Con: Every postthoracotomy patient does not deserve thoracic epidural analgesia

Grant, Raymer P.

doi:10.1016/s1053-0770(99)90277-x

Cited by 21 publications

(9 citation statements)

References 22 publications

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“…Thoracic epidural analgesia is commonly used after thoracotomy. However, there are risks associated with the techniques such as neurological injury and paraplegia [44]. Sometimes, the epidural technique fails due to difficult anatomy [45].…”

Section: Discussionmentioning

confidence: 99%

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

et al. 2014

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ObjectiveThe most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epidural blockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue.Summary of BackgroundThoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy.MethodsTwo reviewers independently searched the databases PubMed, EMBASE, and the Cochrane Library (last performed on 1 February, 2013) for reports of studies comparing post-thoracotomy epidural analgesia and paravertebral blockade. The same individuals independently extracted data from the appropriate studies.ResultEighteen trials involving 777 patients were included in the current analysis. There was no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4–8, 24, 48 hours, and the rates of pulmonary complications and morphine usage during the first 24 hours were also similar. However, paravertebral blockade was better than epidural analgesia in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p = 0.01), hypotension (p<0.00001), and rates of failed block were lower in the paravertebral blockade group (p = 0.01).ConclusionsThis meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.

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Section: Discussionmentioning

confidence: 99%

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

et al. 2014

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“…5 Epidural blockade has been shown to reduce the intraoperative surgical stress response and has possible advantages for cardiovascular, respiratory, coagulation, gastrointestinal, metabolic and immune function. 25 39 However, thoracic epidurals can cause hypotension, neurological injury, 15 and are contra-indicated in the presence of coagulopathy or local sepsis.…”

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confidence: 99%

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

Davies

Myles

Graham

2006

British Journal of Anaesthesia

712

356

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Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI. We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4-8, 24 or 48 h, WMD 0.37 (95% CI: -0.5, 121), 0.05 (-0.6, 0.7), -0.04 (-0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery.

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“…Sometimes, however, the extent of surgery is unclear until histopathology results are obtained during surgery or a thoracoscopic procedure is complicated by bleeding or inadequate surgical exposure, and so an open thoracotomy is performed. In addition, epidural block is contraindicated in patients with coagulopathy or local sepsis, 4 and some patients refuse neuraxial block because of concern regarding spinal cord injury and permanent paraplegia.…”

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confidence: 99%