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Meta-Analysis
. 2016 Feb 21;2(2):CD009121.
doi: 10.1002/14651858.CD009121.pub2.

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy

Joyce H Y Yeung  1 , Simon Gates, Babu V Naidu, Matthew J A Wilson, Fang Gao Smith
Affiliations
Meta-Analysis

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy

Joyce H Y Yeung et al. Cochrane Database Syst Rev. .

Abstract

Background: Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy.

Objectives: To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness.

Search methods: We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review.

Selection criteria: We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis).

Main results: We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs.

Authors' conclusions: Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.

PubMed Disclaimer

Conflict of interest statement

Joyce HY Yeung: The preparation of this systematic review was supported by a small grant from Queen Elizabeth Hospital Charities (Sources of support). Joyce Yeung is a co‐applicant on NIHR Research for Patient Benefit grant, Thoracic epidural and paravertebral block in reducing chronic post‐thoracotomy pain ‐ a feasibility study. Joyce Yeung is chief investigator in Evaluation of non‐technical skills in ALS courses funded by Resuscitation Council UK Research Grant.

Simon Gates: none know

Babu V Naidu: none known

Matthew JA Wilson: Grants/grants pending: UK National Institute of Health Research. Expert testimony: medical expert witness ‐ Obstetric Anaesthesia.The financial activities listed reflect my regular salary from my main employer (Sheffield University), occasional medical expert witness work, restricted to Obstetric Anaesthesia and grants supporting my academic activities in other research areas. None of these declarations have a direct relationship to the submitted work.

Fang Gao Smith: none known

Figures

1
1
1 Study flow diagram (Search dates October 2013, reran January 2015)
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 2 Major complications, outcome: 2.1 Cardiovascular complications.
5
5
Forest plot of comparison: 2 Major complications, outcome: 2.2 Respiratory complications.
1.1
1.1. Analysis
Comparison 1 30‐day mortality, Outcome 1 30‐day mortality.
2.1
2.1. Analysis
Comparison 2 Major complications, Outcome 1 Cardiovascular complications.
2.2
2.2. Analysis
Comparison 2 Major complications, Outcome 2 Respiratory complications.
2.3
2.3. Analysis
Comparison 2 Major complications, Outcome 3 Neurological complication (Delirium).
2.4
2.4. Analysis
Comparison 2 Major complications, Outcome 4 Unexpected ITU admission.
3.1
3.1. Analysis
Comparison 3 Acute pain, Outcome 1 VAS scores 2 to 6 hours.
3.2
3.2. Analysis
Comparison 3 Acute pain, Outcome 2 VAS scores at 24 hours.
3.3
3.3. Analysis
Comparison 3 Acute pain, Outcome 3 VAS scores at 48 hours.
3.4
3.4. Analysis
Comparison 3 Acute pain, Outcome 4 Failure of technique.
4.1
4.1. Analysis
Comparison 4 Minor complications, Outcome 1 Hypotension.
4.2
4.2. Analysis
Comparison 4 Minor complications, Outcome 2 Nausea and vomiting.
4.3
4.3. Analysis
Comparison 4 Minor complications, Outcome 3 Excessive sedation.
4.4
4.4. Analysis
Comparison 4 Minor complications, Outcome 4 Pruritis.
4.5
4.5. Analysis
Comparison 4 Minor complications, Outcome 5 Urinary retention.
5.1
5.1. Analysis
Comparison 5 Hospital stay, Outcome 1 Duration of hospital stay.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD009121

References

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Yeung 2011
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