Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis

Abstract

A continuous paravertebral block is used when pain relief is required beyond the duration of a single-injection paravertebral block. Surgical procedures requiring an incision into the pleural cavity are some of the most painful procedures postoperatively and, if not managed appropriately, can lead to chronic pain. The current gold standard for post-cardiothoracic surgery pain management is epidural analgesia, which has contraindications, a failure rate of up to 12% and risk of complications such as epidural abscess and spinal haematoma. This systematic review and meta-analysis aimed to investigate the use of a continuous paravertebral block for post-cardiothoracic surgery analgesia. Randomized controlled trials evaluating the continuous paravertebral block against epidural analgesia, wound infiltration, placebo or standard care (intravenous opioids) for post-cardiothoracic surgery analgesia were considered for inclusion in the systematic review. PubMed, EMBASE, The Cochrane Library and the University of York Centre for Reviews and Dissemination databases were searched from inception to 15 September 2014. Risk of bias and generalizability were assessed using a modified Downs and Black checklist. A meta-analysis was conducted on suitable studies comparing the continuous paravertebral nerve block with epidural anaesthesia, with fixed-effects models being used to pool the effects. Twenty-three randomized controlled trials with 1120 participants were included. The continuous paravertebral block was associated with a significant improvement in incidence of nausea and vomiting (odds ratio = 0.29, 95% confidence interval = [0.16, 0.56]), hypotension (odds ratio = 0.16, 95% confidence interval = [0.06, 0.41]) and urinary retention (odds ratio = 0.22, 95% confidence interval = [0.09, 0.52]) compared with the epidural block. No statistically significant difference in pain relief was reported. The continuous paravertebral block has equivalent analgesic effects to epidural analgesia, wound infiltration and standard care, but is associated with a lower incidence of nausea and vomiting, hypotension and urinary retention than epidural analgesia.

The impact of ultrasound‐guided continuous serratus anterior plane block versus intravenous patient‐controlled analgesia on the incidence and severity of post‐thoracotomy pain syndrome: A randomized, controlled study

“…Continuous PVB may be a solid alternative to TEA with equal analgesic effects. However, PVB is still a neuroaxial technique that carries some neurological risks in addition to the risk of technical failure in 6%–12% of cases (Scarfe et al, ). The selected technique, thoracic interfacial SAPB, is an excellent alternative to other locoregional analgesic techniques, in the authors’ opinion.…”

Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study

“…A recent meta-analysis has shown that the paravertebral block has equivalent analgesic effects to epidural analgesia and is associated with a lower incidence of nausea, vomiting, hypotension, and urinary retention 15. However, the reported failure rate is 6–12%, and the risk of neurological damage should not be underestimated 16.…”

Combined analgesic treatment of epidural and paravertebral block after thoracic surgery

“…Recently, as an alternative analgesic method, PVB is reported to have good pain-control efficacy and fewer side effects. A number of studies that compare PVB with EPI for thoracotomy and meta-analysis studies reveal PVB provides comparable analgesia with EPI and has better side effect profile (6,(8)(9)(10). Generally, EPI is blindly administered into the epidural space, and results in bilateral anesthesia.…”

“…Recently, paravertebral block (PVB) has been reported as an alternative to EPI (4)(5)(6)(7). PVB has equivalent analgesic effects to EPI and have a lower incidence of side effects, such as nausea, vomiting, hypotension and urinary retention (8)(9)(10).…”