Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression
2009; Elsevier BV; Volume: 103; Issue: 5 Linguagem: Inglês
10.1093/bja/aep272
ISSN1471-6771
AutoresAlwyn Kotzé, Andy Scally, Simon Howell,
Tópico(s)Nausea and vomiting management
ResumoVarious techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890–990 mg per 24 h compared with 325–472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%–38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed. Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890–990 mg per 24 h compared with 325–472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%–38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed. Thoracotomy frequently causes severe postoperative pain and significant morbidity.10Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-657Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar 27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar Atelectasis, pneumonia, pulmonary embolism, and emergency intensive care admission have all been found to be related to poor analgesia and consequent immobility.27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar 66Pluijms WA Steegers MAH Verhagen AFTM Scheffer GJ Wilder-Smith OHG Chronic post-thoracotomy pain: a retrospective study.Acta Anaesthesiol Scand. 2006; 50: 804-808Crossref PubMed Scopus (151) Google Scholar Postoperative pain is thought to be the single most important factor leading to ineffective ventilation and impaired secretion clearance after thoracotomy.71Richardson J Sabanathan S Mearns AJ et al.Efficacy of pre-emptive analgesia and continuous extrapleural block on post-thoracotomy pain and pulmonary mechanics.J Cardiovasc Surg. 1994; 35: 219-228PubMed Google Scholar Severe or inadequately treated acute pain after thoracotomy also predicts conversion to chronic post-thoracotomy pain27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar 66Pluijms WA Steegers MAH Verhagen AFTM Scheffer GJ Wilder-Smith OHG Chronic post-thoracotomy pain: a retrospective study.Acta Anaesthesiol Scand. 2006; 50: 804-808Crossref PubMed Scopus (151) Google Scholar and long-term post-surgical fatigue.73Richardson J Sabanathan S Shah R Post-thoracotomy spirometric lung function: the effect of analgesia.J Cardiovasc Surg. 1999; 40: 445-446PubMed Google Scholar Thoracic paravertebral block (PVB) has been shown to provide superior post-thoracotomy analgesia and lung function, compared with systemic opioids or intrapleural local anaesthetics (LA).30Detterbeck FC Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.Ann Thorac Surg. 2005; 80: 1550-1559Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar 73Richardson J Sabanathan S Shah R Post-thoracotomy spirometric lung function: the effect of analgesia.J Cardiovasc Surg. 1999; 40: 445-446PubMed Google Scholar Three systematic reviews have compared the efficacy of PVB and thoracic epidural analgesia (TEA) after thoracotomy.27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar 30Detterbeck FC Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.Ann Thorac Surg. 2005; 80: 1550-1559Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar 45Joshi GP Bonnet F Shah R et al.A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia.Anesth Analg. 2008; 107: 1026-1040Crossref PubMed Scopus (457) Google Scholar Detterbeck30Detterbeck FC Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.Ann Thorac Surg. 2005; 80: 1550-1559Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar found that PVB provided equivalent pain relief to TEA, but did not quantitatively compare complications between the two techniques. A meta-analysis by Davies and colleagues27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar showed that PVB provides pain relief as good as TEA, using LA with or without opioid, but with fewer side-effects, technical problems, and failed blocks. Perhaps more importantly, PVB reduced postoperative pulmonary complications by 64% compared with epidural analgesia.27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar Recently,45Joshi GP Bonnet F Shah R et al.A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia.Anesth Analg. 2008; 107: 1026-1040Crossref PubMed Scopus (457) Google Scholar it was found that PVB provided analgesia after thoracotomy that was comparable with TEA using LA only, but possibly less effective than TEA using LA with opioid. However, PVB reduced the incidence of pulmonary complications compared with systemic analgesia, whereas TEA did not.45Joshi GP Bonnet F Shah R et al.A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia.Anesth Analg. 2008; 107: 1026-1040Crossref PubMed Scopus (457) Google Scholar PVB may theoretically be a safer technique than TEA, at least in terms of the chances of serious spinal cord injury from epidural space infection41Grewal S Hocking G Wildsmith JAW Epidural abscesses.Br J Anaesth. 2006; 96: 292-302Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar or spinal canal haematoma.67Richardson J Paravertebral anesthesia and analgesia.Can J Anaesth. 2004; 51: R1-R6Crossref PubMed Google Scholar The systematic reviews to date27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar 30Detterbeck FC Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.Ann Thorac Surg. 2005; 80: 1550-1559Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar 45Joshi GP Bonnet F Shah R et al.A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia.Anesth Analg. 2008; 107: 1026-1040Crossref PubMed Scopus (457) Google Scholar studied PVB as a single generic technique, regardless of drug choice, dose, or administration technique. The optimal drug(s) for PVB have to date not been reviewed. We therefore undertook a systematic review with the aim of determining how the following variables influence the quality of post-thoracotomy analgesia with PVB: (i)LA dose;(ii)administration technique, that is, continuous infusion or intermittent boluses;(iii)choice of LA agent;(iv)the addition of fentanyl or clonidine to LA;(v)pre-emptive PVB;(vi)the addition of patient-controlled opioids to PVB. This review followed the Quality of Reporting of Meta-analyses (QUORUM) guidelines.57Moher D Cook JC Eastwood S Olkin I Rennie D Stroup DF Improving the quality of reports of meta-analyses of randomized controlled trials: the QUORUM statement.Lancet. 1999; 354: 1896-1900Abstract Full Text Full Text PDF PubMed Scopus (3943) Google Scholar Data were extracted and analysed in keeping with the methods used in similar meta-analyses27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar as far as was appropriate. The MEDLINE and EMBASE databases were searched without language restriction up to May 2008, using the Athens portal of the United Kingdom National Library for Health. The predetermined inclusion criteria were: (i)randomized controlled trials (RCTs) in which at least one trial group received paravertebral LA with or without additives, and(ii)postoperative pain control, pulmonary function, or both reported as outcome measure.Only trials involving adult patients were considered. The keywords 'paravertebral block', 'nerve block', 'paravertebral', 'extrapleural', 'subpleural', 'retropleural', 'intercostal nerve block', 'thoracotomy', 'pneumonectomy', 'oesophagectomy', and the corresponding Medical Subject Headings (MeSH) were used alone and combined with Boolean operators. The electronic search identified 66 papers for consideration. The abstracts of the identified articles were reviewed to determine if the study met the inclusion criteria of the review. In addition, the reference lists of trials included in previous reviews of analgesia for thoracotomy27Davies RG Myles PS Graham JM A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials.Br J Anaesth. 2006; 96: 418-426Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar 30Detterbeck FC Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.Ann Thorac Surg. 2005; 80: 1550-1559Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar 45Joshi GP Bonnet F Shah R et al.A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia.Anesth Analg. 2008; 107: 1026-1040Crossref PubMed Scopus (457) Google Scholar 73Richardson J Sabanathan S Shah R Post-thoracotomy spirometric lung function: the effect of analgesia.J Cardiovasc Surg. 1999; 40: 445-446PubMed Google Scholar were checked. Data concerning the PVB group of each randomized trial were extracted into Microsoft Excel® and analysed using STATA® (StataCorp LP, College Station, TX, USA). Average pain scores were recorded as if on a 100 mm visual analogue scale (VAS). Where scores were reported on 0–10 long ordinal scales, these were converted to a 100 mm VAS. VAS scores obtained at times close to each other were grouped together to maximize the number of trials included for each analysis. Any VAS score obtained between 6 and 10 h after operation was included with those obtained at 8 h, and VAS scores obtained on the first postoperative day or from 20 to 24 h after operation were grouped at 24 h. Pain scores were assumed to have been obtained at rest unless otherwise stated by the authors. Spirometric measurements were recorded as a percentage of the preoperative values. Complications and side-effects of the PVB itself were recorded where these were identified by the trial authors. A complication rate of zero was only recorded where it was specifically stated that a complication did not occur. The total LA dose in the first 24 h was calculated as overall indicator of dosage, using the formula: total dose=loading dose+24×(infusion dose h−1). Dosages were calculated for a patient weighing 70 kg where weight-related dosages were reported. For dosages reported as a simple range, the midpoint was used. Continuous data are presented as mean values and the standard error (se) of the mean. Where the standard deviation (sd) was reported, the se was calculated using the formula for a normal distribution (se=sd/√n). When no sd was given, it was imputed with the t-test if the P-value was stated; otherwise the sd was estimated as half of the mean value. When the median and range only were reported for continuous outcomes, the mean and sd were estimated by assuming that the mean was equivalent to the median and that the sd was one-quarter of the range.44Higgins JPT Green S Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration, 2008www.cochrane-handbook.orgCrossref Scopus (2) Google Scholar 64O'Rourke K Mixed means and medians: a unified approach to deal with disparate outcome summaries.Symposium on Systematic Reviews: Pushing the Boundaries. 2002; (Oxford): 49Google Scholar For continuous data, indirect comparisons between groups of trials were made by means of metaregression, using univariate analysis, and a random effects model. This was necessary because of great heterogeneity between the original randomized comparisons, described below. Two-tailed P-values were calculated for dichotomous data, using Fisher's exact test. Of the 31 RCTs identified,1Alaya M Auffray J-P Alouini T et al.Comparison of extrapleural and interpleural analgesia using bupivacaine after thoracotomy.Ann Fr Anesth. 1995; 14: 249-255Crossref PubMed Scopus (3) Google Scholar 4Barron DJ Tolan MJ Lea RA A randomized controlled trial of continuous extrapleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic.Eur J Anaesthesiol. 1999; 16: 236-245Crossref PubMed Scopus (0) Google Scholar 7Berrisford RG Sabanathan SS Mearns AJ Bickford-Smith PJ Pulmonary complications after lung resection: the effect of continuous extrapleural intercostal nerve block.Eur J Cardiothorac Surg. 1990; 4: 407-411Crossref PubMed Scopus (35) Google Scholar, 8Bhatnagar S Mishra S Madhurima S Gurjar M Mondal AS Clonidine as an analgesic adjuvant to continuous paravertebral bupivacaine for post-thoracotomy pain.Anaesth Intensive Care. 2006; 34: 586-591PubMed Google Scholar, 9Bilgin M Akcali Y Oguzkaya F Extrapleural regional versus systemic analgesia for relieving postthoracotomy pain: a clinical study of bupivacaine compared with metamizol.J Thorac Cardiovasc Surg. 2003; 126: 1580-1583Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 10Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-657Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar 13Carabine UA Gilliland H Johnston JR McGuigan J Pain relief after thoracotomy: comparison of morphine requirements using an extrapleural infusion of bupivacaine.Reg Anesth. 1995; 20: 412-417PubMed Google Scholar, 14Casati A Alessandrini P Nuzzi M et al.A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery.Eur J Anaesthesiol. 2006; 23: 999-1004Crossref PubMed Scopus (82) Google Scholar, 15Catala E Casa JI Unzueta MC et al.Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies.J Cardiothorac Vasc Anesth. 1996; 10: 586-588Abstract Full Text PDF PubMed Scopus (38) Google Scholar 26Dauphin A Lubanska-Hubert E Young JEM et al.Comparative study of continuous extrapleural intercostal nerve block and epidural morphine in post-thoracotomy pain.Can J Surg. 1997; 40: 431-436PubMed Google Scholar 28De Cosmo G Aceto P Campanale A et al.Comparison between epidural and paravertebral intercostals nerve block with ropivacaine after thoracotomy: effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar 29Deneuville M Bisserier A Regnard JF et al.Continuous intercostals analgesia with 0.5% ropivacaine after thoracotomy: a randomized study.Ann Thorac Surg. 1993; 55: 381-385Abstract Full Text PDF PubMed Scopus (52) Google Scholar 31Dhole S Mehta Y Saxena H et al.Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar 33Eng J Sabanathan S Continuous extrapleural intercostals nerve block and post-thoracotomy pulmonary complications.Scand J Thorac Cardiovasc Surg. 1992; 26: 219-223Crossref PubMed Scopus (19) Google Scholar 36Fibla JJ Molins L Mier JM Sierra A Vidal G Comparative analysis of analgesic quality in the postoperative of thoracotomy: paravertebral block with bupivacaine 0.5% vs ropivacaine 0.2%.Eur J Cardiothorac Surg. 2008; 33: 430-434Crossref PubMed Scopus (27) Google Scholar 38Garutti I Olmedilla L Cruz P et al.Comparison of the hemodynamic effects of a single 5 mg/kg dose of lidocaine with or without epinephrine for thoracic paravertebral block.Reg Anesth Pain Med. 2008; 33: 57-63Crossref PubMed Google Scholar 46Kaiser AM Zollinger A De Lorenzi D et al.Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar 52Luketich JD Land SR Sullivan EA et al.Thoracic epidural versus intercostal nerve catheter plus patient-controlled analgesia: a randomized study.Ann Thorac Surg. 2005; 79: 1845-1850Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 53Marrett E Bazelly B Taylor G et al.Paravertebral block with ropivacaine 0.5% versus systemic analgesia for pain relief after thoracotomy.Ann Thorac Surg. 2005; 79: 2109-2114Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 54Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Abstract Full Text PDF PubMed Scopus (97) Google Scholar 62Navlet MG Garutti I Olmedilla L Paravertebral ropivacaine, 0.3%, and bupivacaine, 0.25%, provide similar pain relief after thoracotomy.J Cardiothorac Vasc Anesth. 2006; 20: 644-647Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar 63Ng A Swanevelder J Pain relief after thoracotomy: is epidural analgesia the optimal technique?.Br J Anaesth. 2007; 98: 159-162Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar 65Perttunen K Nilsson E Heinonen J et al.Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Abstract Full Text PDF PubMed Scopus (129) Google Scholar 68Richardson J Jones J Atkinson R The effect of thoracic paravertebral blockade on intercostals somatosensory evoked potentials.Anesth Analg. 1998; 87: 373-376PubMed Google Scholar, 69Richardson J Sabanathan S Eng J et al.Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia.Ann Thorac Surg. 1993; 55: 377-380Abstract Full Text PDF PubMed Scopus (59) Google Scholar, 70Richardson J Sabanathan S Jones J et al.A prospective, randomized comparison of preoperative and continuous epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Abstract Full Text PDF PubMed Scopus (243) Google Scholar 72Richardson J Sabanathan S Mearns AJ et al.A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery.Br J Anaesth. 1995; 75: 405-408Abstract Full Text PDF PubMed Scopus (65) Google Scholar 75Sabanathan S Mearns AJ Bickford-Smith PJ et al.Efficacy of continuous extrapleural intercostal nerve block on post-thoracotorny pain and pulmonary mechanics.Br J Surg. 1990; 77: 221-225Crossref PubMed Scopus (100) Google Scholar 80Theissen O Boileau S Cornet C et al.Analgesia after thoracotomy using continuous extrapleural bupivacaine.Ann Fr Anesth. 1993; 12: 265-272Crossref PubMed Scopus (6) Google Scholar 83Watson DS Panian S Kendall V et al.Pain control after thoracotomy: bupivacaine versus lidocaine in continuous extrapleural intercostal nerve blockade.Ann Thorac Surg. 1999; 67: 825-829Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar 84Wedad M Zaki MK Haleem M The effect of addition of wound infiltration with local anaesthetics to interpleural block on post-thoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block.Egypt J Anaesth. 2004; 20: 67-72Google Scholar six were excluded from meta-analysis. One31Dhole S Mehta Y Saxena H et al.Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar was conducted in patients undergoing minimally invasive coronary artery surgery, rather than thoracotomy. One small trial54Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Abstract Full Text PDF PubMed Scopus (97) Google Scholar had an unexplained drop-out rate of 30% (three of 10) in the PVB group within 24 h and none in the control group. Another9Bilgin M Akcali Y Oguzkaya F Extrapleural regional versus systemic analgesia for relieving postthoracotomy pain: a clinical study of bupivacaine compared with metamizol.J Thorac Cardiovasc Surg. 2003; 126: 1580-1583Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar compared repeated paravertebral boluses of bupivacaine against systemic analgesia. Both the stated dose (0.1 mg kg−1) and bolus size (1–2 ml) of bupivacaine was 10–20-fold lower than every other trial, or the recommended dose. It is therefore probable that the dose quoted in the paper was simply a misprint. No correction was found in the following year's issues of the journal, and the author did not reply to communications to confirm the dose used. The trial was therefore excluded from meta-analysis. Two small trials (with a total of 20 patients in the PVB groups between them) were published in French.1Alaya M Auffray J-P Alouini T et al.Comparison of extrapleural and interpleural analgesia using bupivacaine after thoracotomy.Ann Fr Anesth. 1995; 14: 249-255Crossref PubMed Scopus (3) Google Scholar 80Theissen O Boileau S Cornet C et al.Analgesia after thoracotomy using continuous extrapleural bupivacaine.Ann Fr Anesth. 1993; 12: 265-272Crossref PubMed Scopus (6) Google Scholar One trial38Garutti I Olmedilla L Cruz P et al.Comparison of the hemodynamic effects of a single 5 mg/kg dose of lidocaine with or without epinephrine for thoracic paravertebral block.Reg Anesth Pain Med. 2008; 33: 57-63Crossref PubMed Google Scholar investigated specifically the haemodynamics of PVB and reported no data on pain or pulmonary function (Fig. 1). The 25 trials included had recruited 763 patients to 31 PVB treatment arms (Table 1). Obtaining original patient data for all the included trials proved impossible.Table 1Details of included studies. B, bupivacaineTrialnCompared againstLoading doseMaintenance24 h totalPCAGroups receiving bupivacaine infusionsPerttunen and colleagues65Perttunen K Nilsson E Heinonen J et al.Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Abstract Full Text PDF PubMed Scopus (129) Google Scholar15Epidural (local only)+single-injection IC nerve blocks8–12 ml 0.25% B4–8 ml h−1 0.25% B385YesRichardson and colleagues70Richardson J Sabanathan S Jones J et al.A prospective, randomized comparison of preoperative and continuous epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Abstract Full Text PDF PubMed Scopus (243) Google Scholar46Epidural (local only)20 ml 0.5% B (pre-incision)+20 ml 0.25% B (end of surgery)0.1 ml kg−1 h−1 0.5% B990YesBhatnagar and colleagues8Bhatnagar S Mishra S Madhurima S Gurjar M Mondal AS Clonidine as an analgesic adjuvant to continuous paravertebral bupivacaine for post-thoracotomy pain.Anaesth Intensive Care. 2006; 34: 586-591PubMed Google Scholar14Two paravertebral groups: plain bupivacaine and bupivacaine+clonidine. Plain group's data usedB 2 mg kg−1 (0.125%)0.5 mg kg−1 h−1 (0.125%)980NoBarron and colleagues4Barron DJ Tolan MJ Lea RA A randomized controlled trial of continuous extrapleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic.Eur J Anaesthesiol. 1999; 16: 236-245Crossref PubMed Scopus (0) Google Scholar22Two paravertebral groups: bupivacaine, lidocaine, against placebo. Bupivacaine group usedB 0.3 ml kg−1 0.25%0.1 ml kg−1 h−1 0.25%472.5NoSabanathan and colleagues75Sabanathan S Mearns AJ Bickford-Smith PJ et al.Efficacy of continuous extrapleural intercostal nerve block on post-thoracotorny pain and pulmonary mechanics.Br J Surg. 1990; 77: 221-225Crossref PubMed Scopus (100) Google Scholar29Placebo (both had access to i.m. opioid)B 100 mg0.1 ml kg−1 h−1 0.5% B940NoDauphin and colleagues26Dauphin A Lubanska-Hubert E Young JEM et al.Comparative study of continuous extrapleural intercostal nerve block and epidural morphine in post-thoracotomy pain.Can J Surg. 1997; 40: 431-436PubMed Google Scholar24Lumbar epidural morphine infusionB with epinephrine 1:200 0000.1 ml kg−1 h−1 0.5% B950YesCatala and colleagues15Catala E Casa JI Unzueta MC et al.Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies.J Cardiothorac Vasc Anesth. 1996; 10: 586-588Abstract Full Text PDF PubMed Scopus (38) Google Scholar15Two paravertebral regimes: infusion and paravertebral bupivacaine and norepinephrine boluses 6-hourlyB 0.375% 15 ml with epinephrine 1:200 0005 ml h−1 0.25% B with epinephrine 1:200 0006.25NoRichardson and colleagues72Richardson J Sabanathan S Mearns AJ et al.A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery.Br J Anaesth. 1995; 75: 405-408Abstract Full Text PDF PubMed Scopus (65) Google Scholar22Interpleural bupivacaineB 150 mg0.1 ml kg−1 h−1 0.5% B990YesCarabine and colleagues13Carabine UA Gilliland H Johnston JR McGuigan J Pain relief after thoracotomy: comparison of morphine requirements using an extrapleural infusion of bupivacaine.Reg Anesth. 1995; 20: 412-417PubMed Google Scholar10PCA morphineB 25 mg5 ml h−1 0.25% bupivacaine325YesEng and Sabanathan33Eng J Sabanathan S Continuous extrapleural intercostals nerve block and post-thoracotomy pulmonary complications.Scand J Thorac Cardiovasc Surg. 1992; 26: 219-223Crossref PubMed Scopus (19) Google Scholar40Placebo (both had access to i.m. opioid)B 100 mg0.5 mg kg−1 h−1 bupivacaine940NoBerrisford and Saban
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