Continuous paravertebral block as an analgesic method in thoracotomy

Información del artículo

Abstract

Introduction

Open thoracotomy is one of the surgical procedures that is still very painful in the postoperative period, which, in this type of surgery can have on respiratory function and subsequent recovery of the patient.

Patients and method

The aim of the study is to assess continuous paravertebral thoracic block as an analgesic technique in thoracotomy. A total of 139 patients undergoing pulmonary resection surgery by posterolateral thoracotomy received postoperative analgesia using a 1.5% lidocaine infusion (7–10ml/h) through a thoracic paravertebral catheter for at least 48h. Pain intensity measured on the visual analogue scale (VAS) both at rest (passive VAS) and during stimulated cough (active VAS) was recorded at time of discharge from the Recovery Unit, and on the second, third and fourth day post-surgery. Postoperative complications and the need for analgesic rescue were studied.

Results

On discharge from recovery, 98.6% of the patients had mild pain (passive VAS <3), 1.4% had moderate pain (passive VAS 4–6) and none with severe pain (EVA >6); on the 2nd day post-surgery, 97.9% had mild pain, and 1.2% moderate pain; on the third day 98.6% had mild pain and 0.7% moderate pain; and on the 4th day 100% had mild pain. There were no complications arising from the analgesic technique.

Conclusions

Continuous thoracic paravertebral analgesia is effective and safe in controlling post-thoracotomy pain.

Keywords:

Postoperative period

Analgesia thoracic surgery

Postoperative complications

Conduction anaesthesia

Paravertebral block

Local anaesthetic

Lidocaine

Resumen

Introducción

La toracotomía abierta es uno de los procedimientos quirúrgicos con postoperatorio más doloroso, hecho que en este tipo de cirugía puede repercutir sobre la función respiratoria y posterior recuperación del paciente.

Paciente y método

El propósito del estudio es evaluar el bloqueo paravertebral continuo torácico como técnica analgésica en la toracotomía. Ciento treinta y nueve pacientes sometidos a cirugía de resección pulmonar mediante toracotomía posterolateral recibieron analgesia postoperatoria mediante infusión de lidocaína al 1,5% (7–10ml/h) a través de un catéter paravertebral torácico y durante un mínimo de 48h. La intensidad del dolor mediante la escala analógica visual (EVA) tanto en reposo (EVA pasivo) como durante la tos incentivada (EVA activo) fue registrada al alta de la unidad de reanimación, al segundo, tercer y cuarto día postoperatorio. Se estudiaron las complicaciones postoperatorias y la necesidad de analgesia de rescate.

Resultados

Al alta de reanimación un 98,6% de los pacientes presentaron un dolor leve (EVA pasivo < 3), un 1,4% dolor moderado (EVA pasivo 4–6) y 0% un dolor severo (EVA > 6); en el 2.° día postoperatorio un 97,9% tuvieron un dolor leve, y un 1,2%, dolor moderado; en el 3.er día un 98,6%, un dolor leve, y un 0,7%, dolor moderado; y al 4.° día un 100% presentaron dolor leve. No se encontraron complicaciones derivadas de la técnica analgésica.

Conclusiones

La analgesia paravertebral torácica continua es efectiva y segura en el control del dolor postoracotomía.

Palabras clave:

Periodo postoperatorio

Analgesia cirugía torácica

Complicaciones postoperatorias

Anestesia de conducción

Bloqueo paravertebral

Anestésico local

Lidocaína

El Texto completo está disponible en PDF

References

[1.]

P. Gerner.

Posthoracotomy pain management.

Anesthesiology Clin, 26 (2008), pp. 355-367

[2.]

A. Dauphin, E. Lubanska-Hubert, J.E. Young, J.D. Miller, W.F. Bennett, H.D. Fuller.

Comparative study of continuous extrapleural intercostals nerve block and lumbar epidural morphine in post-thoracotomy pain.

Can J Surg, 40 (1997), pp. 431-436

Medline

[3.]

I.J. Broome, K.M. Sherry, C.S. Reilly.

A combined chest drain and intrapleural catheterfor posthoracotomy pain relief.

Anesthesia, 48 (1993), pp. 724-726

[4.]

J.D. Gough, A.B. Williams, R.S. Vaughan, J.F. Khalil, E.G. Butchart.

The control of post-thoracotomy pain. A comparative evaluation of thoracic epidural fentanyl infusions and cryo-analgesia.

Anesthesia, 43 (1988), pp. 780-783

[5.]

K. Joucken, L. Michel, J.C. Schoevaerdsts, A. Mayné, P. Randour.

Cryoanalgesia for post-thoracotomy pain relief.

Acta Anesthesiol Belg, 38 (1987), pp. 179-183

[6.]

A.D. Baxter, S. Laganiére, B. Samson, J. Stewart, K. Hull, L. Goernert.

A comparison of lumbar epidural and intravenous fentanyl for post-thoracotomy analgesia.

Can J Anaesth, 41 (1994), pp. 184-191

http://dx.doi.org/10.1007/BF03009829 | Medline

[7.]

W.E. Hurford, R.P. Dutton, P.H. Alfille, D. Clement, R.S. Wilson.

Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for post-thoracotomy analgesia.

J Cardiothoracic Vasc Anesth, 7 (1993), pp. 521-555

[8.]

F.W. Burgess, D.M. Anderson, D. Colonna, D.G. Cavanaugh.

Thoracic epidural analgesia with bupivacaine and fentanyl for postoperative thoracotomy pain.

J Cardiothoracic Vasc Anesth, 8 (1994), pp. 420-424

[9.]

D.N. Bimston, J.P. McGee, M.J. Liptay, W.A. Fry.

Continuos paravertebral extrapleural infusion for post-thoracotomy pain management.

Surgery, 126 (1999), pp. 650-656

Medline

[10.]

A. Vogt, D.S. Singer, C. Theurillat, M. Curatolo.

Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery.

Br J Anaesth, 95 (2005), pp. 816-821

http://dx.doi.org/10.1093/bja/aei250 | Medline

[11.]

G. Della Rocca, C. Coccia, L. Pompei, M.G. Costa, F. Pierconti, P. Di Marco, et al.

Post-thoracotomy analgesia: epidural vs intravenous morphine continous infusion.

Minerva Anestesiol, 68 (2002), pp. 681-693

Medline

[12.]

R.P. Grant, J.F. Dolman, J.A. Harper, S.A. White, D.G. Parsons, K.G. Evans, et al.

Patient-controlled lumbar epidural fentanyl compared with patient-controlled intravenous fentanyl for post-thoracotomy pain.

Can J Anaesth, 39 (1992), pp. 214-219

http://dx.doi.org/10.1007/BF03008779 | Medline

[13.]

C. McCroy, D. Diviney, J. Moriaty, D. Luke, D. Fitzgerald.

Comparison between repeat bolus intrathecal morphine and an epidurally delivered bupivacaine and fentanyl combination in the management of post-toracotomy pain with or without cyclooxygenase inhibition.

J Cardiothorac Vasc Anaesth, 16 (2002), pp. 607-611

[14.]

K. Perttunen, E. Kalso, J. Heinonen, J. Salo.

IV diclofenac in postthoracotomy pain.

Br J Anaesthe, 68 (1992), pp. 474-480

[15.]

O. Solak, A. Turna, A. Pekcolaklar, M. Metin, A. Sayar, O. Solak, et al.

Transcutaneous electric nerve stimulation in postthoracotomy pain: a randomized prospective study.

Thorac cardiovasc Surg, 55 (2007), pp. 182-185

http://dx.doi.org/10.1055/s-2006-924631 | Medline

[16.]

C.M. Miller-Jones, D. Phillips, E.A. Pitchford, C.J. Smallpeice.

Transcutaneous electric nerve stimulation in postthoracotomy pain relief.

Anesthesia, 35 (1980), pp. 1018

[17.]

I.D. Conacher.

Pain relief after thoracotomy.

Br J Anaesthe, 65 (1990), pp. 806-812

[18.]

F. Benedetti, S. Vighetti, C. Ricco, M. Amanzio, L. Bergamasco, C. Casadio, et al.

Neurophysiologic assessment of nerve impairment in posterolateral amd muscle-sparing thoracotomy.

J Thorac Cardiovasc Surg, 115 (1998), pp. 841-847

http://dx.doi.org/10.1016/S0022-5223(98)70365-4 | Medline

[19.]

S.H. Pennefather, M.E. Akrofi, J.B. Kendall, G.H. Russell, N.D. Scawn.

Ipsilateral shoulder pain after thoracotomy with epidural analgesia: the influence of phrenic infiltration with lidocaine.

Anesth Analg, 93 (2001), pp. 260-264

Medline

[20.]

M. Barak, D. Iaroshevski, E. Poppa, A. Ben-Nun, Y. Katz.

Low volume interescalene brachial plexus block for post-thoracotomy shoulder pain.

J Cardiothorac Vas Anesth, 21 (2007), pp. 554-557

[21.]

S.M. Klein, A. Bergh, S.M. Steele.

Thoracic paravertebral block for breast surgery.

Anesth Analg, 90 (2000), pp. 1402-1405

Medline

[22.]

I.D. Conacher, M. Kokri.

Postoperative paravertebral bloks for thoracic surgery. A radiological appraisal.

Br J Anaesth, 59 (1987), pp. 155-161

Medline

[23.]

G. Purcell-Jones, D.M. Justins.

Postoperative paravertebral bloks for thoracic surgery.

Br J Anaesth, 61 (1988), pp. 369-370

Medline

[24.]

P.S. Myles, C. Bain.

Underutilization of paravertebral block in thoracic surgery.

J Cardiothorac Vasc Anesth, 20 (2006), pp. 635-638

http://dx.doi.org/10.1053/j.jvca.2006.06.007 | Medline

[25.]

G.P. Joshi, F. Bonnet, R. Shah, R.C. Wilkinson, F. Camu, B. Fischer, et al.

A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia.

Anesth Analg, 107 (2008), pp. 1026-1240

http://dx.doi.org/10.1213/01.ane.0000333274.63501.ff | Medline

[26.]

S.E. Hill, R.A. Keller, M. Stafford-Smith, K. Grichnik, W.D. White, T.A. D’Amico, et al.

Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures.

Anesthesiology, 104 (2006), pp. 1047-1053

Medline

[27.]

E. Marret, B. Bazelly, G. Taylor, N. Lembert, A. Deleuze, J.X. Mazoit, et al.

Paravertebral block with ropivacaine 0.5% versus systemic analgesia for pain relief after thoracotomy.

Ann Thorac Surg, 79 (2005), pp. 2109-2113

http://dx.doi.org/10.1016/j.athoracsur.2004.07.030 | Medline

[28.]

J. Richardson, S. Sabanathan, J. Jones, R.D. Shah, S. Cheema, A.J. Mearns.

A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.

Br J Anaesth, 83 (1999), pp. 387-392

Medline

[29.]

M.G. Navlet, I. Garutti, L. Olmedilla, J.M. Pérez-Peña, M.T. San Joaquin, G. Martinez-Ragues, et al.

Paravertebral ropivacaine, 0.3%, and bupivacaine, 0.25%, provide similar pain relief after thoracotomy.

J Cardiothorac Vasc Anesth, 20 (2006), pp. 644-647

http://dx.doi.org/10.1053/j.jvca.2006.02.032 | Medline

[30.]

M. Cantó, M.J. Sanchez, M.A. Casas, M.L. Bataller.

Bilateral paravertebral blockade for conventional cardiac surgery.

Anaesthesia, 58 (2003), pp. 367-370

[31.]

R.G. Davies, P.S. Myles, J.M. Graham.

A comparison of analgesic efficacy and side effects of paravertebral vs epidural blockade for thoracotomy-asystematic review and meta-analysis of randomized trials.

Br J Anaesth, 96 (2006), pp. 418-426

http://dx.doi.org/10.1093/bja/ael020 | Medline

[32.]

P.D. Slinger.

Perioperative fluid management for thoracic surgery: the puzzle of postneumonectomy pulmonary edema.

J Cardiothorac Vasc Surg, 9 (1995), pp. 442-445

[33.]

R. Renck, C.J. McCartney, V.W. Chan.

Neurological complications after regional anesthesia: contemporary estimates of risk.

Anesth Analg, 104 (2007), pp. 965-974

http://dx.doi.org/10.1213/01.ane.0000258740.17193.ec | Medline

[34.]

K. Tanaka, R. Watanabe, T. Harada.

Extensive application of epidural anesthesia and analgesia in university hospital: incidence of complications related to technique.

Reg Anesth, 18 (1993), pp. 34-38

Medline

[35.]

R.M. Giebler, R.U. Scherer, J. Peters.

Incidence of neurologic complications relarted to thoracic epidural catheterisation.

Anesthesiology, 86 (1995), pp. 55-63

Medline

[36.]

K.C. Dockman, S.A. Shedd, R.F. Spetzler.

Spinal epidural hematoma associated with epidural anesthesia: complications of systemic heparinization in patients receiving peripheral vascular thrombolitic therapy.

Anesthesiology, 86 (1997), pp. 55-63

Medline

[37.]

M.A. Chaney.

Side effects of intrathecal and epidural opioids.

Can J Anaesth, 83 (1995), pp. 387-392

[38.]

E. Vilà, R. García-Guasch, S. Sabaté, M. Lucas, J. Canet, GrupoANESCAT.

Anesthesia in thoracic surgery in Catalonia: results of a survey carried out in 2003.

Arch Bronconeumol, 444 (2008), pp. 586-590

[39.]

M.K. Karkamar, P.T. Chui, G.M. Joynt.