Fibla Juan J, Molins Laureano, Mier Jose Manuel, Sierra Ana, Vidal Gonzalo
Department of Thoracic Surgery, Hospital Universitari Sagrat Cor., C/Viladomat 288, 08029 Barcelona, Spain.
Eur J Cardiothorac Surg. 2008 Mar;33(3):430-4. doi: 10.1016/j.ejcts.2007.12.003. Epub 2008 Jan 16.
Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine).
Prospective randomized study of 70 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (AT or PT) patients were randomized to receive a bolus of 15 ml of bupivacaine 0.5% or 20 ml of ropivacaine 0.2% before closing the thoracotomy. They postoperatively received 10 ml of bupivacaine or 15 ml of ropivacaine every 6h combined with methamizol (every 6h). Subcutaneous meperidine was employed as rescue drug. The level of pain was measured with the visual analogic scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as rescue drug and secondary effects was also recorded.
We did not register secondary effects in relation to the paravertebral catheter (paravertebral or cutaneous bleeding or hematoma, respiratory depression (respiratory rate <8 breaths per minute), cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting and pruritus). Eleven patients (16%) needed meperidine as rescue drug (six with ropivacaine and five with bupivacaine). Mean VAS values were the following: all the cases (n=70): 5.2+/-2.1, AT (n=38): 4.5+/-2.1, PT (n=32): 5.9+/-1.7, bupivacaine (n=35): 4.9+/-2.1, ropivacaine (n=35): 5.4+/-1.9, AT with bupivacaine (n=19): 4.2+/-2.2, AT with ropivacaine (n=19): 4.9+/-2.0, PT with bupivacaine (n=16): 5.7+/-1.6, PT with ropivacaine (n=16): 6.0+/-1.7.
Post-thoracotomy analgesia combining paravertebral catheter and a nonsteroidal anti-inflammatory drug is a safe and effective practice, VAS values are acceptable (only 16% of patients required meperidine as rescue). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.5 vs 5.9, p<0.01). Bupivacaine got slightly better VAS values than ropivacaine (4.9 vs 5.4 p<0.05). Higher doses and volumes of local anesthetic could be used to obtain better VAS values.
在开胸术后疼痛管理中，椎旁阻滞是硬膜外镇痛的一种有效替代方法，然而，对于不同组之间改变药物和剂量时最合适的策略，尚无既定指南。我们的目的是通过比较该手术中最常用的药物（布比卡因与罗哌卡因）来评估椎旁阻滞的有效性。
对70例行开胸手术的患者进行前瞻性随机研究。患者分为两个独立组（前外侧开胸术（AT）和后外侧开胸术（PT））。手术结束时，在直视下于切口水平的胸段椎旁间隙插入一根导管。在每组（AT或PT）中，患者被随机分配在关胸术前接受15毫升0.5%布比卡因或20毫升0.2%罗哌卡因的推注。术后每6小时给予10毫升布比卡因或15毫升罗哌卡因，并联合使用安乃近（每6小时一次）。皮下注射哌替啶用作补救药物。术后1、6、24、48和72小时用视觉模拟评分法（VAS）测量疼痛程度。还记录了使用哌替啶作为补救药物的情况及副作用。
我们未记录到与椎旁导管相关的副作用（椎旁或皮肤出血或血肿、呼吸抑制（呼吸频率<8次/分钟）、心脏毒性、意识模糊、镇静、尿潴留、恶心、呕吐和瘙痒）。11名患者（16%）需要使用哌替啶作为补救药物（6名使用罗哌卡因，5名使用布比卡因）。平均VAS值如下：所有病例（n = 70）：5.2±2.1，AT组（n = 38）：4.5±2.1，PT组（n = 32）：5.9±1.7，布比卡因组（n = 35）：4.9±2.1，罗哌卡因组（n = 35）：5.4±1.9，AT联合布比卡因组（n = 19）：4.2±2.2，AT联合罗哌卡因组（n = 19）：4.9±2.0，PT联合布比卡因组（n = 16）：5.7±1.6，PT联合罗哌卡因组（n = 16）：6.0±1.7。
椎旁导管联合非甾体类抗炎药用于开胸术后镇痛是一种安全有效的方法，VAS值可接受（仅16%的患者需要使用哌替啶作为补救）。它避免了与硬膜外镇痛相关的副作用风险。接受AT手术的患者比接受PT手术的患者疼痛程度轻（4.5对5.9，p<0.01）。布比卡因的VAS值略优于罗哌卡因（4.9对5.4，p<0.05）。可使用更高剂量和体积的局部麻醉药以获得更好的VAS值。
