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  • Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial

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Regional Anesthesia and Acute Pain: Original Articles
Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial
  1. Kristin L. Schreiber, MD, PhD*,
  2. Jacques E. Chelly, MD, PhD, MBA†,
  3. R. Scott Lang, MD†,
  4. Ezeldeen Abuelkasem, MD, MSc†,
  5. David A. Geller, MD‡,
  6. J. Wallis Marsh, MD, MBA‡,
  7. Allan Tsung, MD‡ and
  8. Tetsuro Sakai, MD, PhD†
  1. From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Departments of †Anesthesiology and ‡Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
  1. Address correspondence to: Tetsuro Sakai, MD, PhD, Department of Anesthesiology, University of Pittsburgh School of Medicine. UPMC Montefiore, Suite N469.11, 200 Lothrop St, Pittsburgh, PA 15213 (e-mail: sakait{at}upmc.edu).

Abstract

Background and Objectives Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection.

Methods This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0–10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function.

Results Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (−12.6 [15.8] vs −3.8 [16.2]; P = 0.016).

Conclusions This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.

https://doi.org/10.1097/AAP.0000000000000422

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    Footnotes

    • Authors' Contributions: K.L.S.: study design, coordination, patient recruitment, data collection and analysis, and writing of first and subsequent drafts of manuscript; J.E.C.: study conception, design, and data analysis; R.S.L. and E.A.: study coordination, patient recruitment, and data collection; D.A.G., J.W.M., and A.T.: study coordination and patient recruitment; T.S.: study conception, design, study coordination, patient recruitment, data collection, data analysis, and writing of first and subsequent drafts of manuscript. All authors read and approved the final manuscript.

      This study was supported in part by the National Institutes of Health, Bethesda, MD, through grant UL1-TR-000005 (The Clinical & Translational Science Institute).

      A part of the results and analyses has been presented in abstract form at the 109th Annual Meeting of the American Society of Anesthesiologists; New Orleans, LA; October 11-15, 2014.

      The authors declare no conflict of interest.

      Trial Registration: ClinicalTrials.gov Identifier NCT01407666.

      Department/institution to which the work is attributed: Department of Anesthesiology, University of Pittsburgh School of Medicine.