Juan J Fibla1, Laureano Molins2, José M Mier3, Jorge Hernandez3, Ana Sierra4. 1. Department of Thoracic Surgery, Hospital Universitari del Sagrat Cor (HUSC), Barcelona, Spain juanjofibla@gmail.com. 2. Department of Thoracic Surgery, Hospital Universitari del Sagrat Cor (HUSC), Barcelona, Spain Department of Thoracic Surgery, Hospital Clinic (HC), Barcelona, Spain. 3. Department of Thoracic Surgery, Hospital Universitari del Sagrat Cor (HUSC), Barcelona, Spain. 4. Department of Anaesthesiology, Hospital Universitari del Sagrat Cor (HUSC), Barcelona, Spain.
Abstract
OBJECTIVES:Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump. METHODS: We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy--ANT--and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. RESULTS: Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6. CONCLUSIONS: Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion.
RCT Entities:
OBJECTIVES:Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump. METHODS: We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy--ANT--and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. RESULTS: Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6. CONCLUSIONS: Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion.
Authors: Bridget Bishop; Brett Pearce; Luke Willshire; Matthew Kilpin; William Howard; Laurence Weinberg; Chong Tan Journal: Anesth Pain Med Date: 2019-10-09