Department of Thoracic Surgery, Hospital Universitari Sagrat Cor., C/Viladomat 288, 08029 Barcelona, Spain.
Eur J Cardiothorac Surg. 2009 Nov;36(5):901-5; discussion 905. doi: 10.1016/j.ejcts.2009.05.041. Epub 2009 Jul 16.
Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours.
The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded.
We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n=60): 4.7+/-2.0; AT (n=32): 4.0+/-2.1; PT (n=28): 5.6+/-1.8; pre-RS (n=30): 4.8+/-1.9; post-RS (n=30): 4.6+/-2.0; AT-pre-RS (n=16): 4.1+/-2.0; AT-post-RS (n=16): 3.9+/-2.1; PT-pre-RS (n=14): 5.6+/-1.6; PT-post-RS (n=14): 5.4+/-1.7.
Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p<0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p>0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.
椎旁阻滞（PVB）是一种替代硬膜外镇痛的有效方法，可用于治疗开胸术后疼痛。肋骨撑开（RS）是一种重要的有害刺激，被认为是开胸术后疼痛的主要原因。我们的假设是，在 RS 之前通过插入的椎旁导管（PVC）给予罗哌卡因 0.2% 负荷量可以减少术后前 72 小时的疼痛。
采用前瞻性随机研究连续纳入 60 例接受开胸手术的患者。患者分为两组（前开胸组（AT）和后外侧开胸组（PT））。在切口水平的胸椎旁间隙直视下插入导管。在每组中，患者随机接受 RS 前（预 RS）或 RS 后（后 RS）20ml 0.2%罗哌卡因。术后每 6 小时接受 15ml 0.2%罗哌卡因联合甲灭酸（每 6 小时）。皮下哌替啶作为解救药物。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。还记录了哌替啶的需要作为解救药物和次要效应。
我们没有在 PVC（椎旁或皮肤出血或血肿、呼吸抑制、心脏毒性、意识混乱、镇静、尿潴留、恶心、呕吐或瘙痒）方面发现与 PVC 相关的次要效应。7 例（11.6%）患者需要哌替啶作为解救药物（预 RS 4 例，后 RS 3 例）。平均 VAS 值如下：所有病例（n=60）：4.7+/-2.0；AT（n=32）：4.0+/-2.1；PT（n=28）：5.6+/-1.8；预 RS（n=30）：4.8+/-1.9；后 RS（n=30）：4.6+/-2.0；AT-预 RS（n=16）：4.1+/-2.0；AT-后 RS（n=16）：3.9+/-2.1；PT-预 RS（n=14）：5.6+/-1.6；PT-后 RS（n=14）：5.4+/-1.7。
开胸术后镇痛结合 PVC 和非甾体抗炎药是一种安全有效的方法。VAS 值可接受（仅 11.6%的患者需要哌替啶）。它可以预防与硬膜外镇痛相关的副作用风险。接受 AT 的患者比接受 PT 的患者疼痛程度更低（4.0 对 5.6；p<0.01）。RS 前给予罗哌卡因 PVB 与 RS 后给予的 PVB 相比，VAS 值相似（4.8 对 4.6；p>0.05）。PVC 的插入时间似乎并不影响术后疼痛水平。
