Continuous Intercostal Nerve Block for Pain Relief after Thoracotomy

Sabanathan, S; Smith, P. J.; Pradhan, Gautam Narsing; H, Hashimi; Eng, Jibah; Mearns, Alan J.

doi:10.1016/s0003-4975(10)64657-7

Cited by 122 publications

(43 citation statements)

References 9 publications

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“…Recent modifications to this technique have utilized ultrasound and nerve stimulation [47]. Alternatively, catheters can be placed in the paravertebral space intraoperatively under direct vision by the surgeon before chest closure [48]. These methods avoid some of the concerns regarding epidural placement in the presence of difficult anatomy, local sepsis, or impaired coagulation.…”

Section: Discussionmentioning

confidence: 99%

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

et al. 2014

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ObjectiveThe most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epidural blockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue.Summary of BackgroundThoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy.MethodsTwo reviewers independently searched the databases PubMed, EMBASE, and the Cochrane Library (last performed on 1 February, 2013) for reports of studies comparing post-thoracotomy epidural analgesia and paravertebral blockade. The same individuals independently extracted data from the appropriate studies.ResultEighteen trials involving 777 patients were included in the current analysis. There was no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4–8, 24, 48 hours, and the rates of pulmonary complications and morphine usage during the first 24 hours were also similar. However, paravertebral blockade was better than epidural analgesia in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p = 0.01), hypotension (p<0.00001), and rates of failed block were lower in the paravertebral blockade group (p = 0.01).ConclusionsThis meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.

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Section: Discussionmentioning

confidence: 99%

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

et al. 2014

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“…1,2 The principle of paravertebral analgesia has been known since 1905, 3 but in 1988, the opportunity was used to place a catheter into the paravertebral extrapleural space under direct inspection before chest closure. 4 This procedure can be simply used after surgery for a continuous intercostal nerve block. Since 1988, several clinical trials have shown the efficacy of a continuous thoracic paravertebral block with bupivacaine to relieve pain and to improve impaired respiratory function after thoracotomy.…”

mentioning

confidence: 99%

Plasma Concentrations and Analgesic Effects of Ropivacaine 3.75 mg/mL During Long-Term Extrapleural Analgesia After Thoracotomy

Meyer¹,

Siauw²,

Scholz³

et al. 2005

Regional Anesthesia and Pain Medicine

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“…These catheters may be placed (i) in the interpleural space between the visceral and parietal pleura 5-8 , (ii) alongside the nerve in the subcostal groove as a single 9-12 or multiple 13-15 catheter technique, or (iii) in the extrapleural space outside the parietal pleura 4,16-24 . Evidence suggests that all three of these techniques may have the same sites of spread to multiple levels, both along adjacent intercostal spaces extrapleurally and via the paravertebral space 9,10,15,16,[25][26][27][28][29] .A single catheter placed extrapleurally along the paravertebral gutter spreads local anaesthetic both cephalad and caudad to block several intercostal nerves. Posteromedial spread may also block the sympathetic chain and posterior primary rami.…”

mentioning

confidence: 99%

Continuous Extrapleural Intercostal Nerve Block for Post Thoracotomy Analgesia in Children

1997

Anaesth Intensive Care

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Thoracotomy is a painful procedure which causes marked impairment of pulmonary function. Adequate analgesia after thoracotomy improves compliance with physiotherapy and decreases the risk of atelectasis 1 . In paediatric practice, parenteral opioids are the mainstay of treatment 2 and are associated with respiratory depression, sedation, nausea, vomiting, decreased gut motility and pruritus.Regional blockade has been advocated by many authors to reduce or negate the need for parenteral opioids after thoracotomy. Techniques described include extradural block 1,3,4 and intercostal nerve block either via injection of multiple intercostal spaces, or by insertion of a catheter to provide continuous blockade of intercostal nerves. These catheters may be placed (i) in the interpleural space between the visceral and parietal pleura 5-8 , (ii) alongside the nerve in the subcostal groove as a single 9-12 or multiple 13-15 catheter technique, or (iii) in the extrapleural space outside the parietal pleura 4,16-24 . Evidence suggests that all three of these techniques may have the same sites of spread to multiple levels, both along adjacent intercostal spaces extrapleurally and via the paravertebral space 9,10,15,16,[25][26][27][28][29] .A single catheter placed extrapleurally along the paravertebral gutter spreads local anaesthetic both cephalad and caudad to block several intercostal nerves. Posteromedial spread may also block the sympathetic chain and posterior primary rami. SUMMARYThe safety and efficacy of continuous extrapleural intercostal nerve block has been well established in adults. This review of our initial paediatric experience suggests a role for this technique in children and discusses risks and benefits relative to other forms of regional analgesia for thoracotomy.Nine children aged one to twelve years received extrapleural infusions of bupivacaine 0.1-0.2% following lateral thoracotomy for lung resection. An extrapleural catheter was placed by the surgeon prior to thoracotomy closure, and correctly positioned under direct vision external to the parietal pleura alongside the vertebral column. An intraoperative loading dose of bupivacaine, 0.25-0.5% (0.28±0.1 ml/kg, mean±SD) was injected so as to raise a bleb under the parietal pleura which spread longitudinally to bathe several intercostal nerves in the paravertebral gutter. The chest wall was then closed. Infusions of bupivacaine were commenced in the recovery room and continued at a constant rate of 0.21±0.09 ml/kg/h for 72±15 hours. The mean dose of bupivacaine was 284±97 µg/kg/h. Patients also received standard analgesia as an intravenous morphine infusion (10-50 µg/kg/h), or patient-controlled analgesia. Nursing staff were specifically instructed not to alter their usual management of variable rate morphine infusions which are titrated to adequate analgesia.Morphine requirements in the first 48 postoperative hours remained less than 30 µg/kg/h, oral fluids were well tolerated after 31.2±19.1 hours, nasogastric tubes were removed at 16.7±11.2 hours. Post...

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Continuous Intercostal Nerve Block for Pain Relief after Thoracotomy

Cited by 122 publications

References 9 publications

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

Plasma Concentrations and Analgesic Effects of Ropivacaine 3.75 mg/mL During Long-Term Extrapleural Analgesia After Thoracotomy

Continuous Extrapleural Intercostal Nerve Block for Post Thoracotomy Analgesia in Children

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