ABSTRACT
Continuous paravertebral block is commonly used for post-thoracotomy analgesia and compares favourably with other systemic and regional methods with regard to safety and efficacy. No major complications of continuous paravertebral block for post-thoracotomy analgesia have been reported previously. We report here a case of systemic local anaesthetic toxicity from continuous paravertebral block administration after thoracotomy and lobectomy leading to seizure, aspiration, and ultimately, death. Potential contributing factors in this case included small patient size, concomitant antifungal therapy, extensive surgical disruption of the pleurae, and inappropriate paravertebral bolus administration. Postoperative delirium was a diagnostic confounder. We discuss the potential causes and means of avoiding similar complications in the future.
Subject(s)
Anesthetics, Local/adverse effects , Bupivacaine/adverse effects , Nerve Block/adverse effects , Pain, Postoperative/prevention & control , Aged , Anesthetics, Local/administration & dosage , Bupivacaine/administration & dosage , Drug Administration Schedule , Fatal Outcome , Humans , Lung Diseases, Fungal/surgery , Male , Mycetoma/surgery , Nerve Block/methods , Pain, Postoperative/etiology , Risk Factors , Thoracic Vertebrae , Thoracotomy/adverse effectsABSTRACT
BACKGROUND: Meta-analysis and systematic reviews of epidural compared with paravertebral blockade analgesia techniques for thoracotomy conclude that although the analgesia is comparable, paravertebral blockade has a better short-term side-effect profile. However, reduction in major complications including mortality has not been proven. METHODS: The UK pneumonectomy study was a prospective observational cohort study in which all UK thoracic surgical centres were invited to participate. Data presented here relate to the mode of analgesia and outcome. Data were analysed for 312 patients having pneumonectomy at 24 UK thoracic surgical centres in 2005. The primary endpoint was a major complication. RESULTS: The most common type of analgesia used was epidural (61.1%) followed by paravertebral infusion (31%). Epidural catheter use was associated with major complications (odds ratio 2.2, 95% confidence interval 1.1-3.8; P=0.02) by stepwise logistic regression analysis. CONCLUSIONS: An increased incidence of clinically important major post-pneumonectomy complications was associated with thoracic epidural compared with paravertebral blockade analgesia. However, this study is unable to provide robust evidence to change clinical practice for a better clinical outcome. A large multicentre randomized controlled trial is now needed to compare the efficacy, complications, and cost-effectiveness of epidural and paravertebral blockade analgesia after major lung resection with the primary outcome of clinically important major morbidity.
