Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 264--265

Invited Commentary

Yatin Mehta 
 Medanta Insititute of Critical Care and Anaesthesiology, Gurgaon, Haryana, India

Correspondence Address:
Yatin Mehta
Medanta Insititute of Critical Care and Anaesthesiology, Medanta, The Medicity Sector 38, Gurgaon, Haryana

How to cite this article:
Mehta Y. Invited Commentary.Ann Card Anaesth 2012;15:264-265

How to cite this URL:
Mehta Y. Invited Commentary. Ann Card Anaesth [serial online] 2012 [cited 2023 Jan 29 ];15:264-265
Available from:

Full Text

El-Morsy et al., [1] in a well-conducted randomized blinded prospective study, compared paravertebral block (PVB) with thoracic epidural analgesia (TEA) in pediatric patients undergoing thoracotomy. The authors found higher failure rate and complications like nausea, vomiting, hypotension, and urinary retention with TEA, but other parameters were comparable. These findings are similar to those of our previous studies in adult patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) [2] and in robotic assisted coronary artery bypass surgery. [3]

PVB is an old technique, [4] but has not become very popular after thoracotomy as compared to TEA, intercostal nerve block, [5] or interpleural block [6] despite lower incidence of complications. In earlier studies, PVB was performed blindly mostly by loss of resistance technique; [7],[8] but in the present paper, the authors used a nerve stimulator for PVB and ultrasound for performing TEA. Utilization of these techniques would certainly reduce the failure rate of these techniques of blocks while probably reducing the complications. The complications of PVB are few like intercostal vessel puncture with subsequent hematoma/hemothorax, [9] pain at the site of puncture, [10] and pleural/lung puncture with resultant pneumothorax. [11],[12],[13],[14] In the present series there was no incidence of pneumothorax, but after a thoracotomy that is really not significant. Apparently, PVB has far lesser complications than TEA.

Although multiple paravertebral injections have been used for post-thoracotomy pain, [9],[15] continuous paravertebral infusion of bupivacaine or ropivacaine with or without fentanyl is the preferred method and has been used in many studies [16],[17] and provides satisfactory and comparable analgesia. [7] Great advances in pain management have occurred in the last 20 years. Patient outcomes in thoracic surgery, including postoperative mobility, duration of hospital stay, atelectasis, pneumonia, and chronic pain syndrome, may be directly related to pain. [18] Given that there is no significant difference in analgesia with PVB compared to TEA as also shown in this study, PVB should be considered in much larger number of patients than it is done at present. [19] PVB should be used post-thoracotomy whenever possible and, in my opinion, we as anesthesiologists are as much responsible for analgesia as for anesthesia.


1El-Morsy GZ, El-Deeb A, El-Desousky T, Elsharkawy AA, Elgamal MA. Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. Ann Card Anaesth 2012;15:259-63.
2Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for post-operative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2001;15:288-92.
3Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth 2008;11:91-6.
4Richardson J, Sabanathan S, Mearns AJ, Shah RD, Goulden C. A prospective randomized comparison of interpleural and paravertebral analgesia in thoracic surgery. Br J Anaesth 1995;75:405-8.
5Richardson J, Sabanathan S, Mearns AJ, Evans CS, Bembridge J, Fairbrass M. Efficacy of pre-emptive analgesia and continous extrapleural intercostal nerve block on postthoracotomy pain and pulmonary mechanics. J Cardiovasc Surg 1994;
6 Mehta Y, Swaminathan M, Mishra Y, Trehan N. A comparative Evaluation of Intrapleural and Thoracic Epidural analgesia for Postoperative pain relief after minimally invasive Direct Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 1998;12:162-5.
7Navlet MG, Garutti I, Olmedilla L, Perez-Pena JM, San Joaquin MT, Martinez-Ragues G, et al. Paravertebral ropivacaine, 0.3% and bupivacaine, 0.25%, provide similar pain relief after thoracotomy. J Cardiothorac Vasc Anesth 2006;20:644-7.
8Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001;95:771-80.
9Agnolett V, Piraccini E, Tonini S, Taurchini M, Alifano M, Gambale G, et al. Paravertebral Blockade for Cardiothoracic Surgery: J Cardiothorac Vasc Anesth 2010;24:867-74.
10Lonnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia 1995;50:813-5.
11Conacher ID, Slinger P. Pain management, In: Kaplan JA, Slinder PD (editors). Thoracic Anesthesia, 3 rd ed. Philadephia, PA: Churchill Livingstone; 2003. p. 432-64.
12Naja Z, Lonnqvist PA. Somatic paravertebral nerve blockade incidence of failed block and complications. Anaestheisa 2001;56:1184-8
13Daly DJ, Myles PS. update on the role of paravertebral blocks for thoracic surgery: Are they worth it? Curr Opin Anaesthesiol 2009;22:38-43.
14Thomas PW, Sanders DJ, Berrisford RG. Pulmonary haemorrhage afer percutaneous paravertebral block. Br J Anaesth 1999;83:668-9.
15Kaya FN, Turker G, Basagan-Mogol E, Goren S, Bayram S, Gebitekin C. Preoperative multiple-injection thoracic paravertebral blocks reduce postoperative pain and analgesia requirements after video-assisted thoracic surgery; J Cardiothorac Vasc Anesth 2006;20:639-43.
16Grider JS, Mullet TW, Saha SP, Harned ME, Sloan PA. A randomized double-blind trial comparing continuous thoracic epidural bupivacaine with and without poioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth 2012;26:83-9.
17Novak-Jankovic V, Milan Z, Potocnik I, Stupnik T, Maric S, Stopar-Pintaric T, et al. A prospective, randomized, double-blinded comparison between multimodal thoracic paravertebral bupivacaine and levobupivacaine analgesia in patients undergoing lung surgery. J Cardiothorac Vasc Anesth 2012;26:863-7 .
18Sullivan EA. the role of the anesthesiologist in thoracic surgery: we can make a difference. J Cardiothorac Vasc Anesth 2009;23:761-5.
19Myles PS, Bain C. Underutilization of paravertebral block in thoracic surgery: J Cardiothorac Vasc Anesth 2006;20:635-8.