Page 246 Acute Pain Management

Thoracic
Paravertebral blocks
Following cosmetic breast surgery thoracic paravertebral blockade resulted in modest
benefits only; reduced nausea (at 24 hours) and opioid requirements compared with general
anaesthesia (Klein, Bergh et al, 2000 Level II). After breast cancer surgery, no difference in opioid
requirements or pain scores was found (Moller et al, 2007 Level II).
Continuous thoracic paravertebral blockade was as effective as thoracic epidural analgesia
for pain relief after thoracotomy (Davies et al, 2006 Level I), with a better side‐effect profile
(less urinary retention, hypotension and nausea and vomiting) than epidural analgesia and
resulted in a lower incidence of postoperative pulmonary complications (Davies et al, 2006
Level I). Similarly, in a comparison of different modes of analgesia for thoracotomy,
paravertebral and epidural techniques provided superior analgesia to intrathecal, interpleural,
intercostal and systemic opioid techniques; paravertebral blocks resulted in less hypotension
than epidural analgesia with local anaesthetic and paravertebral blocks reduced the incidence
of pulmonary complications compared with systemic analgesia (Joshi et al, 2008 Level I).
Continuous thoracic paravertebral blockade was also effective for pain relief in patients
with multiple unilateral rib fractures (Shukula et al, 2008 Level IV).

Intercostal and interpleural blocks
There was no evidence that continuous interpleural analgesia provided superior analgesia
compared with thoracic epidural analgesia following thoracotomy for minimally invasive direct
coronary artery bypass surgery (Mehta et al, 1998 Level II). However, after thoracotomy for
correction of aortic coarctation or patient ductus arteriosus, thoracic epidural analgesia
resulted in better pain relief and pulmonary function than continuous interpleural analgesia
(Yildirim et al, 2007 Level II).
CHAPTER 7 thoracotomy (Debreceni et al, 2003 Level II).
Continuous epidural analgesia was superior to continuous intercostal analgesia following

Needle and catheter localising techniques
Stimulating catheters have been compared with non‐stimulating catheter techniques in
establishing continuous femoral nerve blockade for postoperative analgesia following total
knee arthroplasty. There was no difference in quality of postoperative analgesia between
these two insertion techniques (Morin, Eberhart et al, 2005 Level II; Barrington et al, 2008 Level II).
Stimulating catheters have also been compared with non‐stimulating catheter techniques at
other anatomical locations with inconclusive results (Rodriguez et al, 2006 Level II; Dauri et al,
2007 Level II; Stevens et al, 2007 Level II).
Ultrasound guidance has been compared with stimulating and non‐stimulating techniques for
continuous infraclavicular brachial plexus blockade. The combination of ultrasound and nerve
stimulator guidance (with stimulating catheters) resulted in the highest primary success and
reduced secondary catheter failure (Dhir & Ganapathy, 2008 Level II). In comparison with a
peripheral nerve stimulator (PNS), blocks performed using ultrasound guidance were found
to be more likely to be successful (RR for block failure 0.41; 95% CI 0.26 to 0.66), faster to
perform (mean 1 minute less to perform with ultrasound), and have faster onset (29% shorter
onset time; 95% CI 45% to 12%), and longer duration (mean difference 25% longer; 95% CI
12% to 38%) than those performed with PNS guidance (Abrahams et al, 2009 Level I). In one RCT
comparing blocks performed using PNS or ultrasound guidance, there was no difference in
block performance time (but this was only 5 minutes for both techniques), block failure rate,
or incidence of postoperative neurological symptoms, however there was enhanced motor
block at 5 minutes when ultrasound was used (Liu et al, 2009 Level II).
198 Acute Pain Management: Scientific Evidence