Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis

Abstract

Though once considered the gold standard, epidural anaesthesia has complications that may be significant and include hypotension, urinary retention, partial or patchy block and, in rare cases, devastating neurological injuries also. Paravertebral block (PVB) is an alternative technique for unilateral surgical procedures like thoracotomy, which may offer similar analgesic effectiveness and a more favourable side-effect profile than epidural analgesia. This systematic review and meta-analysis of published randomized clinical trials aims to compare thoracic paravertebral with thoracic epidural analgesia (TEA) in thoracotomy for lung surgery. Five hundred and forty-one patients from 12 clinical trials have been included in this systematic review and meta-analysis. We found that visual analogue scale (VAS) scores at rest and during activity/coughing at 4-8, 24 and 48 h postoperatively were similar in both the PVB and TEA groups. Considering studies not included in the previous meta-analysis, a VAS score on activity at 48 h is significantly better in the PVB group (mean difference 0.40 cm; 95% confidence interval [95% CI] 0.77, 0.02; Mantel-Haenszel (M-H) fixed). Hypotension (odds ratio 0.13; 95% CI 0.06, 0.31; M-H fixed) and urinary retention are more common in the epidural analgesia group. So, we conclude that thoracic PVB may be as effective as thoracic epidural analgesia for post-thoracotomy pain relief and is also associated with fewer complications.

Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis

“…If the values for continuous variables were reported as median and as interquartile range (IQR) or total range, the mean value was estimated using the median and the low and high ends of the range for samples smaller than 25; for samples greater than 25, the actual median was used [6]. The mean and SD were estimated from the median and the low and high ends of the range for samples smaller than 15, as range/four for samples from 15 to 70, and as range/six for samples more than 70 [6].…”

“…The mean and SD were estimated from the median and the low and high ends of the range for samples smaller than 15, as range/four for samples from 15 to 70, and as range/six for samples more than 70 [6]. If only an IQR was available, SD was estimated as IQR/1.35 [15,24].…”

Minimally Invasive Esophagectomy

“…It is associated with less incidence of failed block and reduces hypotension and urinary retention when it is compared with TEA. Several recent reviews and meta-analyses defend its beneits [51][52][53], and it is a standard practice in some UK hospitals for minimally invasive esophagectomy. Local data also show shorter stays in the intensive therapy unit comparing with TEA.…”

Falling after epidural analgesia: lessons from obstetric anesthesia

“…After reviewing studies in several meta-analyses suggesting an increased incidence of hypotension with TEA, we found that, in virtually all of these trials, the investigators used bupivacaine or ropivacaine concentrations that were higher or equal to 0.125% or 0.2%, respectively. 11,12 Unfortunately, few studies have investigated the relationship between much lower concentrations of local anesthetics (e.g., ''ultra-low-dose'' epidurals) and the incidence of lower limb motor block, hypotension, and IAFs in the surgical population. Moreover, studies consistently report a higher incidence of lower limb motor block with lumbar epidurals than with thoracic epidurals.…”

“…Après avoir examiné les études dans plusieurs méta-analyses suggérant une augmentation de l'incidence de l'hypotension avec la TEA, nous avons constaté que dans quasiment tous ces essais, les investigateurs avaient utilisé des concentrations de bupivacaïne ou de ropivacaïne qui étaient égales ou supérieures à, respectivement, 0,125 % ou 0,2 %. 11,12 Malheureusement, peu d'études se sont intéressées aux rapports entre des concentrations d'anesthésiques locaux beaucoup plus faibles (par exemple, les péridurales à « dose ultra basse ») et l'incidence des blocs moteurs des membres inférieurs, l'hypotension et les accidents et chutes des patients hospitalisés dans la population chirurgicale. De plus, les études ont régulièrement signalé une incidence des blocs moteurs des membres inférieurs plus élevée avec les péridurales lombaires qu'avec les péridurales thoraciques.…”