebral catheters, with no neurological deficit. The most frequent adverse effect was failure of the technique due to incorrect positioning, obstruction or dislodgement of the catheter (4%).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Although we studied a smaller population, our safety results are comparable to those reported by Walker et al., since we observed no serious TPVB-related complications or toxicity due to continuous bupivacaine infusion; however, the rate of minor catheter-related adverse events (1 case [5.88%] of incorrect positioning that required removal, and 2 cases [11.76%] of accidental catheter dislodgement) was higher in our study. We suggest implementing preventive measures to avoid accidental catheter dislodgement, such as subcutaneous tunnelling and ultrasound-guided puncture and catheter placement, which would minimize the risk of incorrect positioning and reduce the incidence of block failure and complications associated with paravertebral space puncture.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Regarding bupivacaine toxicity, according to a recent review performed by the <span class="elsevierStyleItalic">European Society of Regional Anaesthesia</span> (ESRA) and the <span class="elsevierStyleItalic">American Society of Regional Anaesthesia</span> (ASRA),<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> potentially high total bupivacaine plasma levels are common with infusions of 0.25% bupivacaine at 0.25-0.5 mg/kg/h in infants. Effective post-thoracotomy analgesia could have been achieved with a lower concentration (bupivacaine 0.125% with epinephrine 1: 400,000) at a dose of 0.2 ml/kg/h, but this would not have prevented systemic accumulation, since concentrations greater than 3 μ/ml have been recorded at 48 h. Based on these considerations, and bearing in mind that our patients were not infants, the bupivacaine doses used in our study are safe. This, however, this does not completely rule out the risk of toxicity, which is higher in children. Our patients, as described above, were therefore subject to close haemodynamic, cardiological and neurological monitoring in the PICU. Ropivacaine and levobupivacaine are less cardiotoxic than bupivacaine and provide similar quality and duration of analgesia. Our hospital does not stock levobupivacaine, and under our PADU protocol, ropivacaine is reserved for children under 1 year of age.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Unlike our protocol, in which 0.125% bupivacaine is combined with fentanyl for continuous TPVB, other authors have reported using 0.25% bupivacaine in children without an opioid adjuvant.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> There is still no consensus on the optimal dose of LA in continuous paravertebral block.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although the benefits of using drugs such as fentanyl as an adjuvant to LA in continuous paravertebral block have been described (longer effect, better quality analgesia),<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> there is no evidence from studies in children<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>; therefore, more efficacy and safety studies are needed. Based on our experience, we believe that the dose of bupivacaine used in our protocol and its combination with fentanyl for continuous paravertebral block provided good post-thoracotomy pain control and few complications.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Finally, we believe further studies are needed to compare the paravertebral technique with thoracic epidural for post-thoracotomy pain control in children.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion, continuous catheter perfusion of bupivacaine and fentanyl provides effective and safe analgesia and reduces postoperative opioid requirements in children undergoing lateral thoracotomy for ASD closure.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Thoracotomy is more painful than conventional median sternotomy, and in our experience, post-thoracotomy continuous TPVB for ASD closure provides good analgesia without interfering with postoperative recovery, permitting this surgery to be performed under a fast-track protocol.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1728903" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1526394" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1728904" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1526393" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-21" "fechaAceptado" => "2021-05-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1526394" "palabras" => array:5 [ 0 => "Thoracic paravertebral catheter" 1 => "Atrial septal defect" 2 => "Minimally invasive surgery" 3 => "Thoracotomy" 4 => "Paediatric population" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1526393" "palabras" => array:5 [ 0 => "Catéter paravertebral torácico" 1 => "Cierre de la comunicación interauricular" 2 => "Cirugía mínimamente invasiva" 3 => "Toracotomía" 4 => "Población pediátrica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lateral thoracotomy is replacing traditional median sternotomy for atrial septal defect (ASD) closure in children in order to improve cosmetic outcomes. Continuous paravertebral block has been described as an effective and safe analgesic technique in children. The aim of this study is to assess pain management by continuous perfusion of local anesthetic through a thoracic paravertebral catheter (PVC) in a pediatric population after thoracotomy closure of ASD, and its effectiveness in a fast-track program.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Descriptive cross-sectional study. Analgesic effectiveness, perioperative and safety-related data were analyzed in 21 patients who underwent thoracotomy closure of ASD with PVC. In the postoperative period, patients received continuous perfusion of bupivacaine 0.125% and fentanyl (1 mcg.ml-1) at 0.2 ml.kg-1.h-1 through the PVC.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The median of mean pain scale score for each patient was 1.5. All patients were extubated in the operating theatre. No patient with PVC required opioid rescue. The median length of stay in the Pediatric Intensive Care Unit was 48 hours. There were 3 adverse events related to PVC: 1 due to malposition and 2 due to accidental removal. No other complications or cases of local anesthetic toxicity were recorded.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">PVC provides effective, safe, opioid-saving analgesia in the postoperative period of ASD closure by thoracotomy in the context of a fast-track protocol.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La toracotomía lateral está sustituyendo la esternotomía media clásica para el cierre de la comunicación interauricular (CIA) en niños con objetivo de obtener un menor impacto estético. El bloqueo paravertebral continuo se ha descrito como una técnica analgésica efectiva y segura en niños. El objetivo del estudio es valorar el control analgésico tras el cierre de CIA por toracotomía mediante la administración de anestésico local en perfusión continua a través de un catéter paravertebral torácico (CPV) en población pediátrica, y su efectividad en un programa <span class="elsevierStyleItalic">fast-track</span>.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal descriptivo. Se analizaron datos de efectividad analgésica, datos perioperatorios y relacionados con la seguridad en 21 pacientes intervenidos de cierre de CIA mediante toracotomía con CPV. En el periodo postoperatorio se empleó una perfusión continua a través del CPV de bupivacaína 0,125% y fentanilo (1 mcg. ml<span class="elsevierStyleSup">-1</span>) a 0,2 ml.kg<span class="elsevierStyleSup">-1</span>. h<span class="elsevierStyleSup">-1</span>.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La mediana de las puntuaciones medias en las escalas de dolor de cada paciente fue 1,5. Todos los pacientes se extubaron en quirófano. Ningún paciente con CPV requirió rescate con opioides. La mediana de tiempo de estancia en la Unidad de Cuidados Intensivos Pediátricos fue de 48 horas. Se objetivaron 3 eventos adversos relacionados con el CPV: 1 debido a mala posición y 2 por salida accidental. No se registraron otras complicaciones ni casos de toxicidad por anestésicos locales.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El CPV proporciona una analgesia efectiva y segura en el postoperatorio de cierre de CIA mediante toracotomía en el contexto de un protocolo <span class="elsevierStyleItalic">fast-track</span> disminuyendo el consumo postoperatorio de opioides.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Álvarez-Baena L, Hervías M, Ramos S, Cebrián J, Pita A, Hidalgo I. Analgesia paravertebral torácica continua tras cirugía mínimamente invasiva de cierre de comunicación interauricular en población pediátrica: análisis de eficacia y seguridad. Rev Esp Anestesiol Reanim. 2022;69:259–265..</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 752 "Ancho" => 1005 "Tamanyo" => 44083 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiographic image showing the spread of contrast administered through a catheter in the right thoracic paravertebral space in a 5-year-old patient undergoing thoracotomy for ASD closure.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1184 "Ancho" => 2088 "Tamanyo" => 113313 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mean scores on the adapted pain scale by age subgroup. 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