Effects of programmed intermittent thoracic paravertebral bolus of levobupivacaine on the spread of sensory block: a randomized, controlled, double-blind study.

BACKGROUND AND OBJECTIVES: This randomized, controlled, double-blind trial compared the effectiveness of levobupivacaine delivery of a programmed intermittent paravertebral bolus with a continuous paravertebral infusion. METHODS: Thirty-two consecutively enrolled patients who underwent unilateral video-assisted thoracic surgery were randomized to receive either a programmed intermittent paravertebral bolus of 10 mL of 0.2% levobupivacaine every 2 hours (Bolus group, n=16) or a continuous paravertebral infusion of 0.2% levobupivacaine at 5 mL/hour (Infusion group, n=16) after the operation. Postoperatively, after injection of 20 mL of 0.25% levobupivacaine through the paravertebral catheter, a mechanical infusion pump was set depending on the assigned group. The primary efficacy outcome was the number of anesthetized dermatomes 24 hours after the initial bolus of levobupivacaine. The secondary efficacy outcomes included the number of anesthetized dermatomes at other time points, pain at rest and coughing, additional analgesic use and patient acceptance of the analgesic technique. Arterial levobupivacaine concentration was measured to ensure safety. P<0.05 was considered statistically significant. RESULTS: The mean (95% CI) number of anesthetized dermatomes 24 hours after the initial bolus of levobupivacaine was significantly larger among subjects receiving programmed intermittent bolus (n=16) compared with those receiving continuous infusion (n=16; 6.8 (5.7-7.9) vs 3.1 (2.0-4.2); p<0.001). The arterial levobupivacaine concentration did not reach a toxic level. CONCLUSIONS: The programmed intermittent paravertebral bolus of levobupivacaine provided a wider dermatomal spread of sensory block than continuous paravertebral infusion with an identical hourly dose of levobupivacaine. TRIAL REGISTRATION NUMBER: UMIN000022532.

[Perioperative Pain Management of Minimally Invasive Esophagectomy with Bilateral Continuous Thoracic Paravertebral Block].

Minimally invasive esophagectomy has become popular as a surgical procedure for esophageal cancer. We describe bilateral continuous thoracic paravertebral blocks for perioperative pain management in 3 patients who underwent minimally invasive esophagectomy. After anesthesia induction, bilateral thoracic paravertebral catheters were placed under ultrasound guidance with the patients in left lateral decubitus position at the sixth or seventh right intercostal space and eighth or ninth left intercostal space, respectively. Multiple ports for thoracoscopic procedures were located between the right third and ninth intercostal spaces. Laparoscopy-assisted gastric tube reconstruction was performed with skin incisions at bilateral T7-10 dermatomes. Intraoperative intermittent bolus injections of ropivacaine through the thoracic paravertebral catheters were used in combination with sevoflurane-remifentanil anesthesia, followed by continuous thoracic paravertebral infusion of ropivacaine for postoperative analgesia with continuous intravenous fentanyl infusion and periodical intravenous acetaminophen administration. Numerical rating scales of postoperative pain at rest and when coughing were 4 or less for 48 hr after surgery. No complications related to thoracic paravertebral catheterization were observed. Bilateral continuous thoracic paravertebral blocks at different intercostal levels can provide good perioperative analgesia for minimally invasive esophagectomy.

Sympathotomy for palmar hyperhidrosis: the cutting versus clamping methods.

PURPOSE: Endoscopic thoracic sympathectomy/sympathotomy for the treatment of palmar hyperhidrosis is generally performed by either cutting or clamping the sympathetic chain. However, it remains unclear as to which of these methods is more effective and has fewer side effects. This study was conducted to compare the effects of sympathotomy by cutting or clamping at T3 on two outcomes--postoperative palmar sweating and compensatory sweating; it also evaluated postoperative patient satisfaction. METHODS: The participants were among 289 patients who underwent bilateral sympathotomy at T3 for palmar hyperhidrosis. These patients were sent questionnaires by mail to assess their self-reported degree of postoperative palmar sweating and compensatory sweating, as well as their level of satisfaction. Of the 92 patients who responded to the questionnaire, 54 had undergone sympathotomy by cutting (cutting group) and 38 by clamping (clamping group). RESULTS: The degree of postoperative palmar sweating was significantly lower in the cutting group than in the clamping group. However, compensatory sweating was significantly more severe in the cutting group than in the clamping group. No significant difference was observed in the degree of patient satisfaction between the groups. CONCLUSIONS: Sympathotomy by clamping at T3 was less effective in reducing the primary symptom of postoperative palmar sweating, but induced less compensatory sweating than did sympathotomy by cutting at T3. However, both methods were similar with regard to patient satisfaction. The degree of postoperative palmar sweating and the severity of compensatory sweating were inversely correlated with the degree of patient satisfaction.