This manuscript briefly outlines a mutlimodal approach to post operative pain after open and VATS thoracic surgery. One important aspect of the multimodal thetapy is the use of liposomal bupivacaine for intercostal blocks and subcutaneous infiltration.

Abstract
BACKGROUND:
Pain relief using regional neuroaxial blockade is standard care for patients undergoing major thoracic surgery. Thoracic epidural analgesia (TEA) provides effective postoperative analgesia but has unwanted side effects, including hypotension, urinary retention, nausea, and vomiting, and is highly operator dependent. Single-shot intercostal nerve and paravertebral blockade have not been widely used because of the short duration of action of most local anesthetics; however, the recent availability of liposomal bupivacaine (LipoB) offers the potential to provide prolonged blockade of intercostal nerves (72 to 96 hours). We hypothesized that a five-level unilateral posterior intercostal nerve block using LipoB would provide effective analgesia for patients undergoing thoracic surgery.
METHODS:
We identified patients who underwent lung resection using intraoperative LipoB posterior intercostal nerve blockade and retrospectively compared them with a group of patients who had TEA and who were matched for age, sex, type of surgery, and surgical approach. We analyzed perioperative morbidity, pain scores and narcotic requirements.
RESULTS:
There were 54 patients in each group. Mean hospital stay was 3.5 days and 4.5 days (p = 0.004) for LipoB group and TEA group, respectively. There were no significant differences in perioperative complications, postoperative pain scores, or in narcotic utilization between LipoB group and TEA group. No acute toxicity related to LipoB was observed.
CONCLUSIONS:
Posterior intercostal nerve blockade using LipoB is safe and provides effective analgesia for patients undergoing thoracic surgery. It may be considered as a suitable alternative to TEA.

Conclusions: “…the present review claimed that transurethral catheter could be discontinued safely on the day after surgery”

OBJECTIVES Gastric tube necrosis is a major cause of mortality after oesophagectomy. The construction of the gastric tube used for oesophageal reconstruction involves a division of several arteries leading to a reduction in the blood supply at the fundus, which is used for the oesophageal anastomosis. This study was undertaken to determine the effect of thoracic epidural anaesthesia and intravenous phenylephrine on haemodynamics and blood flow in the tubularized stomach.

METHODS Ten patients undergoing an oesophagectomy were prospectively studied. Pulmonary artery catheters were used to measure haemodynamic changes, and laser Doppler flow probes were used to measure gastric blood flow. The effects of an intraoperative thoracic epidural and subsequent intravenous phenylephrine infusion were documented.

RESULTS The administration of a thoracic epidural bolus of bupivacaine 0.25% at 0.1 ml kg resulted in a significant reduction in flux at the anastomotic end of the newly formed gastric tube from a median of 57–41 perfusion units (P = 0.003). A subsequent intravenous phenylephrine infusion titrated to restore mean arterial pressure significantly increased the flux at the anastomotic end from a median of 41–66 perfusion units (P = 0.009).

CONCLUSIONS An intravenous phenylephrine infusion can reverse the epidural bolus-induced reduction in blood flow at the anastomotic end of the newly formed gastric tube.

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; P¼0.02) 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.

Background. Paravertebral regional anaesthesia is used to treat pain after several surgical
procedures. This study aimed to improve on our first published ultrasound-guided approach
to the paravertebral space (PVS) and to investigate a possible discrepancy between the
needle, catheter, and contrast dye position.
Methods. In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches
combined with loss of resistance (LOR) and after an interim analysis performed 36 novel,
pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was
controlled by a first computed tomography (CT) scan. After placement of the catheters,
the tips were assessed by a second CT and the spread of injected contrast dye was
assessed by further CT scans. The part of the PVS near the intervertebral foramen was
defined as the primary target to reach.
Results. The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34
(94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches
were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed:
three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of
LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected
in the epidural space. In two cases, insertion of the catheter was not possible. In cases
with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (SD)]
vertebral segments.
Conclusions. Our new PUSG technique has a high success rate for paravertebral needle
placement. Although needles were correctly positioned, catheters were usually found
distant from the needle-tip position.
Keywords: anatomy, regional; intercostal nerv

Background. The safety of epidural anaesthesia in patients at risk for right ventricular
pressure overload remains controversial. We compared the haemodynamic effects of vascular
and cardiac autonomic nerve block, induced by selective lumbar (LEA) and high thoracic epidural
anaesthesia (TEA), respectively, in an animal model subjected to controlled acute right
ventricular pressure overload.
Methods. Eighteen pigs were instrumented with epidural catheters at the thoracic (T) and
lumbar (L) level and received separate injections at T2 (1 ml) and L3 (4 ml) with saline (s) or
bupivacaine 0.5% (b). Three groups of six animals were studied: (i) a control group (LsþTs), (ii)
LEA group (LbþTs), and (iii) TEA group (LsþTb). Haemodynamic measurements including
biventricular pressure-volumetry were performed. Right ventricular afterload was then
increased by inflating a pulmonary artery (PA) balloon. Measurements were repeated after
30 min of sustained right ventricular afterload increase.
Results. LEA decreased systemic vascular resistance (SVR) and did not affect ventricular function.
TEA had minor effects on SVR but decreased left ventricular contractility while baseline
right ventricular function was not affected. Control and LEA-treated animals responded similarly
to a PA balloon occlusion with an increase in right ventricular contractility and heart rate.
Animals pretreated with a TEA did not show this positive inotropic response and developed
low cardiac output in the presence of right ventricular pressure overload.
Conclusions. In contrast to LEA, TEA reduced the haemodynamic tolerance to PA balloon
occlusion by inhibiting the right ventricular positive inotropic response to acute pressure overload

Objective: The aim of this study was to identify predictors
of delayed endotracheal extubation defined as the need for
postoperative ventilatory support after open thoracotomy
for lung resection.
Design: An observational cohort investigation.
Setting: A tertiary referral center.
Participants: The study population consisted of 2,068 patients
who had open thoracotomy for pneumonectomy, lobectomy,
or segmental lung resection between January
1996 and December 2005.
Interventions: Not applicable.
Measurements and Main Results: Preoperative and intraoperative
variables were collected concurrently with the patient’s
care. Risk factors were identified using logistic regression
with stepwise variable selection procedure on 1,000
bootstrap resamples, and a bagging algorithm was used to
summarize the results. Intraoperative red blood cell transfusion,
higher preoperative serum creatinine level, absence of a
thoracic epidural catheter, more extensive surgical resection,
and lower preoperative FEV1 were associated with an increased
risk of delayed extubation after lung resection.
Conclusion: Most predictors of delayed postoperative extubation
(ie, red blood cell transfusion, higher preoperative serum
creatinine, lower preoperative FEV1, and more extensive
lung resection) are difficult to modify in the perioperative period
and probably represent greater severity of underlying lung
disease and more advanced comorbid conditions. However,
thoracic epidural anesthesia and analgesia is a modifiable factor
that was associated with reduced odds for postoperative
ventilatory support. Thus, the use of epidural analgesia may
reduce the need for post-thoracotomy mechanical ventilation

Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890–990 mg per 24 h compared with 325–472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%–38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

Review Article