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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 91-96
Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery


1 Department of Anaesthesiology and Critical Care, Escorts Heart Institute and Research Centre, New Delhi, India
2 Department of Cardiac Surgery, Escorts Heart Institute and Research Centre, New Delhi, India

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   Abstract 

Minimally invasive surgery with robotic assistance should elicit minimal pain. Regional analgesic techniques have shown excellent analgesia after thoracotomy. Thus the aim of this study was to compare thoracic epidural analgesia (TEA) technique with paravertebral block (PVB) technique in these patients with regard to quality of analgesia, complications, and haemodynamic and respiratory parameters.
This was a prospective randomised study involving 36 patients undergoing elective robotic-assisted coronary artery bypass grafting (CABG). TEA or PVB were administered in these patients. The results revealed no significant differences with regard to demographics, haemodynamics, and arterial blood gases. Pulmonary functions were better maintained in PVB group postoperatively; however, this was statistically insignificant. The quality of analgesia was also comparable in both the groups.
We conclude that PVB is a safe and effective technique for postoperative analgesia after robotic-assisted CABG and is comparable to TEA with regard to quality of analgesia.

Keywords: Paravertebral analgesia, pulmonary function test, robotic cardiac surgery, thoracic epidural analgesia

How to cite this article:
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

How to cite this URL:
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 [serial online] 2008 [cited 2019 Oct 19];11:91-6. Available from: http://www.annals.in/text.asp?2008/11/2/91/41576


Minimally invasive techniques have revolutionised the field of cardiac surgery. With the introduction of computerised tele-manipulator known as surgical robot, cardiac surgery can be performed through smaller incisions. It offers potential for minimal scarring, reduced recovery times, less inflammatory response to surgery, and reduced transfusion requirement as compared to the open procedure. [1]

Although this technique is associated with smaller incision, the pain due to thoracotomy persists. Postoperative pain causes a reduction in respiratory mechanics, reduced mobility, and increase in hormonal and metabolic activity. Deterioration of the respiratory mechanics can lead to pulmonary complications, and hypoxaemia may lead to myocardial ischaemia, cerebrovascular accidents, delayed wound healing, and prolonged hospital stay. [2] Therefore, various regional techniques have been used in conjunction with general anaesthesia to alleviate postoperative pain in minimally invasive surgery. [2],[3] Thus, we compared thoracic epidural analgesia (TEA) technique with paravertebral block (PVB) technique with regard to quality of analgesia, complications, and haemodynamic and respiratory parameters in patients undergoing robotic-assisted coronary artery bypass grafting (CABG).

Robotic system [4]

The da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) consists primarily of two components: surgeon's viewing with control console; and surgical arms [Figure 1],[Figure 2], which hold and move the surgical instruments. The surgeon operates from the console while looking into a high-resolution three-dimensional stereoscopic display of the operating field. The manipulating instrument controllers are positioned below the surgeon console display. Two mechanical arms that activate at their distal extremities support the tele-manipulated instruments. The instrument tips reproduce the surgeon's hand movements. The mechanical units of the instruments have seven degrees of freedom and are able to minimise the flexibility of the human wrist. An additional video cart carries a light source, continuous carbon dioxide (CO 2 ) insufflator, and a conventional two-dimensional monitor.


   Materials and Methods Top


After approval from the institutional review board and obtaining informed consent, 36 patients of either sex undergoing elective CABG using robotic assistance were included in the prospective randomised study. Patients were randomised either to group A, i.e., TEA ( n = 19); or group B, i.e., PVB ( n = 17). Patients with left ventricular ejection fraction (LVEF) <35%, anomaly of the vertebral column, receiving heparin and antiplatelet medication within the preceding week and with significant respiratory disease were excluded from the study. Patients requiring preoperative inotropic support or intra-aortic balloon counterpulsation were also excluded. Pulmonary function tests were performed in all the patients.

All the patients were premedicated with oral lorazepam 2 mg and morphine sulphate 0.1 mg/kg with glycopyrrolate 0.2 mg as an antisialagogue intramuscularly, 60 minutes preoperatively. On arrival in the operating room, pulse oxymeter and ECG (lead II and V 5 ) were applied. After securing venous access, radial artery cannulation was performed. External defibrillator pads were applied to the patient.

In TEA group (group A), epidural space was catheterised with a 16G epidural catheter (SIMS, Portex Inc., Keene, NH, UK) using a midline approach at cervical (C)7:Thoracic (T)1 interspace in a sitting awake patient before induction of anaesthesia. In PVB group (group B), the left paravertebral space was catheterised with the same catheter at the T 4 :T 5 level using standard method. [5] All the regional blocks were performed by the same operator. A loss-of-resistance technique with a saline-filled syringe was used for PVB, while hanging-drop technique was used for TEA, and the catheter tip was advanced approximately 4 cm beyond the needle tip. A test dose of 3 ml of 2% lidocaine, plain, was injected through the catheter in all the patients in supine position to rule out subarachnoid placement of the catheter. In both the groups, bolus dose of 8 ml of 0.5% bupivacaine was injected through the catheter in supine position; followed by an infusion of 0.25% bupivacaine at the rate of 0.1 ml/kg/hr, which was continued in the postoperative period. Correct placement of the catheter was confirmed by testing sensation to pinprick 15 to 20 minutes after the injection of the bolus dose in group A. All the patients were anaesthetised with midazolam, fentanyl, and isoflurane in oxygen and air, and muscle relaxation was achieved with vecuronium bromide. Double-lumen endobronchial intubation was performed in all the patients using 41F left-sided Robertshaw-type PVC tube (SIMS, Portex Inc., Keene, NH, UK). The correct placement of the tube was confirmed by fibreoptic bronchoscopy.

Monitoring included a continuous two-lead ECG with ST segment analysis, direct arterial pressure, pulmonary artery pressure, temperature, oxygen saturation by pulse oximetry, end-tidal CO 2 and volatile anaesthetic agent, thermodilution cardiac output and derived haemodynamic parameters, arterial blood gases, urine output, activated clotting time, and regional wall motion by transoesophageal echocardiography (TOE). Haemodynamic data including heart rate (HR), mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP), central venous pressure (CVP), and cardiac index (CI) were recorded before incision, as baseline; during one-lung ventilation (OLV); after thoracotomy; and after revascularization.

All the patients were prepared and draped as for conventional cardiac surgery, permitting sternotomy, if required. After exclusion of the left lung, the first port position (camera) was placed in the fourth left intercostal space (ICS) at the level of midclavicular line. CO 2 was insufflated into the left pleural space so as to obtain an intrapleural pressure of 5 to 10 mm Hg to allow exploration of the pleural cavity with a two-dimensional endoscope. The second port was placed into the fourth left ICS at the level of anterior axillary line. The third port was placed into the sixth left ICS, also at the level of anterior axillary line.

The surgical arm of the robotic system was positioned through the ports into the thoracic cavity, and left internal mammary artery (LIMA) dissection was started using a three-dimensional (30°) endoscope, electrocautery, and the grasper. CO 2 administration into pleural space was continued to maintain intrapleural pressure of 5 to 10 mm Hg. Heparin (2 mg/kg) was administered after dissection of the LIMA. After LIMA harvesting, left minithoracotomy incision was made in the fourth ICS, and LIMA-to-left anterior descending artery (LAD) grafting was performed under direct vision using a stabiliser.

After surgery, patients were transferred to the recovery room and extubated whenever they qualified for extubation. An independent observer who was blinded to the analgesic techniques recorded visual analogue scale (VAS) at 12 hours, 24 hours after surgery at rest and while coughing (0-no pain; 10-maximum pain). If the VAS score at rest was >5 or whenever the patient demanded, additional analgesia was provided with diclofenac sodium 75 mg intramuscularly. Acid-base analysis was performed immediately and 1 hour after extubation. Bedside pulmonary function tests were performed 2 hours after the removal of chest drainage tubes. All the complications were also noted. All the data are presented as mean ± SD. The mean values of the two groups of data were analyzed using the two-tailed Student t test. A P value <0.05 was considered significant.


   Results Top


Patients in both groups were comparable with regard to demographic data, i.e., age, sex, height, weight, and body surface area [Table 1]. Other parameters like surgical time, hospital stay, analgesic and muscle relaxant requirements, and time to extubate were also comparable [Table 2].

Haemodynamic data, including HR, MAP, MPAP, CVP, and CI were also comparable at all the points [Table 3]. Respiratory parameters, including arterial oxygen tension (PaO 2 ) and arterial carbon dioxide tension (PaCO 2 ), were also comparable in both the groups at specified intervals [Table 4]. Pulmonary function tests such as forced expiratory volume in one second (FEV 1 ), forced vital capacity (FVC), peak expiratory flow rate (PEFR), maximum ventilatory volume (MVV) showed marginally better results in group B [Table 5] as compared with group A; however, they were statistically not significant except that there was a significant decrease in pulmonary functions postoperatively in both the groups as compared to preoperative values.

VAS scores were slightly higher in group B as compared with group A; however, rescue analgesia requirement was more in group A. These values, however, were statistically insignificant [Table 6],[Table 7].

Re-exploration was performed in two patients in group B and in one patient in group A due to excessive bleeding and ST change in the ECG. Transient numbness of the upper limb was noted in two patients in group A, which recovered on temporarily stopping the infusion of local anaesthetic [Table 8]. None of the patients had any complication related to insertion of the catheter in either technique.


   Discussion Top


Robotic-assisted surgery is an evolving technique. The goal of this technique is to perform the operative procedure with the smallest incision possible and with decreased surgical stress while enhancing the surgical dexterity and elimination of tremors. After extensive trials in animals and cadavers, a prototype of the robot system was introduced into clinical practice in 1998. [6] Now, a number of centres worldwide are performing robotic-assisted cardiac surgery, which includes CABG, valve surgery, and atrial septal defect repair.

Use of TEA for cardiac surgery is well documented. It helps in effective pain control, which can suppress surgically mediated hormonal and metabolic responses. [7] Moreover, subendocardial blood flow and myocardial oxygen supply improve secondary to the sympathetic blockade. [8] It also allows early awakening and extubation and improves pulmonary functions. However, extensive sympathetic blockade may cause hypotension, and risk of epidural haematoma is a major concern in cardiac surgery. [9] Literature search revealed that TEA can be administered safely in patients who have received heparin; however, the timing of catheterisation is important. [10],[11] It is notable that in our experience no case of bloody tap or epidural haematoma has been encountered till date.

PVB is also a well-accepted technique for post-thoracotomy pain relief. [12] It is safer and easier to perform than TEA and can be performed easily after induction of anaesthesia. PVB affects intercostal nerves, ipsilateral sympathetic chain, and posterior rami, which mediate backache from straining of posterior spinal muscles and ligaments. Continuous infusion of local anaesthetic provides effective analgesia, restores respiratory mechanics, and prevents early reduction of pulmonary functions. [13] This type of unilateral analgesia is required in robotic-assisted CABG. Moreover, its role in cardiac surgery has also been well documented at our centre by Dhole et al. [2] They found PVB to be as effective as TEA after minimally invasive direct coronary artery bypass grafting surgery. It has also been shown to be effective in postoperative analgesia after thoracotomy. [14] Hypotension and urinary retention are less frequently associated with PVB although the pain scores were comparable. [15] Moreover, there is no risk of epidural haematoma in the event of conversion to conventional CABG.

In the present study, the haemodynamics were well maintained during the intraoperative period in both the groups. Although there was transient increase in CVP and MPAP during OLV, pulmonary function test values were better maintained in the PVB group during postoperative period, indicating better analgesia. Blood gas analysis revealed comparable PaO 2 and PaCO 2 values in both the groups after extubation. The duration of ventilation was also comparable.

VAS scores at rest and coughing were slightly higher in the PVB group (statistically insignificant), but rescue analgesic requirement were lower; so it can be concluded that analgesic effect was similar in both the groups.

Two patients in group A had transient numbness in the upper limb, which disappeared on temporarily stopping the infusion of local anaesthetic. None of the patients in group B had numbness or any other complication related to the PVB. Two patients in group A had complete heart block treated with permanent pacemaker insertion, which was not related to the technique.

Major limitations of the study were the number of patients, lack of control group, relation between VAS and other parameters to explain analgesia, and learning curve associated with the surgical technique. Therefore, larger randomised controlled trials are required.

In conclusion, PVB appears to be a safe and effective technique for postoperative analgesia after robotic-assisted CABG and is comparable to TEA with regard to quality of analgesia. In addition, it may be used safely in patients having recent anticoagulation; and it provides unilateral analgesia, which is required in this surgery.

 
   References Top

1.Sugantha G. Anaesthesia for minimally invasive cardiac surgery. Best Pract Clin Anaesthesiol 2002;16:63-80.  Back to cited text no. 1    
2.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.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Mehta Y, Swaminathan M, Mishra Y, Trehan N. A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1998;12:162-5.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Mishra YK, Wasir H, Sharma M, Sharma KK, Mehta Y, Trehan N. Robotically enhanced coronary artery bypass surgery. Indian Heart J 2004;56:622-7.  Back to cited text no. 4  [PUBMED]  
5.Eason MJ, Wyatt R. Paravertebral thoracic block: A reappraisal. Anaesthesia 1979;34:638-42.  Back to cited text no. 5  [PUBMED]  
6.Mohr FW, Falk V, Diegeler A, Autschback R. Computer enhanced coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1999;117:1212-3.  Back to cited text no. 6    
7.Moore CM, Cross MH, Desborough JP, Burrin JM, Macdonald IA, Hall GM. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth 1995;75:387-93.  Back to cited text no. 7    
8.Kirno K, Friberg P, Grzegorzyk A, Milocco I, Ricksten SE, Lundin S. Thoracic epidural anesthesia during coronary artery bypass surgery: Effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg 1994;79:1075-81.  Back to cited text no. 8    
9.Schmidt A, Nolte H. Subdural and epidural hematomas following epidural anesthesia: A literature review. Anaesthesist 1992;41:276-84.  Back to cited text no. 9  [PUBMED]  
10.Odoom JA, Sih IL. Epidural analgesia and anticoagulant therapy: Experience with one thousand cases of continuous epidurals. Anaesthesia 1983;38:254-9.  Back to cited text no. 10  [PUBMED]  
11.Sanchez R, Nygard E. Epidural anesthesia in cardiac surgery: Is there an increased risk? J Cardiothorac Vasc Anesth 1998;12:170-3.  Back to cited text no. 11    
12.Hardy I, Ahmed S. Pain control following thoracic surgery. In: Ghosh S, Latimer R, editors. Thoracic anaesthesia- principles and practice. Oxford: Butterworth-Heinemann; 1999. p. 265-7.  Back to cited text no. 12    
13.Catala E, Casas JI, Unzueta MC, Diaz X, Aliaga L, Villar Landeira JM. Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies. J Cardiothorac Vasc Anesth 1996;10:586-8.  Back to cited text no. 13    
14.Mathews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions for bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989;62:204-5.  Back to cited text no. 14    
15.Perttunen K, Nilson E, Heinonnen J, Hirvisalo EL, Salo JA, Kalso E. Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain. Br J Anaesth 1995;75:541-7.  Back to cited text no. 15    

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Correspondence Address:
Yatin Mehta
Department of Anaesthesiology and Critical Care, Indraprastha Apollo Hospitals, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.41576

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