THORACIC PARA VERTEBRAL BLOCK IS SUPERIOR TO THORACIC EPIDURAL (PRO SESSION) Dr Sanjay Agrawal

Pain control following thoracotomy and thoracic surgery remains a significant clinical challenge No single pain relief modality is adequate Multimodal analgesic approach is superior using regional and systemic analgesic techniques

The state of art in preventing post thoracotomy pain. Romero et al. Semin Thorac Cardiovasc Surg : Adequate analgesic regimen for thoracic surgery is critical Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapies Integration of multimodal analgesia techniques with multidisciplinary rehabilitation program can enhance recovery, reduce hospital stay, and facilitate early convalescence.

Epidural technique for postoperative pain: gold standard no more? Rawal N. Reg Anesth Pain Med ;37:310-7 Reg Anesth Pain Med. Newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as believed. Benefits in a decrease in the incidence of cardiovascular and pulmonary complications limited to high risk surgery patients Less invasive regional analgesic techniques are as effective as epidural analgesia. Techniques like paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty.

Update on the role of Paravertebral block for thoracic surgery: are they worth it? Daly et al.Curr Opi Anesthesiol2009 Feb;22:38-43 There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy Important side-effects appear to be less frequent with paravertebral block than with thoracic epidural analgesia Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia 

Comparison of the analgesic efficacy and side- effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials Davies et al. Br. J. Anaesth :

Copyright restrictions may apply. Davies, R. G. et al. Br. J. Anaesth : ; doi: /bja/ael020 A meta-analysis of trials comparing PVB with epidural analgesia on postoperative pulmonary complications

Copyright restrictions may apply. Davies, R. G. et al. Br. J. Anaesth : ; doi: /bja/ael020 A meta-analysis of trials comparing PVB with epidural analgesia on morphine consumption after surgery

Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. Raveglia etal. J Thorac Cardiovasc Surg ;147 : J Thorac Cardiovasc Surg. 52 patients were randomized into 2 groups, epidural catheter( group A) and paravertebral catheter( group B). significant differences (P <.05) in favor of group B for cough and rest pain control and respiratory function(FEV1)& ambient air saturation levels No differences in blood cortisol trends between the 2 groups Collateral effects such as vomiting, nausea, low pressure, or urinary retention were observed only in group A. No collateral effects were recorded in the paravertebral group.

CONCLUSIONS: According to data, drugs administered through a paravertebral catheter are very effective. Moreover, it does not present contraindications to its positioning or collateral effects.

A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis. Ding X et al PLoS One May 5;9:e96233.PLoS One. 18 trials- 1 January 2006 to 2 February patients were included.

Figure 2. Meta-analyses of postoperative analgesic efficacy of PVB compared with that of EPI A) VAS scores 4– 8 h; B) VAS scores 24 h; C) VAS scores 48 h; D) morphine consumption 24 h. Ding X, Jin S, Niu X, Ren H, Fu S, et al. (2014) A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis. PLoS ONE 9(5): e doi: /journal.pone no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4-8, 24, 48 hours

Figure 3. Meta-analyses of adverse side effect of PVB with that of EPI A) Urinary retention; B) nausea and vomiting; C) hypotension; D) rates of failed technique; E) pulmonary complications. Ding X, Jin S, Niu X, Ren H, Fu S, et al. (2014) A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis. PLoS ONE 9(5): e doi: /journal.pone paravertebral blockade was better than epidural analgesia

Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. El-Morsy etal. Ann Card Anaesth ;15: Ann Card Anaesth. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups After induction of general anesthesia divided to receive thoracic epidural catheter ( group E ) and thoracic paravertebral catheter (group P) Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively.

Results & Conclusion Analgesia, serum cortisol level, and pulmonary function parameters were comparable incorrect placement of catheter was significantly higher in epidural group complications were higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively) comparable pain score and pulmonary function in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

Thoracic epidural or paravertebral catheter for analgesia after lung resection: is the outcome different? Elsayed et al. J Cardiothorac Vasc Anesth Feb;26(1):78-82.J Cardiothorac Vasc Anesth. retrospective analysis in tertiary referral center 1,592 patients who had undergone thoracotomy for lung resection between May 2000 and April multivariable logistic regression model was used to develop a propensity matched score of 1:1 for epidural and paravertebral block Paravertebral catheter analgesia with morphine patient-controlled analgesia seems as effective as thoracic epidural for reducing the risk of postoperative complications. The authors additionally found that paravertebral catheter use is associated with a shorter hospital stay and may be a better form of analgesia for fast-track thoracic surgery

Advantages of Paravertebral blocks Equipotent/enhanced analgesia Ipsilateral block of afferent pain pathways Low failure rate Less Haemodynamic effects Improved postoperative respiratory functions Useful in patients on anticoagulants/thromboprophylaxis

Conclusion Paravertebral block provides equipotent analgesia with reduced complications and is therefore an superior alternative to thoracic epidural.