|Year : 2015 | Volume
| Issue : 3 | Page : 413-419
Paravertebral block against intercostal nerve block for postoperative pain relief in open renal surgery: a randomized controlled trial
Hazem El Sayed Moawad1, Diaa-Eldin Taha2
1 Department of Anesthesiology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
2 Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
|Date of Submission||20-Dec-2014|
|Date of Acceptance||26-Apr-2015|
|Date of Web Publication||29-Jul-2015|
Hazem El Sayed Moawad
Department of Anesthesiology, Mansoura University Hospital, Mansoura, 35514
Source of Support: None, Conflict of Interest: None
Renal surgeries are usually associated with significant postoperative pain. Ineffective postoperative pain management may result in clinical and psychological changes that increase morbidity and mortality. In the current study, intercostal nerve block (ICB) and paravertebral block (PVB) were compared with regard to their analgesic efficacy, hemodynamic stability, blood gasometric profile, and postoperative complication.
Patients and methods
After local Ethics Committee approval, 100 patients, aged between 20 and 60 years, American Society of Anesthesiologists (ASA) physical status I or II, scheduled for elective open renal surgery were enrolled in this study. Patients were randomized into two groups to receive either ICB (ICB group) with bupivacaine (0.5%; n = 50) or PVB (PVB group) with bupivacaine (0.5%; n = 50). The postoperative visual analogue scale score for pain, patients' satisfaction score, and the need for analgesia were evaluated.
The mean postoperative visual analogue scale scores demonstrated significant decrease in the PVB group compared with the ICB group during quite and motion states (P < 0.05). Patient satisfaction was greater in the PVB group than in the ICB group (P < 0.0001). The mean time elapsed before the first request for analgesia in the PVB group was 17.37 2.70 h, whereas patients in the ICB group started to request for analgesia after 8.96 1.88 h (P < 0.0001). The total analgesic consumption (meperidine) at 24 h postoperatively showed a significant decrease in the PVB group compared with the ICB group (P < 0.05).
PVB and ICB are safe analgesic techniques, and they decrease the postoperative pain score and analgesic requirements after open renal surgery. PVB provides more patient satisfaction and a longer duration of analgesia postoperatively.
Keywords: intercostal block, paravertebral block, renal surgery
|How to cite this article:|
Moawad HE, Taha DE. Paravertebral block against intercostal nerve block for postoperative pain relief in open renal surgery: a randomized controlled trial
. Ain-Shams J Anaesthesiol 2015;8:413-9
|How to cite this URL:|
Moawad HE, Taha DE. Paravertebral block against intercostal nerve block for postoperative pain relief in open renal surgery: a randomized controlled trial
. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Oct 22];8:413-9. Available from: http://www.asja.eg.net/text.asp?2015/8/3/413/159008
| Introduction|| |
Renal surgeries are usually associated with significant postoperative pain. Ineffective postoperative pain management may induce deep-vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, and insomnia. Therefore, postoperative analgesia after renal surgeries is essential to reduce the incidence of postoperative complications  . Patients undergoing renal surgeries may suffer from impaired renal function; which dictates judicious use of systematic analgesics in these patients. Therefore, regional nerve blocks can be a good alternative or be used as a useful adjunctive in such patients  . Paravertebral block (PVB) and intercostal nerve block (ICB) techniques can provide anesthesia and analgesia in thoracic and abdominal surgeries. When performed correctly, both can provide good results and may be considered as appropriate alternatives to the standard methods of providing analgesia (e.g. epidural analgesia, intravenous opioids). The advantage of these techniques over epidural analgesia is related to the unilateral nature of these blocks and a less extensive sympathetic block, and therefore an attendant decrease in overall complications (e.g. lack of hypotension)  .
ICB is a simple technique, it is easy to perform, and reduces the analgesic requirements and the inpatient stay in a variety of surgeries, such as thoracic, upper gastrointestinal, and breast surgeries  . However, its analgesic effect does not last long enough, and it is generally necessary to be repeated, with an increased risk of pneumothorax  .
PVB produces ipsilateral analgesia, and has been advocated mainly in unilateral surgeries such as thoracotomy, chest wall surgery, breast surgery, and renal surgery  . The effect of pre-emptive single-injection PVB in comparison with preemptive single-injection ICB in open renal surgery in adult patients has not been undertaken previously. Therefore, in the current study, the ICB and the PVB groups were compared with regard to their hemodynamics, blood gasometric profile, analgesic effect, need for postoperative analgesia, and postoperative complications.
| Patients and methods|| |
After the local Ethics Committee approval, a written informed consent was obtained from all patients participating in this randomized trial. Between June 2012 and April 2014, 100 patients aged 20-60 years, with an American Society of Anesthesiologists (ASA) physical status I or II, scheduled for elective open renal surgery in the Urology and Nephrology Center, Mansoura University, were enrolled in this study.
Exclusion criteria included patients with a history of hepatic insufficiency, patients under chronic treatment with opioids, patients with hypersensitivity to bupivacaine or meperidine, or patients with contraindication to regional anesthesia, such as infection at the puncture site, anatomical deformities, or coagulation disorders.
The patients were randomized into two groups (using sealed envelopes and computer-generated random tables) of 50 patients each, to receive either ICB (ICB group) with bupivacaine 0.5% or PVB (PVB group) with bupivacaine 0.5%.
All patients were thoroughly assessed preoperatively by history taking, physical examination, and laboratory evaluation. One day before the surgery, the study protocol of the ICB and the PVB procedures was explained to each patient. All patients were instructed on the use of the 10-cm visual analogue scale (VAS) for pain assessment. All patients were premedicated with 10 mg diazepam administrated orally at the night of the surgery.
On arrival of the patients to the operative theater, and after application of the standard monitoring including ECG, noninvasive blood pressure, and pulse oximetry, a peripheral intravenous cannula (18 G) was inserted. All patients were sedated by intravenous midazolam 1-3 mg. Lactated Ringer's solution was infused. Arterial blood gases were taken preoperatively (basal reading).
In the ICB group, under complete aseptic precaution, unilateral percutaneous intercostal nerve blockade was performed with the patients in the lateral decubitus position. Patients were given unilateral ICB 6 to 8 cm paravertebrally at the levels of the T7-T11 thoracic vertebrae using the ICB technique as described by Moore  . A mixture of isobaric bupivacaine 0.5% and epinephrine 1/200 000 was used, and 3 ml was injected at each intercostal nerve for a total of 15 ml. The block was performed by the anesthesiologist and was considered as pre-emptive analgesia.
In the PVB group, under complete aseptic precaution, PVB was performed while the patient was in the sitting position at the level of the T10 thoracic vertebra by the loss-of-resistance technique (with saline) using an 18-G Tuohy needle (Perifix; B. Braun Melsungen AG, Destruir, Germany) according to the Eason and Wyatt technique  . After skin wheal of lidocaine local anesthetic 2%, the needle was inserted perpendicularly, aiming for contact with the transverse process of the T10 thoracic vertebra, then sliding the needle caudally for 1-1.5 cm into the paravertebral space. Then, 15 ml of isobaric bupivacaine 0.5% was injected as a single bolus dose into the paravertebral space. The sensory level was tested with pin prick and ice pack before the induction of general anesthesia (GA) in both groups.
After preoxygenation, GA was induced in all patients with fentanyl 1-2 μg/kg, propofol 1-2 mg/kg, and rocuronium bromide (0.6-0.9 mg/kg), followed by intubation with an adequate endotracheal tube. Anesthesia was maintained with isoflurane (1-2%) in an oxygen and air mixture. Controlled ventilation was achieved by a Drager model (Febius; S. No: URMN-0005; Labeck, Germany) ventilator to maintain an end tidal carbon dioxide tension (EtCO 2 ) around 35 mmHg. The heart rate, noninvasive mean arterial blood pressure, and oxygen saturation (by pulse oximetry) were monitored throughout the surgery at 5-min intervals by a Drager (S. No: 5493308560) monitor. Neuromuscular block was antagonized in both groups with neostigmine 0.04 mg/kg and atropine 0.02 mg/kg at the end of the surgery.
On arrival to the recovery room, all patients received oxygen 5 l/min during the first hour. Postoperative pain was assessed in both groups over 24 h using a linear VAS for pain assessment. The scale consists of 10-cm horizontal lines ranging from 0 (no pain) to 10 (worst imaginable pain). Patients were asked to mark the line vertically at a point that matched their pain  . The pain intensity was rated as mild (VAS: 0-3), moderate (VAS: 4-6), and severe (VAS: 7-10). The VAS score was recorded at the early postoperative time, and then at 1, 4, 8, 12, 18, and 24 h postoperatively. The pain score was assessed during a quiet breathing period (quite VAS) and after voluntary cough (dynamic VAS). When the patients experienced pain (VAS ≥ 4), meperidine 50 mg was given intravenously. The time to the first request for analgesia requirement (the postoperative time/h from emergence until the patient starts to ask for analgesia) and the total amount of meperidine administered to each patient were recorded. At the times of pain evaluation, the heart rate, the mean arterial blood pressure, and arterial blood gases were recorded. Any postoperative adverse events such as nausea, vomiting, shivering, hypotension, bradycardia, or respiratory complications (desaturation: SpO 2 <90%; bradypnea: respiratory rate<9 breaths/min, etc.) were recorded. At the end of the study period, the satisfaction VAS system was used to evaluate patients' satisfaction in a manner similar to that used to measure pain  . The overall patient satisfaction was assessed using a 10-point VAS with 0 representing extremely unsatisfied and 10 representing extremely satisfied  . Complications related to PVB or ICB techniques such as pneumothorax were also recorded. A chest radiography was requested in both groups for any patient who had difficulty in breathing, desaturation, or diminished air entry during the study period.
Data were analyzed using SPSS (Statistical Package for Social Sciences) version 15 (IBM, Chicago). Qualitative data were presented as number and percent. Comparison between groups was performed by the χ2 -test. Quantitative data were presented as mean ± SD. The Student t-test was used to compare two groups. P-value less than 0.05 was considered to be statistically significant. The sample size was calculated using an online statistical calculator (G Power version 3). A minimal sample size of 80 patients was needed to achieve a power level of 0.8, α level of 0.05, and an anticipated effect size (f2 ) of 0.15. To compensate for potential exclusion, 50 patients were recruited in each group.
| Results|| |
A total of 100 patients undergoing open renal surgery were enrolled in this study, and one patient in the PVB group was excluded due to a failed block. There were no significant differences between both groups with respect to their demographic data, duration, and types of surgery [Table 1].
|Table 1: Patients' characteristics, duration of surgery (min), and types of renal surgery|
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There was no statistically significant difference in heart rate and mean arterial blood pressure in both groups throughout the study period [Table 2]. In contrast, no statistically significant differences were found concerning the arterial oxygen tension (PaO 2 ), arterial carbon dioxide tension (PaCO 2 ), and pH on comparing the two studied groups at different time points [Table 3].
During the study period, mean postoperative VAS scores demonstrated a significant difference between both groups postoperatively during quite and dynamic states (P < 0.05) [Figure 1] and [Figure 2]. The mean time elapsed before the first request for analgesia in the PVB group was 17.37 ± 2.70 h, whereas patients in the ICB group started to request for analgesia after 8.96 ± 1.88 h (P < 0.0001) [Table 4].
|Figure 1: The quite VAS score (0– 10) in the studied groups. Data are presented as median and interquartile range. ICB, intercostal nerve block; PO, postoperative; PVB, paravertebral block; VAS, visual analogue scale. *Significant compared with the PVB g roup.|
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|Figure 2: The dynamic VAS score (0– 10) in the studied groups. Data are presented as median and interquartile range. ICB, intercostal nerve block; PO, postoperative; PVB, paravertebral block; VAS, visual analogue scale. *Significant in comparison with the PVB g roup.|
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The total analgesia consumption (meperidine) at 24 h postoperatively was significantly less in the PVB group compared with the ICB group (P < 0.05) [Table 4]. There was no significant difference in the incidence of postoperative complications between the studied groups [Table 4]. In the current study, we did not confront any other intraoperative complications such as pneumothorax or intrathecal spread of the local anesthetic. Patient satisfaction was greater in patients in the PVB group compared with patients in the ICB group (7.73 ± 0.97 vs. 6.30 ± 0.91; P < 0.0001) [Figure 3].
|Figure 3: Patient satisfaction scores in the studied groups. Data are presented as median and interquartile range. ICB, intercostal nerve block; PVB, paravertebral block. *Significant in comparison with the ICB group.|
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|Table 4: The first request for analgesia (h), total consumption of postoperative analgesia (mg/day), and postoperative complications in the studied groups|
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| Discussion|| |
The present study was designed to evaluate the usefulness of preoperative ICB in comparison with preoperative PVB to alleviate pain after open renal surgery through flank incision. We found that pain scores and analgesia requirements were significantly reduced in patients in the PVB group during the first 24 h postoperatively in comparison with patients of the ICB group (P < 0.05).
Our results support the findings of previous studies that showed that PVB decreased the postoperative pain and analgesia requirements after renal surgery using flank incision  . Several methods can be used for pain relief after open renal surgery. The systemic use of narcotics or anti-inflammatory drugs administered either alone or in combination do not often result in satisfactory pain relief  . Regional analgesia for pain management has been reported extensively for pain control after thoracotomy. However, regional analgesia in open renal surgery has not received similar interest in the literature  . A single-shot PVB technique using bupivacaine can provide analgesia for up to 18 h  . Pneumothorax, local anesthetic toxicity, the spread of the injection to the epidural space causing hypotension and bilateral block are some of the complications associated with PVB  . Some studies have shown that pre-emptive PVB analgesia provide better pain control rather than at the end of the surgical procedure  .
Ozbek et al.  reported that pre-emptive PVB plus morphine patient controlled analgesia (PCA) compared with only morphine PCA provides superior analgesia with reduction of postoperative opioid consumption after lumbar laminectomy.
Compared with continuous epidural analgesia, postoperative PVB for open nephrectomy results in lowering of the morphine dose and side effects related to the use of morphine  . Single-injection PVB resulted in similar analgesia, but greater hemodynamic stability than epidural analgesia in patients undergoing open renal surgery  .
Langille et al.  reported that intraoperative PVB is feasible and provides safe and effective postoperative analgesia for open renal and adrenal surgery using the flank approach.
Vogt et al.  studied the effect of single-injection PVB for postoperative pain treatment after thoracoscopic surgery. They found low pain scores at rest and on coughing. In another study, PVB was reported to provide postoperative analgesia equal to or may be even superior to conventional lumbar epidural analgesia in pediatric patients undergoing renal surgery  .
Ouerghi and colleagues found that continuous ICB and PVB were effective and safe methods for post-thoracotomy pain management. They believe that both methods might be a valuable alternatives to thoracic epidural analgesia for unilateral surgical procedures. They suggest that continuous ICB should be considered when PVB is contraindicated or seems to be technically difficult  . In a meta-analysis based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and the lumbar vertebrae are associated with less pain during the immediate postoperative period as well as with less postoperative nausea and vomiting and greater patient satisfaction compared with GA. Patient satisfaction with PVB was high, and patients who received PVB were more satisfied with their anesthetic management than patients who received GA or field block. These findings support our study results  . Similarly, Naja et al.  reported that VAS pain scores both at rest and during activity were significantly lower in the PVB group compared with the GA group after breast surgery (P = 0.01).
There are a limited number of publications in relation to the use of ICB in urological surgery and postoperative pain relief  . Lekhak et al.  demonstrated that ICB is generally safe and simple to perform and may represent an advantage over the use of PVBs or the use of a paravertebral catheter, which are inserted much more medially than the intercostal blocks used here, and may result in subarachnoid injection. Although the value of a single ICB has been questioned  , the study conducted by Perttunen et al.  found that analgesia after a single ICB with bupivacaine could last up to 20 h, but required intravenous morphine as a supplement. In another study to evaluate ICB analgesia after renal transplantation, the patients had reduced pain and used less morphine only in the first 4 h postoperatively  . In the current study, the analgesia in the ICB group lasted for about 8 h, and then the patients started to ask for analgesia.
A review of randomized studies evaluating the analgesic efficacy of ICB in thoracotomy found that it was effective as epidural analgesia and superior to oral analgesia alone, but continuous infusion with a catheter was required to obtain the best results  . Viney and colleagues demonstrated that patients undergoing percutaneous nephrolithotomy (PCNL) derive benefit from ICB administered in the immediate postoperative period. They experience significantly enhanced postoperative analgesia in the first 12 h after surgery and significantly quicker mobilization with shorter hospital stays. Fewer analgesics were required postoperatively with no complications experienced secondary to the ICB technique  .
Taylor and colleagues reported that ICB with bupivacaine 0.375% provided good-quality analgesia for a median duration of 16 h with a significant reduction in morphine requirements in patients undergoing video-assisted thoracoscopy. They concluded that percutaneous ICB is a simple and safe technique to provide postoperative analgesia for these patients and may be beneficial in 'fast-track' thoracoscopic surgery  .
In this study, there was no statistically significant difference between the studied groups with regard to gasometric parameters. This result is in accordance with a previous study , . In the present study, there was no statistically significant difference between the studied groups with regard to reported postoperative complications. This result was supported by previous reports , . In agreement with other studies, patient satisfaction was greater in patients in the PVB group compared with patients in the ICB group. Patients who received PVB were more satisfied with their anesthetic management than patients who received ICB , .
This study has certain limitations including the fact that single-injection techniques are limited by the duration of the local anesthetic used. Also, the postoperative follow-up duration for analgesia was short; we recommend further studies including the administration of local anesthetics by continuous infusion and a long-time follow-up for at least 48 h postoperatively.
| Conclusion|| |
PVB and ICB are safe analgesic techniques, and they decrease pain and reduce the analgesia requirement in the early postoperative period in open renal surgery. PVB provides a more satisfactory analgesic effect that lasts for a longer duration.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Moawad HE, Mousa SA, El-Hefnawy AS. Single-dose paravertebral blockade versus epidural blockade for pain relief after open renal surgery: a prospective randomized study. Saudi J Anaesth 2013; 7: 61-67.
Sinha S, Mukherjee M, Chatterjee S, Vijay MK, Hazra A, Ray M. Comparative study of analgesic efficacy of ropivacaine with ropivacaine plus dexmedetomidine for paravertebral block in unilateral renal surgery. Anaesth Pain Intensive Care 2012; 16:38-42.
Hidalgo NRA, Ferrante FM. Complications of paravertebral, intercostal nerve blocks and interpleural analgesia. Finucane BT (ed.), Complications of regional anesthesia
. New York: Springer, Science+Business Media; 2007. 102-120.
Viney R, Garston H, Patel P, Devarajan R. Perioperative intercostal nerve blockade in percutaneous nephrolithotomy a comparative cohort study. Br J Med Surg Urol 2010; 3:106-110.
Rawal N, Sjostrand UH, Dahlstrom B, Nydahl PA, Ostelius J. Epidural morphine for postoperative pain relief: a comparative study with intramuscular narcotic and intercostal nerve block. Anesth Analg 1982; 61:93-98.
Moore DC. Intercostal nerve block for postoperative somatic pain following surgery of thorax and upper abdomen. Br J Anaesth 1975; 47:Suppl:284-286.
Eason MJ, Wyatt R. Paravertebral thoracic block - a reappraisal. Anaesthesia 1979; 34:638-642.
Dolan P, Sutton M. Mapping visual analogue scale health state valuations onto standard gamble and time trade-off values. Soc Sci Med 1997; 44:1519-1530.
Fisher CG, Belanger L, Gofton EG, Umedaly HS, Noonan VK, Abramson C, et al
. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Spine (Phila Pa 1976) 2003; 28:739-743.
Awwad ZM, Atiyat BA. Pain relief using continuous bupivacaine infusion in the paravertebral space after loin incision. Saudi Med J 2004; 25:1369-1373.
Dahl JB, Kehlet H. Non-steroidal anti-inflammatory drugs: rational for use in severe postoperative pain. Br J Anaesth 1991; 66:703-712.
Bondár A, Szûcs S, Iohom G. Thoracic paravertebral blockade. Med Ultrason 2010; 12:223-227.
Ozbek TH, Gedik YE, Gunes Y, Yilmaz D, Isik G.The analgesic effect of preemptive lumbar paravertebral block in patients undergoing laminectomy. Neurosurg Q 2009; 19:160-163.
Naja MZ, Ziade MF, Lonnqvist PA Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol 2003; 20:897-903.
Zhang W, Wan Z, Zhou R, Xu K, Xiao P, Liang Z, et al.
Application of continuous thoracic paravertebral nerve block guided by nerve stimulator on postoperative pain relief for nephrectomy. Zhonghua Yi Xue Za Zhi 201494:1812-1814.
Langille GM, Launcelott GO, Rendon RA. Access to the extrapleural space at the time of surgery for continuous paravertebral block after flank incision: description of the technique and case series. Urology 2013; 81:675-678.
Vogt A, Stieger DS, Theurillat C, Curatolo M. Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery. Br J Anaesth 2005; 95:816-821.
Lönnqvist PA, Olsson GL. Paravertebral vs epidural block in children. Effects on postoperative morphine requirement after renal surgery. Acta Anaesthesiol Scand 1994; 38:346-349.
Ouerghi S, Frikha N, Mestiri T, Smati B, Mebazaa MS, Kilani T, Ben Ammar MS. A prospective, randomised comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain. SAJAA 2008; 14:19-23.
Thavaneswaran P, Rudkin GE, Cooter RD, Moyes DG, Perera CL, Maddern GJ. Brief reports: paravertebral block for anesthesia: a systematic review. Anesth Analg 2010; 110:1740-1744.
Knowles P, Hancox D, Letheren M, Eddleston J. An evaluation of intercostal nerve blockade for analgesia following renal transplantation. Eur J Anaesthesiol 1998; 15:457-461.
Lekhak B, Bartley C, Conacher ID, Nouraei SM. Total spinal anaesthesia in association with insertion of a paravertebral catheter. Br J Anaesth 2001; 86:280-282.
Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A review of current techniques. Anesthesiology 1994; 81:737-759.
Perttunen K, Nilsson E, Heinonen J, Hirvisalo EL, Salo JA, Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain. Br J Anaesth 1995; 75:541-547.
Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005; 80:1550-1559.
Taylor R, Massey S, Stuart-Smith K. Postoperative analgesia in video-assisted thoracoscopy: the role of intercostal blockade. J Cardiothorac Vasc Anesth 2004; 18:317-321.
Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, et al
. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86:598-612.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]