Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial.
OBJECTIVE
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.
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.
Kristin L
KL
Schreiber
Jacques E
JE
Chelly
R Scott
RS
Lang
Ezeldeen
E
Abuelkasem
David A
DA
Geller
J Wallis
JW
Marsh
Allan
A
Tsung
Tetsuro
T
Sakai
D000328:Adult; D000368:Aged; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods*; D016058:Analgesia, Patient-Controlled / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D062186:Arterial Pressure / Q000187:drug effects; D001777:Blood Coagulation / Q000187:drug effects; D017558:Elective Surgical Procedures; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D010414:Pennsylvania; D011446:Prospective Studies; D020127:Recovery of Function; D012119:Respiration / Q000187:drug effects; D013147:Spirometry; D013997:Time Factors; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D004091:Hydromorphone