Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery

Background. Thoracoscopic surgery can be associated with considerablepostoperative pain. While the benefits of paravertebral blockon pain after thoracotomy have been demonstrated, no investigationson the effects of paravertebral block on pain after thoracoscopyhave been conducted. We tested the hypothesis that a single-injectionthoracic paravertebral block, performed preoperatively, reducespain scores after thoracoscopic surgery. Methods. Of 45 patients recruited, 40 completed the study. Theywere randomly allocated to two groups: the paravertebral groupreceived i.v. patient-controlled analgesia (PCA) with morphineplus single-injection thoracic paravertebral block with bupivacaine0.375% and adrenaline 1:200 000 0.4 ml kg^–1 (n=20). Thecontrol group was treated with a back puncture without injectionand morphine PCA (n=20). Results. The main outcomes recorded during 48 h after surgerywere pain scores using the visual analogue scale (VAS, 0–100).Secondary outcomes were cumulative morphine consumption andpeak expiratory flow rate (PEFR). Half an hour and 24 h aftersurgery, median (25th–75th percentiles) VAS on coughingin the paravertebral group was 31.0 (20.0–55.0) and 30.5(17.5–40.0) respectively and in the control group it was70.0 (30.0–100.0) and 50.0 (25.0–75.0) respectively.The difference between the groups over the whole observationperiod was statistically significant (P<0.05). Twenty-fourand 48 h after surgery, median (25th–75th percentiles)cumulative morphine consumption (mg) was 49.0 (38.3–87.0)and 69.3 (38.8–118.5) respectively in the paravertebralgroup and 51.2 (36.0–84.1) and 78.1 (38.4–93.1)in the control group (statistically not significant). No differenceswere found in PEFR or the incidence of any side-effects betweengroups. Conclusion. We conclude that single-shot preoperative paravertebralblock improves post-operative pain treatment after thoracoscopicsurgery in a clinically significant fashion.      

全麻复合胸椎旁阻滞对单孔胸腔镜手术术后疼痛及快速康复的影响

目的探讨全麻复合超声引导下单次胸椎旁阻滞对单孔胸腔镜手术患者术后疼痛和快速康复的影响。方法择期行单孔胸腔镜手术的患者30例,男20例,女10例,采用随机数字表法将患者分为两组,每组15例。C组采用单纯全凭静脉麻醉,T组于麻醉诱导前采用超声引导下单次椎旁神经阻滞,术中行全凭静脉麻醉。两组患者术后均不采用镇痛装置,若术后静息时VAS评分4分,则予单次剂量地佐辛5~20mg,一天最多不超过120mg。记录术后1、4、8、12h的Ramsay镇静评分,术前1d、术后4、8、12、24h的机械痛阈值,术后第1次疼痛反馈时间,术后24h内地佐辛用量及不良反应情况,第1次下床活动时间和术后住院时间。结果与C组比较,T组术后8、12h Ramsay评分明显降低(P0.05),术后4、8h机械痛阈值明显升高(P0.05),第1次疼痛反馈时间明显延长(P0.05),术后24h内地佐辛用量明显减少(P0.05),第1次下床活动时间和住院时间明显缩短(P0.05),术后24h恶心呕吐等不良反应发生率明显降低(P0.05)。结论全麻复合单次胸椎旁阻滞可有效缓解单孔胸腔镜手术患者术后的切口疼痛,减少术后24h内阿片类药物用量,降低不良反应发生,有利于术后早期下床活动,缩短患者住院时间。     

Multiple nerve blocks after video-assisted thoracic surgery (VATS)

Introduction  

Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS.     

Plasma concentration of ropivacaine after intercostal blocks for video-assisted thoracic surgery

Background. Absorption of local anaesthetics following intercostalblocks is rapid. Therefore, plasma concentrations of ropivacaineduring intercostal blocks with ropivacaine 2, 5, 7.5 and 10mg ml^–1 (ropivacaine 5 ml injected into each of four intercostalspaces) in patients undergoing video-assisted thoracic surgerywere determined. Methods. After informed consent and ethics committee approval,64 patients were randomly allocated to four groups for intercostalnerve block (ropivacaine 2, 5, 7.5 or 10 mg ml^–1 at theend of surgery). Central (mixed) venous and arterial plasmasamples were collected before the start of intercostal application,and 2, 5, 10, 15, 20, 30, 45, 60 and 90 min afterwards. Plasmaconcentrations of ropivacaine were measured by high performanceliquid chromatography. Results. Maximum venous plasma concentrations occurred afterthe mean times of 10.7 (range, 5–15), 10.8 (5–20),11.3 (5–20) and 12.2 (5–45) min, respectively foreach group. The groups had mean concentrations of 1.3 (SD, 0.6;range, 0.3–2.3), 2.1 (1.0; 0.5–4.5), 2.4 (1.0; 1.2–5.1)and 2.5 (0.9; 1.7–5.6) µg ml^–1, respectively.Maximum arterial plasma concentration following 1.0% ropivacaineoccurred after 16 (5–45) min with a mean of 2.3 (0.6;1.5–3.6) µg ml^–1. No signs of central nervoussystem or cardiac toxicity were observed. Conclusions. After intercostal blocks the absorption of ropivacaineis rapid compared with other techniques for regional anaesthesiaand results in relatively high venous and arterial plasma concentrations,especially if a dose of 100 mg or more is used. Br J Anaesth 2002; 89: 251–3     

Preoperative ampiroxicam reduces postoperative pain after hand surgery

We performed a double blind randomised controlled study to assess whether the preoperative administration of ampiroxicam reduced the level of postoperative pain in 120 patients who underwent surgery to a hand under brachial plexus block. We found that preoperative (pre-emptive) administration of ampiroxicam significantly reduced the postoperative pain levels and the need for postoperative analgesia.     

Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery

OBJECTIVE: To compare continuous thoracic epidural analgesia (TEA) and paravertebral block (PVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) surgery for quality of analgesia, complications, compliance to chest physiotherapy, hemodynamics, and respiratory effects. DESIGN: Prospective, randomized study. SETTING: Specialty research hospital. PARTICIPANTS: Forty-one consenting patients undergoing MIDCAB surgery. INTERVENTIONS: Patients in the TEA group had an epidural catheter inserted at the T4-5 interspace, whereas patients in the PVB group had a catheter inserted in the paravertebral space on the left side at the T4-5 level. MEASUREMENTS AND MAIN RESULTS: Parameters evaluated included visual analog scale pain scores at rest and while coughing, supplemental analgesic requirement, complications, hemodynamics, and respiratory parameters. Measurements were made at 2-hour intervals for 12 hours beginning at 10 minutes after endotracheal extubation. There was no statistically significant difference in visual analog scale scores and requirement of supplemental analgesia between the 2 groups. Cardiac index at 4 hours and 6 hours was significantly higher in the TEA group. Patients in the PVB group had significantly lower respiratory rates at 8, 10, and 12 hours. All other parameters were comparable. In 1 patient, the epidural space could not be catheterized. One patient in the TEA group had transient hypotension, and 1 patient complained of backache at the site of the epidural catheter insertion. CONCLUSION: PVB is as effective as TEA for postoperative analgesia after MIDCAB surgery. PVB is technically easier than TEA and may be safer than TEA because no complications were seen in the PVB group.     

超声引导下横突-胸膜中点阻滞与胸椎旁神经阻滞用于单孔胸腔镜手术后镇痛效果的比较

目的 比较超声引导下横突-胸膜中点阻滞(MTPB)与胸椎旁神经阻滞(TPVB)用于单孔胸腔镜手术术后镇痛的效果。
方法 选择择期行单孔胸腔镜手术患者80例,男36例,女44例,年龄18～65岁,BMI 19～28 kg/m²,ASA Ⅰ―Ⅲ级。采用随机数字表法分为MTPB组（M组）和TPVB组（P组）,每组40例。手术结束后M组行超声引导下MTPB,P组行TPVB,两组均注射0.5%罗哌卡因15 ml。两组患者术后均采用PCIA。记录神经阻滞操作时间、穿刺深度,记录术后2、6、12、24、48 h安静和咳嗽时VAS疼痛评分,记录镇痛泵首次按压时间、总按压次数、舒芬太尼使用量和补救镇痛例数,记录穿刺相关并发症、镇痛不良反应发生情况。
结果 与P组比较,M组神经阻滞操作时间明显缩短（P<0.05）,进针深度明显变浅（P<0.05）。术后2、6、12、24、48 h两组安静和咳嗽时VAS疼痛评分差异无统计学意义。两组患者术后镇痛泵首次按压时间、总按压次数、舒芬太尼用量和补救镇痛率差异无统计学意义。两组患者术后恶心、呕吐等不良反应差异无统计学意义。
结论 MTPB或TPVB联合术后PCIA应用于单孔胸腔镜手术患者,术后均可取得良好的镇痛效果,但MTPB操作简单、安全,可作为单孔胸腔镜手术患者术后镇痛方案的选择。     

Magnesium sulfate does not reduce postoperative analgesic requirements

BACKGROUND: Because magnesium blocks the N-methyl-D-aspartate receptor and its associated ion channels, it can prevent central sensitization caused by peripheral nociceptive stimulation. However, transport of magnesium from blood to cerebrospinal fluid (CSF) across the blood-brain barrier is limited in normal humans. The current study was designed to evaluate whether perioperative intravenous magnesium sulfate infusion affects postoperative pain. METHODS: Sixty patients undergoing abdominal hysterectomy received 50 mg/kg intravenous magnesium sulfate as a bolus dose followed by a continuous infusion of 15 mg x kg(-1) x h(-1) for 6 h (magnesium group) or the same volume of isotonic saline (control group). At the end of surgery, serum and CSF magnesium concentration were measured in both groups. The cumulative postoperative analgesic consumption was measured to assess the analgesic effect using a patient-controlled epidural analgesia device. Pain intensities at rest and during forced expiration were evaluated at 6, 24, 48, and 72 h postoperatively. RESULTS: At the end of surgery, patients in the magnesium group had significantly greater postoperative serum magnesium concentrations compared with both preoperative and control group values (P < 0.001). Despite significantly higher serum magnesium concentrations in the magnesium group, there was no significant difference in magnesium concentration measured in postoperative CSF. Cumulative postoperative analgesic doses were similar in both groups. However, there was observed an inverse relation between cumulative postoperative analgesic consumption and the CSF magnesium concentration in both groups. Visual analog pain scores at rest and during forced expiration were similar and less than 4 in both groups. CONCLUSIONS: Perioperative intravenous administration of magnesium sulfate did not increase CSF magnesium concentration and had no effects on postoperative pain. However, an inverse relation between cumulative postoperative analgesic consumption and the CSF magnesium concentration was observed. These results suggest that perioperative intravenous magnesium infusion may not be useful for preventing postoperative pain.     

Chylothorax after video-assisted thoracic surgery

A 27-year-old male was admitted to our hospital with an abnormal shadow on chest X-ray. Chest computed tomography (CT) showed a localized mediastinal tumor. Thoracoscopic resection of the tumor was performed and the pathological diagnosis was bronchogenic cyst. Chylothorax occurred on postoperative day 1. Low fat diet therapy was performed. The discharge of chyliform pleural effusion was stopped on postoperative day 10. Thoracic drainage tube was removed and the patient discharged from hospital on postoperative day 19. He has been well for 10 months since operation, with no recurrence of the tumor or chylothorax.     

胸椎旁神经阻滞和竖脊肌平面阻滞用于胸腔镜肺叶切除术术后镇痛效果的Meta分析

目的:通过Meta分析方法评价超声引导下胸椎旁神经阻滞（thoracic paravertebral nerve block, TPVB）和竖脊肌平面阻滞（erector spinae plane block, ESPB）用于胸腔镜肺叶切除术术后镇痛的效果。方法:计算机检索PubMed、Web of Science、C...     

Epidural dexamethasone reduces postoperative pain and analgesic requirements

PURPOSE: Epidural steroids may have potential advantages for providing postoperative analgesia. We therefore undertook a study to evaluate the efficacy of epidurally administered dexamethasone in reducing postoperative morphine requirements, as a measure of analgesia following laparoscopic cholecystectomy. METHODS: In a randomized, double-blind study, 94 patients undergoing laparoscopic cholecystectomy were randomly assigned to one of three groups. Group 1 (Control) patients received dexamethasone 5 mg iv with epidural injection of 0.25% bupivacaine 8 mL and normal saline 2 mL, Group 2 (D1) patients received normal saline 2 mL iv with epidural injection of 0.25% bupivacaine 8 mL and dexamethasone 5 mg in normal saline 2 mL, and Group 3 (D2) patients received normal saline 2 mL iv with epidural injection of dexamethasone 5 mg in normal saline 10 mL. After surgery, morphine 2-4 mg iv was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale (VAS) pain scores at rest and with effort, and time to first analgesic administration were recorded by a blinded observer. RESULTS: Total morphine consumption for the first 24 hr following surgery was lower in both epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reduction in morphine consumption in Group D1 was 53.9% and in Group D2 was 52.9% in the first 24 hr. Postoperatively at 12 hr, 18 hr and 24 hr, the VAS scores at rest and during effort were also lower in the epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reductions in VAS scores with effort at 12 hr, 18 hr and 24 hr in Group D1 were 50%, 52.9% and 50% respectively, and in Group D2 percentage reductions in pain scores with effort were 54.8%, 58.8% and 55.5% at corresponding sampling intervals. CONCLUSION: Preoperative epidural administration of dexamethasone 5 mg, with or without bupivacaine, reduces postoperative pain and morphine consumption following laparoscopic cholecystectomy.     

电视胸腔镜围手术期并发症的回顾性分析

目的：探讨电视胸腔镜围手术（VATS）围手术期并发症原因和防治措施。方法：回顾分析374例VATS的围手术期并发症发生情况,将患者按年龄分3组,老年组（125例）、中青年组（216例）、儿童组（33例）。结果：发生围手术期并发症34例,占9．1％,其中1例死亡。中青年组织和儿童组并发症发生率分别为5．1％和3．0％,而老年组的并发症发生率为17．6％,3组之间差异有极显著意义（P＜0．01）。结论：手术者的经验和患者年龄与VATS围术期并发症的发生有关;强调循环渐进的原则可降低其发生率。     

前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后镇痛效果的比较

目的比较前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后的镇痛效果。方法选择择期行胸腔镜手术患者60例,男38例,女22例,年龄18～65岁,BMI 18～25kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为前锯肌平面阻滞组(S组)和胸椎旁阻滞组(T组),每组30例。两组患者均采用支气管插管静脉全身麻醉,术后采用PCIA。S组于麻醉诱导前行超声引导下前锯肌平面阻滞,T组则行超声引导下胸椎旁阻滞,两组均使用0.4%罗哌卡因30ml,阻滞完成后30min使用针刺法测定并记录感觉阻滞平面;记录阻滞操作时间、起效时间、持续时间;记录术后2、4、8、12、24、48h的静息和咳嗽VAS评分;记录首次按压镇痛泵时间、术后48h内镇痛泵有效按压次数、舒芬太尼使用总量和哌替啶补救性镇痛例数;记录阻滞相关并发症、镇痛不良反应发生情况。结果与T组比较,S组阻滞操作时间明显缩短,阻滞持续时间明显延长(P0.01);S组术后12h静息时和咳嗽时VAS评分明显降低(P0.01),S组PCIA首次按压时间明显延长,S组PCIA 48h内按压次数、舒芬太尼使用量明显减少(P0.01),两组气胸、恶心呕吐发生率差异无统计学意义。结论超声引导下前锯肌平面阻滞或胸椎旁阻滞均可为胸腔镜手术患者提供良好术后镇痛,但前锯肌平面阻滞较胸椎旁阻滞作用更持久、操作时间更短、并发症更少,且能有效减少患者术后对阿片类药物的需求量。     

Preoperative epidural fentanyl reduces postoperative pain after upper abdominal surgery

Forty patients, American Society of Anesthesiology (ASA) physical status 1–2, undergoing subtotal gastrectomy were enrolled in this study. The patients were allocated to two groups with or (group P) and without (group C) preoperative epidural fentanyl 100 μg. Postoperatively, all patients received continuous infusion of the study solution, containing fentanyl 30 μg·ml⁻¹ and 2 mg/ml bupivacaine, at a rate of 0.7 ml·h⁻¹ for 72 h. The scores on the Prince Henry Hospital self-assessed pain scale (PHPS) were recorded at 0, 4, 12, 24, 48, and 72 h after the surgery. We compared the total rescue doses of analgesics during each period of 24 h until 72 h postoperatively. Although the total rescue doses of analgesics were not different between the groups, the median PHPS score was lower in group P than in group C, except at 0 h after the surgery. Preoperative epidural fentanyl 100 μg may increase the analgesic potency of postoperative epidural low-dose infusion of bupivacaine with fentanyl.     

Preoperative oral dextromethorphan does not reduce pain or analgesic consumption in children after adenotonsillectomy

In this randomized, double-blinded, placebo-controlled, prospective study, we evaluated the analgesic efficacy of dextromethorphan 0.5 mg/kg or 1.0 mg/kg p.o. 1 h before adenotonsillectomy in 57 children 6-12 yr of age. Anesthetic management was standardized. Morphine 0.075 mg/kg i.v. and acetaminophen 25-35 mg/kg p.r. were administered after anesthetic induction but before the start of surgery. A 4-point behavioral score (1 = asleep, 2 = awake and calm, 3 = awake and crying, 4 = thrashing) was recorded on admission to and discharge from the postanesthesia care unit (PACU). In the PACU, pain was assessed with Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and recorded every 15 min until the patient was transferred to the day surgery unit (DSU). In the DSU, patients rated their pain using a 10-cm baseline 0-10 visual analog pain scale (VAS) every 30 min until they were discharged home. A 24-h VAS was obtained by phone interview, and parental satisfaction was scored (yes/no) regarding their child's postoperative analgesia. Morphine 0.025 mg/kg i.v. was administered to children with CHEOPS score >6, who verbalized pain, or who were crying in any consecutive 5-min observation periods in the PACU. Total morphine consumption was recorded. The study groups were comparable with respect to demographic variables. We were unable to detect any differences between study groups with respect to postoperative morphine consumption, CHEOPS, behavior scores, VAS, or parental satisfaction. Implications: Premedication with dextromethorphan 0.5 or 1.0 mg/kg p.o. does not improve postoperative analgesia in school-aged children who receive preemptive morphine 0.075 mg/kg i.v. and acetaminophen 25-35 mg/kg p.r. during nitrous oxide and desflurane anesthesia for adenotonsillectomy.     

The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain

Background. Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Postoperative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

Methods. Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.

Results. No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 ± 6 vs 89 ± 12 beats per minute, p < 0.001), respiratory rates (15 ± 2 vs 18 ± 3 respirations per minute, p < 0.01), pain score (1.9 ± 0.6 vs 2.7 ± 0.5, p < 0.01), and postoperative analgesic requirements (20 ± 18 vs 50 ± 21 mg pethidine HCL, p < 0.001) were significantly lower in group A. There was no significant difference in blood pressures.

Conclusions. Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.     

超声引导下胸椎旁神经阻滞和菱形肌-肋间肌阻滞对胸腔镜术后恢复质量的影响

目的 观察超声引导下胸椎旁神经阻滞(TPVB)和菱形肌-肋间肌阻滞(RIB)对胸腔镜手术患者术后早期疼痛及术后康复质量的影响。
方法 选择全麻下行胸腔镜肺癌根治术患者78例,男51例,女27例,年龄50～70岁,ASAⅠ或Ⅱ级。随机分为两组:超声引导下TPVB组(A组)和超声引导下RIB组(B组),每组39例。全麻诱导前,A组、B组分别采用0.33%罗哌卡因25 ml行超声引导下TPVB和RIB。记录阻滞操作时间和阻滞持续时间。记录术后2、6、24静息和活动时VAS疼痛评分。记录术后24 h内舒芬太尼用量和补救镇痛例数。记录开始进食时间、开始下地时间和术后住院时间。记录PACU低氧血症、气胸、穿刺部位出血或血肿、局麻药中毒、术后谵妄、术后肺不张、恶心呕吐等并发症的发生情况。
结果 B组阻滞操作时间明显短于A组(P<0.05)。两组阻滞持续时间、不同时点静息和活动时VAS疼痛评分、术后24 h内舒芬太尼用量、补救镇痛率、开始进食时间、开始下地时间、术后住院时间差异无统计学意义。两组并发症发生率差异无统计学意义。
结论 在胸腔镜肺癌根治术中,行超声引导下菱形肌-肋间肌阻滞的患者术后恢复质量不差于行胸椎旁神经阻滞的患者。     

胸椎旁神经阻滞对开胸手术患者静脉镇痛效果的影响

目的 研究胸椎旁神经阻滞对开胸于术后静脉镇痛效果的影响.方法 择期全麻下肺叶切除术的患者102例,随机分成二三组:Ⅰ组,32例,单纯全麻;Ⅱ组,36例,于全麻诱导后行胸椎旁神经阻滞;Ⅲ组,34例.于全麻诱导前行硬膜外阻滞.三组均于术毕缝皮时启动患者静脉自控镇痛(PCIA)泵行芬太尼、氟比洛芬酯静脉镇痛,分别于患者清醒拔除气管导管后即刻(T1)、术后24 h(T2)、48 h(T3)进行视觉模拟评分(VAS),记录启动自控按钮次数及背景输注总量.结果 三组24、48 h PCIA泵的背景输注总晕差异无统计学意义.Ⅱ、Ⅲ组在T1、T2时的VAS均低于Ⅰ组(P＜0.05),术后48 h内启动自控按钮次数明显少于Ⅰ组(P＜0.05).结论 在开胸手术前行胸椎旁神经阻滞或硬膜外阻滞可以增强芬太尼、氟比洛芬酯的静脉镇痛效果.