Thoracic Paravertebral Block in Pain Management After Renal Surgery
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Objective: The objective of the study was to assess the usefulness of ThPVB in postoperative
      pain management after open renal resection surgery.

      Design, setting, participants: It was a prospective, randomised, open label study held in a
      university hospital between 08.2013-12.2014. 58 Patients enrolled in the study were scheduled
      for elective open renal surgery (open nephrectomy or open nephron-sparing surgery) and
      randomised into two groups - group PVB (n=27) and group GEN (n=31).

      Interventions: PVB group received preoperative ThPVB with 0,5% bupivacaine followed by
      general anaesthesia. GEN group received standard general anaesthesia. Both groups were
      treated postoperatively with oxycodone IV PCA (patient controlled analgesia) combined with
      non-opioid analgesics as rescue drugs. The investigators recorded pain severity in VAS,
      oxycodone requirement in time points, total oxycodone requirement, and sedation levels
      throughout the first 48h. The investigators measured opioid related adverse events 24 and 48
      h postoperatively and patients satisfaction 48h postoperatively.
    

Detailed description: 
      In PVB group before the induction of general anaesthesia a single shot thoracic paravertebral
      blockade was performed. ThPVB was performed on Th7-Th10 level, approximately 2,5 - 3 cm
      lateral from the top of the spinous process with prior ultrasound control of the depth of the
      transverse process and the pleura. To make the procedure safer the investigators used
      peripheral nerve stimulation with an isolated 10 cm needle with a start current of 2,5 mA.
      The needle was inserted until visible muscle activity from intercostal muscles appeared, with
      a current of 0,5-0,3mA (paravertebral space identification). Next 0,3 ml kg-1 0,5% plain
      bupivacaine was injected after negative aspiration for air and blood. The efficacy of the
      blockade was checked after 20 minutes with cold saline.

      In both groups, PVB and GEN general anaesthesia was induced with midazolam 0,1 mgkg-1,
      propofol 2 mgkg-1, cis-atracurium 0,15 mgkg-1 and fentanyl 1,5 µgkg-1. Patients were
      intubated with a standard single lumen tracheal tube. Anaesthesia was maintained with 1 MAC
      (Minimal Alveolar Concentration) sevoflurane. For surgical analgesia the investigators used
      fractional doses of fentanyl 1-3 mg kg-1 if HR (heart rate) or MBP (mean blood pressure)
      raised above 20% of basal values. Waking up from anaesthesia was in a post-anaesthesia care
      unit.

      Postoperative pain management schedule was identical in both groups. After the surgery, if
      pain appeared, the patient was given oxycodone i.v. titrated to achieve acceptable analgesia
      level or until side effects appeared. Every patient received a PCA (Patient controlled
      analgesia) device with a 1 mgml-1 concentration oxycodone solution with a programmed single
      bolus dose of 1 mg and a lockout time of 5 minutes. Additionally, patients were given 1g i.v.
      paracetamol every 6 hours and 100 mg of i.v. ketoprofen every 12 hours.

      For 48 h postoperatively, the investigators monitored HR, SBP (systolic blood pressure) , DBP
      (diastolic blood pressure), sedation level in Ramsay scale, pain intensity at rest in VAS
      (visual analogue score) scale, oxycodone requirement in pre-selected time points and total
      oxycodone requirement. The investigators also recorded opioid-related adverse events 24 and
      48 h postoperatively in OBAS scale and patients' satisfaction regarding postoperative
      analgesia 48 h postoperatively in Likert scale.
    

Intervention name(s): Paravertebral blockade (PVB); Sopodorm; Propofol WZF; Nimbex; Fentanyl WZF; Sevorane; Intubation; Oxynorm; Paracetamol Kabi; Ketonal; Bupivacaine WZF
Intervention type(s): Procedure; Drug; Drug; Drug; Drug; Drug; Device; Drug; Drug; Drug; Drug
Intervention description(s): preoperative ThPVB performed unilaterally at Th10 level; midazolam 0,1 mgkg-1 intravenously (anesthesia induction); propofol 2 mgkg-1intravenously (anesthesia induction); cis-atracurium 0,15 mgkg-1 intravenously (anesthesia induction); fentanyl 1,5 µgkg-1 intravenously (anesthesia induction); sevoflurane in 1 MAC (Minimal Alveolar Concentration) - anesthesia maintenance; Intratracheal intubation with a single lumen endotracheal tube; 1 mgml-1 concentration oxycodone solution intravenously; 1g paracetamol intravenously every 6 hours; 100 mg ketoprofen intravenously every 12 hours; 0,3 ml kg-1 0,5% plain bupivacaine (regional anesthesia - paravertebral blockade)
Intervention MeSH terms: Acetaminophen; Fentanyl; Bupivacaine; Propofol; Sevoflurane
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: PVB; PCA; nephrectomy; postoperative pain