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GGG�/qqqq����.d���.���vvvvvv����Lower Thoracic Paravertebral Block as an Adjuvant to General Anesthesia for Renal/ Uretric Surgeries--- A case series.
Abstract
Objective: The main objective of this case series is to highlight the effectiveness of continuous paravertebral block (PVB) with the addition of clonidine to bupivacaine, as a supplement to general anaesthesia, in the care of open renal/ ureteric surgery. 
Methods: Continuous PVB was instituted in 25 ASA I & II patients of either sex at T8-T9 level. Twelve milliliters of 0.25% bupivacaine was administered. General anaesthesia was then induced, followed by tracheal intubation. Ten milliliters of bupivacaine 0.25% was repeated every hour through the catheter.  Fentanyl 1�g/kg was repeated if heart rate or blood pressure rose more than 20% above the baseline. Clonidine 1�g/kg added to 10 ml of 0.25% bupivacaine was administered at the end of the surgery. Visual Analogue Scale (VAS) was observed at regular intervals. Inj tramadol 50 mg iv was administered on demand or if VAS was >3. Requirements of intraoperative and postoperative opioids, VAS and duration of postoperative analgesia were observed. Catheters were removed after the second postoperative day.
Results: Block was successful in all 25 patients. None of the patients required any additional intraoperative opioids. Duration of analgesia ranged from 20-24 hours. None of the patients experienced any complications.
Conclusion: PVB is a simple and effective adjunct to general anaesthesia for patients undergoing renal/ ureteric surgeries.
Introduction
	Opioids are commonly used to provide intraoperative analgesia but when used in large doses, lead to undesirable effects such as delayed recovery, postoperative nausea & vomiting and even respiratory depression. Simultaneous use of regional anaesthesia techniques helps in minimizing the use of intraoperative opioids and hence their associated adverse effects. Epidural analgesia has been the gold standard for surgeries involving the abdomen and pelvis, but not without its side effects.1
	Paravertebral block (PVB), utilized unilaterally may surmount some of the problems associated with epidural analgesia2 and has been used extensively for breast, abdominal and thoracic surgeries.3-5 However, despite good success in these surgeries, PVB remains underutilized for renal/ ureteric surgeries. Therefore, we prospectively studied 25 adult ASA I and II patients undergoing unilateral renal/ ureteric surgery under general anaesthesia for intraoperative and postoperative pain relief using a continuous PVB.






Methods
Twenty five ASA I & II patients in the age group of 18-65 years of either sex undergoing renal/ ureteric surgery under general anaesthesia with tracheal intubation were recruited between January 2012 and March 2013. Patients with any contraindication to paravertebral block, difficult airway and allergy to any of the drugs used were excluded from the study. After written informed consent, ipsilateral PVB was instituted at T8-T9 level with an 18 G Touhy needle in the sitting position. After identification of thoracic PVB space by loss of resistance to air, epidural catheter was threaded 3-4 cm inside the space. Twelve ml of 0.25% bupivacaine was administered after negative aspiration for blood. General anaesthesia was then induced using a standard regimen comprising of fentanyl 2�g/ kg and thiopentone 5mg/kg with 66% nitrous oxide in oxygen and 1-2% sevoflurane. Tracheal intubation was facilitated by rocuronium 0.9mg/kg. Ten milliliters of bupivacaine 0.25% was repeated every hour through the catheter.  Fentanyl 1�g/kg was repeated if heart rate or blood pressure rose more than 20% above the baseline. Clonidine 1�g/kg was added to 10 ml of 0.25% bupivacaine administered as the last intraoperative top up. Postoperatively Visual Analogue Scale (VAS) was observed half hourly for the first two hours and then hourly till VAS >3 or patient demanded analgesia. This was defined as duration of analgesia and constituted the end point of the study. Ten ml of 0.25% bupivacaine was administered at this point of time and subsequently. Inj. tramadol 50 mg IV was administered as a rescue analgesic. A top up of Clonidine 1�g/kg added to 10 ml of 0.25% bupivacaine was administered at 24 hour intervals thereafter. Requirements of intraoperative and postoperative opioids, VAS, duration of postoperative analgesia and total number of PVB top ups in the next 48 hours were observed. Any side effects of clonidine such as dry mouth, sedation, bradycardia and hypotension were also noted. Catheters were removed after the second postoperative day.















Results
Block was successful in all 25 patients. Patient characteristics are depicted in Table 1. None of the patients required any additional intra operative opioids. Duration of analgesia ranged from 20-24 hours (Mean 23 � 1.20 hrs). A single dose of iv tramadol was required in 12/25 patients on the second postoperative day. None of the patients experienced any complications either due to the block or drugs administered.
Table 1: Results
n=25Sex (M:F)17:8Age (years)43.16 �7.61Surgery (renal: ureteric)4:19Duration of surgery (hours)3.20 � 0.70No. of intraoperative top ups (mean)2




Discussion
Paravertebral Block was successful in all 25 patients and decreased the use of intraoperative opioids. This technique provided excellent intra- and postoperative analgesia for approximately 24 hours in all the patients. 
PVB was first performed in 1905.6 Its use declined over the years until a publication by Eason and Wyatt in 1979 began a renaissance.7 Since then, PVBs have been extensively utilized for breast and thoracic surgeries. For abdominal and pelvic surgeries, epidural analgesia has been the technique of choice mainly due to bilateral nature of the tissue injury. However, renal and ureteric surgeries are mainly unilateral although there is a small cross over of opposite nerves. Since the lumbar incision is usually muscle cutting, post operative pain is intense and opioids alone are insufficient. NSAID�s although provide good analgesia, may be contraindicated in these patients due to nephrotoxicity.  In spite of this unilateral neural distribution, epidural has remained the gold standard.
PVB as compared to the thoracic epidural block, is easier to learn with comparable/better analgesia than epidural block.  There is less risk of neurological complications and as sympathetic block is not bilateral, hypotension is rare.8,9 Since anticoagulation not an absolute contraindication, it requires less monitoring than thoracic epidurals. PVB probably inhibits central reflex involved in pain thus providing longer pain relief than epidural analgesia.
Lonnqvist10 and Berta et al11 have used single injection PVB in children undergoing renal surgery with good results. The duration of analgesia was limited. A recent study by Moawad et al however suggests that single shot PVB is comparable to thoracic epidural in patients undergoing open renal surgeries.12 
Addition of clonidine to local anaesthetics further prolongs the analgesic duration due to its interaction between axonal ionotropic, metabolic, or structure proteins on the nerve fibre,13 as was seen in our cases, and this may lead to decreased incidence of sedation, nausea, vomiting and constipation due to opioid sparing effect.  
The complications of this block are low and comparable to other blocks. Interpleural injections may occur causing small pneumothoraces which can be managed conservatively. Tension pneumothorax is a theoretical risk but no case has been reported.9 Bilateral blocks may occur due to contra lateral spread of the drug and tends to occur if the injection site is medial or with catheter technique. However, we did not encounter any bilateral block.
Limitations of our case series include non availability of ultrasound guidance and comparison with thoracic epidural analgesia. Further studies are required to establish its beneficial effects over the epidural technique.
Conclusion
PVBs are easy to perform, have a high success rate, minimal complications and offer significant potential advantages to patients. PVBs are strongly recommended for all unilateral renal/ ureteric surgeries under general anaesthesia as an alternative to thoracic epidural or systemic opiate analgesia.











References
El-Morsy GZ, El-Deeb A, El-Desouky T, Elsharkawy AA, Elgamal MAF. Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. Ann Card Anaesth 2012;15:259-63.
Tighe SQM, Greene MD, Rajadurai M. Paravertebral Block. CEACCP 2010;10:133-7.
Gartner R, Jensen MB, Nielson J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. J Am Med Assoc 2009;302:1985-92.
Bhattacharya P, Mandal MC, Mukhopadhyay S, Das S, Pal PP, Basu SR. Unilateral paravertebral block: An alternative to conventional spinal anaesthesia for inguinal hernia repair. w�������������>	A	B	Q	b	f	l	v	~		�	�	�	�	�	�	�	0
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