COMPARISON OF PARAVERTEBRAL NERVE BLOCK VERSUS THORACIC EPIDURAL BLOCK USING LEVOBUPIVACAINE 0.5%
WITH FENTANYL FOR PATIENTS UNDERGOING THORACOTOMY UNDER GENERAL ANAESTHESIA
Dissertation submitted to
THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY In partial fulfilment for the award of the degree of
DOCTOR OF MEDICINE IN
ANAESTHESIOLOGY
BRANCH X
REGISTRATION NO:201720020
INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE MADRAS MEDICAL COLLEGE CHENNAI- 600003
MAY – 2020
CERTIFICATE OF THE GUIDE
This is to certify that the dissertation titled COMPARISON OF PARAVERTEBRAL NERVE BLOCK VERSUS THORACIC EPIDURAL BLOCK USING LEVOBUPIVACAINE 0.5%
WITH FENTANYL FOR PATIENTS UNDERGOING THORACOTOMY UNDER GENERAL ANAESTHESIA is a bonafide research work done by Dr.G.S.VINOTH in partial fulfilment of the requirement for the degree of DOCTOR OF MEDICINE in Anaesthesiology.
Guide
PROF.DR.M.BHAVANI, M.D.,
Professor of Anaesthesiology,
Institute of Anaesthesiology and critical care, Madras Medical College
Chennai.
Date:
Place:
CERTIFICATE
This is to certify that the dissertation titled, COMPARISON OF PARAVERTEBRAL NERVE BLOCK VERSUS THORACIC EPIDURAL BLOCK USING LEVOBUPIVACAINE 0.5% WITH FENTANYL FOR PATIENTS UNDERGOING THORACOTOMY UNDER GENERAL ANAESTHESIA submitted by DR.G.S.VINOTH in partial fulfilment for the award of the degree of DOCTOR OF MEDICINE in Anaesthesiology by The Tamilnadu Dr.M.G.R medical university, Chennai is a bonafide record of work done by him in the INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE, Madras Medical College, during the academic year 2017 -2020 .
Prof.Dr.R.JAYANTHI M.D.,F.R.C.P.(Glasg) THE DEAN,
Madras medical college,
Rajiv Gandhi Govt general hospital, Chennai-600003
Prof.Dr.ANURADHA SWAMINATHAN M.D.,D.A.,
Professor and director,
Institute of anaesthesiology and critical care, Madras medical college,
Chennai-600003
DECLARATION
I hereby declare that the dissertation titled, COMPARISON OF PARAVERTEBRAL NERVE BLOCK VERSUS THORACIC EPIDURAL BLOCK USING LEVOBUPIVACAINE 0.5% WITH FENTANYL FOR PATIENTS UNDERGOING THORACOTOMY UNDER GENERAL ANAESTHESIA has been prepared by me under the guidance of PROF.DR.M.BHAVANI, M.D.,Professor of Anaesthesiology, INSTUTUTE OF ANAESTHESIOLOGY AND CRITICAL CARE, MADRAS MEDICAL COLLEGE, CHENNAI, in partial fulfilment of the regulations for the award of the degree of M.D (Anaesthesiology), examination to be held in May 2020. This study was conducted at INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE, MADRAS MEDICAL COLLEGE, CHENNAI.
I have not submitted this dissertation previously to any journal or any university for the award of any degree or diploma.
DR.G.S.VINOTH Date :
Place: Chennai
ACKNOWLEDGEMENT
I am extremely thankful to Dr. JAYANTHI M.D., FRCP.(Glasg), Dean, Madras Medical College, for her permission to carry out this study. I am immensely grateful to PROF. DR. ANURADHA SWAMINATHAN, M.D., D.A., Director and Professor, Institute of Anaesthesiology and Critical Care, for her concern and support in conducting this study.
I am extremely grateful and indebted to my guide
PROF.DR.M.BHAVANI, MD.,D.A., Professor of Anaesthesiology, Institute of anaesthesiology and critical care for her concern, inspiration, meticulous guidance, expert advice and constant encouragement in doing and preparing this dissertation.
It is my pleasure to thank Dr.V.SENTHILKUMAR M.D., Dr.SIVAKANTH M.D., Dr.DEEPTHI M.D., Dr.SUGANTHALAKSHMI M.D., for their support and encouragement.
I am thankful to the Head of the Department, cardiothoracic surgery for permitting me to conduct this study in patients.
I am thankful to Dr.Parthasarathy M.D., Community Medicine, for the help rendered by him.
I am thankful to the Institutional Ethical Committee for their guidance and approval for this study.
I am thankful to all my colleagues, family and friends for their help and advice in carrying out this dissertation.
Lastly I am greatly indebted and thankful to all the patients and their family members for willingly submitting themselves for this study.
CONTENTS
S.NO CONTENTS PAGE NO.
1. INTRODUCTION
1
2. AIMS AND OBJECTIVES
7
3. ANATOMY
8
4. PARAVERTEBRAL BLOCK AND THORACIC EPIDURAL
10
5. PHARMACOLOGY OF BUPIVACAINE
19
6. REVIEW OF LITERATURE
23
7. MATERIALS AND METHODS
29
8. OBSERVATION AND RESULTS
36
9. DISCUSSION
71
10. SUMMARY
75
11. CONCLUSION
76
12. BIBLIOGRAPHY
77
13. ANNEXURES
82
INTRODUCTION
PATHOPHYSIOLOGY OF PAIN IN THORACIC SURGERY
One of the most painful surgical incision is the thoracotomy incision.
Nociceptive transmission is via Ad and C fibers and can be considered in three discrete routes.
1. Intercostal nerves carry impulses from the skin and intercostal muscles.
2. Stimuli from lung and mediastinum are carried by the vagus nerve
3. The visceral pleura is relatively insensitive, except to stretch. Parietal pleura, which is highly sensitive to noxious stimuli, receives innervation from intercostal and phrenic nerves.
In addition, latissimus dorsi and serratus anterior are supplied by the thoracodoral and long thoracic nerves, respectively. These arise from roots C5- C7 via the brachial plexus.
Thoracotomy for lung resection usually involves a skin incision at the 5th intercostal space, a variable degree of muscle cutting and either excision or division of a rib.
Upto three chest drains are kept after thoracotomy.
Shoulder pain is a common complaint after thoracotomy.
BACKGROUND
Thoracic paravertebral block has been pioneered by Hugo sellheim of Leipzig in the year 1905.
In the year 1919, Kappis developed the paravertebral block technique in the present day use.
Eason and Wyatt, in the year 1979 introduced the technique of paravertebral catheter placement.
The safety and efficacy of paravertebral block has been improved and well understood these days and used more frequently now a days.
The technique can also be used in children
It provides not only analgesia but can also be used for surgical anaedthesia.
Paravertebral block is a regional anaesthesia technique in which the local anaesthetic is injected in the paravertebral space where the spinal nerves emerges out from the intervertebral foramen
Paravertebral block can produce unilateral somatic and sympathetic nerve blockade which helps in suppressing the neuroendocrine stress response in patients undergoing major thoracic and abdominal surgeries.
Paravertebral block can be given as a single shot analgesic technique or can be used as a continuous infusion by catheter placement.
Bilateral paravertebral block is still under study.
Paravertebral block is found to be superior to intercostal nerve blocks and epidural block in safety and efficacy.
This block can be performed by landmark technique, nerve stimulator guided technique or ultrasound guided technique.
The advantages of paravertebral block over epidural is it is easier to perform, less failure rate, reduced hematoma risk, less neurological adverse effects, no hypotension, no urinary retention.
Thoracic epidural which is considered the gold standard for thoracic surgeries not only blocks the pain sensation from the surgical site but also provides
This helps the patient in better hemodynamics in the intraoperative period and also better postoperative analgesia with improved respiratory functions.
Thoracic epidural differs from lumbar epidural technique as the spinous processes are steeply aligned, epidural space has less fat content, ligamentum flavum is less likely to be in midline and the dura is less adherent to the bony structures surrounding it.
Thoracic epidural block can be used as continuous infusion or as patient controlled analgesia.
The lateral thoracotomy incision is extremely painful and the intensity of pain depends upon the site and extent of the incision.
There is reduction in the functional residual capacity, reduced ability to take a deep breath or cough out the sputum post thoracotomy due to intense pain. Due to this the patient may not be able to clear the secretions out and progressively may lead to pneumonia and atelectasis.
With the advent of thoracic epidural and paravertebral blocks we are able to alleviate the post thoracotomy pain and improve the patient outcome.
Not a single shot but a continuous infusion technique helps to maintain a constant pain relief and better patient compliance.
The importance in managing pain in the post thoracotomy patients cannot be overstated as pain may cause splinting which leads to poor respiratory efforts which in turn leads to atelectasis and hypoxemia
Pain also stimulates the sympathetic system which increases the myocardial oxygen demand which increases the after load causing significant arrhythmias.
It may also increase the length of hospital stay and chronic bed ridden patients may end up with deep vein thrombosis.
MODES OF ANALGESIA:
Parenteral analgesics Opioids
NSAIDs Ketamine
Dexmedetomidine
Nerve blocks:
Intercostal nerve blocks
Intrapleural infusion of local anaesthetics cryoalagesia
Epidural analgesia Paravertebral block
AIMS AND OBJECTIVES:
AIM
Comparison of Paravertebral Nerve Block vs thoracic Epidural Block by using levobupivacaine 0.5% with fentanyl for patients undergoing THORACOTOMY under General Anaesthesia.
OBJECTIVES
Complication rate
To evaluate the duration of postoperative analgesia
To assess peroperative and postoperative hemodynamics
Post-operative numerical scale.
THORACIC PARAVERTEBRAL BLOCK:
ANATOMY OF PARAVERTEBRAL SPACE:
It is a triangular space which is bounded
Posteriorly by superior costotransverse ligament Medially by vertebral body and vertebral foramen
Anterolaterally by parietal pleura and innermost vertebral membrane The thoracic paravertebral space starts from T1 to T12.
It is divide into anterior and posterior compartment as subserous and sub endothoracic compartment respectively.
The contents of this space includes the spinal nerves, sympathetic chain, white and grey rami communicans, intercostal nerves and fat.
The thoracic spinal nerve roots and the sympathetic chain arises from the lateral vertebral foramen and course anterior to the transverse processes close to the parietal pleura
The nerve becomes the intercostal nerve as it enters the plane between innermost and inner intercostal muscles.
ANATOMY OF THE PARAVERTEBRAL SAPCE:
Figure 1:
Figure showing the anatomy of the paravertebral space and its relations
THORACIC PARAVERTEBRAL BLOCK TECHNIQUE:
Patient should be turned to lateral position with the operating side on top. The patients should be made to bend their back and bring their knees to chest. This position has to be maintained by an assistant. The back should be painted with povidone iodine and draped with sterile towels.
Figure 2:
Showing the landmark technique of thoracic paravertebral block.
Under strict aseptic precautions, thoracic spine has to be palpated and a skin wheel should be created at 2.5cm lateral to T5 Thoracic spine with 1%
Lignocaine. Tuohy needle should be inserted till it hits the corresponding transverse process and then it should be walked over inferiorly and angulated slightly laterally. A change in resistance should be felt when the needle pierces superior costotransverse ligament using loss of resistance syringe. Epidural catheter has to be inserted through the needle. After adequate skin infiltration with 1% Lignocaine tunnelling has to be done and catheter passed through it and should be fixed. Patient turned to supine position. Local anaesthetic should be given through the catheter after negative aspiration for blood and CSF.
INDICATIONS:
Anaesthesia for breast surgery,hernioraphy Postoperative analgesia for thoracotomy Thoracoabdominal oesophageal surgery Video assisted thoracoscopic surgery Renal surgery
Liver resection Cholecystectomy
In chronic pain management-benign and malignant neuralgia.
CONTRAINDICATIONS:
Patient refusal
Allergy to local anaesthetic
Local sepsis or sepsis in chest cavity Coagulopathy
Concurrent anticoagulation therapy
COMPLICATIONS:
Bradycardia with hypotension Vasovagal episode
Epidural placement of catheter Epidural/intrathecal spread Pleural puncture
Pneumothorax Horner syndrome
ANATOMY OF EPIDURAL SPACE:
Epidural space is a potential space between periosteum lining the vertebral canal and the spinal dura mater.
It extends from the foramen magnum till the sacral hiatus and surrounds the dura mater posteriorly, laterally and anteriorly.
Boundaries:
Cranially-foramen magnum
Caudally-sacrococcygeal ligament
Anteriorly-posterior longitudinal ligament Posteriorly-ligamentum flavum and laminae
Laterally-vertebral pedicles and intervertebral foramina
Contents of the epidural space includes The areolar connective tissue
Fat
Spinal nerve roots with their dural sleeves Lymphatics
Blood vessels-the Batson venous plexus.
INDICATIONS:
Thoracic surgeries including Thoracotomy
Thoracic aneurysm repair Pectus repair
Thymectomy VATS
Upper abdomen surgeries including Oesophagectomy Gastrectomy Hepatic resection Cholecystectomy Pancreatic surgeries
Lower abdominal surgeries and urogenital or gynaecologic procedures.
CONTRAINDICATIONS:
Patient refusal Local infection Severe hypovolemia Coagulopathy
Raised intracranial tension Severe aortic stenosis Severe mitral stenosis
Concurrent anticoagulation therapy COMPLICATIONS:
Back ache,head ache
Transient neurological symptoms Subdural injection
Subarachnoid injection Systemic toxicity
Meningitis,arachnoiditis Epidural hematoma/abscess
PHARMACOLOGY OF BUPIVACINE:
Bupivacine is a long acting local anaesthetic belonging to amide group.
Mepivacine, Bupivacine and Ropivacine are characterized as pipecoloxylidides.
Addition of butyl group to the piperidine nitrogen of mepivacine results in bupivacine, which is 35 times more lipid soluble and has potency and duration of action 3to4 times that of mepivacine.
CHEMICAL STRUCTURE:
MECHANISM OF ACTION
Local anesthetics bind to specific sites in voltage gated Na+ current , thereby reducing excitability of neuronal, cardiac or central nervous system tissue.
Local anesthetics prevent transmission of nerve impulses (conduction blockade) by inhibiting passage of sodium ions through ion selective sodium channels in nerve membranes.
The sodium channel itself is a specific receptor for local anesthetic molecules.
Failure of an increase in sodium channel ion permeability
Slows the rate of depolarization so that threshold potential is not reached and hence action potential is not reached.
Local anesthetics does not alter the resting transmembrane potential or threshold potential.
METABOLISM
Possible way of metabolism of bupivacaine include aromatic hydroxylation, Ndealkylation, amidehydrolysis and conjugation.
Only the N-dealkylated metabolite N desbutylbupivacine, has been measured in blood or urine after epidural or spinal anesthesia.
The mean total urinary excretion of bupivacaine and its dealkylation and hydroxylation metabolites account for >40% of total anesthetic dose.
Alpha 1-acid glycoprotein Is the most important plasma protein binding site of bupivacaine and its concentration is increased in many clinical situations,including postoperative trauma.
Bupivacine has slow onset of action with average duration of action after infiltration ranges from 240 to 480 seconds.
Maximum single dose for infiltration is around 175mg and the bupivacaine toxicity features manifest if the plasma concentration exceeds 3mcg/ml8.
pK of Bupivacine is 8.1 and it is 95% protein bounded.
USES
Topical anesthesia
Local infiltration
Peripheral nerve blockade
Neuraxial anesthesia
Paravertebral anesthesia
ADVERSE EFFECTS
Allergy to Bupivacine
Cardiotoxicity–Precipituous hypotension,cardiac dysrhythmias and atrioventricular blocks. Premature ventricular contractions, widening of QRS complexes and ventricular tachycardias are the most common arrhythmias seen, though other arrhythmias including supraventricular tachycardia, atrio-ventricular block and ST-T wave changes can also occur but are less common. Cardiotoxic plasma concentration of bupivacaine are 8 to 10mcg/ml.
Neurotoxicity–vertigo, tinnitus, twitching, slurred speech and seizures
REVIEW OF LITERATURE:
1)Kaiser AM, Zollinger A, De Lorenzi D, Largiador F, Weder W.concluded that continuous paravertebral and epidural blocks, beginning before operation as part of a balanced analgesic regimen, were highly effective for post-thoracotomy pain. In this study, he found that paravertebral analgesia was superior in terms of analgesia, pulmonary function, neuroendocrine stress responses, side effects and postoperative respiratory morbidity.
2)Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ.
conducted a prospective randomized study between thoracic epidural and paravertebral bupivacaine in 100 adult patients. The visual analogue pain score (VAS) at rest and on cough was significantly lower in the paravertebral group (P=0.02 and 0.0001, respectively).
3)Bimston DN, McGee JP, Liptay MJ, Fry WA. found that both the methods of analgesia provide adequate postoperative pain control. Epidural infusion demonstrated an improved efficacy early in the postoperative course but provided statistically similar analgesia to paravertebral by postoperative day 2.
Neither group demonstrated a greater number of pain-related complications.
Narcotic-induced complications such as pruritus, nausea/vomiting, and postural hypotension/mental status changes/respiratory depression were seen with
statistically similar frequency in both epidural and paravertebral arms. Urinary retention was noted to be significantly more frequent in patients with epidural catheters. Drug toxicity was not observed with either epidural or paravertebral infusion and concluded that continuous paravertebral infusion as an improved method of post-thoracotomy analgesia that can be placed and managed by the surgeon.
4)Davies RG, Myles PS, Graham JM. Their systematic review found no difference in analgesia with PVB techniques when compared with epidural regimens. PVB was associated with improvements in respiratory function and a reduction in complications. It appears that PVB is advantageous and can be recommended for major thoracic and upper abdominal surgery.
5) Marco Scarci, Abhishek Joshi, Rizwan Attia. concluded that PVB can be at least as effective as epidural analgesia. It also has a better side-effect profile and a lower complication rate than epidural analgesia
6)Accordind to Watson A, Allen PR the incidence of respiratory complications and the effect on outcome were studied in two groups of patients undergoing thoracoabdominal esophagogastrectomy for esophageal cancer during a 15-year
1975 through 1985 in whom thoracic epidural analgesia was not used; the second group comprised 75 patients who underwent operation from 1985 through 1990 in whom thoracic epidural analgesia was used routinely.The results of this study suggest that the routine use of thoracic epidural analgesia during thoracoabdominal esophagogastrectomy for esophageal cancer reduces the incidence of fatal and nonfatal respiratory complications and should be incorporated into routine surgical management of operable esophageal cancer.
7)Asida SM, Youssef IA, Mohamad AK, Abdelrazik AN concluded that continuous thoracic PVB with bupivacaine provides effective analgesia after thoracic surgery supported by lower values of VAS pain scores at rest and when coughing as compared to systemic analgesia with significant less incidence of complications and side effects such as pulmonary complications, PONV and pruritus.
8) De Cosmo G, Federico B, Sessa F, Fiorini F, Fortunato G, et al.concluded that continuous incisional infusion of local anesthetics is not as effective as paravertebral analgesia to reduce pain after thoracotomy. Continuous PVB is associated with better pain relief without mobility worsening. However, we believe that in the future studies investigating a combination of these two methods without achieving toxic doses of local anesthetic should be performed
to find the most effective, safety and easy to perform analgesia technique for the management of post thoracotomy pain.
9)According to Kundra P, Varadharajan R, Yuvaraj K, Vinayagam S. Lung functions are well-preserved in patients undergoing modified radical mastectomy under general anesthesia supplemented with Paravertebral or IPB.
IPB is as effective as PVB for post-operative pain relief. PVB has the added advantage of achieving a more complete block.
10) Sahu A1, Kumar R1, Hussain M1, Gupta A1, Raghwendra KH1.
Ropivacaine and Bupivacaine had no difference in intraoperative analgesia as shown by intraoperative hemodynamic parameters. Bupivacaine got better post- operative VAS scores (P < 0.05) in mean and after first, 6 h and 24 h.
11)According to Daly DJ1, Myles PS there is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural
analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.
12)Ding X1, Jin S1, Niu X2, Ren H2, Fu S3, Li Q
Eighteen 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)
This 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.
13)According to Júnior Ade P, Erdmann TR et al there were no statistically significant differences in pain relief after thoracotomy between EB and PVB.
PVB showed a lower incidence of side effects with reduced frequency of urinary retention and hypotension.
MATERIALS AND METHODS STUDY DESIGN:
Prospective randomized comparative study STUDY:
COMPARATIVE EVALUATION OF THORACIC EPIDURAL VERSUS THORACIC PARAVERTEBRAL BLOCK FOR POST THORACOTOMY PAIN RELIEF WITH 0.25% BUPIVACAINE
Authored by: Dr.T.Santhosh Kumar, Dr.R.Rajendran Published on Aug 2003 in IJA
After getting approval from our institution’s ethics committee, this study was conducted among 40 patients belonging to ASA PS I, II and III who undergoes for elective thoracotomy surgery under general anaesthesia.
The age distribution was selected between 15-65 years.
All patients have undergone thorough preoperative examination.
The procedure was explained to the patient in their own language and consent was obtained. All patients underwent examinations like height, weight, vitals like blood pressure, heart rate and basic investigations like complete blood
count, renal function tests, chest X ray, ECG. All major systems were examined and airway examination was also done. Visual analogue scale was explained to the patient with pictorial representation.
INCLUSION CRITERIA:
• Age : 15 years to 65yrs.
• ASA : I,II,III
• Surgery : Elective
• Body Mass Index <35
• Who have given valid informed consent EXCLUSION CRITERIA:
• Not satisfying inclusion criteria.
• Not willing
• Bleeding disorders and Coagulation abnormalities
• Kyphoscoliosis
• Allergy to drugs used.
• Patient refusal.
• Patients with severe cardiovascular, Endocrine, respiratory, renal, hepatic, Psychiatric diseases.
Materials:
• 18G venflon
• Epidural set
• Drugs–
Inj.levobupivacaine,Inj.Glycopyrrolate,Inj.Thiopentone,Inj.Fentany l,Inj.Succinylcholine,Inj.Atracurium,Inj.Neostigmine,Sevoflurane,I nj.Dexamethasone,Inj.Paracetamol,Inj.Tramadol, emergency drugs and Ringer lactate, normal saline,
• Monitors – ECG, NIBP, SPO2 and EtCO2.
GROUP P-20 patients in this group received thoracic paravertebral block using 0.5% bupivacaine with fentanyl
GROUP E-20 patients in this group received thoracic epidural block using 0.5%
bupivacaine with fentanyl
After obtaining the informed consent patients were shifted inside the operation theatre and the monitors were connected. Intravenous access was obtained with 16G intravenous cannula. Patients were turned to lateral position with the operating side on top. The patients were made to bend their back and bring their knees to chest. This position was maintained by an assistant. The back was painted with povidone iodine and draped with sterile towels. Under strict aseptic
precautions patient in group P received thoracic paravertebral block and patients in epidural group received thoracic epidural block as mentioned earlier. Patients were premedicated with 1.5mg of inj.Midazolam, 2mcg/kg of inj. Fentanyl and 0.2mg of inj.Glycopyrrolate. Induction was done with Inj. propofol 2mg/kg and Inj.Vecuronium 0.1mg/kg. Inj.Lignocard 1.5mg/kg was given 90seconds before intubation to attenuate the stress response. Patients were then intubated with appropriate sized double lumen tube and the position is confirmed and fixed.
Bladder was catheterized and the surgery started after proper positioning.
Anesthesia, was maintained with 1% Sevoflurane along with O2 40% and N2O 60%.
After the surgery is over, patients were turned supine and the volatile agents were cut off and ventilation was assisted. Once the arterial blood gas reports were within normal range and patients had recovered adequately from the neuromuscular blockade, they were reversed with inj.Glycopyrrolate 10mcg/kg/min and inj.Neostigmine 50mcg/kg. After adequate oral suctioning, patient was extubated.
All the patients were kept in postoperative intensive care units. Intraoperatively Patient’s heart rate and blood pressure were noted for every 5 minutes till first hour and then for every 30 minutes till eight hours and then hourly till 24 hour postoperative period. Postoperatively VAS score was noted for every 30 minutes till 8 hours and then hourly till 24 hours postoperatively. Analgesia was
was given for rescue analgesia. Other complications of Bupivacine were also closely monitored.
The following parameters were monitored:
Heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure, VAS score
VAS SCALE:
STATISTICAL ANALYSIS
All the data were initially entered to Microsoft Excel 2010 initially and then the spreadsheets were used for statistical analysis using SPSS version 20.0.
1. DESCRIPTIVE STATISTICS:
Descriptive statistics were calculated in the form of frequency, percentage, mean and standard deviation, median and inter-quartile range.
Descriptive data were represented using various tables, graphs, diagrams etc.
2. INFERENTIAL STATISTICS:
For inferential statistics, various tests of significance were used according to the type of variables dealt with. To compare the various continuous variables, Student‘t’ test was used. Chi-square test was done to compare the various categorical variables. To reduce the error in approximation during Chi-square test, Yates’s correction for continuity was used.
Factorial repeated measures ANOVA was applied to test the difference in mean VAS score, Heart rate, blood pressure and mean arterial pressure (continuous dependent variable) in per-operative and post-operative time points across the two groups such as Epidural and Paravertebral Group (categorical independent variable used as between subjects’ factor).
3. TESTS FOR NORMALITY:
Kolmogorov Smirnov Test and Shapiro –Wilk Tests were used to test whether the data follow normal distributions or not. Since the test was statistically not significant (p=0.584 i.e. p>0.05), the data was assumed to follow normal distribution.
4. SIGNIFICANCE LEVEL:
For all the statistical tests of significance, p value of <0.05 was considered to reject the null hypothesis.
OBSERVATION AND RESULTS
Table 1: Age distribution of the study sample (n=40)
Age group
Epidural Group n (%)
Paravertebral Group n (%)
Total n (%)
<20 years 2 (10) 2 (10) 4 (10)
21 to 30 years 4 (20) 4 (20) 8 (20)
31 to 40 years 5 (25) 6 (30) 11 (27.5)
41 to 50 years 5 (25) 4 (20) 9 (22.5)
51 to 60 years 3 (15) 3 (15) 6 (15)
61 to 70 years 1 (5) 1 (5) 2 (5)
Total 20 (100) 20 (100) 40 (100)
Comments: The age distribution of study subjects in both groups were similar and only minor difference was observed.
Table 2: Comparison of mean age of the study sample (n=40)
Group N
Mean Age (years)
Std.Deviation
Mean Difference
Student ‘t’
test p value Paravertebral 20 38.35 12.918
0.250 0.952
Epidural 20 38.10 13.054
Comments: The minor difference in mean age between the two groups was not statistically significant (p>0.05) and hence both the groups were comparable.
Fig 1: Comparison of mean age of the study sample (n=40)
Table 3: Gender distribution of the study sample (n=40)
Gender
Epidural Group n (%)
Paravertebral Group n (%)
Total n (%)
Female 4 (20) 5 (25) 9 (22.5)
Male 16 (80) 15 (75) 31 (77.5)
Total 20 (100) 20 (100) 40 (100)
Chi-square p value: 0.705
Comments: The gender distribution of study subjects in both groups can be considered as similar as the minor difference observed was not statistically significant (p>0.05). Hence both the groups were comparable.
Fig 2: Gender distribution of the study sample (n=40)
4
16
5
15
0 2 4 6 8 10 12 14 16 18
Female Male
Epidural Paravertebral
Table 4: Comparison of mean weight of the study sample (n=40)
Group N
Mean Weight (Kgs)
Std.Deviation
Mean Difference
Student ‘t’
test p value Paravertebral 20 60.00 8.784
0.250 0.926
Epidural 20 60.25 8.149
Comments: The minor difference in mean weight between the two groups was not statistically significant (p>0.05) and hence both the groups were comparable with regards to body weight.
Fig 3: Comparison of mean weight of the study sample (n=40)
Table 5: Comparison of mean heart rate of the study groups at various per- operative time points (n=40)
Mean Heart rate
Epidural group Paravertebral Group
Student ‘t’
test p value Mean HR Std. Deviation Mean HR
Std.
Deviation
0 min 83.4 9.3 82.9 11.5 0.881
5 min 83.2 9.6 83.0 12.0 0.954
10 min 83.3 9.3 84.1 12.7 0.821
15 min 84.9 10.8 86.1 13.6 0.749
20 min 85.0 9.8 87.0 12.1 0.578
25 min 86.3 10.0 87.0 13.0 0.829
30 min 87.4 11.3 87.4 14.0 1.000
45 min 88.9 12.0 86.5 14.3 0.561
60 min 90.4 13.6 87.1 14.5 0.463
75 min 91.3 12.0 86.3 13.9 0.231
90 min 91.6 13.2 87.1 13.6 0.284
105 min 92.0 12.2 86.6 15.3 0.229
120 min 91.2 11.6 87.0 14.5 0.318
135 min 91.4 12.6 85.7 12.2 0.158
150 min 90.9 13.0 84.3 11.5 0.100
165 min 89.6 12.6 85.6 11.5 0.307
180 min 90.1 12.5 84.7 11.2 0.154
Factorial- Repeated measures ANOVA test was used to test the difference in mean heart rate at time points in the per-operative period between the
epidural and paravertebral groups.
Model
mean heart rate variation over time
mean heart rate variation between 2 groups
Wilks’s Lambda F 3.158 1.722
df 16,23 16,23
p value 0.006 0.114
Comments:
1. There was no statistically significant difference between the mean heart rate between the 2 groups throughout the per-operative period as suggested by the student ‘t’ test.
2. Variation in heart rate: In factorial repeated measures ANOVA, there was a statistically significant variation in mean heart rate over time as p<0.05.
However, this variation in heart rate happened to be relatively less in subjects who received paravertebral block in comparison to subjects who received epidural block and also the variations were in same direction in both the groups but this difference in changes of heart rate in between the 2 groups was not statistically significant.
Fig 4: Comparison of mean heart rate at various per-operative time points (n=40)
83.4 83.2
83.3 84.9
85 86.3
87.4 88.9
90.4
91.3 91.6 92
91.2 91.4 90.9
89.6 90.1
82.9 83 84.1
86.1 87 87
87.4
86.5 87.1
86.3 87.1
86.6 87
85.7 84.3
85.6 84.7
82 84 86 88 90 92 94
0 50 100 150
TIME (MINS)
Epidural Paravertebral
Table 6: Comparison of mean systolic blood pressure (SBP) of the study groups at various per-operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean SBP
Std.
Deviation
Mean SBP
Std.
Deviation
0 min 120.4 6.2 119.5 6.2 0.649
5 min 119.7 6.3 119.8 6.1 0.960
10 min 119.3 6.0 121.8 4.9 0.166
15 min 119.1 5.8 121.7 5.6 0.151
20 min 115.1 6.3 122.1 6.9 0.002
25 min 109.7 8.9 120.6 6.4 <0.001
30 min 109.1 10.2 120.6 6.2 <0.001
45 min 107.5 10.6 119.1 5.0 <0.001
60 min 105.0 12.1 119.9 3.4 <0.001
75 min 103.9 12.0 118.9 5.2 <0.001
90 min 103.4 13.6 119.0 4.5 <0.001
105 min 105.6 12.4 118.0 5.3 <0.001
120 min 106.5 11.1 118.8 5.2 <0.001
135 min 107.1 10.6 119.9 4.5 <0.001
150 min 107.8 10.5 120.3 5.0 <0.001
165 min 108.3 9.5 121.4 4.3 <0.001
180 min 110.2 9.2 121.1 4.3 <0.001
Factorial- Repeated measures ANOVA test was used to test the difference in mean systolic blood pressure (SBP) at time points in the per-operative period between the epidural and paravertebral groups.
Model
mean SBP variation over time
mean SBP variation between 2 groups
Wilks’s Lambda F 2.838 2.519
df 16,23 16,23
p value 0.011 0.021
Comments:
1. There was a statistically significant difference between the mean SBP between the 2 groups throughout the per-operative period except in the first 15 minutes of surgery with subjects in epidural group experiencing lesser systolic blood pressure (fall in SBP) than subjects in the paravertebral group as suggested by the student‘t’ test.
2. Variation in SBP: In factorial repeated measures ANOVA, there was a statistically significant variation in mean systolic blood pressure over time as p<0.05. However, this variation in SBP happened to be minimal in subjects who received paravertebral block in comparison to statistically significant drop in SBP among subjects who received epidural block and this difference in variation of SBP between the 2 groups was statistically significant.
Fig 5: Comparison of systolic blood pressure (SBP) at various per- operative time points (n=40)
120.4 119.7
119.3 119.1 115.1
109.7 109.1
107.5 105
103.9 103.4
105.6 106.5 107.1 107.8 108.3 110.2 119.5
119.8 121.8
121.7 122.1
120.6
120.6 119.1 119.9
118.9 119
118 118.8
119.9 120.3
121.4 121.1
100 105 110 115 120 125
0 50 100 150
TIME (MINS)
Epidural Paravertebral
Table 7: Comparison of mean diastolic blood pressure (DBP) of the study groups at various per-operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean DBP
Std.
Deviation
Mean DBP
Std.
Deviation
0 min 78.1 4.9 77.6 4.4 0.737
5 min 77.0 5.5 76.9 5.8 0.978
10 min 76.4 6.2 77.7 5.2 0.461
15 min 74.9 6.6 76.7 4.9 0.305
20 min 74.4 6.9 78.0 4.2 0.058
25 min 72.1 7.1 76.9 5.0 0.018
30 min 70.2 8.1 78.1 5.3 0.001
45 min 68.6 7.8 77.4 4.6 <0.001
60 min 67.7 6.4 77.9 4.6 <0.001
75 min 66.9 6.9 77.2 5.2 <0.001
90 min 66.1 8.0 76.3 5.0 <0.001
105 min 67.4 6.7 76.0 6.2 <0.001
120 min 68.0 5.3 76.4 5.9 <0.001
135 min 68.3 6.3 76.6 4.8 <0.001
150 min 67.5 6.7 77.7 4.9 <0.001
165 min 68.1 6.9 77.9 3.8 <0.001
180 min 69.0 6.6 78.9 4.9 <0.001
Factorial- Repeated measures ANOVA test was used to test the difference in mean diastolic blood pressure (DBP) at time points in the per-operative period between the epidural and paravertebral groups.
Model
mean DBP variation over time
mean DBP variation between 2 groups
Wilks’s Lambda F 7.261 4.816
df 16,23 16,23
p value <0.001 <0.001
Comments:
1. There was a statistically significant difference between the mean DBP between the 2 groups throughout the per-operative period except in the first 20 minutes of surgery with subjects in epidural group experiencing lesser diastolic blood pressure (fall in DBP) than subjects in the paravertebral group as suggested by the student‘t’ test.
2. Variation in DBP: In factorial repeated measures ANOVA, there was a statistically significant variation in mean diastolic blood pressure over time as p<0.05. However, this variation in DBP happened to be minimal in subjects who received paravertebral block in comparison to statistically significant drop in DBP among subjects who received epidural block and this difference in variation of DBP between the 2 groups was statistically significant
Fig 6: Comparison of diastolic blood pressure (DBP) at various per- operative time points (n=40)
78.1
76.4 77
74.9 74.4
72.1 70.2
68.6 67.7
66.9 66.1
67.4 68 68.3
67.5 68.1 69 77.6
76.9
77.7 76.7 78
76.9 78.1
77.4 77.9 77.2
76.3 76 76.4 76.6
77.7 77.9 78.9
64 66 68 70 72 74 76 78 80
0 50 100 150
TIME (MINS) Epidural Paravertebral
Table 8: Comparison of mean arterial pressure (MAP) of the study groups at various per-operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean MAP
Std.
Deviation
Mean MAP
Std.
Deviation
0 min 91.9 5.0 91.2 4.9 0.656
5 min 90.8 5.5 90.9 5.5 0.977
10 min 90.2 5.9 92.2 4.6 0.249
15 min 89.5 5.8 91.4 4.9 0.270
20 min 87.6 6.3 92.4 4.7 0.010
25 min 83.8 7.8 91.1 5.1 0.001
30 min 82.8 8.5 91.9 5.3 <0.001
45 min 81.4 8.6 90.9 4.4 <0.001
60 min 80.4 8.8 91.5 3.9 <0.001
75 min 79.0 8.3 90.7 4.9 <0.001
90 min 78.3 9.6 90.2 4.3 <0.001
105 min 79.8 8.3 89.6 5.5 <0.001
120 min 80.5 6.7 90.2 5.5 <0.001
135 min 81.0 7.4 90.6 4.4 <0.001
150 min 80.7 7.4 91.7 4.5 <0.001
165 min 81.3 7.5 92.1 3.7 <0.001
180 min 82.4 7.0 92.7 4.3 <0.001
Factorial- Repeated measures ANOVA test was used to test the difference in mean arterial pressure (MAP) at time points in the per-operative period between the epidural and paravertebral groups.
Model
mean MAP variation over time
mean MAP variation between 2 groups
Wilks’s Lambda F 5.966 4.838
df 16,23 16,23
p value <0.001 <0.001
Comments:
1. There was a statistically significant difference between the mean MAP between the 2 groups throughout the per-operative period except in the first 15 minutes of surgery with subjects in epidural group experiencing lesser mean arterial pressure (fall in MAP) than subjects in the paravertebral group as suggested by the student‘t’ test.
2. Variation in MAP: In factorial repeated measures ANOVA, there was a statistically significant variation in mean arterial blood pressure over time as p<0.05. However, this variation in MAP happened to be minimal in subjects who received paravertebral block in comparison to statistically significant drop in MAP among subjects who received epidural block and this difference in variation of MAP between the 2 groups was statistically significant.
Fig 7: Comparison of mean arterial pressure (MAP) at various per- operative time points (n=40)
91.9 90.8
90.2 89.5
87.6
83.8 82.8
81.4 80.4
79 78.3
79.8 80.5 81 80.7 81.3 82.4 91.2
90.9 92.2
91.4 92.4
91.1 91.9
90.9 91.5 90.7
90.2
89.6 90.2 90.6
91.7 92.1 92.7
76 78 80 82 84 86 88 90 92 94
0 50 100 150
TIME (MINS)
Epidural ParavertebralTable 9: Comparison of Visual Analog score (VAS) of the study groups at various post-operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean VAS
Std.
Deviation
Mean VAS
Std.
Deviation
0 min 1.1 0.3 1.0 0.0 0.163
30 min 1.1 0.3 1.0 0.0 0.163
1 hour 1.1 0.3 1.1 0.2 0.560
1.5 hours 1.0 0.0 1.0 0.0 1.000
2 hours 1.1 0.3 1.0 0.0 0.154
2.5 hours 1.1 0.3 1.0 0.0 0.154
3 hours 1.1 0.3 1.1 0.3 1.000
3.5 hours 1.1 0.3 1.1 0.2 0.560
4 hours 1.3 0.5 1.1 0.2 0.041
4.5 hours 1.5 0.5 1.1 0.2 0.004
5 hours 1.5 0.5 1.2 0.4 0.018
5.5 hours 1.5 0.5 1.1 0.3 0.013
6 hours 1.8 0.4 1.1 0.3 <0.001
10 hours 1.8 0.4 1.3 0.5 0.001
14 hours 1.6 0.5 1.5 0.5 0.350
18 hours 1.9 0.3 1.8 0.4 0.389
22 hours 1.7 0.5 1.8 0.4 0.267
24 hours 1.7 0.4 1.8 0.4 0.442
Factorial- Repeated measures ANOVA test was used to test the difference in mean Visual Analog score (VAS) at time points in the post-operative period between the epidural and paravertebral groups.
Model
mean VAS variation over time
mean VAS variation between 2 groups
Wilks’s Lambda F 40.002 6.183
df 17,22 17,22
p value <0.001 <0.001
Comments:
1. There was a statistically significant difference between the mean VAS between the 2 groups from 4 hours to 10 hours in the post-operative period with subjects in paravertebral group experiencing lesser mean VAS score than subjects in the epidural group as suggested by the student‘t’ test.
2. Variation in VAS: In factorial repeated measures ANOVA, there was a statistically significant variation in mean visual analog score (VAS) over time as p<0.05. However, this variation in VAS happened to be minimal in subjects who received paravertebral block during the first 6 hours in comparison to subjects who received epidural block and this difference in variation of VAS between the 2 groups was statistically significant.
Fig 8: Comparison of Visual Analog score (VAS) at various post-operative time points (n=40)
1.1 1.1 1.1
1 1.1
1.1 1.1 1.1
1.3 1.5
1.5 1.5
1.8 1.8
1.6
1.9
1.7 1.7
1 1 1.1
1 1 1 1.1
1.1 1.1 1.1 1.2
1.1 1.1 1.3
1.5
1.8 1.8 1.8
0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
0 5 10 15 20
TIME (HOURS)
Epidural ParavertebralTable 10: Comparison of heart rate of the study groups at various post- operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean HR
Std.
Deviation
Mean HR
Std.
Deviation
0 min 88.6 10.6 85.2 12.6 0.356
30 min 90.0 11.5 84.6 13.7 0.189
1 hour 90.6 12.2 85.5 12.8 0.214
1.5 hours 89.7 12.5 84.9 11.8 0.224
2 hours 88.3 10.7 84.4 13.0 0.301
2.5 hours 87.9 10.3 84.6 12.0 0.342
3 hours 87.2 10.2 85.2 12.4 0.571
3.5 hours 87.9 10.7 85.6 11.2 0.502
4 hours 86.9 10.3 84.0 9.6 0.346
4.5 hours 86.9 9.8 83.6 10.6 0.320
5 hours 87.7 9.4 83.6 12.8 0.261
5.5 hours 87.2 8.7 83.1 11.6 0.213
6 hours 85.9 9.4 84.3 11.8 0.639
10 hours 84.7 8.3 85.2 12.2 0.892
14 hours 86.7 10.4 83.7 10.5 0.363
18 hours 85.4 8.3 85.1 10.6 0.947
22 hours 84.0 8.8 84.1 12.8 0.954
24 hours 85.5 9.1 84.1 11.1 0.653
Factorial- Repeated measures ANOVA test was used to test the difference in mean heart rate (HR) at time points in the post-operative period between the epidural and paravertebral groups.
Model
mean HR variation over time
mean HR variation between 2 groups
Wilks’s Lambda F 1.054 0.751
df 17,22 17,22
p value 0.447 0.724
Comments:
1. There was no statistically significant difference between the mean heart rate between the 2 groups throughout the post-operative period as suggested by the student‘t’ test.
2. Variation in HR: In factorial repeated measures ANOVA, there was no statistically significant variation in mean heart rate over time as p>0.05.
Also whatever minimal variation occurred in HR among subjects who received paravertebral block was similar to HR variation in subjects who received epidural block as the difference in variation of HR between the 2 groups was not statistically significant.
Fig 9: Comparison of heart rate at various post-operative time points (n=40)
88.6 90 90.6
89.7
88.3 87.9
87.2 87.9
86.9 86.9 87.7
87.2 85.9
84.7
86.7
85.4
84
85.5 85.2
84.6 85.5 84.9
84.4 84.6 85.2
85.6
84 83.6
83.6 83.1
84.3
85.2
83.7
85.1
84.1 84.1
82 83 84 85 86 87 88 89 90 91
0 5 10 15 20
TIME (HOURS)
EpiduralParavertebral
Table 11: Comparison of mean arterial pressure (MAP) of the study groups at various post-operative time points (n=40)
Time
Epidural group Paravertebral Group
Student ‘t’
test p value Mean MAP
Std.
Deviation
Mean MAP
Std.
Deviation
0 min 84.2 4.9 91.2 4.7 <0.001
30 min 84.7 6.1 91.4 5.4 0.001
1 hour 84.8 5.5 90.6 5.5 0.002
1.5 hours 85.2 7.1 90.3 5.9 0.018
2 hours 84.7 6.0 90.0 5.7 0.008
2.5 hours 85.0 6.0 90.0 5.7 0.011
3 hours 84.9 6.7 90.3 5.5 0.008
3.5 hours 85.3 6.5 91.6 4.8 0.001
4 hours 84.8 7.2 91.5 4.9 0.002
4.5 hours 85.4 6.6 91.2 5.7 0.006
5 hours 86.6 5.9 91.1 5.2 0.013
5.5 hours 87.2 5.6 90.0 5.2 0.110
6 hours 87.5 6.3 90.1 4.6 0.153
10 hours 87.3 6.8 89.3 5.9 0.327
14 hours 87.2 6.3 90.2 5.1 0.108
18 hours 87.5 6.4 90.8 5.5 0.089
22 hours 88.0 6.8 89.5 6.0 0.435
24 hours 87.9 6.4 89.7 6.6 0.388
Factorial- Repeated measures ANOVA test was used to test the difference in mean arterial pressure at time points in the post-operative period between the epidural and paravertebral groups.
Model
Mean MAP variation over time
mean MAP variation between 2 groups
Wilks’s Lambda F 0.650 0.758
df 17,22 17,22
p value 0.816 0.717
Comments:
1. There was a statistically significant difference between the mean MAP between the 2 groups till 5 hours in the post-operative period with subjects in epidural group experiencing lesser mean MAP than subjects in the paravertebral group as suggested by the student‘t’ test.
2. Variation in MAP: In factorial repeated measures ANOVA, there was no statistically significant variation in mean arterial pressure (MAP) over time as p>0.05. Also whatever minimal variation occurred in MAP among subjects who received paravertebral block was similar to MAP variation in subjects who received epidural block as the difference in variation of MAP between the 2 groups in the post-operative period was not statistically significant.
Fig 10: Comparison of mean arterial pressure (MAP) at various post- operative time points (n=40)
84.2 84.7
84.8 85.2
84.7 85
84.9 85.3
84.8 85.4
86.6 87.2
87.5
87.3 87.2 87.5 88 87.9 91.2 91.4
90.6 90.3
90 90 90.3 91.6
91.5 91.2
91.1
90 90.1
89.3
90.2
90.8
89.5 89.7
83 84 85 86 87 88 89 90 91 92 93
0 5 10 15 20
TIME (HOURS) Epidural Paravertebral
DISCUSSION
The mean per operative heart rate in patients received epidural block was ranging from 83.2 to 92.0 and patients received paravertebral block had mean heart rate ranging from 82.9 to 87.4 which is statistically insignificant.
The patients in epidural group experienced higher heart rate than patients in paravertebral group which is statistically significant over time but this difference in change in heart rate between the two groups were not significant.
In this study, there was no significant change with respect to heart rate between the 2 groups. This correlates with P. J. Mathews and Conacher et al, studies.
This signifies that both the techniques produces comparable level of analgesia.
Most of the patients in epidural group had mean per operative systolic blood pressure ranging from 103.4 to 120.9 and in the patients in paravertebral group ranging from 118.0 to 122.1 which is statistically significant.
The patients in the epidural group experienced a significant drop in per operative systolic blood pressure than the patients in paravertebral group who had minimal drop in blood pressure which is statistically significant.
This signifies that there is hemodynamic stability in paravertebral block.
Most of the patients in epidural group had mean per operative diastolic blood pressure ranging from 66.1 to 78.1 and in the patients in paravertebral group ranging from 76.0 to 78.9 which is statistically significant.
The patients in the epidural group experienced a significant drop in per operative diastolic blood pressure than the patients in paravertebral group who had minimal drop in diastolic blood pressure which is statistically significant.
This signifies that there is hemodynamic stability in paravertebral block.
The per operative mean blood pressure in patients received epidural block were ranging from 78.3 to 91.9 and in patients received paravertebral block were ranging from 89.6 to 92.7 which is statistically significant.
The patients in the epidural group experienced a significant drop in per operative mean blood pressure when compared to patients in paravertebral group who had minimal drop in mean blood pressure which is statistically significant. The significant incidence of hypotension in epidural group compared to thoracic paravertebral group correlates with the study of P.J.
This signifies that there is hemodynamic stability in paravertebral block than epidural blood in maintaining blood pressure.
The visual analogue scale score post operatively was meaningfully less in patients received paravertebral block compared to patients received epidural block by 0.1 mean score points which is statistically significant form first 4 to 10 hrs since P<0.05.This result correlates with Richardson et al. who conducted a prospective randomized study between thoracic epidural and paravertebral bupivacaine in 100 adult patients. The visual analogue pain score (VAS) at rest and on cough was significantly lower in the paravertebral group (P=0.02 and 0.0001, respectively).
There was a statistically significant difference between two groups over time in which the patients in paravertebral group experienced lesser pain over 24 hrs postoperatively than the patients in epidural group.
This signifies that the paravertebral block gives better analgesia when compared to epidural analgesia.
The postoperative mean blood pressure in patients received epidural block were
ranging from 83.1 to 85.6 which is statistically insignificant over time and also between the two groups since the variation between them was minimal and the P>0.05
The postoperative mean heart rate in patients received epidural block were ranging from 84.0 to 90.6 and in patients received paravertebral block were ranging from 83.1 to 85.6 which is statistically insignificant over time and also between the two groups.
This signifies that the postoperative maintenance of hemodynamics were comparable in both the groups.
From this study in both the groups the postoperative opioid requirement was minimal and hence the analgesic effect in both the groups were comparable.
There was no complications found in both the techniques in the postoperative period with better respiratory outcome.
SUMMARY
We conducted a prospective randomized clinical study comparing the hemodynamics and analgesic efficacy of Paravertebral Nerve Block versus thoracic Epidural Block by using levobupivacaine 0.5% with fentanyl for patients undergoing THORACOTOMY under General Anaesthesia. In this study 40 patients have been selected and segregated into two groups randomly.
Of them
Group E received epidural block and Group p received paravertebral block.
Heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure, VAS score were monitored.
In this study it was observed that per operative heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure was maintained in paravertebral group than epidural group.
It was also observed that VAS score was less in paravertebral group when compared to epidural group.
CONCLUSION
Thoracic epidural is still considered the gold standard for post thoracotomy pain relief. Single shot paravertebral block is widely used but the introduction of continuous infusion through pararvertebral space provided better analgesic effect and hemodynamic stability.
From this study we conclude that paravertebral block is superior to epidural block in providing better analgesia and maintaining hemodynamics peroperatively and in the postoperative period without postoperative complications.
BIBLIOGRAPHY
1)Wu CL, Fleisher LA. Outcomes research in regional anaesthesia and analgesia. Anaesth Analg. 2000;91:1232. [PubMed] [Google Scholar]
2)Khelemsky Y, Noto CJ. Preventing post-thoracotomy pain syndrome. Mt Sinai J Med. 2012;79(1):133–39. [PubMed] [Google Scholar]
3)Slinger PD. International Anaesthesia Research Society 2004 Review Course Lectures. Tampa, FL: 2004. Thoracic anaesthesia. In: Slinger PD, editor; pp.
116–22. [Google Scholar]
4)Licker M, de Perrot M, Hohn L, Tschopp JM, Robert J, Frey JG, et al.
Perioperative mortality and major cardio-pulmonary complications after lung surgery for non-small cell carcinoma. Eur J Cardiothoracic Surg. 1999;15:314–
19. [PubMed] [Google Scholar]
5)Watson A, Allen PR. Influence of thoracic epidural analgesia on outcome after resection for esophageal cancer. Surgery. 1994;115:429–
32. [PubMed] [Google Scholar]
6)Asida SM, Youssef IA, Mohamad AK, Abdelrazik AN. Post-thoracotomy pain relief: Thoracic paravertebral block compared with systemic opioids. Egyptian Journal of Anaesthesia. 2012;28(1):55–60.[Google Scholar]
7)De Cosmo G, Federico B, Sessa F, Fiorini F, Fortunato G, et al. Postoperative Analgesia in Thoracic Surgery: A Comparison between Continuous
Paravertebral Nerve Block and Continuous Incisional Infusion with OnQ Pain Relief System. J Anaesthe Clinic Res. 2012;4:279. [Google Scholar]
8)Kundra P, Varadharajan R, Yuvaraj K, Vinayagam S. Comparison of paravertebral and interpleural block in patients undergoing modified radical
mastectomy. Journal of Anaesthesiology Clinical
Pharmacology. 2013;29(4):459–64. [PMC free article] [PubMed] [Google Scholar]
9)Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral
extrapleural infusion for post-thoracotmy pain
management. Surgery. 1999;126:650–56. [PubMed] [Google Scholar]
10)Debreceni G, Molnar Z, Szelig L. Continuous epidural or intercostal analgesia following thoracotomy: a prospective randomized double-blind clinical trial. Acta Anaesth Scand. 2003;47:1091–95. [PubMed] [Google Scholar]
11)Perttunen K, Nilsson E, Heinonen J, Hirvisalo EL, Salo JA, Kalso E.
Epidural, paravertebral and intercostal nerve blocks in post-thoracotomy pain. Br J Anaesth. 1995;75:541–47. [PubMed] [Google Scholar]
12)Ibrahim AI, Mamdouh NM. Comparison between continuous thoracic epidural block and continuous thoracic paravertebral block for thoracotomy
pain relief. Ain Shams Journal of Anaesthesiology. 2009;2:16–26. [Google Scholar]
13)Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth. 1999;83(3):387–
92. [PubMed] [Google Scholar]
14)Kaiser AM, Zollinger A, De Lorenzi D, Largiador F, Weder W. Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain. Ann Thorac Surg. 1998;66:367–72.[PubMed] [Google Scholar]
15)Messina M, Boroli F, Landoni G, Bignami E, Dedola E, N’zepa Batonga J, et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol. 2009;75:616–21. [PubMed] [Google Scholar]
16)Kanazi GE, Ayoub CM, Aouad M, Abdallah F, Sfeir PM, Adham AB, et al.
Subpleural block is less effective than thoracic epidural analgesia for postthoracotomy pain: a randomised controlled study. Eur J Anaesthesiol. 2012;29:186–89. [PubMed] [Google Scholar]
