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Background: Regional analgesia provides adequate management of pain during mastectomies and early postoperative period. The erector spinae plane block (ESPB) is a promising regional technique. This study compared the efficacy of ESPB versus paravertebral block (PVB) catheters for pain management in modified radical mastectomy (MRM). Methods: This randomized, double-blind, non-inferiority study recruited 70 adult female cases planned for MRM. The patients were equally randomized into two groups: group ESPB and group PVB. The blocks were performed before general anesthesia induction with 20 ml bupivacaine 0.25%, then 0.1 ml/kg/hr continuous infusion through a catheter. Results: The duration of block performance was significantly lower in the group ESPB than in the group PVB (P < 0.001). The total morphine consumption in 48 h postoperative was 1.54 ± 3.74 mg in group ESPB and 1.68 ± 3.48 mg in group PVB (P = 0.878). Patients required fentanyl and postoperative morphine in the 1st 48 h, time to 1st request analgesia insignificantly differed between groups. Intraoperative and postoperative heart rate, mean arterial pressure and oxygen saturation, and visual analog scale at rest and movement insignificantly differed between groups. Postoperative pneumothorax occurred in one case in group PVB and did not occur in group ESPB. Conclusions: In MRM, analgesic efficacy of preoperative ultrasound-guided ESPB and PVB is comparable, and ESPB is an easier technique and more safer to perform when compared to PVB. [ABSTRACT FROM AUTHOR]

Bariatric surgical patients are vulnerable to cardiopulmonary depressant effects of opioids. The enhanced recovery after surgery (ERAS) protocol to improve postoperative morbidity recommends regional anesthesia for postoperative pain management. However, there is limited evidence that peripheral nerve blocks (PNB) have added benefit. Study the effect of PNB on postoperative pain and opioid use following bariatric surgery. Academic medical center, United States. We conducted a cohort study of patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. A total of 44 patients received the control ERAS protocol with preoperative oral extended-release morphine sulfate (MS), while 45 patients underwent a PNB with either intrathecal morphine (IM) or oral MS per local ERAS protocol. The PNB group either underwent preoperative bilateral T7 paravertebral (PVT) PNBs (27 patients) with IM or postoperative transversus abdominis plane (TAP) PNBs (18 patients) with oral MS. The primary outcome compared total opioid consumption between the ERAS control group and the PNB group up to 48 hours postoperatively. Secondary outcomes included comparison by block type and postoperative pain scores. PVT or TAP PNB patients had a reduction in mean postoperative oral morphine equivalent (OME) requirements compared with the ERAS protocol cohort at 24 hours (93.9 versus 42.8 mg), P <.0001; at 48 hours (72.6 versus 40.5 mg); and in pain scores at 24 hours (5.64/10 versus 4.46/10), P =.02. OME and pain scores were higher in the SG cohort. Addition of truncal PNB to standard ERAS protocol for bariatric surgical patients reduces postoperative total opioid consumption. 1 Perioperative Truncal Peripheral Nerve Blocks in patients underwent Sleeve Gastrectomy or Roux-en-Y Gastric Bypass resulted in a 54% reduction in oral morphine equivalents (OMEs) requirements perioperatively and up to 24 hours postoperatively 2 Intraoperative and PACU OME requirements showed a 73% reduction in the block group versus the control group 3 There was a 67% reduction in OME requirements in the paravertebral block (PVT) group compared to the transversus Abdominis plane (TAP) group [ABSTRACT FROM AUTHOR]

This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. This investigation was performed at a large quaternary referral center. Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block. [ABSTRACT FROM AUTHOR]

This study aimed to identify the benefits of thoracic paravertebral block (PVB) by focusing on its role in reducing chronic postsurgical pain (CPSP) after thoracic surgery. A systematic review and meta-analysis of randomized controlled trials (RCTs). Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. Patients undergoing thoracic surgeries. Paravertebral block for postoperative analgesia. A total of 1,028 adult patients from 10 RCTs were included in the final analysis. The incidence of CPSP at 3 months after surgery was not reduced in the PVB group compared with the no-block (odds ratio [OR] 0.59, 95% CI 0.34-1.04; p = 0.07; I2 = 6.96%) and other-block (OR 1.39, 95% CI 0.30-6.42; p = 0.67; I2 = 77.75%) groups. The PVB did not significantly reduce the incidence of CPSP after 6 months from surgery when compared with no block (OR 0.44, 95% CI 0.08-2.53; p = 0.36; I2 = 87.53%) and other blocks (OR 1.17, 95% CI 0.71-1.95; p = 0.93; I2 = 45.75%). The PVB significantly decreased postoperative pain at 24 and 48 hours at rest compared with the no- block group. The pain score was higher in the PVB group than in the other block groups 48 hours after surgery at rest. Thoracic PVB does not prevent CPSP after thoracic surgery. Further large RCTs are required to confirm and validate the authors' results. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of the study was to assess the efficacy of different peripheral nerve blocks, compared to conventional methods (analgesics and epidural block), for pain relief in rib fracture patients. MATERIALS AND METHODS: PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design with propensity matching. The primary outcome of interest was patient's reported pain scores, both at rest and on coughing/movement. The secondary outcomes were length of hospital stay, length of stay at intensive care unit (ICU), need for rescue analgesic, arterial blood gas values and parameters of lung function test. STATA was used for statistical analysis. RESULTS: The meta-analysis was conducted with 12 studies. Compared to conventional methods, peripheral nerve block was associated with better pain control at rest 12 hours (SMD -4.89, 95% CI: -5.91, -3.86) and 24 hours (SMD -2.58, 95% CI: -4.40, -0.76) after institution of block. At 24 hours after block, the pooled findings indicate better pain control on movement/coughing for the peripheral nerve block group (SMD -0.78, 95% CI: -1.48, -0.09). There were no significant differences in the patient's reported pain scores at rest and on movement/coughing at 24 hours post-block. There were no differences in the overall risk of any complications (RR 0.48, 95% CI: 0.20, 1.18), pulmonary complication (RR 0.71, 95% CI: 0.35, 1.41) and in-hospital mortality (RR 0.62, 95% CI: 0.20, 1.90) between the two groups. Peripheral nerve block was also associated with a relatively lower need for rescue analgesic (SMD -0.31, 95% CI: -0.54, -0.07). There were no differences in the length of ICU and hospital stay, risk of complications, arterial blood gas values or functional lung parameters, i.e., PaO2 and forced vital capacity between the two management strategies. CONCLUSIONS: Peripheral nerve blocks may be better than conventional pain management strategies for immediate pain control (within 24 hours of initiation of block) in patients with fractured ribs. This method also reduces the need for rescue analgesic. The skills and experience of the health personnel, facilities for care available and the cost involved should guide the decision on which management strategy to utilize. [ABSTRACT FROM AUTHOR]

: Open renal surgeries are usually associated with significant pain which may increase morbidity and mortality if left untreated. Several methods are used to control pain after these surgeries including opioids, non-steroidal anti-inflammatory drugs and regional anesthetic techniques. This study aimed at comparing the thoracic paravertebral block (PVB) versus transversus abdominis plane block (TAP) in patients undergoing open renal surgeries. : Between November 2017 and November 2018 at Assiut University Hospital, urology department 60 patients undergone open renal surgeries had been randomly allocated into two groups; group (PVB) (n = 30) who received (PVB), and group (TAP) (n = 30) who received TAP block. The regional anesthetic technique was performed in each patient after induction of general anesthesia and before performing the surgery. The primary outcome was the total analgesic consumption in the first 24 h postoperatively. Secondary outcomes included the time to the first analgesic request and the Visual Analogue Scale score (VAS) during the first 24 h postoperatively. : Total analgesic consumption during the first 24 h postoperatively was significantly lower in PVB group compared to TAP group. The VAS scores were significantly lower in PVB group compared to TAP group during the first 12 h postoperatively. However, the time to first analgesic request was non-significant between both groups. : The TAP block was effective, safe and comparable to PVB for pain control following open renal surgeries. However, the paravertebral block was more potent. : ClinicalTrials.gov: NCT04697420 [ABSTRACT FROM AUTHOR]

INTRODUCTION: THE PARAVERTEBRAL BLOCK REPRESENTS AN ANAESTHETIC TECHNIQUE DONE MAINLY IN BREAST SURGERY AND IN THORACIC SURGERY, EITHER AS A SOLE ANAESTHETIC TECHNIQUE, EITHER FOR POSTOPERATIVE ANALGESIA. OBJECTIVES: WE STUDIED THE EFFICIENCY OF THE PARAVERTEBRAL BLOCK IN BREAST ONCOLOGY SURGERY AS AN ANAESTHETIC TECHNIQUE COMPARED TO GENERAL ANAESTHESIA, AND WE FOLLOWED THE SURGICAL ACT, THE PACIENT'S COMFORT, POSTANAESTHETIC ADVERSE EFFECTS AND POSTOPERATIVE ANALGESIA. MATERIALS: IN THE STUDY GROUP WE HAD 14 PATIENTS, 7 HAD UNILATERAL PARAVERTEBRAL BLOCK WITH OR WITHOUT LIGHT SEDATION AND 7 HAD GENERAL ANAESTHESIA WITH OROTRAHEAL INTUBATION. THE PATIENTS GAVE THEIR CONSENT FOR THE BLOCK AFTER RECEIVING INFORMATION REGARDING THE BENEFITS AND THE RISKS FOLLOWING THE TECHNIQUE. THE BLOCKS HAD BEEN MADE UNDER ULTRASOUND GUIDANCE, IN ASEPTIC CONDITIONS. RESULTS: BASED ON THE RESULTS, WE SHOWED THAT THE PATIENTS WITH PARAVERTEBRAL BLOCK FOR BREAST SURGERY WITH OR WITHOUT LIGHT SEDATION HAD SURGICAL COMFORT, HAD PROPER ANALGESIA DURING AND AFTER SURGERY FOR 12-15 HOURS, NO NAUSEA AND VOMITING WERE RECORDED COMPARED TO THE GENERAL ANAESTHESIA GROUP, DID NOT NEED IV OR ORAL ANALGESIA DURING THE DAY OF SURGERY, HAD EARLY MOBILISATION. CONCLUSION: UNILATERAL PARAVERTEBRAL BLOCK FOR BREAST SURGERY IS AN EFFICIENT ANAESTHETIC TECHNIQUE FOR BREAST RESECTION AS LONG AS AXILARY LYMPH NODE RESECTION IS NOT NEEDED. PARAVERTEBRAL BLOCK OFFERS SURGICAL AND ANALGETIC BENEFITS. [ABSTRACT FROM AUTHOR]

To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. A propensity score–matched retrospective study. A single tertiary medical center between January 2018 and December 2020. Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0. 032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0. 042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0. 001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0. 012). This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption. [ABSTRACT FROM AUTHOR]

Surgical resection is the treatment of choice both for early-stage lung cancer and pulmonary metastatic disease. For patients with lung tumors who are not eligible for surgery, the minimally invasive modality of radiofrequency ablation (RFA) may be curative and, thus, should be considered. However, opinions regarding the optimal anesthetic technique for pulmonary RFA differ. Here the authors report their experience with the use of ultrasound-guided paravertebral block in minimally-sedated patients undergoing pulmonary RFA. This retrospective study was conducted at a single institution. The 17 consecutive patients underwent 19 pulmonary RFA procedures for primary lung tumor or lung metastases. In all patients, RFA was performed according to the protocol of the hospital. Anesthesia in patients receiving RFA for lung tumors consisted of a thoracic paravertebral block (TPVB), performed between T4 and T8, with minimal sedation. This approach allowed intraoperative communication with the patient and apnea pauses as needed. There were no complications after TPVB, which was well-tolerated by all patients. Only two patients required an alfentanil bolus during RFA because of pleuritic pain. No patient required conversion from sedation to general anesthesia. There were no episodes of hemodynamic instability or desaturation (SaO 2 ≤95%), and excessive sedation prevented patient collaboration in only one patient. In conclusion, ultrasound-guided single-injection TPVB is a safe and effective anesthetic technique for high-risk patients undergoing RFA for a primary lung tumor or lung metastases. [ABSTRACT FROM AUTHOR]

Formerly management of malignant tumors of lower limb was mainly through amputation. After advancement in neoadjuvant chemo-radiotherapy, saving the limb through lower limb-sparing surgery became the main line for management. Different regional techniques are used for perioperative pain control in limb-sparing surgeries. One of these techniques is lumbar paravertebral block. It is a regional technique that provides ipsilateral analgesia resulting in somatic and sympathetic blockade in a continuous dermatomal manner. The study included 60 cancer patients scheduled for lower limb sparing surgeries. Patients were randomly allocated into two groups to receive either lumbar paravertebral block Group P with 25 ml of Bupivacaine 0.25%, with adrenaline 1:200,000 or general anesthesia Group C. There was a statistically significant decrease in hemodynamics values for Group P compared to Group C at most of the study times. Intraoperative fentanyl consumption was lower in Group P compared to Group C (107.1 ± 22.89 ug versus 233.43 ± 49.29 ug), respectively. VAS scores were lower for Group P compared to Group C with lower postoperative morphine consumption in Group P compared to Group C (8.65 ± 3.57 mg versus 16 ± 3.15 mg) respectively. Ultrasound guided paravertebral block can be used as an effective perioperative analgesic modality for cancer patients undergoing lower limb sparing surgeries. [ABSTRACT FROM AUTHOR]

To compare the analgesic effects of thoracic paravertebral block versus lidocaine infusion for management of post-thoracotomy pain. 60 patients who were scheduled for thoracotomy were randomly divided into two equal groups: IV group received 1.5 mg/kg of 1% lidocaine over 10 min then infusion of 1.5 mg/kg/h, and thoracic paravertebral group (PVB) received 10 ml lidocaine 1% over 30 s then infusion of 1.5 mg/kg/h through catheter was inserted under ultrasound guidance. Hemodynamic and respiratory variables, frequency and duration of postoperative mechanical ventilation, duration of ICU stay, time till start of respiratory exercise and till chest tube removal, analgesia was assessed using 100-point visual analogue scale and defined as VAS <30 mm at rest, and in case of inadequate analgesia, IV morphine 2 mg bolus was given. Frequencies of complications and postoperative hospital stay were also recorded. 17 patients of both groups were maintained on MV for mean duration of 1.5 ± 0.5 days. PVB group was successfully weaned from MV and extubated after significantly shorter duration. Mean duration of ICU stay, time till start of respiratory exercise, and till removal of chest tube were significantly shorter in PVB group. All patients requested analgesia, but the frequency of consumption and mean number of requests were significantly higher in IV group. VAS scores determined at 1, 2, 12, 36 and cumulative 48 hours were significantly lower in PVB group compared to IV group. Ultrasound guidance allowed safe paravertebral space catheterization. PVB using continuous lidocaine infusion provided adequate analgesia for post-thoracotomy pain with significant reduction of rescue analgesia, shorter time till respiratory exercises start, minimal complications and shorter hospital stay. [ABSTRACT FROM AUTHOR]

Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB). This was a retrospective observational study of routinely recorded data. The study was performed at a single healthcare system. All patients underwent robotic MIDCAB. Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS. In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC. These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB. [ABSTRACT FROM AUTHOR]

Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries. Systematic review and meta-analysis. The present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019. Twelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery. The results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV. [ABSTRACT FROM AUTHOR]

Observa‐se aumento do número de pacientes submetidos à cirurgia por neoplasia mamária. Seroma é a mais frequente complicação pós‐operatória que aumenta a morbidade. Há muito tempo, considera‐se o Bloqueio Paravertebral Torácico (BPVT) a técnica padrão‐ouro para o controle da dor pós‐operatória. O BPVT provoca, igualmente, o bloqueio da inervação simpática. Identificar o efeito do BPVT na redução de seroma em pacientes que realizaram mastectomia e dissecção dos linfonodos axilares. Foram incluídas no estudo 40 pacientes do sexo feminino ASA I – II, entre 18 e 65 anos de idade, submetidas a mastectomia eletiva unilateral com ressecção de linfonodos axilares. As pacientes foram randomizadas em grupo BPVT e grupo controle. As pacientes do grupo BPVT foram submetidas ao BPVT guiado por ultrassom no nível de T1 e 20 mL de bupivacaína 0,25% foram administrados antes da cirurgia. Bomba de infusão IV ACP foi prescrita para todas as pacientes. Na 24ª hora pós‐operatória foram registradas a quantidade de produção de seroma, o consumo de morfina e a avaliação da dor pela escala de avaliação numérica (NRS – do inglês Numeric Rating Scale). A quantidade média de seroma na 24ª hora pós‐operatória foi 112,5 ± 53,3 mL no grupo controle e 74,5 ± 47,4 mL no grupo BPVT (p = 0,022). Na 24ª hora pós‐operatória a pontuação NRS foi semelhante nos dois grupos (p = 0,367), porém o consumo médio de morfina foi 5,6 ± 4 mg no grupo BPVT e 16,6 ± 6,9 mg no grupo controle (p < 0,001). O BPVT reduz a quantidade de seroma enquanto proporciona analgesia efetiva em pacientes que se submetem a mastectomia e remoção dos linfonodos axilares. Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked. With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery. Forty ASA I – II female patients aged 18 – 65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient‐controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively. Mean seroma formation at postoperative 24th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery. [ABSTRACT FROM AUTHOR]

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Objective: To investigate effect of ketamine–bupivacaine in thoracic paravertebral block (TPVB) on acute and chronic pain after breast cancer surgery. Study Design: Prospective randomized controlled study. Setting: Cancer Institute. Methods: Ninety patients were assigned to receive TPVB with 20 ml bupivacaine 0.25% (Group I), combined with ketamine 0.5 mg/kg (Group II) or 1 mg/kg (Group III). Assessments included; analgesia time, post-operative morphine consumption, VAS scores, hemodynamics, sedation, adverse events and Douleur Neuropathic 4 questions (DN4) scores in 1st, 2nd and 3rd post-operative months. Results: Time to first request of analgesia was (17.76 ± 10.85h) in group I vs. (23.00 ± 1.51h, P = 0.188) and (37.33 ± 2.06h, P < 0.000) in group II and III, with significant difference between group II and III (P < 0.000). Dose of morphine in group I was (10.80 ± 2.53 mg) vs. (7.25 ± 2.31 mg, P = 0.135) and (6.20 ± 1.20 mg, P < 0.02) in group II and III, with no difference between group II and III. VAS scores were lower in Group III compared with group I and II (P < 0.05). Mean DN4 score in 1st month postoperative in Group I was (3.50 ± 0.90) vs. (3.07 ± 1.17, P = 0.114) and (2.70 ± 0.65, P < 0.000) in Group II and III, with no difference between Group II and III. Twelve patients in group I had DN4 Score ≥4 vs. 10 (P = 0.372) and 3 (P < 0.000) patients in group II and III, with significant difference between Group II and III (P < 0.001). DN4 score showed no difference between groups in 2nd and 3rd postoperative months. Conclusion: Ketamine-bupivacaine in TPVB controlled acute post-operative pain in a dose-dependent manner and decreased DN4 scores one month after breast cancer surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT02462681. [ABSTRACT FROM AUTHOR]

Objective The optimal regional technique for minimally invasive direct coronary artery bypass (MIDCAB) has yet to be determined. The aim of this study was to compare the efficacy of ultrasound-guided serratus anterior plane block (SAPB) with paravertebral block (PVB) and no block for controlling acute thoracotomy pain after robotic-assisted coronary artery bypass grafting (CABG). Design This is a retrospective study. Multiple variable regression analyses were performed. Setting The study was performed as a single institution. Participants All patients underwent robotic-assisted CABG. Intervention Data were analyzed from 197 patients during a 27-month period. Charts were abstracted manually to ascertain type of nerve block, age, gender, use of home opioids, use of adjuncts for opioid reduction, Society of Thoracic Surgeons predicted long length of stay (LOS), total opioid consumption during the 72 hours after surgery, and postoperative LOS. The authors' primary outcome was total morphine equivalents consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS. Measurements and Main Results Patients who received SAPB did not have significantly different opioid consumption than patients who had no block (p = 0.15), but it was increased significantly compared to patients administered PVB (PVB v SAPB catheter, p = 0.049; PVB v SAPB single shot, p = 0.049). There were no significant differences between groups in terms of postoperative LOS. Conclusion These findings suggest SAPB might not cover adequately the incisional and tube pain associated with MIDCAB. If validated by prospective studies, these findings suggest that SAPB should be considered only for patients who are not candidates for PVB. [ABSTRACT FROM AUTHOR]

Background: Thoracoscopic lobectomy is less painful than normal thoracotomy, but pain management is still an issue in the postoperative period. Thoracic epidural analgesia (TEA) is considered as the gold standard for post-thoracotomy pain control, but is associated with numerous risks.Methods: A total of 114 patients undergoing thoracoscopic lobectomy were randomly divided into three groups. Patients in the PVB-R group received a single-dose 0.5% ropivacaine paravertebral block (PVB), combined with patient-controlled intravenous analgesia (PCIA) after extubation during the 48-h postoperative period; those in the PVB-RD group received a single-dose 0.5% ropivacaine and dexmedetomidine (1 μg/kg) PVB, combined with the same PCIA scheme; and those in the TEA group received intraoperative thoracic epidural anesthesia with 0.5% ropivacaine, and a single dose of epidural morphine (0.03 mg/kg) after extubation combined with the same PCIA scheme. The dose and first time of postoperative analgesia, verbal rating score (VRS), change in catecholamine, cortisol and cytokine levels, change in hemodynamic parameters, and side effects during the postoperative period were recorded.Results: Compared to the PVB-R group, the dose of postoperative analgesia and VRS were lower and the first time of postoperative analgesia were longer in the PVB-RD and TEA group. Patients in the PVB-RD group had a lower incidence of side effects compared to those in the TEA group.Conclusions: Single-dose 0.5% ropivacaine combined with dexmedetomidine (1 μg/kg) PVB provides satisfactory postoperative pain control after thoracoscopic lobectomy, and can reduce the incidence of postoperative side effects. [ABSTRACT FROM AUTHOR]

Objectives To determine the preferences and perceptions regarding analgesic options for video-assisted thoracic surgery (VATS) among thoracic anesthesiologists in Canada. Design A cross-sectional survey of thoracic anesthesiologists with 30 multiple choice questions was e-mailed through an online survey tool called FluidSurveys was performed to members of the Canadian Anesthesiologists’ Society. Setting A nationwide survey. Participants Members of Canadian Anesthesiologists’ Society who provide thoracic anesthesia Interventions None. Measurements and Main Results Participant characteristics and outcomes are described using counts and percentages. The frequency of use of each technique for each surgical category is described in percentages and 95% confidence intervals. Based on the responses obtained from individual centers, approximately 469 anesthesiologists provided thoracic care in Canada at the time of the survey. The response rate to the survey was 19% (n = 89). Epidural analgesia was preferred by 93.42% (95% CI 85-98) for open surgeries compared with 41% (30-52) for VATS lobectomies. The difference was statistically significant—52% (37-67). Patient-controlled analgesia was preferred by 27% (19-39) for VATS lobectomies and 46% (35-57) for VATS minor resections. Only 14% preferred paravertebral block for any VATS surgeries. Conclusions The use of analgesic techniques for VATS surgeries is variable and largely dictated by provider preferences. The majority still prefer epidural analgesia compared with paravertebral catheter (placed either by the anesthesiologist or surgeon). A broadly acceptable choice that is effective, safe, and technically less demanding requires comparative effectiveness studies and more uniform training for physicians. [ABSTRACT FROM AUTHOR]

Local anesthetic injected into a wedge-shaped space lateral to the spinal nerves as they emerge from the intervertebral foramina produces somatosensory and sympathetic nerve blockade effective for anesthesia and for managing pain of unilateral origin from the chest and abdomen. Paravertebral blockade (PVB) is versatile and may be applied unilaterally or bilaterally. Unlike thoracic epidural, the PVB technique may be used to avoid contralateral sympathectomy, thereby minimizing hypotension and leading to better preservation of blood pressure. There are no reports on systemic toxicity associated with bilateral PVB despite the need for relatively large doses of local anesthetics. This review includes an important historic background and captures the resurgence of PVB—an almost lost technique. Thoracic PVB provides post-thoracotomy pain relief comparable with thoracic epidural analgesia (TEA) with lower side effects supported by moderate-quality evidence. The feasibility and potential of bilateral thoracic PVB for bilateral thoracic surgery appear practical. However, there is existing controversy in the assumption that thoracic PVB is a satisfactory, safer alternative when anticoagulation status is a contraindication to thoracic epidural placement. During the last 2 decades of systematic reviews and meta-analyses, both TEA and PVB have been deemed appropriate in the management of thoracic surgery. A multimodal approach to analgesia includes regional techniques for thoracic surgery that may reduce the likelihood of the development of postoperative complications and chronic pain. Purpose of This Review The authors evaluated current opinion, clinical practice, new multimodal adjuvants, regional anesthesia, and innovation and technology related PVB in the thoracic surgery patient population. The review focuses on history, techniques, application, ease of placement, and relative safety of this regional technique. For this review, studies and reference lists were retrieved from the Cochrane library, Embase, and Medline from January 1995 through January 2017. Summary Existing evidence demonstrates noninferiority of thoracic PVB compared with TEA for postoperative analgesia, with fewer side effects for unilateral and bilateral thoracic surgery, including video-assisted thoracoscopy. The determining factors in selecting the regional technique of choice include the following: (1) tolerance of side effects associated with TEA, (2) consensus on best practice or technique, and (3) operator experience. There is no consensus on the optimal approach for thoracic PVB technique or any standardization when comparing the landmark, ultrasound-guided, or stimulation-based PVB approaches. Moreover, the efficacy of TEA compared with PVB in preventing post-thoracotomy chronic pain syndrome has not been investigated thoroughly and requires future clinical trials. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate whether continuous paravertebral block at levels T1 and T2 with bupivacaine infusion can improve the survival of free flaps in maxillofacial reconstruction. The study was designed as a randomized controlled trial and included 36 adult patients scheduled for maxillofacial free flap reconstruction under general anesthesia. Patients were randomly divided into two groups: patients in group A received continuous paravertebral block at levels T1 and T2, while patients in group B served as controls. Postoperatively, a skin thermometer was used to assess the skin temperature. Perfusion of the flaps was evaluated by analysis of skin color, turgor, and capillary refill. Survival of the free flap was recorded. The surface temperature of the reconstructive flap, skin color score, and capillary refill score were significantly higher in group A patients than in group B patients during follow-up. The total perfusion score was significantly higher in group A than in group B at 16 h and 20 h postoperative ( P = 0.041 and P = 0.039, respectively). Re-operation was recorded in three cases in group B (16.7%) ( P = 0.031). Continuous paravertebral block at levels T1 and T2 can increase the skin temperature and improve skin color and capillary refilling, which are indices of adequate tissue perfusion and indicate maxillofacial free flap survival. [ABSTRACT FROM AUTHOR]

Objectives To assess the effect of paravertebral administration of dexmedetomidine as an adjuvant to local anesthetic on the intraoperative anesthetic drug requirement and incidence of post-thoracotomy pain syndrome. Design Prospective, randomized, controlled, double-blind trial. Setting Single university hospital. Participants The study comprised 30 patients who underwent elective thoracotomy and were assigned randomly to either the Ropin or Dexem group (n = 15 each). Interventions All patients received the study medications through paravertebral catheter. Patients in the Ropin group received a bolus of 15 mL of 0.75% ropivacaine over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine at 0.1 mL/kg/hour. Patients in the Dexem group received 15 mL of 0.75% ropivacaine plus dexmedetomidine, 1 µg/kg bolus over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine plus 0.2 µg/kg/hour of dexmedetomidine at 0.1 mL/kg/hour. Measurements and Main Results The primary outcome of the study was intraoperative anesthetic drug requirement. The secondary outcome was the incidence of post-thoracotomy pain syndrome 2 months after surgery. The amount of propofol required for induction of anesthesia was significantly less in the Dexem group (Dexem 49.33±20.51 v 74.33±18.40 in the Ropin group, p = 0.002). End-tidal isoflurane needed to maintain target entropy was significantly less in the Dexem group at all time points. Intraoperative fentanyl requirement was lower in the Dexem group (Dexem 115.33±33.77 v 178.67±32.48 in the Ropin group, p = 0.002). Postoperative pain scores and morphine consumption were significantly less in the Dexem group (p<0.001). The incidence of post-thoracotomy pain syndrome was comparable between the 2 groups (69.23% v 50%, p = 0.496). Conclusions Paravertebral dexmedetomidine administration resulted in decreased intraoperative anesthetic drug requirement, less pain, and lower requirements of supplemental opioid in the postoperative period. However, it had no effect on the incidence of post-thoracotomy pain syndrome. [ABSTRACT FROM AUTHOR]

Objective Effective postoperative pain management has been shown to be a positive predictive factor for postoperative recovery following a thoracotomy. The primary objective of this study was to examine the efficacy and safety of continuous paravertebral blockade in managing acute postsurgical pain following unilateral and bilateral single-lung transplantation. Design The authors conducted a prospective observational trial of patients. Setting The study was conducted in an academic university hospital. Participants Patients (≥18 years of age) who underwent either unilateral or bilateral single-lung transplantation and received a postoperative paravertebral catheter. Interventions Paravertebral catheters were placed via an ultrasound-guided technique on either postoperative day 1 or 2. After placement, a continuous infusion of 0.2% ropivacaine was run at 0.2 to 0.25 mL/kg/h with maximum dose of 7 mL/h per side in bilateral lung transplant patients, and 14 mL/h in unilateral lung transplant patients. Measurements and Main Results Patients were followed up to 120 hours after placement of catheters, and pain scores, opioid use, and adverse events were recorded. There were 35 patients who completed the study from October 2013 to December 2014 (21 bilateral transplants and 14 unilateral transplants). The mean time to paravertebral catheter placement was 1.14 days in the overall group, with median time to extubation occurring 543 minutes after placement (range, 23-2,985 minutes). Catheters remained in place for a mean of 7.18 days. The mean maximal pain scores for both groups was 5.94 (day 1), 6.26 (day 2), 6.20 (day 3), 5.12 (day 4), and 5.60 (day 5). There were no adverse events related to the paravertebral catheters in either group. Conclusions Paravertebral catheters provide a feasible option for postoperative pain control following unilateral or bilateral single-lung transplant in adult patients. Future research should focus on randomized trials of thoracic epidurals compared to paravertebral catheters. [ABSTRACT FROM AUTHOR]

Resumo Justificativa Estão descritas várias técnicas locorregionais para a abordagem da dor aguda e dor crônica após cirurgia de mama. O ideal seria uma técnica fácil de fazer, reprodutível, com pouco desconforto para as doentes, com poucas complicações e que permitirá um bom controle da dor aguda e uma diminuição da incidência de dor crônica, notadamente dor neuropática do intercostobraquial, por ser a entidade mais frequente. Objetivos Estudar a aplicação de bloqueio paravertebral com picada única no pré‐operatório de cirurgia mamária de grande porte. Avaliar numa primeira fase o controle de dor aguda e náuseas‐vômitos no pós‐operatório (NVPO) nas primeiras 24 horas e numa segunda fase a incidência de dor neuropática na região do nervo intercostobraquial seis meses após a cirurgia. Métodos Foram incluídas 80 doentes do sexo feminino, ASA I ‐ II , entre 18 e 70 anos, submetidas a cirurgia mamária de grande porte sob anestesia geral, estratificadas em dois grupos: anestesia geral (anestesia geral inalatória com opioides segundo resposta hemodinâmica) e paravertebral (bloqueio paravertebral com picada única em T4 com ropivacaína 0,5% + adrenalina 3 μg/mL com um volume de 0,3 mL/kg pré‐operatoriamente e posterior indução e manutenção com anestesia geral inalatória). No pós‐operatório imediato foi colocada PCA ( Patient‐controlled analgesia ) de morfina programada com bolus a demanda durante 24 horas. Foram registados fentanil intraoperatório, consumo de morfina pós‐operatória, complicações relacionadas com as técnicas, dor em repouso e ao movimento a 0, 1 h, 6 h e 24 h, assim como os episódios de NVPO. Foram analisadas todas as variáveis identificadas como fatores de cronificação da dor idade, tipo de cirurgia, ansiedade segundo escala de HADS ( Hospital Anxiety and Depression scale ), dor pré‐operatória; acompanhamento no domicílio; índice de massa corporal (IMC), tratamentos adjuvantes de quimioterapia/radioterapia e foi verificada a homogeneidade das amostras. Aos seis meses da cirurgia foi avaliada, segundo escala DN4, a incidência de dor neuropática na área do nervo intercostobraquial. Resultados O grupo paravertebral teve valores de VAS (Escala Visual Analógica) em repouso mais baixos ao longo das 24 horas de estudo 0 h 1,90 (± 2,59) versus 0,88 (± 1,5); 1 h 2,23 (± 2,2) versus 1,53 (± 1,8); 6 h 1,15 (± 1,3) versus 0,35 (± 0,8); 24 h 0,55 (± 0,9) versus 0,25 (± 0,8) com significado estatístico às 0 e às 6 horas. Em relação ao movimento o grupo paravertebral teve valores de VAS mais baixos e com significância estatística nos quatro momentos de avaliação: 0 h 2,95 (± 3,1) versus 1,55 (± 2,1); 1 h 3,90 (± 2,7) versus 2,43 (± 1,9) 6 h 2,75 (± 2,2) versus 1,68 (± 1,5); 24 h 2,43 (± 2,4) versus 1,00 (± 1,4). O grupo paravertebral consumiu menos fentanil (2,38 ± 0,81 μg/Kg versus 3,51 ± 0,81 μg/Kg) e menos morfina no pós‐operatório (3,5 mg ± 3,4 versus 7 mg ± 6,4), com diferença estatisticamente significativa. Na avaliação de dor crônica aos seis meses no grupo paravertebral houve menos casos de dor neuropática na região do nervo intercostobraquial (três versus sete ) embora sem significância estatística. Conclusões O bloqueio paravertebral com picada única permite um adequado controle da dor aguda com menor consumo de opioides intraopreatórios e pós‐operatórios, mas aparentemente não consegue evitar a cronificação da dor. Mais estudos são necessários para esclarecer o papel do bloqueio paravertebral na cronificação da dor em cirurgia mamária de grande porte. Background Several locoregional techniques have been described for the management of acute and chronic pain after breast surgery. The optimal technique should be easy to perform, reproducible, with little discomfort to the patient, little complications, allowing good control of acute pain and a decreased incidence of chronic pain, namely intercostobrachial neuralgia for being the most frequent entity. Objectives The aim of this study was to evaluate the paravertebral block with preoperative single needle prick for major breast surgery and assess initially the control of postoperative nausea and vomiting (PONV) and acute pain in the first 24 hours and secondly the incidence of neuropathic pain in the intercostobrachial nerve region six months after surgery. Methods The study included 80 female patients, ASA I ‐ II , aged 18‐70 years, undergoing major breast surgery, under general anesthesia, stratified into 2 groups: general anesthesia (inhalation anesthesia with opioids, according to hemodynamic response) and paravertebral (paravertebral block with single needle prick in T4 with 0.5% ropivacaine + adrenaline 3 μg/mL with a volume of 0.3 mL/kg preoperatively and subsequent induction and maintenance with general inhalational anesthesia). In the early postoperative period, patient‐controlled analgesia (PCA) was placed with morphine set for bolus on demand for 24 hours. Intraoperative fentanyl, postoperative morphine consumption, technique‐related complications, pain at rest and during movement were recorded at 0 h, 1 h, 6 h and 24 h, as well as episodes of PONV. All variables identified as factors contributing to pain chronicity age, type of surgery, anxiety according to the Hospital Anxiety and Depression Scale (HADS), preoperative pain, monitoring at home; body mass index (BMI) and adjuvant chemotherapy/radiation therapy were analyzed, checking the homogeneity of the samples. Six months after surgery, the incidence of neuropathic pain in the intercostobrachial nerve was assessed using the DN4 scale. Results The Visual Analogue Scale (VAS) values of paravertebral group at rest were lower throughout the 24 hours of study 0 h 1.90 (± 2.59) versus 0.88 (± 1.5) 1 h 2.23 (± 2.2) versus 1.53 (± 1.8) 6 h 1.15 (± 1.3) versus 0.35 (± 0.8); 24 h 0.55 (± 0.9) versus 0.25 (± 0.8) with statistical significance at 0 h and 6 h. Regarding movement, paravertebral group had VAS values lower and statistically significant in all four time points: 0 h 2.95 (± 3.1) versus 1.55 (± 2.1); 1 h 3.90 (± 2.7) versus 2.43 (± 1.9) 6 h 2.75 (± 2.2) versus 1.68 (± 1.5); 24 h 2.43 (± 2.4) versus 1.00 (± 1.4). The paravertebral group consumed less postoperative fentanyl (2.38 ± 0.81 μg/kg versus 3.51 ± 0.81 μg/kg) and morphine (3.5 mg ± 3.4 versus 7 mg ± 6.4) with statistically significant difference. Chronic pain evaluation of at 6 months of paravertebral group found fewer cases of neuropathic pain in the intercostobrachial nerve region (3 cases versus 7 cases), although not statistically significant. Conclusions Single‐injection paravertebral block allows proper control of acute pain with less intraoperative and postoperative consumption of opioids but apparently it cannot prevent pain chronicity. Further studies are needed to clarify the role of paravertebral block in pain chronicity in major breast surgery. [ABSTRACT FROM AUTHOR]

Objective To compare paravertebral block under thoracoscopy with wound infiltration at an early stage after video-assisted thoracic lobectomy surgery. Design A prospective, randomized, triple-blinded, placebo-controlled trial. Setting A single-center university hospital. Participants Patients scheduled for video-assisted thoracic lobectomy surgery between February 20, 2014 and June 1, 2014 randomly were allocated into paravertebral block (PVB) (n = 35) and infiltration (n = 35) groups. Interventions In the PVB group, 0.5% ropivacaine was injected into the paravertebral space by the surgeon under direct vision with placebo infiltration of saline in the wounds. In the infiltration group, the wounds were infiltrated with 0.5% ropivacaine by the surgeon with a placebo paravertebral block. Subsequently, patient-controlled intravenous morphine analgesia and paracoxib were administered. Measurements and Main Results The primary endpoints were visual analog scale (VAS) pain scores at rest and on cough 0, 2, 6, and 24 hours after surgery. The secondary endpoints were the total morphine during postoperative 0 hours to 24 hours, adverse events, and patient satisfaction with the analgesia. Sixty-one patients completed the study. VAS score on cough at each time point was significantly lower (p<0.05) and median (25th, 75th) morphine consumption was lower in the PVB group than in the infiltration group (26 [10, 35] mg and 42 [29, 58] mg, p<0.001, respectively). There was no difference in VAS score at rest. Patients in the PVB group had higher satisfaction with analgesia than in the infiltration group (p = 0.003). Conclusions As part of the multimodal postoperative analgesia, intraoperative paravertebral block provided better dynamic pain relief and reduced morphine consumption compared with local wound infiltration. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. Design A randomized, prospective trial. Setting A single tertiary referral academic medical center. Participants 60 patients undergoing robotic mitral valve surgery. Interventions Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. Measurements and Main Results After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. Conclusions The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade. [ABSTRACT FROM AUTHOR]

Objective Postoperative respiratory complications are serious and frequently observed among patients who undergo thoracoabdominal aortic aneurysm (TAAA) repair. Paravertebral block (PVB) can provide effective analgesia for relief of postoperative thoracotomy pain and may reduce respiratory complications. However, the impact of PVB on postoperative pain and respiratory function in patients who undergo TAAA repair requiring intraoperative high-dose heparin administration is unknown. This study examined the efficacy of PVB on postoperative pain and respiratory function after TAAA repairs. Design Retrospective, observational cohort study. Setting Single center in Japan. Participants Fifty-eight consecutive patients who underwent TAAA repair from March 2013 to October 2014. Interventions Application of thoracic PVB. Measurement and Main Results A total of 56 patients were analyzed. Two patients were excluded because 1 patient was dead within 24 hours after surgery and 1 patient was 9 years old. Patients with PVB were defined as group P (n = 17), and patients without PVB as group C (n = 39). There was no significant difference in baseline characteristics between the 2 groups. Both postoperative pain at rest and postoperative pain while coughing were assessed using a numeric rating scale (NRS); the incidence of reintubation and noninvasive positive-pressure ventilation (NPPV) also were compared between the 2 groups. The NRS score of postoperative pain at rest was significantly lower in group P (group P: Median 2, interquartile range 1 to 3; group C: Median 6, interquartile range 5 to 7; p = 0.000), and the NRS score of postoperative pain while coughing was significantly lower in group P (group P: Median 5, interquartile range 3.5 to 6.5; group C: Median 8, interquartile range 7 to 10; p = 0.000). Reintubation rate was significantly lower in group P (group P: 0%, group C: 23%, p = 0.045); the incidences of NPPV (group P: 12%, group C: 46%, p = 0.016) and postoperative pneumonia were significantly lower in group P (group P: 0%, group C: 28%, p = 0.024). Conclusions PVB significantly reduced postoperative pain at rest and while coughing and significantly reduced the reintubation rate, the rate of NPPV use, and postoperative pneumonia without complications. PVB could be a safe and an effective analgesic method that reduces postoperative respiratory exacerbation in patients who undergo TAAA repair. [ABSTRACT FROM AUTHOR]

Objectives To explore the barriers to the use of epidural block (EDB) or paravertebral block (PVB) for thoracotomy or thoracoscopy. Design Cross-sectional ancillary study. Setting French nationwide practice survey. Participants Lead anesthesiologists at centers practicing thoracic surgery completed an online questionnaire. Interventions A 9-item electronic questionnaire regarding perceived barriers to the use of EDB and PVB was developed, including technical factors, nursing factors (training and supervision), and reluctance of non-anesthesiologist colleagues (eg, surgeons, nurses and hospital managers). Descriptive and factorial analyses were conducted, including the current use of the techniques in the model. Measurements and Main Results The questionnaire was answered by 84 of 103 (82%) centers. For both techniques, the most frequently cited barriers were the 4 technical ones and lack of nursing supervision. There was a high rate of do not know/no opinion responses regarding barriers to paravertebral block. The type of center did not influence the responses, but paravertebral block was used more often in university hospitals. Colleague reluctance and time consumption (for both techniques), nursing barriers (for epidural block), and perception of risk and complexity (for paravertebral block), were correlated inversely with actual use. Perception of cost had no influence on practice. Conclusions This survey suggested that the use of epidural or paravertebral block to provide analgesia for thoracic surgery might be increased by multimodal actions focused on improved communication with surgical and managerial teams. Paravertebral block, as an emerging technique, still is insufficiently recognized in France. [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivos A estenose hipertrófica do piloro é uma condição relativamente comum do trato gastrintestinal na infância, que causa um quadro de vômitos em jato e alterações metabólicas que envolvem um alto risco de aspiração durante a indução da anestesia. Assim, recomenda‐se uma técnica sob anestesia geral e indução intravenosa de sequência rápida, pré‐oxigenação e pressão cricoide. Após a correção da alcalose metabólica sistêmica e normalização do pH, o líquido cerebrospinal pode manter um estado de alcalose metabólica. Isso, juntamente com os efeitos residuais de agentes bloqueadores neuromusculares, anestésicos e opioides, pode aumentar o risco de apneia pós‐operatória após anestesia geral. Casos clínicos Apresentamos o manejo bem‐sucedido em três recém‐nascidos que foram submetidos a piloroplastia por apresentar estenose hipertrófica do piloro congênita. O procedimento foi feito sob anestesia geral com intubação orotraqueal e indução de sequência rápida. Em seguida, fez‐se um bloqueio paravertebral guiado por ultrassonografia como método analgésico sem a necessidade de administração de opioides durante o período intraoperatório e que mantém o nível analgésico adequado. Conclusões A anestesia regional é comprovadamente segura e eficaz na prática pediátrica. Consideramos o bloqueio paravertebral guiado por ultrassom com dose única como uma possível opção a outras técnicas regionais descritas, evita o uso de opioides e bloqueadores neuromusculares durante a anestesia geral e reduz o risco de apneia central no pós‐operatório. Background and objectives Hypertrophic pyloric stenosis is a relatively common affection of gastrointestinal tract in childhood that results in symptoms, such as projectile vomiting and metabolic disorders that imply a high risk of aspiration during anesthetic induction. In this way, the carrying out of a technique with general anesthesia and intravenous rapid sequence induction, preoxygenation and cricoid pressure are recommended. After the correction of systemic metabolic alkalosis and pH normalization, cerebrospinal fluid can keep a state of metabolic alkalosis. This circumstance, in addition to the residual effect of neuromuscular blocking agents, inhalant anesthetics and opioids could increase the risk of postoperative apnea after a general anesthesia. Case report We present the successful management in 3 neonates in those a pyloromyotomy was carried out because they had presented congenital hypertrophic pyloric stenosis. This procedure was done under general anesthesia with orotracheal intubation and rapid sequence induction. Then, ultrasound‐guided paravertebral block was performed as analgesic method without the need for administrating opioids within intraoperative period and keeping an appropriate analgesic level. Conclusions Local anesthesia has demonstrated to be safe and effective in pediatric practice. We consider the ultrasound‐guided paravertebral block with one dose as a possible alternative for other local techniques described, avoiding the use of opioids and neuromuscular blocking agents during general anesthesia, and reducing the risk of central apnea within postoperative period. [ABSTRACT FROM AUTHOR]

Resumo Introdução o adequado tratamento da dor pós‐operatória tem sido de fundamental importância nos cuidados com o paciente cirúrgico. Entre as técnicas de analgesia direcionadas para esse grupo de pacientes, o bloqueio paravertebral torácico combinado com a anestesia geral se destaca pelos bons resultados e pela favorável relação risco‐benefício. Muitos anestésicos locais e outros fármacos adjuvantes vêm sendo investigados para uso nessa técnica, com vistas a melhorar a qualidade da analgesia e reduzir os efeitos adversos. Objetivo avaliar a eficácia e a segurança do bloqueio paravertebral em comparação com outros regimes analgésicos e anestésicos em mulheres submetidas a cirurgias para câncer de mama. Métodos revisão integrativa da literatura de 1966 a 2012, feita por meio de termos específicos nos bancos de dados informatizados, de artigos que investigaram as características clínicas e os efeitos adversos e benéficos do bloqueio paravertebral torácico. Resultados no período selecionado, foram identificados 16 estudos randomizados que preenchiam os critérios de seleção estabelecidos para essa revisão bibliográfica. O bloqueio paravertebral torácico demonstrou uma redução significativa da dor pós‐operatória, bem como diminuição da dor durante movimentos do braço após a cirurgia. Conclusão o bloqueio paravertebral torácico reduziu a necessidade pós‐operatória de analgésicos quando comparado ao grupo placebo, notadamente dentro das primeiras 24 horas. O emprego dessa técnica poderia garantir uma analgesia pós‐cirúrgica de relevância clínica. Novos estudos, com maiores grupos populacionais, fazem‐se necessários, uma vez que o bloqueio paravertebral parece promissor em analgesia preemptiva para cirurgia de câncer de mama. Introduction optimum treatment for postoperative pain has been of fundamental importance in surgical patient care. Among the analgesic techniques aimed at this group of patients, thoracic paravertebral block combined with general anesthesia stands out for the good results and favorable risk‐benefit ratio. Many local anesthetics and other adjuvant drugs are being investigated for use in this technique, in order to improve the quality of analgesia and reduce adverse effects. Objective evaluate the effectiveness and safety of paravertebral block compared to other analgesic and anesthetic regimens in women undergoing breast cancer surgeries. Methods integrative literature review from 1966 to 2012, using specific terms in computerized databases of articles investigating the clinical characteristics, adverse effects, and beneficial effects of thoracic paravertebral block. Results on the selected date, 16 randomized studies that met the selection criteria established for this literature review were identified. Thoracic paravertebral block showed a significant reduction of post‐operative pain, as well as decreased pain during arm movement after surgery. Conclusion thoracic paravertebral block reduced postoperative analgesic requirement compared to placebo group, markedly within the first 24 hours. The use of this technique could ensure postoperative analgesia of clinical relevance. Further studies with larger populations are necessary, as paravertebral block seems to be promising for preemptive analgesia in breast cancer surgery. [ABSTRACT FROM AUTHOR]

Objective Paravertebral block (PVB) has been shown to be an ideal aid for analgesia after thoracic or abdominal surgery. The authors studied the safety and efficacy of the single-dose and bilateral ultrasound-guided (USG)-PVB before combined thoracoscopic-laparoscopic esophagectomy (TLE) along with intravenous sufentanil analgesia as a method of pain relief in comparison with intravenous sufentanil as a sole analgesic agent. Design Prospective, randomized study. Setting Single university hospital. Participants Fifty-two patients undergoing TLE. Interventions A USG-PVB was performed before surgery using a solution of 30 mL of 0.5% ropivacaine by 3 injections of 10 mL each at the right T5 and bilateral T8 (PVB group,n = 26) or the saline injection of 10 mL at every site (control group, n = 26). Measurements and Main Results Successful PVBs were achieved in all patients of the PVB group. Intraoperative mean remifentanil usage and end-tidal sevoflurane concentration were lower in the PVB group (p<0.001). Hemodynamic parameters were stable in both groups. Postoperative pain scores both at rest and on coughing were lower during the first 8 hours in the PVB group than those in the control group (p<0.05). Cumulative sufentanil consumption delivered by patient-controlled analgesia (PCA) was significantly lower in the PVB group at all time points (p<0.05). Postoperative pulmonary function was better at the third postoperative day in the PVB group (p<0.05), with quicker hospital discharge and lower hospital costs (p< 0.05). Conclusions The single-dose and bilateral PVB given before TLE combined with sufentanil may provide better postoperative analgesia and early discharge in patients undergoing TLE. [ABSTRACT FROM AUTHOR]

Abstract: Background: Pectoral nerve block (Pecs) is a novel interfascial plane block which can provide analgesia after breast surgery while paravertebral block (PVB) is widely used for this purpose. We evaluated the difference between the two techniques in regard to morphine consumption and analgesic efficacy after modified radical mastectomy (MRM). Methods: Sixty patients undergoing elective MRM were randomly allocated into either PVB with 15–20ml of levobupivacaine 0.25% at the level of fourth thoracic vertebra or Pecs block with 10ml of levobupivacaine 0.25% injected inbetween pectoralis major and pectoralis minor muscle and another 20ml levobubivacaine 0.25% inbetween pectorlis minor and serratus anterior muscle. Primary outcome measure was morphine consumption in the first 24h while secondary outcome measures included pain scores, intraoperative fentanyl consumption as well as postoperative nausea and vomiting (PONV). Results: Postoperative morphine consumed at 24h was significantly lower in Pecs group [21 (20–25) mg] than in PVB group [28 (22–31) mg], (p =0.002). Time for first request of morphine was longer in Pecs group [175 (155–220) min] than in PVB group [137.5 (115–165) min], (p <0.001). Numerical rating score (NRS) at rest was lower in Pecs group compared with PVB group at 1h, 6h and 12h (p <0.001) but at 18h and 24h it was lower in PVB group compared with Pecs group (p =0.008 and <0.001 respectively). During movement, NRS was significantly lower at 1st hour in Pecs group (p <0.001) while at 18h and 24h it was significantly lower in PVB group (p <0.001). PONV was comparable between both groups. Conclusion: Pecs block reduced postoperative morphine consumption in the first 24 and pain scores in the first 12h in comparison with PVB after mastectomy. [Copyright &y& Elsevier]

Objective: The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. Design: A retrospective review. Setting: A single tertiary referral academic hospital. Participants: Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. Interventions: None. Measurements and Main Results: After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. Conclusions: Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit. [Copyright &y& Elsevier]

Objectives: A wide range of insertion points lateral to the midline are recommended for paravertebral blockade. The authors hypothesized that in a given subject, using an insertion point at the tip of the transverse process has a superficial but consistent depth to the pleura. The authors also hypothesized that for a given insertion point, depths to the pleura are related directly to the patient's anthropomorphic indices. Design: Retrospective observational study. Setting: Adult tertiary teaching hospital. Participants: Forty-two adult patients. Interventions: N/A Measurements and Main Results: The authors reviewed the computerized tomography scans of 42 adult patients and correlated patients' body mass index, weight, height, and body surface area with skin and transverse process-to-pleura depths at the level of T4, 25mm from the midline and from the tip of the transverse process. The authors found that the depth to the pleura from the transverse process was significantly deeper at 25mm lateral to the midline than at the tip of the transverse process (21mm [4.2mm] v 12mm [2.7mm], p<0.0001), and its variability was significantly larger (p = 0.005). The authors found significant correlation between anthropomorphic indices and depths to pleura and transverse process (r>0.8, p<0.0001); however, the prediction bands around their regression lines proved too broad to be clinically useful. Conclusions: The authors concluded that an insertion point at the tip of the transverse process may provide effective and safer paravertebral blockade and that depth to the pleura cannot be predicted reliably by patients' morphometric profiles. [Copyright &y& Elsevier]

Objectives: To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. Design: A prospective, randomized, and double-blinded study. Setting: A university hospital. Participants: Forty patients undergoing thoracic surgery. Interventions: Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 μg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required. Measurements and Main Results: The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p < 0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p < 0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p < 0.005). Conclusions: Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine. [Copyright &y& Elsevier]

Awake thoracic surgery is performed by regional anesthesia techniques in spontaneously breathing, fully conscious patients to avoid side-effects of general anesthesia, fasten recovery, and reduce morbidity, particularly in high-risk patients. Results of ongoing experience are promising, and this novel surgical approach has been successfully applied to several thoracoscopic procedures, including management of pleural effusion, wedge resections, lung volume reduction surgery, bullectomy, and thymectomy. In this article, the historical background, main pathophysiology features of the surgical pneumothorax, and the various regional anesthesia techniques as well as reported results are reviewed and critically discussed. [Copyright &y& Elsevier]

Objective: Thoracic paravertebral blocks (PVBs) have been shown to be effective for analgesia after video-assisted thoracoscopic surgery (VATS) with single- and multiple-injection techniques. The efficacy of single-injection PVB was compared with multiple-injection PVB on postoperative analgesia in VATS was studied. Design: Prospective, randomized study. Setting: Single university hospital. Participants: Fifty patients undergoing VATS. Interventions: A nerve stimulator-guided PVB was performed in the sitting position before surgery using a solution of 20 mL 0.5% bupivacaine with 1:200,000 epinephrine by a single injection at T6 (group S, n = 25) or by 5 injections of 4 mL each at T4 to T8 (group M, n = 25). Measurements and Main Results: A successful PVB was achieved in all patients. The times to perform the blocks were 6.8 ± 1.9 minutes in the S group and 17.9 ± 3.0 minutes in the M group (p < 0.001). The times to block onset were 8.3 ± 1.8 minutes in the S group and 7.2 ± 0.9 minutes in the M group (p = 0.014). The numbers of anesthetized dermatomes were 5.8 ± 0.8 for the S group and 6.6 ± 1.1 for the M group (p = 0.009). The postoperative pain scores and morphine consumption with patient-controlled analgesia were comparable in the two groups. There were no significant differences in times to the first mobilization and hospital discharge for two groups. Patient satisfaction with the analgesic procedure was greater in the S group (p < 0.05). No complications were attributed to the blocks. Conclusions: The two techniques provided comparable postoperative analgesia. However, single-injection PVB may represent an advantage over multiple-injection PVB in patients undergoing VATS, with greater patient satisfaction associated with a shorter procedure and the likelihood of decreased complications. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine whether thoracic epidural analgesia (TEA) or a paravertebral catheter block (PVB) with morphine patient-controlled analgesia influenced outcome in patients undergoing thoracotomy for lung resection. Design: A retrospective analysis. Setting: A tertiary referral center. Participants: The study population consisted of 1,592 patients who had undergone thoracotomy for lung resection between May 2000 and April 2008. Interventions: Not applicable. Measurements and Main Results: Patients who received PVBs were younger, had a higher forced expiratory volume in 1 second, had a higher body mass index, a higher incidence of cardiac comorbidity, fewer pneumonectomies, and more wedge resections. A multivariable logistic regression model was used to develop a propensity-matched score for the probability of patients receiving an epidural or a paravertebral catheter. Four patients with an epidural to one with a paravertebral catheter were matched, with 488 patients and 122 patients, respectively. Postmatching analysis now showed no difference between the groups for preoperative characteristics or operative extent. Postmatching analysis showed no significant difference in outcome between the two groups for the incidence of postoperative respiratory complication (p = 0.67), intensive therapy unit (ITU) stay (p = 0.51), ITU readmission (p = 0.66), or in-hospital mortality (p = 0.67). There was a significant reduction in the hospital length of stay in favor of the paravertebral group (6 v 7 days, p = 0.008). Conclusions: 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. [ABSTRACT FROM AUTHOR]

Abstract: Paravertebral block was introduced by Hugo Sellheim in 1905 as a unilateral block preventing the hemodynamic side effects of spinal anaesthesia, but was almost forgotten in the middle of the last century. Eason and Wyatt revitalized the technique in 1979. Ultrasound guidance was first described for vessel cannulation, and gained widespread clinical use in regional anaesthesia. However, anatomical knowledge is a prerequisite for use of ultrasound. The paravertebral region is a wedge-shaped space bounded anteriorly by the parietal pleura, medially by the postero-lateral aspect of the vertebra, the intervertebral foramen, and the intervertebral disc, and posteriorly by the superior costotransverse ligament. Paravertebral block has been reported to be highly efficient for perioperative and chronic pain management, but with reduced adverse effects compared with central neural block. Techniques to reach the paravertebral space include the landmark method, nerve stimulation, the intercostal approach, and placement under direct visualization. Two difficulties of the classic approach have to be considered: (1) the distances from the skin to anatomical landmarks are highly variable and (2) loss of resistance to saline injection may often be overlooked. Several studies have yielded high success rates for ultrasound-guided paravertebral needle placement, without any signs of pleural puncture. However, anatomical data showed that paravertebral catheters inserted through ultrasound-guided, correctly placed needles were often misplaced. In conclusion, there is strong evidence that ultrasound guidance may enhance efficacy and safety of single-shot paravertebral block. However, data concerning ultrasound-guided paravertebral catheterization are conflicting, and further refinements are required to improve continuous paravertebral regional anaesthesia as well. [Copyright &y& Elsevier]

Abstract: Background: Use of adjuncts to local anesthetics is believed to enhance the quality and duration of the peripheral nerve blocks. We tested the hypothesis that addition of ketamine or tramadol to bupivacaine 0.5% in PVB for patients undergoing modified radical mastectomy would enhance postoperative analgesia. Methods: We prospectively randomized 60 ASA I–III women into three groups: group B (n =20) who received PVB using plain bupivacaine 0.5% (control group), group K (n =21) who received ketamine (0.5mgkg−1) added to bupivacaine 0.5%, and group T (n =19) who received tramadol (1.5mgkg−1) added to bupivacaine 0.5%. All the patients were then given a standardized general anesthesia. Primary outcome was the cumulative fentanyl dose given through patient-controlled analgesia (PCA) device in the first 24h after surgery. Secondary outcomes included dose of fentanyl in the postanesthesia care unit (PACU), time to first dose of fentanyl, and visual analogue scale (VAS) pain scores in PACU and ward. Results: The three groups were found to be similar in the cumulative dose of PCA fentanyl in the first 24h (P =0.62). They were also similar in terms of doses of fentanyl used in PACU (P =0.87), time to first dose of fentanyl requested (P =0.57), and VAS pain scores at all time points (P >0.05). Conclusion: We concluded that addition of ketamine (0.5mgkg−1) or tramadol (1.5mgkg−1) to bupivacaine 0.5% in PVB for modified radical mastectomy do not have any analgesia-enhancing effect. [Copyright &y& Elsevier]

Abstract: Background: The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA. Methods: A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded. Results: Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented. Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (

Background and Objectives: Epinephrine is often added to local anesthetic solutions to minimize and slow the systemic absorption of local anesthetics, and thus reduce the possibility of adverse effects of these drugs. In an earlier study we found that the injection of 5 mg/kg of lidocaine via the paravertebral route depressed myocardial contractility by up to 30%, with practically no changes in heart rate or blood pressure. In the present study we investigated whether these alterations are due to systemic absorption of the local anesthetic, and whether such absorption can be minimized by adding epinephrine to the local anesthetic solution. Methods: A prospective, blind, and randomized study was made of 50 patients subjected to lung resection surgery. The subjects were divided into two groups: Lid group (5 mg/kg bolus dose of lidocaine in the thoracic paravertebral space) and Lid+E group (addition of 5 mcg/mL of epinephrine to the local anesthetic). The anesthetic solution was administered through a paravertebral catheter ipsilateral to the operative side. In addition to routine hemodynamic monitoring (heart rate and radial artery blood pressure), an aortic transpulmonary thermodilution catheter was inserted into the femoral artery for recording of the following variables: cardiac index, cardiac function index, maximum pressure derivative, global end diastolic volume, and intrathoracic total blood volume index. Data collection was carried out immediately before administration of the anesthetic solution and 15, 30, and 45 minutes after administration. Measurements were made of the plasma lidocaine levels at those same postparavertebral injection time points. Results: Prior to paravertebral dosing there were no differences in terms of the hemodynamic variables studied. However, 15 minutes after dosing in the Lid+E group, lesser reductions in contractility, cardiac function index, and cardiac index were recorded, compared with the Lid group, with a significant reduction in cardiac filling volumes. Blood lidocaine levels were 53% and 34% lower in Lid+E group, as recorded 15 and 30 minutes after injection. The patients who, 15 minutes after paravertebral injection, had blood lidocaine levels greater than 3 mcg/mL (independently of the type of anesthetic solution used) had a significant reduction in mean blood pressure, cardiac function index, cardiac index, and maximum pressure derivative, compared with the patients with lower blood lidocaine concentrations. Conclusions: Addition of epinephrine to lidocaine when performing thoracic paravertebral block, attenuates the cardiodepressive effects associated with the systemic absorption of lidocaine and also, as a result of the beta-adrenergic consequences of epinephrine, systemic absorption from the paravertebral space. [Copyright &y& Elsevier]

Paravertebral blockade (PVB) is an underused technique that will provide excellent postoperative analgesia for any unilateral surgical procedure of the trunk. A number of different approaches have been described, e.g. direct surgical placement, loss-of-resistance, and nerve stimulator guided approaches. When compared to other techniques for postoperative analgesia in children, PVB has been found superior to these alternatives. The complication and side effects profile also appears acceptable compared to other frequently used techniques. [Copyright &y& Elsevier]

Objective: There is increasing interest in the use of the thoracic paravertebral block (TPVB) in association with general anesthesia for lung-resection surgery. The aim of the study was to evaluate the hemodynamic effects of a 5-mg/kg lidocaine bolus injected in the thoracic paravertebral space during one-lung ventilation (OLV) in noncardiac patients undergoing thoracic surgery. Design: Prospective, observational study. Setting: Tertiary care university hospital. Participant: Twenty patients undergoing thoracotomy for lung resection. Interventions: In addition to standard monitoring, cardiac output, preload parameters (global diastolic volume, total intrathoracic blood volume, and systolic volume variation), and myocardial contractility (dPmax and cardiac function index) were measured with an aortic transpulmonary thermodilution technique. Measurements and Main Results: After OLV initiation, a paravertebral lidocaine bolus of 5 mg/kg (2%) caused decreases in the dPmax and cardiac function index that lasted up to 30 minutes. Accompanying minor reductions in heart rate and systolic blood pressure required no vasoactive drugs and were self-limiting. None of the other hemodynamic parameters studied was significantly altered. Conclusions: In noncardiac patients, TPVB is associated with good hemodynamic stability, despite a small and transient decrease in myocardial contractility that could be related to the drug’s systemic effects after its absorption. [Copyright &y& Elsevier]

Objective: This study was designed to determine whether ropivacaine plus fentanyl was as effective as bupivacaine plus fentanyl in a continuous thoracic paravertebral block after posterolateral thoracotomy. Design: Patients were randomly assigned in a blinded fashion to receive 1 of 2 solutions for paravertebral analgesia. Setting: Multi-institutional university hospital. Participants: Sixty patients undergoing elective thoracotomy. Interventions: A continuous paravertebral infusion of 0.1 mL/kg/h of either 0.3% ropivacaine/fentanyl, 3 μg/mL, or 0.25% bupivacaine/fentanyl, 3 μg/mL, was started on admission to the intensive care unit. Measurements and Main Results: Pain scores (rest, deep breathing, and coughing), spirometry, subcutaneous opioids, or nonsteroidal anti-inflammatory drug consumption and adverse events were assessed for 48 hours. Both techniques provided adequate pain relief for the first 2 days after posterolateral thoracotomy. There were no differences between groups in pain scores at rest, coughing, or movement. There was an improvement of spirometry values between the first and second day in both groups. There were no differences in the requirements for rescue analgesia and side effects between groups. Conclusions: It is concluded that both bupivacaine, 0.25%, and ropivacaine, 0.3%, with fentanyl are equally effective for post-thoracotomy pain control when used via continuous paravertebral blockade. [Copyright &y& Elsevier]