Year : 2007 | Volume
| Issue : 2 | Page : 62-67
Bilateral thoracic paravertebral block versus intraperitoneal bupivacaine for pain management after laparoscopic cholecystectomy
Ashraf A Moussa1, Fahd Bamehriz2
1 Department of Anesthesiology, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
2 Department of Surgery, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
Ashraf A Moussa
Department of Anesthesiology, King Faisal Specialist Hospital and Research Center, PO Box 3354, Riyadh 11211
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||18-Jul-2009|
| Abstract|| |
Background and Objectives: The efficacy of bilateral thoracic paravertebral block (TPVB ) was compared to intraperitoneal ( IP ) bupivacaine in reducing postoperative pain following laparoscopic cholecystectomy (LC ) using a prospective randomized study design.
Methods: We studied forty two patients scheduled for laparoscopic cholecystectomy. All of them received the same technique of general anaesthesia. Patients were randomly allocated into 3 equal groups, 14 patients each; Group PV received bilateral thoracic paravertebral block at T5-6 level with 25 mL of bupivacaine 0.25 % with epinephrine 1 : 200.000 on each side, Group IP received 50 mL of bupivacaine 0.25 % with epinephrine 1:
200.000 sprayed into the peritoneal cavity immediately after the pneumoperitoneum, and Group GA, received general anaesthesia only. Postoperative pain was assessed used visual analogue scale (VAS) and analgesic requirements and complications were recorded.
Results: There was significant decrease in VAS, HR, MAP, and morphine consumption in groups PV & IP when compared to group GA, also there were significant prolongation in time to rescue analgesia and reduction in hospital stay in group PV and IP compared to group GA. In comparison between the 2 active groups, paravertebral block was significantly superior to intraperitoneal bupivacaine in all parameters.
Conclusion: Both TPVB and IP bupivacaine are effective in reducing pain after LC. TPVB is superior to IP bupivacaine in controlling postoperative course of LC.
Keywords: (Analgesics, opioid: Anaesthetic technique: paravertebral block; intraperitoneal. Anaesthetics, local: bupivacaine. Pain: postoperative. Surgery, laparoscopic: cholecystectomy.)
|How to cite this article:|
Moussa AA, Bamehriz F. Bilateral thoracic paravertebral block versus intraperitoneal bupivacaine for pain management after laparoscopic cholecystectomy. Saudi J Anaesth 2007;1:62-7
|How to cite this URL:|
Moussa AA, Bamehriz F. Bilateral thoracic paravertebral block versus intraperitoneal bupivacaine for pain management after laparoscopic cholecystectomy. Saudi J Anaesth [serial online] 2007 [cited 2020 Feb 29];1:62-7. Available from: http://www.saudija.org/text.asp?2007/1/2/62/51863
| Introduction|| |
SINCE ITS INTRODUCTION by Muhe in Germany in 1985  , laparoscopic cholecystectomy (LC) has been the treatment of choice for symptomatic gallstone disease  . The severity of postoperative pain as well as analgesics consumption is significantly less after LC than after an open technique. Visceral and shoulder pain account for most of the pain after LC, whereas patients complain more of the parietal pain after laparotomy  . Rapid recovery after LC and improved postoperative management has led to progressively shorter hospital stay  .
The role of thoracic paravertebral block (TPVB) for postoperative analgesia in patients undergoing LC has been studied and proved effective  . TPVB is the technique of injecting local anaesthetic adjacent to the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramina. This results in somatic and sympathetic nerve blockade in multiple contagious thoracic dermatomes above and below the site of injection  . Data from the use of TPVB in patients undergoing LC is limited and the results are inconclusive  .
Administration of intraperitoneal (IP) local anaesthetic is used by many surgeons as a method of reducing postoperative pain. This technique was first evaluated in patients undergoing gynaecological laparoscopic surgery  . Its application in LC was initially examined in a randomized trial in 1993  .
Since then, many trials involving the efficacy of IP local anaesthetics in LC have been published worldwide. Although a number of these studies have reported a significant reduction in postoperative pain after the use of IP analgesia, others have reported no benefits ,, .
Because of these clinical controversies and so far, there is no study up-to-date that compares the effect of TPVB and IP local anaesthetic instillation for controlling pain after LC, therefore, we performed this prospective, controlled and randomized study to evaluate the safety and effectiveness of these techniques in LC.
| Methods|| |
After approval from the Hospital Ethics Committee, forty two patients in the physical status I-II, aged 18-45 years of both sexes were recruited in this study. Informed written consent was obtained from each patient. All procedures were performed by the same anaesthesiologist and surgical teams.
Exclusion criteria included allergy to local anaesthetics, history of cardiac disease, coagulopathy, infection at the site of TPVB placement, morbid obesity, and patient receiving regular analgesics. Only patients who were likely to have a simple LC without duct exploration or other invasive procedures were included. All patients received premedication in the form of midazolam 15 mg orally, 30 minutes before surgery.
Patients were equally assigned into three different groups, fourteen patients each by pre randomized, sealed envelops, to receive one of three different regimens:
Group (PV): Received bilateral TPVB at the level of T5-6 followed by the standardized general anaesthetic technique used for all patients.
Group (IP): Received the standardized general anaesthetic technique and IP 50 ml of bupivacain 0.25% by the surgeon immediately after pneumoperitoneum. The surgeon was requested to spray 20 ml of the anaesthetic solution into the hepatodiaphragmatic space, 10 ml in the area of gall bladder and 20 ml into the space between liver and kidney.
Group (GA): Received only the standardized general anaesthetic technique.
The General Anaesthesia technique:
General anaesthesia was induced with IV remifentanil 1 µg/kg, propofol 2 mg/kg. Rocuronium 0.6 mg/kg was used to facilitate orotracheal intubation. Anaesthesia was then maintained with remifentanil 0.1-0.4 µg/kg/min and propofol 4-10 mg/kg/hr using 2 separate infusion syringes (Diprifusor ™ , Graseby 3500 by SIMS Watford Herts, UK). Remifentanil and propofol infusion rates were adjusted to maintain blood pressure and heart rate within 20% of preinduction values. Ventilation was maintained with 40 - 50 % oxygen in air and mechanically adjusted to maintain P ET CO2 between 4.6-5.2 KPa with an anaestheic / respiratory analyzer (Capnomac Ultima, Datex, Finland). Muscle relaxation for pneumoperitoneum and surgical procedure was provided with additional doses of Rocuronium. During laparoscopy, intra-abdominal pressure was maintained at 1.3 - 1.8 KPa by carbon dioxide insufflator. Patients were monitored during anaesthesia by continuous ECG, NIBP, Pulse oximetry and capnometry (Solar 8000M, GE, Freiburg, Germany).
At the cessation of surgical procedure, remifentanil and propofol infusions were stopped. Residual neuromuscular blockade was reversed with I.V neostigmine 0.05 mg/kg and glycopyrrolate 5 µg/kg, and the trachea was extubated (defined as end of surgery), when the patient was awake.
Bilateral Thoracic Paravertebral Block technique
Prior to induction of GA, a bilateral TPVB was performed at T5-6 level with the patient in the sitting position. According to the guidelines described by Moore  and Katz  , two sites of injection were marked 2.5 cm lateral to the midline on both sides. Following aseptic preparation of skin each injection site was infiltrated with 0.5-1.0 ml of Lidocaine 1%, using a 29-G needle.
In each side, a 22-gauge Tuohy needle attached via extension tubing to a syringe, was advanced anteriorly in the parasagital plane ( perpendicular to the back in all planes) until it contacted the transverse process, the needle was then withdrawn to the subcutaneous tissue and angled to walk off the cauded edge then advanced anteriorly approximately 1 cm . After careful aspiration of the syringe, 25 mL of 0.25% bupivacaine with 1:200.000 epinephrine was injected over at least one minute. Patients were then returned to the supine position and the efficacy of the block was assessed by recording warming at the dermatomes T1-T10 (Dermatemp, infrared temperature scanner) and testing by pin prick method. Failed TPVB were excluded from the study.
In The Post Anaesthesia Care Unit (PACU)
Postoperative pain was evaluated using Visual Analogue Scale (VAS), where 0 means no pain and 10 the worst imaginable pain. In PACU, all patients received 50 µg/kg of IV morphine as a rescue analgesic when VAS is 4 or higher, every 6 minutes to control postoperative pain
In the ward, patient controlled analgesia was used with morphine concentration 1mg/ml, demand bolus of 2mg, lockout time of 6 minutes, no initial bolus and no basal infusion.
Nurses in the PACU and the ward collected the data were blinded to the patient's group and the authors were not involved in the data collection.
- Heart rate (HR) and Mean Arterial Pressure (MAP) were measured pre-operatively, on admission to Post Anesthesia Care Unit (PACU), and on discharge from PACU (2 hours postoperatively).
- Respiratory rate (RR) and oxygen saturation (SO2) were measured preoperatively, on admission to PACU, and on discharge from PACU.
- Visual Analogue Scale (VAS) was assessed on admission to and on discharge from PACU.
- The time to first analgesic requirement (minutes).
- Postoperative morphine consumption during the first 2 hours and after 24 hours was recorded.
- The incidence of complications including respiratory depression (RR less than 10), oxygen desaturation (SaO2 < 87%) on admission to PACU, re-intubation during the first 24 hours postoperatively, and the incidence of nausea and vomiting (N&V) were recorded as the number of patients needed medical treatment in each group.
A power analysis with a pain score as the primary criterion (Power = 0.90, [alpha] = 0.05 unilateral, with Bonferroni correction) on the basis of previous studies [ 7] ,[ 8] revealed that 12-14 patients were mandatory in each group.
ANOVA test was used to compare and analyze results between groups, while subgroup analysis was achieved by Tuqey's approach. The statistical analysis of means within the groups is achieved via paired t test. A p value < 0.05 was considered significant.
| Results|| |
There was no significant difference between the three groups of patients with regard to demographic data, body mass index, duration of surgery and ASA physical status as shown in [Table 1].
There were no significant haemodynamic changes between all groups before induction of anaesthesia (baseline readings), or during anaesthesia (data not shown). However, there was significant decrease in HR and MAP on admission and on discharge from PACU in groups PV and IP compared to group GA. When Groups PV and IP were compared, no significant differences were found [Table 2].
Pain scores were statistically lower in patients of groups PV and IP as compared to group GA, both on admission and on discharge from PACU at 2 hours postoperatively. When groups PV and IP were compared, pain score values were statistically lower in patients of group PV both on admission and discharge from PACU, [Table 3].
The time to first analgesic requirement was 33.5 ±7.15 min in Group GA, 61.66±9.4 min in Group IP, and 116.08 ± 3.05 min in Group PV. There was significant increase in time for first analgesic requirement in Groups PV and IP when compared to Group GA (P < 0.01), and also in group PV when compared to group IP (P < 0.01) [Table 4].
The morphine consumption in group PV was significantly lower than groups IP and GA both 2 hours postoperatively, on discharge from PACU (5.1± 1.58 mg compared to 8.33±1.82 and 12.91±3.28 mg respectively) and after 24 hours (31.66 ±7.7 mg) compared to 47.33±8.33 and 68.12±22.42 mg respectively. Also, the morphine consumption in group IP was significantly lower than group GA both on discharge from PACU (8.33±1.82 mg compared to 12.91±3.28 mg) and after 24 hours (51.33±8.33 mg compared to 73±22.42 mg), respectively, [Table 4].
There were no significant changes in oxygen saturation and respiratory rate between the three groups on admission to PACU (P > 0.01). In group GA, one patient 7.1%) suffered from transient oxygen de-saturation during the first 24 hours compared to 0 patients in the other 2 groups (P < 0.01). In group GA, 8 patients 57.1%) suffered from postoperative vomiting compared to 5 patients (35.7%) in group IP and 2 patients (14.2%) in group PV, (P < 0.01).
| Discussion|| |
Despite of the various advantages associated with LC, pain remains an issue in the postoperative period  . VAS scores for patients receiving only GA were very similar to those reported by Tsertelli and colleagues, and O'Boyle and colleagues , .
The main finding of the present prospective, randomized study was a significant improvement of postoperative pain relief following LC in patients treated with TPVB and IP local anaesthetic administration compared to patients who received GA only. Furthermore, patients received TPVB were superior to those received IP local anaesthetic administration as regards postoperative pain control, longer time for first rescue analgesia, and lower total morphine consumption. The intra-peritoneal administration of local anaesthetics, being an easy way of applying these drugs, draws much attention of the anesthesiologists. However, there was controversy about the efficacy of this technique in reducing post laparoscopic pain. The difference in outcome of studies on intra-peritoneal instillation of local anaesthetics may result from the nature of surgery, dose, type and timing of instillation of local anaesthetic. Also the failure in some studies to show an analgesic effect may result from the wide area on which the local anaesthetic spread in the peritoneal cavity which cannot be overcome by increasing the dose of local anaesthetic  . It is not possible to increase the dose of local anaesthetic without increasing the risk of systemic toxicity. Although potentially more toxic than lidocaine, bupivacaine has the advantage that it has a longer duration of action. The mean plasma concentration of bupivacaine after intra-peritoneal instillation of 100150 mg plain bupivacaine ranges between 0.92 to 1.14 µg ml -1 , which is well below the toxic concentration of 3 µg ml -1 ,, .
The rationale behind the use of intra-peritoneal route of administration is that the visceral nociceptive conduction can be blocked through the peritoneum exposed to local anaesthetic. Again, absorption from the large peritoneal surface may also occur, which may be a further mechanism of analgesia. In 1997, Williamson et al ,described the use of large volumes of dilute local anaesthetic (80 ml lidocaine 0.5% or 80 ml bupivacaine 0.125%, both with epinephrine) administered before surgery into the peritoneal cavity for the treatment of pain after laparoscopy . They demonstrated significant reductions in mean pain scores in the local anaesthetic groups from eight to 24 hr after surgery compared to the control group  .
The reason for the superiority of TPVB in comparison to IP local anaesthetic administration is probably multi-factorial but two possible explanations can be speculated. First, the duration of postoperative analgesia following instillation of local anaesthetics has been reported to be limited and systematic reviews have questioned the efficacy of this treatment modality for postoperative analgesia , .
A limited duration of action can also be speculated for intra-abdominal instillation of local anaesthetics since the surface area of the peritoneum is large and rapid absorption of the local anaesthetics can, thus, potentially limit the duration and efficacy of this treatment  . Second, cholecystectomy is associated with a substantial component of visceral pain and the incidence of shoulder pain probably reflects a component of diaphragmatic referred pain , . Thus, in order to provide adequate pain relief, both high quality afferent somatic and visceral pain blockade are most likely necessary in order to successfully treat cholecystectomy pain. Contrary to intra-abdominal instillation of local anaesthetics, TPVB has reported to provide high quality afferent blockade with abolishment of somatosensory evoked potentials and has also been found capable of attenuating the postoperative stress response associated with traditional cholecystectomy  . A combined somatic and visceral analgesic effect has also been described for intrapleural anaesthesia, a nerve blocking technique that to a large extent exerts its effect by diffusion of local anaesthetics into the paravertebral space  .
Adequate somatic and visceral blockade will require that the bilateral injections at T5-6 are able to spread to multiple adjacent thoracic segments. Although not specifically studied in the present study, such spread between segments has been verified in both patients and cadaveric studies, and single level injection of local anaesthetic has been also found to result in a multi-segmental anaesthesia , .
Significantly lower incidence of postoperative nausea and vomiting (PONV) in groups PV and IP in comparison to group GA and also significant lower incidence of PONV in group PV when compared to group IP can be easily explained by their lower morphine consumption. Many studies proved that the higher the doses of morphine consumption in the postoperative period, the higher the incidence of PONV , .
In conclusion, combined techniques of general anaesthesia with thoracic paravertebral block is effective in controlling the postoperative pain and has a smooth postoperative course in comparison to the traditional general anaesthesia alone or with intraperitoneal instillation of bupivacaine. This combined technique deserves more widespread use in patients undergoing laparoscopic cholecystectomy.
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[Table 1], [Table 2], [Table 3], [Table 4]