Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study

BMC Anesthesiology, Jun 2019

Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG. This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016–2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events. Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups. Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://bmcanesthesiol.biomedcentral.com/track/pdf/10.1186/s12871-019-0768-9

Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study

Research article Open Access Open Peer Review Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study Lixin Sun†1, Qiujie Li†1, Qiang Wang1, Fuguo Ma1, Wei Han2Email authorView ORCID ID profile and Mingshan Wang1 †Contributed equally BMC Anesthesiology201919:101 https://doi.org/10.1186/s12871-019-0768-9 ©  The Author(s). 2019 Received: 17 April 2018Accepted: 24 May 2019Published: 12 June 2019 Open Peer Review reports Abstract Background Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG. Methods This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016–2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events. Results Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups. Conclusions Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA. Keywords Nerve blockThoracic vertebraAnesthesiaGeneral Background Off-pump coronary artery bypass grafting (OPCABG) is a type of bypass surgery performed on beating heart, without cardiopulmonary bypass (CPB). OPCABG has been developed in Russia mainly to avoid the complications of CPB [1]. The popularity of OPCABG has been declining over the past years in developed countries, but the rate of OPCABG is currently increasing in some countries such as China and India [2]. Nevertheless, the benefits of OPCABG are debatable [3] and it could benefit only some selected patients [4–6]. Thoracic epidural anesthesia (TEA) has been successfully applied in heart surgery and confirmed to have a myocardial protective effect [7–10]. Nevertheless, a cardiac surgery is usually performed in patients receiving anticoagulant therapy and may be associated with an increased risk of an epidural hematoma. The incidence of epidural hematoma has been estimated to be between 1:150,000 and 1:1528 [11]. Furthermore, TEA may also be complicated by hypotension, urinary retention and pulmonary complications related to respiratory muscle blockade in some patients [12, 13]. Although a clinical study [14] has revealed important benefits for TEA in cardiac surgery, its use is still debatable because of the potential risks. Recently, there has been increasing interest in alternative regional techniques, particularly thoracic paravertebral block (PVB), which offers optimal pain control with a better side effects profile [15, 16]. Compared with TEA, PVB can provide comparable pain relief, fewer complications, faster recovery, shorter hospitalization, and lower incidence of postoperative chronic pain [17, 18]. The safety and efficacy of segmental PVB has been reported for postoperative analgesia after modified minimally invasive Heart-Port access cardiac surgery [19], but whether bilateral thoracic paravertebral block can be safely and effectively used in OPCABG remains unknown. We hypothesized that PVB could be useful in patients undergoing OPCABG. Therefore, this study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG, assessing pain (visual analogue scale [VAS] as primary endpoint and rescue analgesia and morphine consumption within 48 h postoperatively, operative time, dose of fentanyl, time to extubation, intensive care unit (ICU) stay, hospital stay, intraoperative parameters (e.g. bradycardia, tachycardia, hypotension and hypertension) and postoperative adverse events (AEs) as secondary endpoints. This was a pilot study comparing PVB combined with GA vs. GA alone in order to observe the advantages and disadvantages of PVB. Methods Patients and study design This was a feasibility study of patients scheduled to undergo OPCABG at the Qingdao Municipal Hospital between July 2016 and May 2017. All patients received preoperative physical examination and plain X-ray. The inclusion criteria were: 1) planned to undergo OPCABG; 2) 50–75 years old; 3) body mass index (BMI) < 30 kg/m2; 4) ASA II or III; and 5) elective surgery. The exclusion criteria were: 1) spine malformation; 2) vertebral space-occupying lesion; 3) infection at the site of paravertebral injection; 4) left ventricular ejection fraction (LVEF) < 40%; 5) endocrine disease; 6) metabolic disease; 7) extracorporeal circulation; 8) allergies; 9) severe hepatic (alanine transaminase [ALT] or aspartate transaminase [AST] > 3 times the upper limit of normal) or renal dysfunction (serum creatinine [SCr] > 178 mmol/L and blood urea nitrogen [BUN] > 9 mmol/L); 10) valvular disease; 11) intra-aortic balloon pump; or 12) neurologic or psychotic disorders. The study was approved by the ethics committee of Qingdao Municipal Hospital (No. 20140806–1). Each patient provided a written informed consent. Randomization and blinding The patients were randomized using sequential sealed envelopes prepared by an independent statistician using a computer-generated random number table. Patients were randomly divided into two groups: the bilateral thoracic PVB combined with GA group (PVB + GA group), and the GA group (GA group). The postoperative assessors were blinded to grouping. Anesthesia All patients received their usual medication on the day of operation, followed by premedication with intramuscular morphine 0.1 mg/kg and midazolam 0.05 mg/kg. Upon arrival in the operating room, 100% oxygen was administered, and peripheral vein Ringer lactate solution was infused at 6–8 ml/kg/h. The patients were monitored with radial artery pressure, heart rate (HR), electrocardiogram (ECG), oxygen saturation (SpO2), end-tidal carbon dioxide (ETCO2), and other hemodynamic parameters using a Datex multi-parameter monitor (GE Healthcare, Waukesha, WI, USA). The flow-directed pulmonary artery catheter and central venous catheter (Arrow International Inc., Asheboro, NC, USA) were placed through the right internal jugular vein in both groups. In the PVB + GA group, bilateral thoracic PVB was performed according to the nerve stimulator-guided technique [20–23] combined with the loss of resistance technique for proper location of the paravertebral space (PVS). Briefly, patients in the right lateral decubitus position received intradermal lidocaine (1%) at T3–4 PVS. An insulated needle attached to a nerve stimulator was advanced between the transverse process of the third and fourth vertebrae, and the current intensity of the nerve stimulator was set to 2–5 mA during initial simulation, and subsequently reduced to 0.4–0.8 mA. PVS could also be identified with the “loss-of-resistance” technique to ensure technical success [23, 24], but neuromuscular stimulation was the primary criterion in cases in which loss of resistance could not be felt. After ensuring the absence of blood, air, or cerebrospinal fluid, a 20G catheter was passed through the needle, with 3 cm of the catheter left in the PVS. After the catheters had been secured, the patient was turned onto the supine position. 0.375% of ropivacaine 20 ml were injected by 2 time with 5 min interval (5 ml in the first time and 15 ml in the second time), followed by 0.375% of ropivacaine infused at 5 ml/h until 30 min before the end of operation [25]. Analgesia block levels were tested by the pinprick method at the middle of the chest. If analgesia block level was less than 2 dermatomes, the patient was withdrawn. Bilateral thoracic PVB was not performed in the GA group. All patients in both groups received GA. GA was induced by midazolam 0.05 mg/kg, etomidate 0.3 mg/kg, fentanyl 4 μg/kg, and vecuronium 0.1 mg/kg. After endotracheal intubation, patients were mechanically ventilated to maintain ETCO2 between 35 and 40 mmHg. The nasopharyngeal temperature and urine volume were monitored. Warming blankets were used to maintain the nasopharyngeal temperature at 36.5–37.5 °C. Anesthesia was maintained by sevoflurane 1 MAC. Fentanyl 10–20 μg/kg and vecuronium 0.1 mg/kg were given when indicated. At the end of the operation, the catheter was removed in the PVB + GA group in order to observe the effect of PVB on postoperative morphine use. All patients in both groups were transferred to the intensive care unit (ICU) without extubation. Beginning at the end of the operation, all patients in both groups received patient-controlled analgesia (PCA) using morphine (1 mg/ml) for 48 h at a loading dose of 2 mg, continuous infusion dose of 0.5 mg/h, bolus of 1 mg, locking time of 10 min, and maximum dose of 20 mg/4 h. Assessments Using the visual analogue scale (VAS; 0 mm = no pain, 100 mm = worst pain imaginable), the patients were asked to rate their pain at rest and during coughing every hour after their arrival and return to consciousness in ICU. If the VAS score was > 5 at rest, rescue analgesia was given with morphine 5 mg IV. Intraoperative adverse events (AEs), including bradycardia, tachycardia, hypotension, hypertension, and postoperative AEs were recorded. Bradycardia was defined as a heart rate < 50 bpm and treated with intravenous atropine 0.01 mg/kg. Tachycardia was defined as a heart rate > 90 bpm and treated with intravenous esmolol 20 mg. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) from baseline and treated with intravenous noradrenaline 5 μg. Hypertension was defined as a 20% increase in SBP from baseline and treated with intravenous urapidil hydrochloride 10 mg. All hemodynamic drugs were repeated as required. Endpoints The primary endpoint was the pain scores within 48 h postoperatively. The secondary endpoints were the rescue analgesia and morphine consumption, dose of fentanyl within 48 h postoperatively, as well as operative time, time to extubation (defined as the time from the end of surgery to the extubation), ICU stay, hospital stay and postoperative AEs (including bradycardia, tachycardia, hypotension and hypertension). Statistical analysis Since this was a pilot study, the sample size was estimated by referring to similar studies [26] rather than an accurate calculation. Continuous data (age, BMI, morphine consumption, operative time, dose of fentanyl, time to extubation, ICU stay, and hospital stay) were expressed as mean ± standard deviation (SD) and analyzed using Student t test for intergroup comparisons. Categorical data (gender, ASA score, diabetes mellitus, chronic obstructive pulmonary disease, renal dysfunction, hypertension, rescue analgesia, and intraoperative and postoperative AEs) were expressed as frequency (percentage) and analyzed using the chi-square test. Ranked data (rest pain score and cough pain score) were expressed as median [IQR] and analyzed using the Wilcoxon rank sum test. All variables, except for pain scores, were baseline characteristics or secondary endpoints. Statistical analysis was performed using PASW Statistics 18.0 (SPSS Inc., Chicago, NY, USA). Two-sided P-values < 0.05 were considered statistically significant. Results Patients Figure 1 presents the patient flowchart. One hundred and fifty-two patients met the inclusion criteria and 92 of them were excluded from the study, including 27 patients due to BMI over 30 kg/m2, 18 patients due to LVEF < 40%, 12 patients due to severe hepatic or renal dysfunction, 10 patients due to carotid artery stenosis or other vascular diseases, 6 patients due to neurologic disorders and 19 patients due to withdrawal of consent. Sixty patients underwent randomization, with 30 patients in each group. One patient was withdrawn from the study due to the failure of PVB on one side and received GA alone. Table 1 presents the baseline characteristics of the patients. Fig. 1 Study flowchart. BMI, body mass index; OPCABG, off-pump coronary artery bypass grafting Table 1 Baseline characteristics of the patients Characteristics PVB + GA (n = 29) GA (n = 30) Male, n (%) 23 (79.3) 21 (70.0) Age (years) 68.2 ± 10.5 70.6 ± 11.7 BMI (kg/m2) 23.0 ± 6.6 24.2 ± 5.1 ASA (II/III) 7/10 9/9 LVEF (%) 55.8 ± 8.1 56.6 ± 10.7 DM, n (%) 13 (44.8) 15 (50.0) COPD, n (%) 3 (10.3) 5 (16.7) Renal dysfunction, n (%) 3 (10.3) 2 (6.7) Hypertension, n (%) 20 (69.0) 18 (60.0) PVB Paravertebral block, GA General anesthesia, BMI Body mass index, ASA American Standards Association, LVEF Left ventricular ejection fraction, DM Diabetes mellitus, COPD Chronic obstructive pulmonary disease. There were no significant differences between the two groups Postoperative pain Both rest and cough pain scores were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group (rest pain: 12 h: 3 [2, 3] vs. 3 [3, 3], P = 0.004; 24 h: 3 [2, 3] vs. 3 [3, 4], P = 0.007; 36 h: 3 [2, 3] vs. 3 [2, 4], P = 0.018; 48 h: 2 [2, 3] vs. 3 [3, 4], P = 0.010; cough pain: 12 h: 4 [3, 4] vs. 4 [4, 5], P = 0.007; 24 h: 3 [3, 5] vs. 4 [4, 5], P = 0.017; 36 h: 4 [3, 5] vs. 5 [3, 6], P = 0.048; 48 h: 4 [3, 4] vs. 5 [3, 6], P = 0.023). There were fewer patients who received rescue analgesia at 12 and 24 h in the PVB + GA group than in the GA group (12 h: 0% vs. 16.7%, P = 0.034; 24 h: 3.4% vs. 20.0%, P = 0.049). The number of patients who received rescue analgesia at 36 and 48 h in the two groups were similar. Morphine consumption at 24 and 48 h was lower in the PVB + GA group compared with the GA group (24 h: 25.6 ± 7.3 vs. 30.7 ± 9.0 mg, P = 0.033; 48 h: 47.6 ± 13.5 vs. 54.3 ± 16.1 mg, P = 0.041) (Table 2). Table 2 Comparison of VAS scores, rescue analgesia and morphine consumption between groups Variable Group n PCA 12 h PCA 24 h PCA 36 h PCA 48 h Rest pain PVB + GA 29 3 [2, 3] 3 [2, 3] 3 [2, 3] 2 [2, 3] GA 30 3 [3, 3] 3 [3, 4] 3 [2, 4] 3 [3, 4] P   0.015 0.023 0.026 0.042 Cough pain PVB + GA 29 3 [2, 3] 3 [2, 3] 3 [2, 3] 2 [2, 3] GA 30 3 [3, 3] 3 [3, 4] 3 [2, 4] 3 [3, 4] P   0.023 0.030 0.027 0.034 Rescue analgesia PVB + GA 29 0 (0) 1 (3.4) 3 (10.3) 2 (6.9) GA 30 5 (16.7) 6 (20.0) 6 (20.0) 7 (23.3) P   0.034 0.049 0.302 0.079 Morphine consumption PVB + GA 29 – 25.6 ± 7.3 – 47.6 ± 13.5 GA 30 – 30.7 ± 9.0 – 54.3 ± 16.1 P    0.033   0.041 VAS Visual analogue scale, PCA Patient-controlled analgesia, PVB Paravertebral block, GA General anesthesia Clinical characteristics Table 3 shows that the time to extubation was shorter in the PVB + GA group compared with the GA group (5.8 ± 1.5 vs. 7.3 ± 1.7 h, P = 0.035), as well as the ICU stay (16.3 ± 3.7 vs. 20.2 ± 4.1 h, P = 0.028). The dose of fentanyl was lower in the PVB + GA group compared with the GA group (1.2 ± 0.2 vs. 1.5 ± 0.3 mg, P = 0.022). There were no differences in operative time and hospital stay between the two groups. Table 3 Clinical characteristics of the patients Variable PVB + GA (n = 29) GA (n = 30) P * Operative time (min) 168 ± 23 176 ± 28 0.279 Dose of fentanyl (mg) 1.2 ± 0.2 1.5 ± 0.3 0.022 Time to extubation (h) 5.8 ± 1.5 7.3 ± 1.7 0.035 ICU stay (h) 16.3 ± 3.7 20.2 ± 4.1 0.028 Hospital stay (d) 9.6 ± 2.1 10.1 ± 2.3 0.459 PVB Paravertebral block, GA General anesthesia, ICU Intensive care unit. *All variables were analyzed using Student t test Adverse events Table 4 presents the intraoperative and postoperative AEs in the two groups. The occurrences of tachycardia (3.4% vs. 27.8%, P = 0.035) and hypertension (0% vs. 16.7%, P = 0.008) were lower in the PVB + GA group compared with the GA group. There were no differences in the occurrences of bradycardia, hypotension, and postoperative AEs between the two groups. Table 4 Intraoperative and postoperative AEs Variable, n (%) PVB + GA (n = 29) GA (n = 30) P * Intraoperative AE  Bradycardia 5 (17.2) 3 (10.0) 0.334  Tachycardia 1 (3.4) 5 (27.8) 0.035  Hypotension 13 (44.8) 10 (33.3) 0.262  Hypertension 0 (0) 5 (16.7) 0.008 Postoperative AE  Nausea 1 (3.4) 3 (10.0) 0.612  Vomiting 0 (0) 1 (3.3) 1.000  Pulmonary infection 0 (0) 1 (3.3) 1.000  Atelectasis 1 (3.4) 1 (3.3) 1.000  Reoperation 0 (0) 1 (3.3) 1.000  Paresthesia 1 (3.4) 0 (0) 0.492 AE Adverse event, PVB Paravertebral block, GA General anesthesia. *All variables were analyzed using chi-square test Discussion It is unknown whether thoracic PVB can be used in patients undergoing OPCABG. Therefore, this pilot study aimed to investigate the feasibility of bilateral PVB combined with GA in patients undergoing OPCABG. The results showed that nerve stimulator-guided bilateral thoracic PVB combined with GA could be efficient in OPCABG to provide high-quality analgesia. However, these findings should be interpreted with caution as non-anticoagulated patients were not assessed in this study. In addition, the risk of AEs is rather difficult to estimate, especially in case of small sample size. Thoracic spinal nerve block has been clinically used since as early as 1905 and has become more popular in recent years due to a number of advantages: simple application, low failure rate, satisfactory analgesia, and less influence on respiration and circulation [26–28]. Previous studies reported unilateral thoracic nerve block combined with GA applied as analgesia in minimally invasive direct coronary artery bypass (MIDCAB) [29–31]. Satisfyingly, unilateral thoracic nerve block combined with GA exhibited remarkable efficacy in postoperative pain relief, while maintaining stable hemodynamics and less postoperative complications [29–31]. In this study, both rest and cough pain scores were lower in patients undergoing OPCABG and fewer patients received rescue analgesia within 24 h postoperatively in the PVB + GA group compared with the GA group. However, it should be noted that similar numbers of patients received rescue analgesia at 36 h and 48 h in both groups. These findings indicate some improvement in analgesia with PVB + GA compared with GA alone. Therefore, PVB may exert beneficial effects in patients undergoing OPCABG, which deserves further investigation. Our study is the first comparative study to evaluate bilateral preoperative thoracic paravertebral block applied to patients undergoing OPCABG. We found that the thoracic nerve block segment was about 5 dermatomes in the PVB + GA group, which is in accordance with the imaging results from Christopher et al. [25] Our results also showed that a lower dosage of fentanyl was used during the operation and less PCA morphine was consumed at 24 and 48 h postoperatively. The extubation time and length of stay in the ICU were shorter in the PVB + GA group, but these factors have little clinical impact, if any. As is well known, pneumothorax, puncturing of blood vessels, local hematoma, hypotension, and epidural block are common complications of thoracic PVB [32, 33]. Fortunately, no local anesthetic toxicity event occurred in the present study. The rate of AEs was not different in both groups. It is worth noting that the biggest PVS is close to the T1–2 or T2–3 intervertebral space, so it is safest to puncture at this site, as the risk for pneumothorax will be lower due to the greater distance between the parietal pleura and pyramis. That is also the reason why we chose T3–4 as the puncture point, which is close to T1–2 or T2–3 PVS, as it increased puncture reliability and reduced AE occurrence. In addition, anesthesia was terminated at 30 min before the end of the operation in this study, for the following reasons: 1) to achieve better postoperative analgesia; 2) to assess safety issues due to a high level of monitoring after cardiac surgery; and 3) since 15 ml of drug was injected on each side, PVB was prone to exert minimal impact on hemodynamics, ensuring stable circulation. Hypotension is an AE that occurs in about 4% of pediatric patients [32]. In breast cancer surgery, PVB did not induce hypotension in any of the patients [34, 35]. Similar results were observed in healthy volunteers [36]. Nevertheless, PVB has a lower risk of hypotension than thoracic epidural analgesia [26, 37, 38]. In the present study, no hypotension occurred in the PVB + GA group, suggesting that hypotension is not a major risk in these patients. Nevertheless, this could vary among different populations of patients with different conditions. This warrants additional study. In the present study, neuromuscular stimulation was used for PVB instead of the ultrasound-guided approach, which is now considered the best approach for PVB [39]. Nevertheless, neuromuscular stimulation is still a valid approach for PVB [22, 23, 40]. China is a developing country that is still adapting to modern approaches. Our hospital has just purchased the ultrasonography (USG) equipment, and the Anesthesiologist have not yet grasped the USG-guided technique. In addition, the learning curve of USG is steep [41]. Hence, even the nerve stimulator has been used in our hospital for many years, the nerve stimulator-guided technique was adopted in the present study until recently. The present study is not without limitations. Despite the randomization, blinding, and control group, this was a pilot study with a small sample size from a single center. Since this was a pilot study, the sample size was estimated by referring to similar studies [26] rather than accurate calculation. In addition, our reduced sample does not allow any conclusions to be drawn about the safety of the procedure, whether for the morbidity of the technique or for the toxicity of local anesthetics. Our future multicenter randomized controlled trial will have a rigorous sample size calculation based on the results of the present study. Additional studies are necessary to confirm the effect of PVB for OPCABG. Conclusions In conclusion, nerve stimulator-guided bilateral thoracic PVB combined with GA could be used efficiently in OPCABG with reduced rescue analgesia and morphine consumption. Additional studies are necessary to examine the potential AEs. Notes Lixin Sun and Qiujie Li contributed equally to this work. Abbreviations AE:  Adverse event ALT:  Alanine transaminase ANOVA:  Analysis of variance AST:  Aspartate transaminase BMI:  Body mass index BUN:  Blood urea nitrogen CI:  Cardiac index CPB:  Cardiopulmonary bypass CVP:  Central venous pressure ECG:  Electrocardiogram ETCO2 :  End-tidal carbon dioxide GA:  General anesthesia HR:  Heart rate ICU:  Intensive care unit LVEF:  Left ventricular ejection fraction MAP:  Mean arterial pressure MIDCAB:  Minimally invasive direct coronary artery bypass MPAP:  Mean pulmonary arterial pressure OPCABG:  Off-pump coronary artery bypass grafting PCA:  Patient-controlled analgesia PCWP:  Pulmonary capillary wedge pressure PVB:  Paravertebral block PVRI:  Pulmonary vascular resistance index PVS:  Paravertebral space SBP:  Systolic blood pressure SCr:  Serum creatinine SD:  Standard deviation SpO2 :  Oxygen saturation SVRI:  Systemic vascular resistance index TEA:  Thoracic epidural anesthesia USG:  ultrasonography VAS:  Visual analogue scale Declarations Acknowledgements Not applicable. Funding This study was supported by the Scientific and Technological Development Guidance Program of Qingdao, China (No. KJZD-13-14-NSH). Authors’ contributions LXS carried out the studies, and drafted the manuscript. QJL, QW and FGM performed the statistical analysis and helped to collect the data. WH and MSW helped to revise the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate The study was approved by the ethics committee of Qingdao Municipal Hospital (No. 20140806–1). Each patient provided a written informed consent. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Authors’ Affiliations (1) Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China (2) Department of Respiratory Medicine, Qingdao Municipal Hospital, 1 Jiaozhou Road, Qingdao, 266011, Shandong, China References Jensen BO, Hughes P, Rasmussen LS, Pedersen PU, Steinbruchel DA. Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial. Circulation. 2006;113:2790–5.View ArticleGoogle ScholarTaggart DP. Off-pump coronary artery bypass grafting (OPCABG)-a ‘personal’ European perspective. J Thorac Dis. 2016;8:S829–S31.View ArticleGoogle ScholarMoller CH, Penninga L, Wetterslev J, Steinbruchel DA, Gluud C. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev. 2012;14:CD007224.Google ScholarShroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361:1827–37.View ArticleGoogle ScholarLamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med. 2013;368:1179–88.View ArticleGoogle ScholarDiegeler A, Borgermann J, Kappert U, Breuer M, Boning A, Ursulescu A, et al. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med. 2013;368:1189–98.View ArticleGoogle ScholarNeskovic V, Milojevic P. High thoracic epidural anesthesia in coronary surgery. Med Pregl. 2003;56:152–6.View ArticleGoogle ScholarPalomero Rodriguez MA, Suarez Gonzalo L, Villar Alvarez F, Varela Crespo C, Moreno Gomez Limon I, Criado Jimenez A. Thoracic epidural anesthesia decreases C-reactive protein levels in patients undergoing elective coronary artery bypass graft surgery with cardiopulmonary bypass. Minerva Anestesiol. 2008;74:619–26.PubMedGoogle ScholarKessler P, Neidhart G, Bremerich DH, Aybek T, Dogan S, Lischke V, et al. High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients. Anesth Analg. 2002;95:791–7 table of contents.PubMedGoogle ScholarSalvi L, Sisillo E, Brambillasca C, Juliano G, Salis S, Marino MR. High thoracic epidural anesthesia for off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2004;18:256–62.View ArticleGoogle ScholarHo AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest. 2000;117:551–5.View ArticleGoogle ScholarConlon NP, Shaw AD, Grichnik KP. Postthoracotomy paravertebral analgesia: will it replace epidural analgesia? Anesthesiol Clin. 2008;26:369–80 viii.View ArticleGoogle ScholarOlivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T, et al. A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10:E357–62.View ArticleGoogle ScholarHemmerling TM, Le N, Olivier JF, Choiniere JL, Basile F, Prieto I. Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia. J Cardiothorac Vasc Anesth. 2005;19:176–81.View ArticleGoogle ScholarRichardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth. 1998;81:230–8.View ArticleGoogle ScholarTighe SQ. Paravertebral block. Anaesthesia. 2002;57:511–2 author reply 2.View ArticleGoogle ScholarJoshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107:1026–40.View ArticleGoogle ScholarDavies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96:418–26.View ArticleGoogle ScholarCarmona P, Llagunes J, Casanova I, Mateo E, Canovas S, Martin E, et al. Continuous paravertebral analgesia versus intravenous analgesia in minimally invasive cardiac surgery by mini-thoracotomy. Rev Esp Anestesiol Reanim. 2012;59:476–82.View ArticleGoogle ScholarWheeler LJ. Peripheral nerve stimulation end-point for thoracic paravertebral block. Br J Anaesth. 2001;86:598–9.PubMedGoogle ScholarBoezaart AP, Raw RM. Continuous thoracic paravertebral block for major breast surgery. Reg Anesth Pain Med. 2006;31:470–6.View ArticleGoogle ScholarNaja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. Eur J Anaesthesiol. 2004;21:489–95.PubMedGoogle ScholarNaja ZM, Raf M, El Rajab M, Ziade FM, Al Tannir MA, Lonnqvist PA. Nerve stimulator-guided paravertebral blockade combined with sevoflurane sedation versus general anesthesia with systemic analgesia for postherniorrhaphy pain relief in children: a prospective randomized trial. Anesthesiology. 2005;103:600–5.View ArticleGoogle ScholarCanto M, Sanchez MJ, Casas MA, Bataller ML. Bilateral paravertebral blockade for conventional cardiac surgery. Anaesthesia. 2003;58:365–70.View ArticleGoogle ScholarHarle CC, Su G. Paravertebral analgesia for cardiac surgery. Tech Reg Anesth Pain Manag. 2008;12:57–63.View ArticleGoogle ScholarBaidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18:626–35.View ArticleGoogle ScholarThavaneswaran P, Rudkin GE, Cooter RD, Moyes DG, Perera CL, reports MGJB. Paravertebral block for anesthesia: a systematic review. Anesth Analg. 2010;110:1740–4.View ArticleGoogle ScholarJunior Ade P, Erdmann TR, Santos TV, Brunharo GM, Filho CT, Losso MJ, et al. Comparison between continuous thoracic epidural and paravertebral blocks for postoperative analgesia in patients undergoing thoracotomy: systematic review. Braz J Anesthesiol. 2013;63:433–42.View ArticleGoogle ScholarDhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2001;15:288–92.View ArticleGoogle ScholarMehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth. 2008;11:91–6.View ArticleGoogle ScholarMehta Y, Swaminathan M, Mishra Y, Trehan N. A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 1998;12:162–5.View ArticleGoogle ScholarNaja Z, Lonnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia. 2001;56:1184–8.View ArticleGoogle ScholarRichardson J, Lonnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice. Br J Anaesth. 2011;106:164–71.View ArticleGoogle ScholarWeltz CR, Greengrass RA, Lyerly HK. Ambulatory surgical management of breast carcinoma using paravertebral block. Ann Surg. 1995;222:19–26.View ArticleGoogle ScholarPusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand. 1999;43:770–4.View ArticleGoogle ScholarSaito T, Den S, Cheema SP, Tanuma K, Carney E, Carlsson C, et al. A single-injection, multi-segmental paravertebral block-extension of somatosensory and sympathetic block in volunteers. Acta Anaesthesiol Scand. 2001;45:30–3.View ArticleGoogle ScholarKoyyalamudi VB, Arulkumar S, Yost BR, Fox CJ, Urman RD, Kaye AD. Supraclavicular and paravertebral blocks: are we underutilizing these regional techniques in perioperative analgesia? Best Pract Res Clin Anaesthesiol. 2014;28:127–38.View ArticleGoogle ScholarBigeleisen PE, Goehner N. Novel approaches in pain management in cardiac surgery. Curr Opin Anaesthesiol. 2015;28:89–94.View ArticleGoogle ScholarOkajima H, Tanaka O, Ushio M, Higuchi Y, Nagai Y, Iijima K, et al. Ultrasound-guided continuous thoracic paravertebral block provides comparable analgesia and fewer episodes of hypotension than continuous epidural block after lung surgery. J Anesth. 2015;29:373–8.View ArticleGoogle ScholarNaja MZ, Ziade MF, Lonnqvist PA. Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol. 2003;20:897–903.View ArticleGoogle ScholarStolz LA, Cappa AR, Minckler MR, Stolz U, Wyatt RG, Binger CW, Amini R, Adhikari S. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. J Vasc Access. 2016;17:366–70.View ArticleGoogle Scholar Copyright © The Author(s). 2019


This is a preview of a remote PDF: https://bmcanesthesiol.biomedcentral.com/track/pdf/10.1186/s12871-019-0768-9

Lixin Sun, Qiujie Li, Qiang Wang, Fuguo Ma, Wei Han, Mingshan Wang. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study, BMC Anesthesiology, 2019, 101, DOI: 10.1186/s12871-019-0768-9