A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia

Joshi, Girish P.; Bonnet, Francis; Shah, Rajesh; Wilkinson, Roseanne C.; Camu, F.; Fischer, Barrie; Neugebauer, Edmund; Rawal, Narinder; Schug, Stephan A.; Simanski, C.; Kehlet, Henrik

doi:10.1213/01.ane.0000333274.63501.ff

Cited by 576 publications

(391 citation statements)

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“…Results of the analyses suggest analgesic equivalence but fewer adverse effects, such as hypotension, nausea and vomiting, urinary retention, and pulmonary complications. [1][2][3] Thus, continuous paravertebral blocks remain an attractive alternative to epidural blocks; however, the optimal approach to paravertebral analgesia is yet to be defined, and many modifications have been described, especially after the advent of ultrasound guidance.…”

Section: Résumémentioning

confidence: 99%

The ultrasound-guided retrolaminar block

Voscopoulos

Palaniappan

Zeballos

et al. 2013

Can J Anesth/J Can Anesth

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Purpose Paravertebral blocks have gained in popularity and offer the possible benefit of reduced adverse effects when compared with epidural analgesia. Nevertheless, pulmonary complications in the form of inadvertent pleural puncture are still a recognized risk. Also, the traditional paravertebral blocks are often technically difficult even with ultrasound guidance and constitute deep noncompressible area injections. We present our experience with the first three patients receiving ultrasound-guided retrolaminar blocks for managing the pain associated with multiple rib fractures. Clinical features The vertebral laminae are identified by ultrasound imaging in a paramedian sagittal plane by sequentially visualizing the pleura and ribs, transverse processes, and the corresponding laminae (from lateral to medial). The block needle is guided to contact the lamina, and the local anesthetic injectate is visualized under real-time imaging. A catheter is inserted and used for continuous analgesia. In three consecutive patients, verbal rating scale (VRS) pain scores were reduced from 10/10 to less than 5/10, and no technical difficulties, complications, or adverse effects were encountered. Conclusions Successful analgesia was achieved in all three cases utilizing continuous infusion and intermittent boluses with ultrasound-guided retrolaminar blocks. These results show the feasibility of this approach for patients with multiple rib fractures. RésuméObjectif Les blocs paravertébraux ont gagné en popularité et offrent l'avantage de réduire potentiellement les effets secondaires comparativement à l'analgésie péridurale. Toutefois, les complications pulmonaires, sous forme de ponction pleurale involontaire, demeurent un risque bien connu. En outre, les blocs paravertébraux conventionnels sont souvent difficiles à réaliser d'un point de vue technique et ce, même sous échoguidage, étant donné qu'il s'agit d'injections profondes réalisées dans des zones non compressibles. Nous rapportons notre expérience auprès des trois premiers patients à recevoir un bloc rétrolaminaire échoguidé pour la prise en charge de la douleur associée à une fracture multiple des cô tes. É léments cliniques Les lames vertébrales sont identifiées par ultrason dans un plan sagittal paramédian en visualisant la plèvre et les cô tes, les apophyses transverses, et les lames correspondantes (des lames latérales aux médiales) séquentiellement. L'aiguille du bloc est guidée jusqu'à ce qu'elle atteigne la lame, et l'anesthésique local injecté est visualisé par imagerie en temps réel. Un cathéter est inséré et utilisé pour l'analgésie en continu. Chez trois patients consécutifs, les scores de douleur sur une échelle visuelle ont baissé de 10/10 à Author contributions Christopher Voscopoulos, Dhamodaran Palaniappan, Jose Zeballos, Kamen Vlassakov, and Hanjo Ko performed blocks. Christopher Voscopoulos, Dhamodaran Palaniappan, Jose Zeballos, Kamen Vlassakov, Hanjo Ko, Michael Kapottos, David Janfaza, and Agnieszka Trzcinka contributed to writing the paper. ...

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Section: Résumémentioning

confidence: 99%

The ultrasound-guided retrolaminar block

Voscopoulos

Palaniappan

Zeballos

et al. 2013

Can J Anesth/J Can Anesth

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“…Previous studies have suggested that local anesthetic doses for TEA should be half those of subpleural analgesia. 4,5 In the current study, the starting bolus doses were given at a ratio of 1:2, but the PCA doses were lower than the doses used in the study by Kanazi et al For supplemental therapy, paracetamol and diclofenac sodium were used in the current study. These bupivacaine doses in the TEA group were sufficient for analgesia, and reduced the rate of complications.…”

Section: Discussionmentioning

confidence: 87%

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial

et al. 2015

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CONTEXT AND OBJECTIVE: Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy. DESIGN AND SETTING: Randomized study at Ankara Numune Education and Research Hospital, in Turkey. METHODS: Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patientcontrolled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patientcontrolled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively. RESULTS: In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression. CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia for relieving postthoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.RESUMO CONTEXTO E OBJETIVO: Dor pós-toracotomia é severa e intensa, causada por trauma de nervos periféricos, músculos e costelas. O objetivo foi comparar analgesia subpleural (SPA) com analgesia epidural torácica (TEA) em pacientes submetidos à toracotomia. TIPO DE ESTUDO E LOCAL: Estudo randomizado no Hospital Educação e Pesquisa de Numune, em Ancara, Turquia. MÉTODOS: Trinta pacientes com o estado físico I-III da Sociedade Americana de Anestesiologistas foram agendados para toracotomia diagnóstica eletiva e escolhidos aleatoriamente para receber, num período de 24 horas, SPA ou TEA, ambas controladas pelo próprio paciente, para controle da dor pós-toracotomia. Os dois grupos receberam mistura de 3 ug/ml de fentanil com solução de 0,05% de bupivacaína por meio de bomba de analgesia controlada pelo paciente. Foi administrada analgesia de resgate por via intravenosa, com 100 mg de tramadol, nos dois grupos. No pós-operatório, a escala visual analógica foi utilizada para medir presença de dor durante a tosse ou em repouso, ao longo de 24 horas. RESULTADOS: No grupo SPA, todos os pacientes necessitaram de analgesia de resgate. Cinco pacientes (33%) necessitaram de analgesia de resgate no grupo TEA (P < 0,05). Os pacientes com SPA exibiram pontuações superiores na escala visual analógica, em repouso e ao tossir, em comparação aos que receberam TEA. Nenhum dos pacientes teve quaisquer efeitos...

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“…düzelmesine hem de komplikasyonların azaltılmasına katkıda bulunduğu bildirilmiştir (1)(2)(3) . Toraks cerrahisi sonrası analjezide rejyonal teknikler (örn, torakal epidural kateter) oldukça etkin olmasına karşın, özel beceri gerektirmesi, her hastaya uygulanamaması (kardiak hastalık, ankilozan spondilit vs) hastaların invaziv girişimi reddetmesi ve ciddi komplikasyon potansiyeli nedeniyle (hematom, infeksiyon, sinir hasarı vb.)…”

Section: Gereç Ve Yöntem: Torakotomi Yapılan 30 Hasta Randomize Olaraunclassified

“…sistemik analjeziklere kıyasla daha etkin analjezi sağladığı ve solunumsal komplikasyonları azalttığı bildirilmektedir (2,13) . Ancak, bu tekniklerin bir çoğunun, invaziv olması nedeniyle ciddi komplikasyon riski içermesi, hastaların istememesi, özel beceri gerektirmesi, bazen teknik hatalar sonucu analjezinin yetersiz kalması ve her hastaya uygulanamaması nedeniyle sistemik ilaç uygulamaları da gerekmektedir (4)(5)(6)(7) .…”

Section: Materyal Ve Metodunclassified