The Pharmacokinetics of Ropivacaine in Elderly Patients Undergoing Nerve Stimulator–Guided Thoracic Paravertebral Block

Abstract Background Postoperative delirium (POD) is characterized by acute brain dysfunction, especially in elderly patients. Postoperative pain is an important factor in the development of delirium, and effective pain management can reduce the risk of POD. Thoracic paravertebral block (TPVB) can effectively relieve postoperative pain and inhibit the perioperative stress and inflammatory response. We investigated whether the combination of TPVB with general anesthesia reduced the occurrence of POD following thoracoscopic lobectomy. Methods A total of 338 elderly patients, aged 65–80 years, who underwent elective surgery for video-assisted thoracoscopic lobectomy (VATS) were randomly assigned to either a patient-controlled intravenous analgesia group (PIA) or a patient-controlled paravertebral-block analgesia group (PBA). POD was evaluated using the 3-min diagnostic confusion assessment method (3D-CAM). The postoperative quality of recovery (QoR) was assessed with Chinese version of QoR-40 scale. Pain intensity was measured using the visual analog scale (VAS) score. Tumor necrosis factor-α (TNF-α) and neurofilament light (NFL) levels were determined using enzyme-linked immunosorbent assay (ELISA) kits. Results Delirium occurred in 47 (28%) of 168 cases in the PIA group and 28 (16.5%) of 170 cases in the PBA group (RR 1.7, p = 0.03). PBA was also associated with a higher rate of overall recovery quality at day 7 after surgery (27.1% vs. 17.3%, P = 0.013) compared with PIA. The incremental change in surgery-induced TNF-α and NFL was greater in the PIA group than PBA group (p < 0.05). Conclusion Thoracic paravertebral block analgesia is associated with lower incidence of postoperative delirium, probably due to its anti-neuroinflammatory effects. Furthermore, as a component of multimodal analgesia, TPVB provides not only superior analgesic but also opioid-sparing effects. Trial registration The study was registered on the Chinese Clinical Trial Registry Center (www.chictr.org.cn; registration number: ChiCTR 2,000,033,238) on 25/05/2018.

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Effectiveness of additional thoracic paravertebral block in improving anesthetic effects of regional anesthesia for proximal humeral fracture surgery in elderly patients: study protocol for a randomized controlled trial

10.21203/rs.2.12510/v1 ◽

2019 ◽

Author(s):

Xiaofeng Wang ◽

Hui Zhang ◽

Zhenwei Xie ◽

Qingfu Zhang ◽

Wei Jiang ◽

...

Keyword(s):

Elderly Patients ◽

Regional Anesthesia ◽

Proximal Humeral Fracture ◽

Humeral Fracture ◽

Paravertebral Block ◽

Cervical Plexus ◽

Thoracic Paravertebral Block ◽

Cervical Plexus Block ◽

Plexus Block ◽

Fracture Surgery

Abstract Background The innervation of shoulder-upper arm area is complicated and unclear. Ultrasound-guided brachial plexus combined with cervical plexus block is probably inadequate for the anesthesia of proximal humeral surgery. Missing blockade of T1-T2 nerves may be the reason. The primary aim of this trial is to investigate the effectiveness of additional T2 thoracic paravertebral block (TPVB) in improving the anesthetic effects of regional anesthesia for elderly patients in proximal humeral fracture surgery. Methods We have designed a two-armed, parallel, randomized controlled trial (RCT) to compare the anesthetic effects of ultrasound-guided brachial and cervical plexus block with or without additional T2 TPVB in terms of the following outcomes: success rate, sensory block and safety. The elderly patients over 65 years old, referred for anterior approach proximal humeral fracture surgery, will be enrolled. Each participant will be randomly assigned 1:1 to receive IC block (combined interscalene brachial plexus with superficial cervical plexus block) or ICTP block (combined thoracic paravertebral block with IC block). The primary outcome is the success rate of surgical anesthesia. The secondary outcomes are as follows: sensory block at surgical area, proportion of participants who need supplementary anesthesia (remifentanil or conversion to general anesthesia), cumulative doses of intraoperative vasoactive medications and adverse events. The necessary sample size is estimated to be 80 patients according to the data of our pilot study. Discussion This RCT aims to demonstrate that whether combined T2 TPVB with brachial and cervical plexus block can provide better anesthetic effects of regional anesthesia in elderly patients undergoing proximal humeral fracture surgery.

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