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The study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection paravertebral block (PVB) after thoracoscopic surgery.Randomized, controlled, double- blinded study.Operating room, postoperative recovery room and ward.Seventy-five patients, aged 18-75 years, ASA I-II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.Patients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.Cumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.There was a significant difference in median [interquartile range, IQR] morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 [9-15] mg; ICNB, 18 [13.5-22.1] mg; ESPB, 22 [15-25.1] mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, -7.5; 95% confidence interval [CI], -12 to -4.5; p = 0.000) and PVB group vs ICNB group (median difference, -6; 95% CI, -9 to -3; p = 0.001), but not for ICNB vs ESPB (median difference, -3; 95% CI, -6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p 0.05).Ultrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery.

Study objective Erector spinae plane (ESP) block is a novel regional anesthesia technique and gaining importance for postoperative pain management. Since it was first described, the clinicians wonder if this new simple technique can replace paravertebral block (PVB). We aimed to compare the postoperative analgesic effect of ESP block and PVB with a control group in breast surgeries. Design Randomized controlled trial. Setting Operating room. Patients Seventy-five ASA I–II patients aged 25–65, who were scheduled to go under elective unilateral breast surgery for breast cancer were included to the study. Interventions Patients were randomized into three groups as ESP, PVB, and Control group. Ultrasound (US) guided ESP block and PVB with 20 ml 0.25% bupivacaine was done preoperatively to the patients according to their groups. Measurements All patients were provided with iv patient-controlled analgesia device for postoperative analgesia. Morphine consumptions and numeric rating scale (NRS) scores for pain were recorded at 1st, 6th, 12th and 24th hours postoperatively. Main results There was a statistically significant difference between ESP and Control groups (p 0,05) for 24-hour morphine consumptions. There was a significant difference between PVB and Control groups for NRS at postoperative 1st and 6th hour (p = 0.018 and p = 0.027 respectively). Conclusions This study has shown that US guided ESP block and PVB provided adequate analgesia in patients undergoing breast surgery and have an opioid sparing effect by reducing morphine consumption. Clinical Trials Registry: NCT03480958 .

This study was undertaken to compare the analgesic efficacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries.Randomised, interventional, blinded clinical trial.Operating rooms of All India Institute of Medical Sciences, New Delhi, India.50 children aged 2-10 years, of ASA status I/II, posted for elective renal surgeries.The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline.Time to first rescue analgesia, time to perform blocks, intraoperative and post-operative hemodynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded.Children in Group P had significantly longer duration of analgesia (p 0.0004) than Group C. Post-operative FLACC scores (p 0.005) and analgesic requirements (p 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μg/kg, compared to 1.8 ± 1.2 μg/kg in group C. Parents in Group P reported greater satisfaction (p 0.02). No complications were seen in either of the groups.This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice.

Study objective The purpose of this study was to compare the efficacy of bilateral ultrasound guided thoracic paravertebral catheters to a thoracic epidural after open pancreatic surgery. Design This was a prospective non-blinded randomized controlled trial. Setting Academic hospital operating room, postoperative recovery area, and ward. Patients 53 patients aged 18 and above who had open pancreatic surgery. Interventions Patients received either bilateral thoracic paravertebral block at T8 with an infusion of 0.2% ropivacaine or thoracic epidural analgesia at T7/8 with an infusion of 0.125% bupivacaine with hydromorphone 6 μg/mL. Measurements Pain scores, opioid use, length of recovery room and hospital stay, adverse events, and incidence of nausea and vomiting. Main results There was no difference in baseline demographics between the two groups. There were no significant differences in pain scores between the two groups in each of the first five days after surgery. There was no difference in length of stay nor nausea and vomiting. There was significantly less modality related adverse events in the paravertebral group compared to the epidural group (p = 0.02). Conclusions The use of thoracic paravertebral catheters provided comparable analgesia and less modality related adverse events when compared to a thoracic epidural in patients undergoing open pancreaticoduodenectomy.

Study objective Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery. Design Systematic review and network meta-analysis. Setting Operating room, postoperative recovery room and ward. Patients Patients scheduled for breast surgery under general anesthesia. Interventions Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced. Measurements Co-primary outcomes were the pain at rest at 0–2 h and 8–12 h. Secondary outcomes were those related to analgesia, side effects and functional status. Main results In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0–2 and 8–12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8–12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques. Conclusions In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Study objective To investigate the effective analgesia for video-assisted thoracic surgery. Design In this prospective non-inferiority study, we evaluated the postoperative analgesic effect of preoperative ultrasound-guided Erector Spinae Plane blocks (ESPB) on T4 and T6 levels in patients undergoing video-assisted thoracic surgery in comparison with paravertebral block (PVB) at the same intervertebral spaces. Setting A university hospital. Patients 66 patients scheduled to undergo video-assisted thoracic surgery under general anesthesia were included. Interventions Patients were randomly allocated to receive ultrasound-guided ESP blocks on T4 and T6 levels (Group ESPB, n = 33) or PVB (Group PVB, n = 33) with 30 mL 0.4% ropivacaine 30 min before anesthesia induction. A continuous flurbiprofen (8 mg/h) was infused postoperatively through a single-use infusion device and intravenous oxycodone supplied as analgesic rescue if needed, with bolus of oxycodone (1 mg) and lockout time being 10 min. Measurements The primary outcome was the postoperative oxycodone consumption at 48 h. Main results Intraoperative use of sufentanil and remifentanil were comparable between these two groups. Pain scores, oxycodone rescue and Quality of Recovery (QoR) 15 on postoperative day 1 and 2 were equivalent between these two groups. Postoperative oxycodone consumption was 7.9 ± 8.7 boluses in ESPB group and 6.9 ± 6.3 boluses in PVB group at 48 h. The cumulative 48 h difference i.e. Oxycodone boluseswith ESPB minus Oxycodone boluseswith PVB was 2 (95% CI -1, 5.6). The lower limit of the 95% CI for this difference was −1, which was within the predefined non-inferiority margin of −10 (Δ). Conclusions Ultrasound-guided ESPB applied before video assisted thoracic surgery was non-inferior in analgesic effect compared with PVB in terms of pain score, analgesic rescue consumption and quality of recovery. Brief summary statement Preoperative Erector spinae plane blocks (ESPB), when in combination with round-the-clock NSAIDs, offered equivalent analgesia and quality of recovery after video assisted thoracic lung surgery compared with paravertebral blocks. Patients who received ESP blocks had similar consumption of oxycodone and length of hospital stay.

The aim of this study was to evaluate the analgesic efficacy and safety of pectoralis-serratus interfascial plane block in comparison with thoracic paravertebral block for postmastectomy pain.A prospective randomized controlled study.Tertiary center, university hospital.Sixty-four adult women, American Society of Anesthesiologists physical status classes I, II, and III, scheduled for unilateral modified radical mastectomy with axillary evacuation.Patients were randomized to receive either pectoralis-serratus interfascial plane block, PS group (n=32), or thoracic paravertebral block, PV group (n=32).Twenty-four-hour morphine consumption and the time to rescue analgesic were recorded. The pain intensity evaluated by visual analog scale (VAS) score at 0, 2, 4, 8, 16, and 24hours postoperatively was also recorded.The median (interquartile range) postoperative 24-hour morphine consumption was significantly increased in PS group in comparison to PV group (PS vs PV), 20 mg (16-23 mg) vs 12 mg (10-14 mg) (P.001). The median postoperative time to first analgesic request was significantly shorter in PS group compared to PV group (PS, 6 hours [5-7 hours], vs PV, 11 hours [9-13 hours]) (P.001). The intensity of pain was low in both groups in VAS 0, 2, and 4hours postoperatively. However, there was significant reduction in VAS in PV group compared to PS group at 8, 16, and 24hours postoperatively.Pectoralis-serratus interfascial plane block was safe and easy to perform and decreased intensity of postmastectomy pain, but it was inferior to thoracic paravertebral block.

Study objective The erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB). Design We systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology. Results 14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I2 = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I2 = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p Conclusions ESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.

Study objective Due to conflicting results published in the literature regarding the analgesic superiority between the paravertebral block and the PECS block, the study objective is to determine which one should be the first line analgesic treatment after radical mastectomy. Design Systematic review, meta-analysis and trial sequential analysis. Setting Operating room, postoperative recovery area and ward, up to 24 postoperative hours. Patients Patients scheduled for radical mastectomy under general anaesthesia. Interventions We searched five electronic databases for randomized controlled trials comparing any PECS block with a paravertebral block. Measurements The primary outcome was rest pain score (0−10) at 2 postoperative hours, analyzed according to the combination with axillary dissection or not, to account for heterogeneity. Secondary outcomes included rest pain scores, cumulative intravenous morphine equivalents consumption and rate of postoperative nausea and vomiting at 24 postoperative hours. Main results Eight trials including 388 patients were identified. Rest pain scores at 2 postoperative hours were decreased in the PECS block group, with a mean difference (95%CI) of −0.4 (−0.7 to −0.1), I2 = 68%, p = 0.01, and a significant subgroup difference observed between radical mastectomy with (mean difference [95%CI]: 0.0 [−0.2 to 0.2], I2 = 0%, p = 1.00), or without axillary dissection (mean difference [95%CI]: −0.7 [−1.1 to −0.4], I2 = 40%, p Conclusions There is low quality evidence that a PECS block provides marginal postoperative analgesic benefit after radical mastectomy at 2 postoperative hours only, when compared with a paravertebral block, and not beyond. Clinical trial number: PROSPERO – registration number: CRD42019131555.

To determine the efficacy of ultrasound-guided thoracic paravertebral block intraoperatively and 24 hours postoperatively in patients undergoing donor nephrectomy.Prospective randomized controlled study.Private foundation university hospital; November 2014 to June 2015.Thirty-two patients undergoing donor nephrectomy (exclusion criteria: coagulation disorders, allergy to local anesthetics, and unwillingness to participate). The final study population comprised 30 patients (15 male, 15 female) randomly assigned to either Group P (paravertebral block, n=14) or Group M (morphine, n=16).In Group P, a unilateral paravertebral catheter was inserted 1 day preoperatively; on the day of surgery, a single-level unilateral paravertebral block was administered through the catheter before general anesthesia. Infusion of bupivacaine continued intraoperatively and postoperatively. Patients in Group M received only general anesthesia, and morphine patient-controlled analgesia was begun postoperatively.Intraoperative analgesic and anesthetic requirement, postoperative numerical rating scale pain scores, additional analgesic consumption during the postoperative period, and incidence of complications related to thoracic paravertebral block (TPVB) like pleural puncture, pneumothorax, epidural spread, injection into the subarachnoid space, intravascular injection, and Horner's syndrome and rate of opioid related adverse reactions like nausea and vomiting, itching, constipation, and respiratory depression.Intraoperative remifentanil consumption was significantly higher in Group M, and postoperative morphine consumption was significantly lower in Group P (P.001). During the first 24 hours postoperatively, the mean numerical rating scale pain scores were similar and there were no significant differences between the 2 groups. There were no statistically significant differences in the additional analgesic consumption and rate of adverse reactions between the 2 groups. We didn't detect any complication related to TPVB in group P.Continuous thoracic paravertebral block provides good intraoperative stability with a low anesthetic requirement and reduces postoperative morphine consumption for up to 24 hours. Ultrasound guided technique enhanced the safety of TPVB and provides analgesia without major complications.

A case of a 10 year old boy who underwent a T10 continuous thoracic paravertebral block (TPVB) using a standard technique for postoperative pain management is reported. In the postoperative recovery area, 10 mL of Omnipaque contrast dye was injected through the catheter and an anteroposterior chest radiograph was performed. The radiograph showed longitudinal spread of contrast parallel to the spine from the T 4 -T 5 intervertebral disc to the T 10 -T 11 intervertebral disc with clear lateral extension of contrast along the fifth through the tenth intercostal nerves.

Thoracic paravertebral block (TPVB) for breast surgery reduces acute and chronic postoperative pain. Using ultrasound for administering the block makes it easier, with its administration at multiple levels decreasing the number of unblocked segments. We conducted this study to evaluate the efficacy and safety of single- vs double-level ultrasound-guided TPVB in patients undergoing total mastectomy with axillary clearance under general anesthesia.This is a prospective, randomized study.Recovery room and operation theater.Sixty ASA I and II patients, aged 18 to 60 years, who were scheduled to undergo total mastectomy with axillary clearance under general anesthesia were enrolled in the study.Patients received either single- (group S) or double-level (group D) ultrasound-guided TPVB at T4 or at T2 and T5 levels, respectively, using 0.3 mL/kg of 0.5% ropivacaine.Primary outcome measure was 24-hour analgesic consumption, and secondary outcomes included number of segments blocked, postoperative pain scores, time to first request for rescue analgesic, and any side effects.The mean total amount of rescue analgesic given in group S was 175.3 ± 70 mg and in group D was 115.7 ± 48 mg (P = .002). Median number of segments showing less sensation to pinprick was 3 in group S and 4 in group D (P.001). The mean time to first request for rescue analgesic was 533 ± 124 minutes in group S and was 611 ± 214 minutes in group D (P = .118).Patients receiving double-level TPVB had significantly less 24-hour analgesic consumption in the postoperative period than those in the single-level TPVB group. This could be due to decreased pain sensation to pinprick in significantly greater number of segments in the double-level TPVB group.

The study objective is to describe our experience with placement and management of thoracic paravertebral block catheters in 2 neonates. The design is retrospective chart review of 2 consecutive newborns undergoing repair of tracheoesophageal fistula. Ultrasound-guided oblique intercostal approach for catheter placement and infusions of dilute ropivicaine for 4-5 days. The measurements are postoperative narcotics and sedatives administered. The main results are neither infant required continuous infusions of sedatives or narcotics. Thoracic paravertebral block catheter infusions for neonatal thoracotomy and chest tube placement may eliminate the need for continuous narcotic infusions and may avoid the need for narcotic and benzodiazepine taper or weaning.

Thoracic bilateral paravertebral block is a technique commonly used in the ambulatory setting for numerous plastic surgery procedures. Paravertebral block has not been reported with abdominoplasty surgery. This case series explores this anesthetic technique in the inpatient and day patient setting.

We describe the successful anesthetic management of a patient with stiff-person syndrome (SPS) undergoing a right inguinal hernia repair, using a somatic paravertebral block supplemented with conscious sedation. We also present the implications of general anesthesia in patients with SPS. The use of regional anesthetic techniques in patients with SPS has the advantage of avoiding exposure to muscle relaxants. The use of general anesthesia in patients with SPS carries the risk of postoperative hypotonia due to enhancement of gamma-aminobutyric acid action on synaptic transmission by drugs that have a gamma-aminobutyric acid agonistic action.

Study Objective To present our preliminary experience using a thoracic paravertebral block (TPVB) as the sole anesthetic in percutaneous hepatic radiofrequency ablation (RFA). Design Retrospective case series of 12 ASA physical status 1, 2, and 3 patients of average risk scheduled for RFA. Setting University medical center. Measurements The first 12 procedures performed using TPVB were analyzed to evaluate the efficacy and safety of this anesthetic technique. Data collected included patients' characteristics, procedure, pain referred during paravertebral punctures, and RFA (verbal numerical scale; VNS). Anesthesia and medical records also were reviewed for any major complications that occurred during or after the RFA. Main Results Ten of the 12 patients presented for hepatocellular carcinoma; the other two patients had melanoma metastasis. Nine patients were ASA physical status 1 or 2; the other three patients were ASA physical status 3. Nine had liver cirrhosis. All patients had normal coagulation profiles. The TPVBs were performed in a median time of 6.5 (4–15) minutes. Onset of sensory loss to pinprick test occurred approximately 15 to 20 minutes after the injections. No evidence of bilateral blockade was seen in any patient. In most cases, the extent of anesthesia ranged from T6 to T11 or T12. In one patient (no. 2), the stimulating needle elicited no sensory or motor response at the T7 level; the local anesthetic was then injected one cm beyond the transverse process. All patients were very pleased with their anesthetic care; all were discharged from the hospital with no procedure-related complications. Conclusion The use of thoracic paravertebral block as the sole anesthetic for RFA of liver produced satisfactory unilateral anesthesia and minor adverse events.

A case of systemic ropivacaine toxicity from a continuous thoracic paravertebral block in an adult patient who received a lobectomy is presented. The catheter was placed by the surgeon. Eleven hours after the start of the infusion, the patient experienced an arrhythmia leading to death. The total venous plasma concentration of ropivacaine was high (3.2 μg/mL). Furthermore, the patient had severe hypoalbuminemia (albumin 24 g/L), which resulted in the increase of the unbound ropivacaine plasma concentration that was responsible for the toxic side effects.

A case of temporary quadriplegia following a continuous thoracic paravertebral block in an adult patient scheduled for video-assisted thoracoscopy is presented. An 18-gauge Tuohy needle was inserted under direct vision by the surgeon but the tip of the catheter was not localized. Postoperatively, the patient developed temporary quadriplegia 90 minutes after the start of a continuous infusion of ropivacaine 0.2%. Imaging studies showed that the catheter was localized in the intrathecal space.

Two patients are presented who underwent successful combined L1 and L2 paravertebral blocks as part of an anesthetic technique for hip arthroscopy.

Implantable cardioverter defibrillators (ICDs) are routinely placed in the cardiac electrophysiology laboratory. Previously, these procedures were performed in the operating room during general anesthesia. In recent years, electrophysiologists have been performing these procedures using local anesthetics in conjunction with intravenous sedation. We report a case in which thoracic paravertebral blocks with mild sedation were successful for infected ICD and laser lead extraction. Randomized, controlled trials are required to determine whether thoracic paravertebral block with sedation is more effective than local anesthesia with sedation in providing adequate anesthesia for ICD placement and extraction.

Paravertebral nerve block has been used for a variety of surgical procedures to provide unilateral anesthesia and postoperative analgesia. We report the successful application of this regional anesthesia modality for outpatient lithotripsy. Preoperatively, thoracic and lumbar paravertebral nerve blocks with 0.5% ropivacaine were placed with ultrasound and nerve stimulator guidance for two patients with ureteral calculi. One patient scheduled for cystoscopy and ureteroscopy with laser lithotripsy received general anesthesia intraoperatively. The second patient underwent extracorporeal shock wave lithotripsy with propofol intravenous sedation. Postoperatively, both patients reported pain scores of zero (Visual Analog Scale) for 24 hours and required no opioid rescue analgesia.

The thoracic paravertebral block is effective in providing anesthesia and postoperative analgesia for thoracic and abdominal surgeries. This case report describes a suspected post-dural puncture headache following bilateral thoracic paravertebral blocks for postoperative analgesia after an umbilical hernia repair.