Ann Thorac Surg 2005;79:2109-2113
© 2005 The Society of Thoracic Surgeons
New technology
Paravertebral Block With Ropivacaine 0.5% Versus Systemic Analgesia for Pain Relief After Thoracotomy
Emmanuel Marret, MDa,*,
Bernard Bazelly, MDb,
Guillaume Taylor, MDb,
Nadège Lembert, MDa,
Arnaud Deleuze, MDa,
Jean-Xavier Mazoit, MD, PhDc,
Francis J. Bonnet, MDa
a Departments of Anesthesiology and Critical Care, Tenon University Hospital, Assistance Publique Hôpitaux de Paris, Paris
b Department of Thoracic and Vascular Surgery, Tenon University Hospital, Assistance Publique Hôpitaux de Paris, Paris
c Service et Laboratoire d’Anesthésie, UPRES Centre Hospitalier, Universitaire de Bicêtre, Université Paris-Sud, Faculté de Médecine du Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
Accepted for publication July 12, 2004.
* Address reprint requests to Dr Marret, Département d’Anesthésie-Réanimation, Hopital Tenon, 4, Rue de la Chine, 75020 Paris, France (E-mail: emmanuel.marret{at}tnn.ap-hop-paris.fr).
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Abstract
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PURPOSE: Paravertebral block in combination to intravenous analgesics could be an alternative to epidural analgesia for postoperative pain control after thoracotomy, but it has been scarcely evaluated so far. We thus assessed the efficacy of paravertebral block using a continuous infusion of ropivacaine in a multimodal analgesic approach.
DESCRIPTION: Forty patients were randomized to receive ketoprofen, paracetamol, and patient-controlled-analgesia (PCA) with intravenous morphine (control group) or the same treatment with a continuous 48-hour infusion of ropivacaine 0.5% (0.1 mL/kg–1/h–1) in a thoracic paravertebral catheter (thoracic paravertebral block [TPVB] group). Visual analog scale (VAS) at rest and when coughing, morphine consumption, and side effects were recorded during the first 48 hours after surgery. Venous blood was sampled at 24 and 48 hours for ropivacaine plasma concentration measurements.
EVALUATION: Mean VAS scores at rest and when coughing were significantly decreased in the TPBV group (p < 0.005). Despite a decrease in the morphine-titrated dose given in the postanesthesia care unit, cumulated morphine consumption was not significantly different between the two groups (51 ± 29 mg and 57 ± 24 mg in the TPVB and control groups, respectively). Side effects (nausea, vomiting, urinary retention) were less frequent in the TPBV group (30% vs 75%; p < 0.005). Plasma ropivacaine concentrations remained below the toxic threshold.
CONCLUSIONS: Continuous paravertebral ropivacaine 0.5% infusion improves pain control after thoracic surgery using a multimodal analgesic approach.
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Introduction
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Posterolateral thoracotomy is a severely painful surgical procedure [1, 2]. Moreover pain after thoracic surgery may promote pulmonary complications preventing airways secretions from clearing, in turn, favoring bronchial obstruction, atelectasia, and pneumonia [3, 4]. Severe postoperative pain may also contribute to the development of chronic pain syndrome [2, 5]. Thoracic epidural analgesia is considered as the gold standard for analgesia in this setting [1, 2]. However thoracic epidural analgesia carries the risk of dural puncture, epidural hematoma, epidural abscess, and side effects such as hypotension, bradycardia, and urinary retention and these commonly occur. Thoracic paravertebral block (TPVB) consists in the administration of a local anesthetic solution close to the spinal cord nerve roots after their exit from the intervertebral foramen [6, 7]. Injection into the thoracic paravertebral space through a catheter demonstrates vertical diffusion lateral to the vertebral column between the parietal pleura and the endothoracic fascia [8, 9]. Thus TPVB produces unilateral analgesia, extending to several thoracic segments, and could be an alternative to thoracic epidural anesthesia for postoperative analgesia after thoracotomy. We consequently conducted a randomized controlled trial to evaluate the effectiveness of a multimodal approach pertaining to pain treatment after thoracic surgery including a continuous thoracic paravertebral infusion of ropivacaine 0.5%.
This prospective randomized controlled study was approved by our institutional Ethical Committee (Comité Consultatif de Protection des Personnes se pretant à la Recherche Biomédicale de la Faculté de Médecine Saint-Antoine) and was carried out in accordance with French law concerning research in human beings.
Included in this study were American Society of Anesthesiologists (ASA) I–III patients scheduled for lung resection by a posterolateral thoracotomy without pleurodesis who ranged in age from 18–80 years. Patients were excluded if they exhibited a contraindication to regional anesthesia (preoperative hemostasis disorder or a local or general infection), a past medical history of gastric ulcer or asthma, chronic renal failure or hepatic dysfunction, chronic preoperative treatment with opioids, or an allergy to nonsteroidal anti-inflammatory drugs.
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Technique
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Forty patients were studied after written informed consent was obtained. The use of a patient-controlled analgesia (PCA) device and the visual analog scale (VAS) for pain measurement was explained those involved in the study the day before surgery. Anesthesia was induced with propofol (2–3 mg/kg–1) and sufentanil (0.5 µg/kg–1). Atracurium (0.5 mg/kg–1) was injected to facilitate orotracheal intubation. Additional 0.2 µg/kg–1 sufentanil boluses were injected during anesthesia when required. A posterolateral thoracotomy was implemented in the fifth intercostal space. A single surgeon (BB) performed all of the operative procedures. Two chest tubes were placed after lobectomy or wedge resection in the eighth or ninth intercostal space, but none were used after pneumonectomy.
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Technology
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At the end of the surgical procedure, patients were allocated randomly by sealed envelopes for the analgesic technique. The TPVB was performed by the anesthetist in charge of the patient, in agreement with the technique described by Eason and Wyatt [10]. Briefly the puncture site was situated 2.5–3 cm laterally to the fifth spinous process and the needle was inserted perpendicularly to the skin. The paravertebral space was located using the loss of resistance technique with an 18-gauge Tuohy needle. An injection of 10 mL of isotonic saline was administered and a catheter was then inserted more than 2–3 cm. After careful aspiration through the catheter, patients received a 20 mL bolus of lidocaine and 1.5% with epinephrine. An injection of 10 mL of contrast medium (Iopamiron 300 mg/mL; Shering Pharmaceutical, Lys-Lez-Lannoy, France) was also administered in the recovery room to ensure that the catheter tip position was in the paravertebral space, as expected (Fig 1). Ropivacaine 0.5% (Naropeine; Astra-Zeneca, Reuil-Malmaison, France) was then infused continuously for more than 48 hours at a rate of 0.1 mL/kg–1/h–1. In the control group a sham catheter was placed behind the patients upon the cessation of anesthesia.
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Fig 1. Chest roentgenogram illustrating the diffusion of contrast medium in the thoracic paravertebral space (arrows).
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All patients received 2 g of propacetamol and 50 mg of ketoprofen intravenously 30 minutes before the end of surgery and then every 6 hours over the course of 4 days. In the recovery room, after tracheal extubation, titrated doses of morphine (2 mg bolus dose at 5 minutes intervals) were injected until the VAS score at rest was less than 30. Patients were connected to a PCA pump (Abbott Pain Manager [APM]; Abbott, Rungis, France) programmed to deliver intravenous morphine in bolus doses of 1 mg with a lockout interval of 7 minutes. Morphine consumption was recorded at 1, 3, 6, 12, 24, 36, and 48 hours after tracheal extubation. At the same time patients evaluated pain at rest and when coughing with a VAS graded from 0 (no pain) to 100 (the worst pain imaginable). During the 48 hours of PCA and paravertebral block use, side effects including respiratory depression (respiratory rate < 8 breaths per minute), sedation, urinary retention, nausea, vomiting, and pruritus were noted. Bladder catheterization was performed when patients were unable to void despite a bladder volume greater than or equal to 500 mL measured by portable ultrasound device (BVI 3000; Diagnostic Ultrasound, Redmond, WA). Venous blood was sampled in the two groups at 24 and 48 hours postoperatively for plasma ropivacaine measurement using gas chromatography.
The aim of this study was to demonstrate the effectiveness of TPVB by detecting a 30% difference in VAS scores on movement between the two groups of patients. The sample size was estimated at 20 patients per group (
= 0.05; ß = 0.20). Data were analyzed using nonparametric analysis (Mann-Whitney U test, 
2 test, or Fisher’s exact test). Comparisons of serial measurements (VAS scores, morphine consumption) were performed using analysis of variance (ANOVA) and then a post-hoc protected least-significant difference [PLSD] Fisher test.
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Clinical Experience
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Patient characteristics, types of surgery, and sufentanil requirements were comparable in the two groups (Table 1). After chest roentgenogram control, no paravertebral catheter was removed because of an incorrect placement. VAS scores at rest decreased during the first 48 hours in both groups (Fig 2). However mean postoperative VAS scores at rest were significantly lower in the TPVB group than in the control group at the 6, 12, and 36 postoperative hours and on coughing from 3–48 postoperative hours (Figs 2 to 3). In the recovery room the mean intravenous dose of morphine given by nurses was significantly higher in the control group than in the TPVB group (9 ± 5 mg vs 6 ± 4 mg; p = 0.02). However the 48-hour cumulative doses of PCA morphine were not significantly different between the two groups (57 ± 24 mg vs 51 ± 29 mg in the control group and TPVB group, respectively) (Fig 4).
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Fig 2. Visual analog scale (VAS) scores at rest during the first 48 hours postoperatively. The two groups were significantly different (*p < 0.05 versus control group). The black bars designate the control group and the white bars designate the thoracic paravertebral block (TPVB) group. Data are expressed as mean ± standard deviation. (H1 = 1 hour; H3 = 3 hours; H6 = 6 hours; H12 = 12 hours; H24 = 24 hours; H36 = 36 hours; H48 = 48 hours.)
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Fig 3. Visual analog scale (VAS) scores for coughing 48 hours postoperatively. The two groups were significantly different (p < 0.001) (*p < 0.05 versus control group). The black bars designate the control group and the white bars designate the thoracic paravertebral block (TPVB) group. Data are expressed as mean ± standard deviation. (H1 = 1 hour; H3 = 3 hours; H6 = 6 hours; H12 = 12 hours; H24 = 24 hours; H36 = 36 hours; H48 = 48 hours.)
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Fig 4. Cumulative patient-controlled-analgesia (PCA) (PCA morphine consumption at different time intervals represented as box plots (25th–75th percentiles). The horizontal bars designate the median values, the vertical bars designate the 10th and 90th percentiles, and the open circles designate the extreme values. The shaded areas represent the control group and the unshaded areas represent the thoracic paravertebral block (TPVB) group. Cumulative morphine consumption was not different between the two groups at any time interval. (H1 = 1 hour; H3 = 3 hours; H6 = 6 hours; H12 = 12 hours; H24 = 24 hours; H36 = 36 hours; H48 = 48 hours.)
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No patients experienced complications related to the thoracic paravertebral catheter placement. Side effects were significantly more frequent in the control group (75% vs 30%; p < 0.005). The most frequently reported side effects were postoperative nausea and vomiting (9 vs 1 in the control and TPVB groups, respectively; p = 0.01). Seven patients experienced urinary retention in the control group in comparison with 5 patients in the TPVB group (not significant). One patient in each group experienced postoperative pneumonia.
The mean values of venous plasma concentrations of ropivacaine were 2.83 ± 1.31 µg/mL–1 at 24 hours and 2.74 ± 1.65 µg/mL–1 at 48 hours. Symptoms of local anesthetic toxicity did not develop in any of the patients.
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Comment
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This study demonstrates the analgesic effect of continuous TPVB mainly supported by lower values of VAS pain scores at rest and when coughing. Paravertebral block was described at the beginning of the twentieth century [11]. More recently because of the possibility of inserting a catheter into the paravertebral space, this block has been evaluated for postoperative analgesia after lateral thoracotomy [12, 13]. Catheter insertion has been described by a surgical approach under direct vision or by a skin puncture as in the current study [12–17]. Studies comparing the efficacy of the two techniques is not currently available, but in the current study, roentgenogram control confirmed that placement by the anesthetist was a reliable technique. Thoracic paravertebral space is a vertically and horizontally open space located between the intercostal and epidural space. Local anesthetic injection can diffuse to upper and lower nerve roots through the paravertebral space. Consequently analgesia achieved using a paravertebral block spans several segments [7–9] and, in contrast to epidural analgesia, mostly unilaterally [7], although extension can occasionally be controlateral [18]. In our study, chest x-rays performed in the recovery room also confirmed that no epidural or intrapleural extension occurred.
Continuous thoracic paravertebral infusion of bupivacaine or lidocaine has been demonstrated to achieve analgesia at rest and when coughing comparable with that induced by thoracic epidural analgesia after thoracotomy [14–16, 19, 20] and with fewer side effects [14, 16, 21]. In comparison with epidural analgesia, postoperative care and monitoring is consequently simplified in patients who benefited from TPVB. This technique could therefore be more suitably adapted to patients in surgical wards who are outside highly monitored intensive care units.
Only a few studies have compared TPVB with intravenous opioid postoperative analgesia [17, 22]. Bilgin and associates have documented lower VAS scores at rest and when coughing in patients given intermittent extrapleural boluses of bupivacaine compared with those receiving intravenous metamizol [22]. Surprisingly the bolus size (1–2 mL) and the dose of bupivacaine administered (38.3 mg/24 h–1) were 10-fold to 20-fold lower than in any of the previous studies suggesting that the lack of double-blinding may have induced a bias with regard to the results of this research. In the study by Carabine and associates, PCA intravenous morphine consumption was decreased considerably in the TPVB group. Because patients did not receive nonopioid analgesics in combination, morphine demand was higher than in the current study [17]. Indeed simultaneous administration of ketoprofen and paracetamol has probably contributed to lower PCA morphine demand regarding the two groups in the current study [23] explaining the lack of difference pertaining to intravenous morphine administration. The use of nonopioid analgesics, such as nonsteroidal anti-inflammatory drugs, is part of the multimodal approach of postoperative analgesia that contributes to strengthen the analgesic efficacy of various treatments [24]. In that occurrence the multimodal treatment included the paravertebral block, the patient-controlled administration of morphine, and the use of ketoprofen and paracetamol during the first 48 hours corresponding to the most painful postoperative period. Combined together these analgesic techniques and agents allow an effective control of pain that could be doubtfully achieved by any of them used solely.
In the current study nausea and vomiting were more frequent in the control group than in the TPVB group. A lower morphine consumption in the recovery room and more suitable pain control during the study-period may possibly explain these results. A decrease in the incidence of nausea and vomiting may also be considered as a benefit of TPVB.
The local anesthetic used in this study was ropivacaine 0.5%. In most of the previous studies concerning TPVB after thoracic surgery, bupivacaine 0.5% was administered to patients. Ropivacaine and bupivacaine are long-acting local anesthetic agents but ropivacaine, which is a pure S(-) enantiomer, is less cardiac toxic than bupivacaine [25]. The bolus dose of bupivacaine cannot exceed 150 mg, whereas the bolus dose of ropivacaine is limited to 250 mg. After 48 hours of continuous infusion into the paravertebral catheter, the measured plasma concentrations of ropivacaine did not exceed a toxic threshold. Others have reported mean plasma peak concentrations of 4.9 µg/mL (maximum 7.48 µg/mL, during a continuous paravertebral infusion of bupivacaine 0.5% at 0.1 mL/kg–1/h–1 [26]). Ropivacaine compared with other local anesthetic agents creates some type of vasoconstrictive effect [27]. This could explain a limitation with regard to plasma absorption of the solution injected into the paravertebral space. No sign of local anesthetic toxicity has been observed so far in patients with a TPVB continuous infusion despite a wide variation in local anesthetic plasma concentrations [14, 26].
Although complications such as dural puncture leading spinal anesthesia, postdural headache [28], and pulmonary hematoma [29] have been occasionally reported, the thoracic paravertebral approach may avoid major complications associated with epidural analgesia such as epidural hematoma, epidural abscess, or spinal cord injury. In a series of 620 blocks performed in adults, Naja and Lonnqvist have reported minor complications which include inadvertent vascular puncture (7%), hematoma at the site of injection (2.4%), signs of epidural or intrathecal spread (1%), and intrapleural catheter placement (0.8%), none of which are life-threatening [30].
We conclude that the combination of continuous TPVB with nonopioid analgesics and PCA intravenous morphine provides effective analgesia after thoracic surgery. This multimodal analgesic technique could be considered as an alternative to thoracic epidural analgesia.
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Disclosures and Freedom of Investigation
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The source of funds used to perform the evaluation was provided by the "Association pour la Recherche en Anesthésie-Réanimation à l’Hôpital Tenon" (Association for Promoting Research in Anesthesia and Intensive Care at Tenon Hospital). The tested technology was not purchased, borrowed, or donated to the study. The authors exhibited full control with regard to the design of the study, the methods used, the outcome parameters, the analysis of data, and the production of the written report.
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Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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Abstract
Introduction
