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Eur J Cardiothorac Surg 2009;35:188. doi:10.1016/j.ejcts.2008.10.011
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Should paravertebral analgesia be used to fast track patients after thoracic surgery?

Hany Elsayed*, Michael Poullis

Liverpool Heart and Chest Hospital, Thomas drive, Liverpool L14 3PE, United Kingdom

Received 25 July 2008; accepted 15 October 2008.

* Corresponding author. Address: 4 Isleham Close, Liverpool L19 4XS, United Kingdom. Tel.: +44 7756985742. (Email: hanyhassan77{at}hotmail.com).

Key Words: Fast track • Paravertebral • Analgesia

We read the article reported by Muehling et al. [1] titled ‘Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway’ with great interest and we must say it is well organised and informative although we think an important point needs to be addressed.

The authors have divided the patients into two groups, where the fast tracked group received a patient controlled epidural analgesia, but we disagree with that, as we believe that providing the patient with paravertebral analgesia can result in a better chance of fast tracking patients with fewer complications.

Richardson and colleagues [2], in a prospective, randomised comparison of epidural versus paravertebral bupivicaine in 95 patients, found a significantly higher incidence of both urinary retention, defined as the requirement for catheterisation, and hypotension, defined as a decrease in preoperative systolic or diastolic blood pressure of 20% or more, in the epidural group. In fact, no patient in the paravertebral group experienced hypotension.

A recently published systematic review and meta-analysis of randomised trials directly compares the analgesic efficacy of paravertebral versus epidural blockade for thoracotomy [3]. All the included studies used a paravertebral catheter technique. Ten studies published between 1989 and 2005 and including 520 adult patients who underwent thoracotomy were included in the meta-analysis. Interestingly, there was a significantly lower incidence of pulmonary complications, defined as clinical evidence of pneumonia and atelectasis, in the paravertebral group.

We have compared 147 patients in our institute who had paravertebral analgesia after lung resections with 2100 patients who had epidural analgesia. The two groups were comparable in terms of risk factors and we found that the paravertebral group had a shorter hospital stay (6 vs 7 days) (p = 0.03). Hence we do advocate using paravertebral analgesia in an attempt to fast track patients after lung resections.

References

  1. Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder-Plassman L, Orend K-H. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 2008;34:174-180.[Abstract/Free Full Text]
  2. Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998;81:230-238.[Free Full Text]
  3. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy. A systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418-426.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
B. M. Muehling, R. Meierhenrich, L. Sunder-Plassmann, and K.-H. Orend
Reply to Elsayed and Poullis
Eur. J. Cardiothorac. Surg., January 1, 2009; 35(1): 188 - 189.
[Full Text] [PDF]

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