SUPPLEMENTARY MATERIAL Supplementary material is available at ICVTS online. Conflict of interest: none declared.
REFERENCES [1] Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A Review of Current Techniques. Anesthesiology 1994;81:737–59. [2] Cook TM, Riley RH. Analgesia following thoracotomy: a survey of Australian practice. Anaesth Intensive Care 1997;25:520–4. [3] Pavelescu D, Mirea L, Pa˘ duraru M, Beuran M, Chiotoroiu A, Grint¸escu I. The role of multimodal analgesia in the decrease of postoperative surgical stress response in major neoplastic thoraco-abdominal surgery. Chirurgia (Bucur) 2011;106:723–8. [4] Liuboshevskiı˘ PA, Artamonova NI, Ovechkin AM. Haemostasis disturbances as the component of the surgical stress-response and possibilities of their correction. Anesteziol Reanimatol 2012;3:44–8. [5] Grant RP. Con: every postthoracotomy patient does not deserve thoracic epidural analgesia. J Cardiothorac Vasc Anesth 1999;13:355–7. [6] Powell ES, Pearce AC, Cook D, Davies P, Bishay E, Bowler GM et al. UKPOS Co-ordinators. UK pneumonectomy outcome study (UKPOS): a prospective observational study of pneumonectomy outcome. J Cardiothorac Surg 2009;4:41. [7] Fortier S, Hanna HA, Bernard A, Girard C. Comparison between systemic analgesia, continuous wound catheter analgesia and continuous thoracic paravertebral block: a randomised, controlled trial of postthoracotomy pain management. Eur J Anaesthesiol 2012;29:524–30. [8] Helms O, Mariano J, Hentz JG, Santelmo N, Falcoz PE, Massard G et al. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study. Eur J Cardiothorac Surg 2011;40:902–6. [9] Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418–26. [10] Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact CardioVasc Thorac Surg 2010;10:92–6. [11] Hayduk LA, Pazderka-Robinson H, Cummings GG, Levers MJ, Beres MA. Structural equation model testing and the quality of natural killer cell activity measurements. BMC Med Res Methodol 2005;5:1. [12] Engelman E, Marsala C. Efficacy of adding clonidine to intrathecal morphine in acute postoperative pain: meta-analysis. Br J Anaesth 2013;110:21–7. [13] Kozar S, Marić S, Jankovič VN. Development of post-thoracotomy pain syndrome in patients undergoing lung surgery—comparison of thoracic paravertebral and epidural analgesia. Periodicum Biologorum 2011;113: 229–33. [14] Wedad M, Zaki MK, Haleem M. The effect of addition of wound infiltration with local anaesthetics to interpleural block on postthoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block. Egypt J Anaesth 2004;20:67–72. [15] Aly HM, Mousa EA, Mohammad SA, Nishiwaki K. A randomized comparison of ultrasound guided thoracic para vertebral block and epidural analgesia for post-thoracotomy pain relief and respiratory function. Egypt J Anaesth 2010;26:189–98. [16] Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2001;15:288–92. [17] Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth 2008;11:91–6. [18] Matthews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989;62:204–5. [19] Perttunen K, Nilsson E, Heinonen J, Hirvisalo EL, Salo JA, Kalso E. Extradural, paravertebral and intercostal nerve blocks for postthoracotomy pain. Br J Anaesth 1995;75:541–7.
635
[20] Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387–92. [21] Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management. Surgery 1999;126: 650–6. [22] De Cosmo G, Aceto P, Campanale E, Congedo E, Clemente A, Mascia A et al. Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: effects on pain relief, pulmonary function and patient satisfaction. Acta Med Rom 2002;40:340–7. [23] Casati A, Alessandrini P, Nuzzi M, Tosi M, Iotti E, Ampollini L et al. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol 2006;23:999–1004. [24] Messina M, Boroli F, Landoni G, Bignami E, Dedola E, N’zepa Batonga J et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol 2009;75:616–21. [25] Gulbahar G, Kocer B, Muratli SN, Yildirim E, Gulbahar O, Dural K et al. A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg 2010;37: 467–72. [26] Mukherjee M, Goswami A, Gupta SD, Sarbapalli D, Pal R, Kar S. Analgesia in post-thoracotomy patients: comparison between thoracic epidural and thoracic paravertebral blocks. Anesth Essays Res 2010;4:75–80. [27] Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med 2011;36:256–60. [28] Kanazi GE, Ayoub CM, Aouad M, Abdallah F, Sfeir PM, Adham AB et al. Subpleural block is less effective than thoracic epidural analgesia for postthoracotomy pain: a randomised controlled study. Eur J Anaesthesiol 2012;29:186–91. [29] Grider JS, Mullet TW, Saha SP, Harned ME, Sloan PA. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth 2012;26:83–9. [30] Kobayashi R, Mori S, Wakai K, Fukumoto K, Saito T, Katayama T et al. Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy: a randomized clinical trial. Surg Today 2013;43: 963–9. [31] Niemi G, Breivik H. The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand 2003;47:439–50. [32] Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002;94:1598–605. [33] Boezaart AP, Lucas SD, Elliott CE. Paravertebral block: cervical, thoracic, lumbar, and sacral. Curr Opin Anaesthesiol 2009;22:637–43. [34] Deneuville M, Bisserier A, Regnard JF, Chevalier M, Levasseur P, Hervé P. Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy: a randomized study. Ann Thorac Surg 1993;55:381–5. [35] Allen MS, Halgren L, Nichols FC III, Cassivi SD, Harmsen WS, Wigle DA et al. A randomized controlled trial of bupivacaine through intracostal catheters for pain management after thoracotomy. Ann Thorac Surg 2009;88:903–10.
eComment. Epidural analgesia versus paravertebral analgesia technique Authors: Jamil Hajj-Chahine Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France doi: 10.1093/icvts/ivu044 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I read with great interest the systematic review and meta-analysis by Baidya et al. in which they compared efficacy of two different strategies for pain control in patients undergoing thoracotomy [1]. After including 12 clinical trials in their analysis, they concluded that there is an equivalent analgesic efficacy of epidural anaesthesia and paravertebral anaesthesia. Recently, the results of an additional randomized study
STATE-OF-THE-ART
D.K. Baidya et al. / Interactive CardioVascular and Thoracic Surgery
636
D.K. Baidya et al. / Interactive CardioVascular and Thoracic Surgery
have been published [2]. In order to be exhaustive, we will summarize the relevant outcomes of the above-mentioned study. Raveglia et al. randomized 52 patients (aged 51-92 years) into two groups. Epidural anaesthesia (EA) group received an infusion of 0.001% fentanyl plus 0.1% bupivacaine through a catheter placed into the T5/6, T6/7 interspaces. Paravertebral anaesthesia (PA) group received an infusion of 0.3% naropine in the same interspace as the thoracotomy incision through a catheter inserted at the end of surgery using the ’de visu’ technique [3]. Regarding pain management, a significant difference in favour of PA, both at rest and during coughing, in the early postoperative period was reiterated in this trial. Moreover data proved that PA is more effective than EA concerning respiratory outcomes both for spirometric lung function and ambient air saturation. Paravertebral anaesthesia in patients undergoing thoracotomy is safe and as effective as EA. It has been used since the 1940s [4] but never gained impetus among thoracic surgeons. Although PA does not have contraindications regarding coagulopathy or anatomical anomalies it should be acknowledged that during treatment some adverse effects may occur, due to the contiguity between the paravertebral space and epidural space. Uncommon adverse effect can be seen such as hypotension, blurred vision and confusion [4]. Conflict of interest: none declared. References [1] Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact CardioVasc Thorac Surg 2014;18:626–36. [2] Raveglia F, Rizzi A, Leporati A, Di Mauro P, Cioffi U, Baisi A. Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg 2014;147:469–73. [3] Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extra pleural infusion for post-thoracotomy pain management. Surgery 1999;126:650–6. [4] Jain S, Datta S. Postoperative pain management. Chest Surg Clin N Am 1997;7:773–99.
eResponse. Re: Epidural analgesia versus paravertebral analgesia technique Authors: Souvik Maitra, Dalim K Baidya and Puneet Khanna Anaesthesiology and Intensive Care, AIIMS, New Delhi doi: 10.1093/icvts/ivu059
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We have read the comment by Hajj-Chahine [1] on our meta-analysis [2] with great interest. It is very encouraging that clinical research continues to focus on thoracic paravertebral block. The author discusses a recently published randomized control trial (RCT) [3] on the same issue addressed in our review. In that RCT, Ravegila et al. found a significant difference in favour of paravertebral analgesia, both at rest and during coughing, in the early postoperative period. They also found that paravertebral block is more effective than epidural analgesia in relation to respiratory outcomes, both for spirometric lung function and ambient air saturation. However, we think that these results should be interpreted cautiously. Several methodological limitations exist in the study. Firstly, the duration of surgery in the epidural analgesia group of patients is significantly higher; this finding seriously calls into question the quality of randomization used here. A longer duration surgery may be due to technical complexity and the degree of surgical dissection may be greater, which may give rise to increased pain and a poor respiratory performance. Secondly, the authors used 0.1% bupivacaine in the epidural and 0.3% ropivacaine in the paravertebral block: are they truly comparable? Thirdly, they inserted the epidural catheter at the T5-T6 or T6-T7 intervertebral space but the paravertebral catheter in the same interspace as the thoracotomy incision. It seems illogical to put the two catheters at different levels. They also mentioned that no patients in either of the two groups required additional analgesia. They did not mention the mean difference of the pain scores at different time points and arterial oxyhaemoglobin saturation. The actual clinical significance may be debatable here. We believe that further high quality RCTs are required in this issue to elucidate the optimum analgesic technique in thoracotomy. Conflict of interest: none declared. References [1] Hajj-Chahine J. eComment. Epidural analgesia versus paravertebral analgesia technique. Interact CardioVasc Thorac Surg 2014;18:635–6. [2] Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact CardioVasc Thorac Surg 2014;18:626–36. [3] Raveglia F, Rizzi A, Leporati A, Di Mauro P, Cioffi U, Baisi A. Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg 2014;147:469–73.
REFERENCES [1] Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A Review of Current Techniques. Anesthesiology 1994;81:737–59. [2] Cook TM, Riley RH. Analgesia following thoracotomy: a survey of Australian practice. Anaesth Intensive Care 1997;25:520–4. [3] Pavelescu D, Mirea L, Pa˘ duraru M, Beuran M, Chiotoroiu A, Grint¸escu I. The role of multimodal analgesia in the decrease of postoperative surgical stress response in major neoplastic thoraco-abdominal surgery. Chirurgia (Bucur) 2011;106:723–8. [4] Liuboshevskiı˘ PA, Artamonova NI, Ovechkin AM. Haemostasis disturbances as the component of the surgical stress-response and possibilities of their correction. Anesteziol Reanimatol 2012;3:44–8. [5] Grant RP. Con: every postthoracotomy patient does not deserve thoracic epidural analgesia. J Cardiothorac Vasc Anesth 1999;13:355–7. [6] Powell ES, Pearce AC, Cook D, Davies P, Bishay E, Bowler GM et al. UKPOS Co-ordinators. UK pneumonectomy outcome study (UKPOS): a prospective observational study of pneumonectomy outcome. J Cardiothorac Surg 2009;4:41. [7] Fortier S, Hanna HA, Bernard A, Girard C. Comparison between systemic analgesia, continuous wound catheter analgesia and continuous thoracic paravertebral block: a randomised, controlled trial of postthoracotomy pain management. Eur J Anaesthesiol 2012;29:524–30. [8] Helms O, Mariano J, Hentz JG, Santelmo N, Falcoz PE, Massard G et al. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study. Eur J Cardiothorac Surg 2011;40:902–6. [9] Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418–26. [10] Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact CardioVasc Thorac Surg 2010;10:92–6. [11] Hayduk LA, Pazderka-Robinson H, Cummings GG, Levers MJ, Beres MA. Structural equation model testing and the quality of natural killer cell activity measurements. BMC Med Res Methodol 2005;5:1. [12] Engelman E, Marsala C. Efficacy of adding clonidine to intrathecal morphine in acute postoperative pain: meta-analysis. Br J Anaesth 2013;110:21–7. [13] Kozar S, Marić S, Jankovič VN. Development of post-thoracotomy pain syndrome in patients undergoing lung surgery—comparison of thoracic paravertebral and epidural analgesia. Periodicum Biologorum 2011;113: 229–33. [14] Wedad M, Zaki MK, Haleem M. The effect of addition of wound infiltration with local anaesthetics to interpleural block on postthoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block. Egypt J Anaesth 2004;20:67–72. [15] Aly HM, Mousa EA, Mohammad SA, Nishiwaki K. A randomized comparison of ultrasound guided thoracic para vertebral block and epidural analgesia for post-thoracotomy pain relief and respiratory function. Egypt J Anaesth 2010;26:189–98. [16] Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2001;15:288–92. [17] Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth 2008;11:91–6. [18] Matthews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989;62:204–5. [19] Perttunen K, Nilsson E, Heinonen J, Hirvisalo EL, Salo JA, Kalso E. Extradural, paravertebral and intercostal nerve blocks for postthoracotomy pain. Br J Anaesth 1995;75:541–7.
635
[20] Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387–92. [21] Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management. Surgery 1999;126: 650–6. [22] De Cosmo G, Aceto P, Campanale E, Congedo E, Clemente A, Mascia A et al. Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: effects on pain relief, pulmonary function and patient satisfaction. Acta Med Rom 2002;40:340–7. [23] Casati A, Alessandrini P, Nuzzi M, Tosi M, Iotti E, Ampollini L et al. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol 2006;23:999–1004. [24] Messina M, Boroli F, Landoni G, Bignami E, Dedola E, N’zepa Batonga J et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol 2009;75:616–21. [25] Gulbahar G, Kocer B, Muratli SN, Yildirim E, Gulbahar O, Dural K et al. A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg 2010;37: 467–72. [26] Mukherjee M, Goswami A, Gupta SD, Sarbapalli D, Pal R, Kar S. Analgesia in post-thoracotomy patients: comparison between thoracic epidural and thoracic paravertebral blocks. Anesth Essays Res 2010;4:75–80. [27] Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med 2011;36:256–60. [28] Kanazi GE, Ayoub CM, Aouad M, Abdallah F, Sfeir PM, Adham AB et al. Subpleural block is less effective than thoracic epidural analgesia for postthoracotomy pain: a randomised controlled study. Eur J Anaesthesiol 2012;29:186–91. [29] Grider JS, Mullet TW, Saha SP, Harned ME, Sloan PA. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth 2012;26:83–9. [30] Kobayashi R, Mori S, Wakai K, Fukumoto K, Saito T, Katayama T et al. Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy: a randomized clinical trial. Surg Today 2013;43: 963–9. [31] Niemi G, Breivik H. The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand 2003;47:439–50. [32] Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002;94:1598–605. [33] Boezaart AP, Lucas SD, Elliott CE. Paravertebral block: cervical, thoracic, lumbar, and sacral. Curr Opin Anaesthesiol 2009;22:637–43. [34] Deneuville M, Bisserier A, Regnard JF, Chevalier M, Levasseur P, Hervé P. Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy: a randomized study. Ann Thorac Surg 1993;55:381–5. [35] Allen MS, Halgren L, Nichols FC III, Cassivi SD, Harmsen WS, Wigle DA et al. A randomized controlled trial of bupivacaine through intracostal catheters for pain management after thoracotomy. Ann Thorac Surg 2009;88:903–10.
eComment. Epidural analgesia versus paravertebral analgesia technique Authors: Jamil Hajj-Chahine Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France doi: 10.1093/icvts/ivu044 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I read with great interest the systematic review and meta-analysis by Baidya et al. in which they compared efficacy of two different strategies for pain control in patients undergoing thoracotomy [1]. After including 12 clinical trials in their analysis, they concluded that there is an equivalent analgesic efficacy of epidural anaesthesia and paravertebral anaesthesia. Recently, the results of an additional randomized study
STATE-OF-THE-ART
D.K. Baidya et al. / Interactive CardioVascular and Thoracic Surgery
636
D.K. Baidya et al. / Interactive CardioVascular and Thoracic Surgery
have been published [2]. In order to be exhaustive, we will summarize the relevant outcomes of the above-mentioned study. Raveglia et al. randomized 52 patients (aged 51-92 years) into two groups. Epidural anaesthesia (EA) group received an infusion of 0.001% fentanyl plus 0.1% bupivacaine through a catheter placed into the T5/6, T6/7 interspaces. Paravertebral anaesthesia (PA) group received an infusion of 0.3% naropine in the same interspace as the thoracotomy incision through a catheter inserted at the end of surgery using the ’de visu’ technique [3]. Regarding pain management, a significant difference in favour of PA, both at rest and during coughing, in the early postoperative period was reiterated in this trial. Moreover data proved that PA is more effective than EA concerning respiratory outcomes both for spirometric lung function and ambient air saturation. Paravertebral anaesthesia in patients undergoing thoracotomy is safe and as effective as EA. It has been used since the 1940s [4] but never gained impetus among thoracic surgeons. Although PA does not have contraindications regarding coagulopathy or anatomical anomalies it should be acknowledged that during treatment some adverse effects may occur, due to the contiguity between the paravertebral space and epidural space. Uncommon adverse effect can be seen such as hypotension, blurred vision and confusion [4]. Conflict of interest: none declared. References [1] Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact CardioVasc Thorac Surg 2014;18:626–36. [2] Raveglia F, Rizzi A, Leporati A, Di Mauro P, Cioffi U, Baisi A. Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg 2014;147:469–73. [3] Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extra pleural infusion for post-thoracotomy pain management. Surgery 1999;126:650–6. [4] Jain S, Datta S. Postoperative pain management. Chest Surg Clin N Am 1997;7:773–99.
eResponse. Re: Epidural analgesia versus paravertebral analgesia technique Authors: Souvik Maitra, Dalim K Baidya and Puneet Khanna Anaesthesiology and Intensive Care, AIIMS, New Delhi doi: 10.1093/icvts/ivu059
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We have read the comment by Hajj-Chahine [1] on our meta-analysis [2] with great interest. It is very encouraging that clinical research continues to focus on thoracic paravertebral block. The author discusses a recently published randomized control trial (RCT) [3] on the same issue addressed in our review. In that RCT, Ravegila et al. found a significant difference in favour of paravertebral analgesia, both at rest and during coughing, in the early postoperative period. They also found that paravertebral block is more effective than epidural analgesia in relation to respiratory outcomes, both for spirometric lung function and ambient air saturation. However, we think that these results should be interpreted cautiously. Several methodological limitations exist in the study. Firstly, the duration of surgery in the epidural analgesia group of patients is significantly higher; this finding seriously calls into question the quality of randomization used here. A longer duration surgery may be due to technical complexity and the degree of surgical dissection may be greater, which may give rise to increased pain and a poor respiratory performance. Secondly, the authors used 0.1% bupivacaine in the epidural and 0.3% ropivacaine in the paravertebral block: are they truly comparable? Thirdly, they inserted the epidural catheter at the T5-T6 or T6-T7 intervertebral space but the paravertebral catheter in the same interspace as the thoracotomy incision. It seems illogical to put the two catheters at different levels. They also mentioned that no patients in either of the two groups required additional analgesia. They did not mention the mean difference of the pain scores at different time points and arterial oxyhaemoglobin saturation. The actual clinical significance may be debatable here. We believe that further high quality RCTs are required in this issue to elucidate the optimum analgesic technique in thoracotomy. Conflict of interest: none declared. References [1] Hajj-Chahine J. eComment. Epidural analgesia versus paravertebral analgesia technique. Interact CardioVasc Thorac Surg 2014;18:635–6. [2] Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact CardioVasc Thorac Surg 2014;18:626–36. [3] Raveglia F, Rizzi A, Leporati A, Di Mauro P, Cioffi U, Baisi A. Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg 2014;147:469–73.
