We read with great interest the article by Hill et al.  1regarding the analgesic efficacy of single-dose, multilevel paravertebral nerve blockade (PVB) for thoracoscopic surgery. Given our own experience with PVBs (160-200 patients per month using both single and continuous, unilateral and bilateral PVBs for a wide variety of cases) in thoracoscopic surgery, we find their results most believable. Single-shot PVB analgesia is not  long-lasting, and pain after thoracoscopic surgery is actually quite significant in the first 24 h and even beyond (especially with the continued presence of a chest tube). Our quarrel with these authors is not with their methods or their findings, but with their conclusions. It is akin to concluding that, because single-dose nerve blocks do not provide prolonged analgesia after total knee replacement, peripheral nerve blocks are of no use for this surgery. Clearly that would be a perverse extrapolation, and most would recognize that such findings indicate the need for continuous blockade.

Our approach to postoperative pain management after thoracoscopic surgery includes routine preoperative placement of a single paravertebral catheter at a level of T5 or T6. This is much more time efficient and comfortable for the patient than placing multiple blocks. We have found no loss of analgesic efficacy by eliminating the single-shot blocks at multiple levels and have observed both clinically and with contrast dye injection that the sole catheter does indeed provide for multiple levels of paravertebral blockade. Besides simplicity and a minimum of side effects, the advantages of a single continuous paravertebral catheter are its effectiveness, its flexibility, and its adaptability. A PVB catheter allows for titration of the local anesthetic and extension of nerve blockade as needed. With further bolus dosing and adjustment of infusion rates, PVB analgesia is individualized before patient discharge from the postanesthesia care unit. In fact, our postanesthesia care unit nurses work closely with our acute interventional postoperative pain service and are most comfortable working with peripheral nerve block infusions. By having a catheter in place, we can also continue the nerve blockade until removal of the chest tube (typically the determining factor in timing of hospital discharge after thoracoscopic surgery), thus minimizing pain and opiate consumption for the duration of this period. Moreover, in the event that the thoracoscopic procedure turns into an open thoracotomy, the PVB catheter is already in position to readily provide postoperative analgesia and adjust it to the patient’s needs.

It has been suggested that thoracic PVB may replace the thoracic epidural technique as the gold standard for providing analgesia for patients undergoing thoracotomy.2In our institution, this has been the case for some time, and it has had a profound and positive impact. We urge our colleagues to move forward in learning and applying continuous PVB in their practices.

*University of Pittsburgh Medical Centers Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania. bendbx@anes.upmc.edu

Hill SE, Keller RA, Stafford-Smith M, Grichnik K, White WD, D’Amico TA, Newman MF: Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology 2006; 104:1047–53
Arnal D, Garutti I, Olmedilla L: Paravertebral analgesia in thoracic surgery. Rev Esp Anestesiol Reanim 2004; 51:438–46