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Table of Contents
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 259-263
Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study


1 Department of Anesthesia, Faculty of Medicine, Mansoura University, Egypt
2 Department of Pediatrics, Faculty of Medicine, Mansoura University, Egypt
3 Department of Cardiothoracic, Faculty of Medicine, Mansoura University, Egypt

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Date of Submission01-Mar-2012
Date of Acceptance26-Jun-2012
Date of Web Publication1-Oct-2012
 

   Abstract 

To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.

Keywords: Epidural block, Paravertebral block, Post-thoracotomy pain

How to cite this article:
El-Morsy GZ, El-Deeb A, El-Desouky T, Elsharkawy AA, Elgamal MA. Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. Ann Card Anaesth 2012;15:259-63

How to cite this URL:
El-Morsy GZ, El-Deeb A, El-Desouky T, Elsharkawy AA, Elgamal MA. Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. Ann Card Anaesth [serial online] 2012 [cited 2014 Dec 18];15:259-63. Available from: http://www.annals.in/text.asp?2012/15/4/259/101848



   Introduction Top


Paravertebral blockade, either single injection or continuous infusion through a catheter, is an effective tool for management of acute postoperative pain. [1] Thoracic paravertebral block has been used for analgesia after thoracotomy, breast surgery, abdominal surgeries, and rib fractures. [2],[3],[4],[5] In the absence of regional anesthesia, in patients of thoracotomy, analgesia can be inadequate or difficult to manage. While epidural analgesia is considered the gold standard for post-thoracotomy pain relief, side effects or complications associated with its use such as hypotension, urinary retention, nausea, itching, and more seriously, epidural hematoma or neurologic injury, can limit its utility. In a population of pediatric patients, risks are possibly higher due to the placement of these catheters under general anesthesia. Therefore, an alternative but equally effective method of analgesia would be preferable. Despite studies showing that paravertebral blockade provides equal postoperative analgesic benefits with lower side effects than epidural in adults, evidence is lacking in pediatric patients. [6],[7]

This study was conducted to compare outcome of paravertebral block versus thoracic epidural block for post-thoracotomy incision pain in pediatric patients. The primary objective was evaluation of postoperative analgesia. Secondary objectives included hormonal responses, side effects, failure rate, and pulmonary function.


   Materials and Methods Top


After ethical committee approval and written parental consent, 60 children were randomly enrolled via computer-generated code in two groups: the thoracic epidural group (group E) and the thoracic paravertebral group (group P). Both blocks were performed in the lateral position after induction of general anesthesia. This study was done in Mansoura University Pediatric hospital between April 2011 and December 2011. Inclusion criteria were elective unilateral thoracotomy, nonpulmonary surgeries. Exclusion criteria include lung disease, family history of sensitivity to local anesthetic, bilateral thoracotomy, obvious deformity of thoracolumbar spine, and coagulopathy.

Solutions for both blocks were prepared by a pharmacist who had no role in the data collection or analysis. General anesthesia was induced with sevoflurane in oxygen, and after establishment of intravenous line, atracurium 0.5 mg/kg was administered to facilitate tracheal intubation. The patients were monitored with electrocardiogram (ECG), noninvasive blood pressure (NIBP), end tidal carbon dioxide (ETCO2), and pulse oximetry. The patients were placed in the right lateral position with the knees, hips and the lumbar spine flexed. After skin preparation, in E - group, an epidural catheter was inserted at T6-9 inter-vertebral space through 20G needle. The epidural space was identified by loss of resistance and guided by ultrasound. After insertion of epidual catheter, bupivacaine 0.25% in a dose of 0.5 ml/kg with fentanyl 1 μg/ kg was given. Postoperatively epidural analgesia was maintained by continuous infusion of 0.25% bupivacaine infused at 0.1 ml/kg/h for 24 hours. In P - group, after skin preparation, spinous processes were identified at T6-9 levels, and a 22G needle was inserted about 1.5-2.5 cm lateral to the midline into the cephalic side of the spinous process, and the needle was advanced perpendicular to the skin, till encountering the costo-transverse ligament. The depth of needle insertion was guided by the following formula - length in millimeters = 10.2 + (0.12 × weight in kilograms), After encountering the costo-transverse ligament the needle was advanced slowly using 2.5-5.0 mA current until contraction of the abdominal muscles occurred. Injection of 0.2 ml of the local anesthetic lead to cessation of muscular contraction. A catheter was inserted, and then bupivacaine 0.25% in a dose of 0.5 ml/kg with fentanyl 1 μg/kg was given. Postoperatively paravertebral analgesia was maintained by continuous infusion of 0.25% bupivacaine infused at 0.1 ml/kg/h for 24 hours. In either group, acetaminophen 15 mg/kg/day was given in four divided doses. In patients of both groups, blood samples were withdrawn preoperatively, and at 10 min after start of block, and 4 h after extubation for assay of serum cortisol level using radioimmunoassay technique (LI4003K, Adaltis, Italy). Failed block was defined as the intraoperative need of more than 0.2 mg/kg of morphine. [8],[9] The case was excluded if accidental intravascular placement of the needle or catheter occurred in any patient in either group. Postoperative chest X-ray was done in all patients to confirm or to rule out accidental pneumothorax. Hypotension, defined as a decrease in blood pressure of more than 20% of baseline value, was treated with intravenous fluid bolus and increments of intravenous ephedrine. Hemodynamic variables were recorded every 10 minutes intraoperatively and every 2 hours postoperatively. Pain score (FLACC), sedation scores and incidence of complications were recorded hourly for 24 h. FLACC (face, legs, activity, cry, consolability) is an observer based five item assessment score and each item is graded from 0 to 2, and pain is graded based on total score (0-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain). [10] Rescue analgesia (morphine 10 μg/ kg) was given if FLACC score was more than 3 and/or on failure of verbal soothing. Number of patients requiring rescue opioid analgesic was recorded .

Master screen Paed (Erich Jaeger GmbH, Germany) was used for Tidal breathing analysis. Appropriate selection of equipment, methodology and trained personnel were verified before tidal breathing analysis to get an accurate and meaningful data. [11] After sedation and 15 min of accommodation (known by regular breathing with no drift), tidal breathing analysis was done preoperatively in order to compare with 6 hours postoperative values. The flow through transparent facemask was measured via computer after calibration. The flow signal was processed and recorded by computer. The facemask was continuously checked to avoid leakage. Parents were usually present during respiratory function testing. For the quantitative evaluation, tidal volume (TV) and inspiratory expiratory (I/E) time ratio were measured from the flow signals. Best of three readings was chosen by a doctor blinded to group assignment.


   Results Top


Sixty-four patients were recruited for the study. Four patients were excluded; three because of parental refusal and one due to coagulopathy. Sixty patients were randomized. Patients with failed block due to technical problems (two in E - group and one in P - group), parental refusal to continue (one in P - group) or vascular puncture (one in E - group) did not complete the study and were not included in analysis [Figure 1]. Patients who needed more than 0.2 mg/kg of morphine (failure of epidural or paravertebral block) were included in analysis. Twenty eight patients in P - group and twenty seven patients in E - group were subjected to analysis. The patient's demographic data, type of surgery and duration of anesthesia were comparable in both groups [Table 1]. Number of patients requiring rescue analgesic were significantly higher in E - group than in P - group (25.9% versus 14.3%, respectively) [Table 2]. Pain scores were comparable in both the groups [Figure 2]. Serum cortisol concentrations in both groups were similar [Figure 3]. Failure rate was significantly higher in E - group than in P - group (7% versus 0%,). The complications were significantly higher in E - group (vomiting 14.8%, urine retention 11.1%, and hypotension 14.8%) than in P - group (0%, 0%, and 3.6%,) [Table 2]. Data derived from tidal breathing analysis were comparable in both groups [Table 2]. Pleural puncture did not occur in any child.
Table 1: Demographic data, duration of surgery and type of surgery


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Table 2: Perioperative data. Values are presented as means ± SD or median with range or number (%)


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Figure 1: Study flowchart

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Figure 2: Postoperative FLACC score in both groups, (FLACC: F - Face; L - Legs; A - Activity; C - Cry; C - Consolabiity)

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Figure 3: Perioperative serum cortisol (μg/dl)

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   Discussion Top


Post-thoracotomy pain is one of the most intense postoperative pain experiences. It is due to surgical wound, disruption of ribs and intercostal nerves, and surgical damage to the chest wall and the pleura, and the presence of thoracotomy tubes. [12] Adequate postoperative analgesia enhances deep breathing and minimizes respiratory complications of thoracotomy. [13] Whereas, inadequate analgesia after thoracotomy in children leads to respiratory dysfunction. [14] Although thoracic epidural block is the gold standard for post-thoracotomy analgesia in adult patients, this technique may fail or contraindicated in children or associated with complications including urinary retention, nausea, itching, hypotension, and respiratory depression. [15] Paravertebral blockade is an effective technique for management of acute pain after various types of surgery. [1] The paravertebral block avoids the severe autonomic dysfunction seen with neuraxial techniques. [16] However, there is no study comparing thoracic paravertebral versus thoracic epidural block in pediatric patients

This study showed that both the techniques, thoracic epidural and thoracic paravertebral block were comparable in pain score, hormonal response, and data derived from tidal breathing analysis. However, complications were significantly higher in thoracic epidural group. Similar to our study, Gulbahar et al, [17] compared epidural and paravertebral continuous block for elective posterolateral thoracotomy and concluded that both the techniques are equally effective in managing the post-thoracotomy pain. The continuous paravertebral block may be preferred due to its ease of application at any desired anatomical locations in a shorter time span and due to lower adverse effects and complications compared with the other technique. Detterbeck [18] conducted a review of prospective, randomized studies for pain relief after thoracotomy. The author reported equally effective analgesia with epidural and paravertebral block for post-thoracotomy pain in adults. Several systematic review and meta-analysis of randomized trials comparing paravertebral versus epidural blockade for thoracotomy pain in adults found no difference in analgesia. [19],[20] In this study, we found a statistically significant failure rate in epidural group compared to paravertebral group, this might be due to false identification of narrow epidural space compared to easy identification of wider paravertebral space in this type of population. A meta-analysis by Davies et al, [19] found similar results when comparing paravertebral versus epidural blockade for thoracotomy pain in adults. Also, the failure of epidural resulted in greater need for analgesic which led to higher complications in the epidural group.

Our study showed no statistically significant difference in tidal breathing parameters analysis (TV and I: E ratio). Richardson et al, [21] reported better preservation of pulmonary function in the paravertebral group and higher side effects in the epidural group. Different age group and parameters might explain the difference.

The stress response to surgery varies according to the type of the surgery, duration of anesthesia, anesthetic agents, hemorrhage and postoperative pain. The stress response results in a 10-fold increase in the blood cortisol levels. [22],[23] An increase in the cortisol level may inhibit natural killer cells activity; wound healing processes and platelets adhesions. Thus affecting postoperative recovery and long-term outcomes. [24] In our study no statistically significant difference in plasma cortisol was found between the two groups. Richardson et al, [21] showed a significant increase in plasma concentrations of cortisol from baseline with both the techniques of analgesia. The stress response is better suppressed by the regional blockade procedures. [25]

In our study, no serious complication of paravertebral block were noted. The potential complications of paravertebral block include, vascular puncture, pneumothorax and total spinal block. [26] Naja et al, [27] Splinter et al, [28] reported no complications in children following thoracic and lumbar paravertebral block.

The limitations of this study is absence of a placebo group as we considered it unethical to omit the use of regional technique to identify the clear benefit of either paravertebral or epidural block. Another limitation of study is addition of fentanyl to paravertebral block as according to many studies it acts by systemic absorption. However, we were aiming for fair comparison between the two techniques and we believe a bolus fentanyl in a dose of 1 μg/ kg in either group could not affect the results. Further studies including third group with intercostal blocks or I.V. opioids for comparison are needed.

We conclude that in pediatric patients, thoracic paravertebral block and thoracic epidural block result in comparable post thoracotomy pain relief, hormone responses and pulmonary function. However, thoracic paravertebral block is associated with significantly less failure rate and side effects.

 
   References Top

1.Cox F, Cousins AJ. Thoracic paravertebral block (PVB) analgesia. J Perioper Pract 2008;18:491-6.  Back to cited text no. 1
    
2.Richardson J, Sabanathan S, Mearns AJ, Evans CS, Bembridge J, Fairbass M. Efficacy of pre-emptive analgesia and continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics. J Cardiovasc Surg (Torino) 1994;35:219-28.  Back to cited text no. 2
    
3.Klein MK, Bergh A, Steele SM, Georgiade GS, Greengrass RA. Thoracic paravertebral block for breast surgery. Anesth Analg 2000;90:1402-5.  Back to cited text no. 3
    
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8.LoÈnnqvist PA, Olsson GL. Paravertebral vs. epidural block in children. Effects on postoperative morphine requirement after renal surgery. Acta Anaesthesiol Scand 1994;38:346-9.  Back to cited text no. 8
    
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19.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.  Back to cited text no. 19
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21.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.  Back to cited text no. 21
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22.Kay NH, Allen MC, Bullingham RE, Baldwin D, McQuay RJ, Moore HA, et al. Influence of meptazinol on metabolic and hormonal responses following major surgery. A comparison with morphine. Anaesthesia 1985;40:223-8.  Back to cited text no. 22
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24.Tacconi F, Pompeo E, Sellitri F, Mineo TC. Surgical stress hormones response is reduced after awake videothoracoscopy. Interact Cardiovasc Thorac Surg 2010;10:666-71.  Back to cited text no. 24
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25.O'Riain SC, Buggy DJ, Kerin MJ, Watson RW, Moriarty DC. Inhibition of the stress response to breast cancer surgery by regional anesthesia and analgesia does not affect vascular endothelial growth factor and prostaglandin E2. Anesth Analg 2005;100:244-9.  Back to cited text no. 25
    
26.Lekhak B, Bartley C, Conacher ID, Nouraei SM. Total spinal anaesthesia in association with insertion of a paravertebral catheter. Br J Anaesth 2001;86:280-2.  Back to cited text no. 26
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28.Splinter WM, Thomson ME. Somatic paravertebral block decreases opioid requirements in children undergoing appendectomy. Can J Anaesth 2010;57:206-10.  Back to cited text no. 28
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Correspondence Address:
Gamal Z El-Morsy
Department of Anesthesia, Faculty of Medicine, Mansoura University
Egypt
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DOI: 10.4103/0971-9784.101848

PMID: 23041682

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