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Journal of Anesthesia

, Volume 33, Issue 1, pp 50–57 | Cite as

Three versus five lumbar paravertebral injections for inguinal hernia repair in the elderly: a randomized double-blind clinical trial

  • Zoher NajaEmail author
  • Saleh Kanawati
  • Ziad El Khatib
  • Fouad Ziade
  • Rakan Nasreddine
  • Ahmad Salah Naja
Original Article

Abstract

Purpose

The objective of the study was to compare three nerve stimulator-guided paravertebral injections versus five injections for elderly patients undergoing inguinal hernia repair in terms of the amount of intraoperative fentanyl and propofol consumption and conversion to general anesthesia. The secondary objective was postoperative pain.

Methods

A prospective, randomized, double-blind clinical trial was performed. 200 elderly patients undergoing unilateral herniorrhaphy were randomized into two groups. Group III received three PVB injections from T12 to L2 and placebo at T11 and L3. Group V received five PVB injections from T11 to L3.

Results

The mean intraoperative fentanyl and propofol consumption were significantly lower in group V (4.9 ± 7.2 µg versus 20.0 ± 12.9 µg and 5.7 ± 11.6 mg versus 34.6 ± 22.9 mg, respectively, p value < 0.0001). Five patients (5.0%) in group III had failed block and were converted to general anesthesia (p value = 0.024). Group V had significantly lower pain scores compared to group III during the first three postoperative days (p value < 0.0001).

Conclusion

The five PVB injection technique is more suitable as a sole anesthetic technique for elderly patients undergoing herniorrhaphy, since it required less intraoperative supplemental analgesia and provided lower postoperative pain scores compared to the three PVB injection technique.

Trial registration

Clinicaltrials.gov identifier: NCT02537860.

Keywords

Nerve block Postoperative pain Geriatric anesthesia 

References

  1. 1.
    Karmakar M. Thoracic paravertebral block. Anesthesiology. 2001;95:771–80.CrossRefPubMedGoogle Scholar
  2. 2.
    White PF. Choice of peripheral nerve block for inguinal herniorrhaphy: Is better the enemy of good? Anesth Analg. 2006;102:1073–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Kehlet H, White PF. Optimizing anesthesia for inguinal herniorrhaphy: general, regional, or local anesthesia? Anesth Analg. 2001;93:1367–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Naja MZ, el Hassan M, Oweidat M, Zbibo R, Ziade MF, Lönnqvist PA. Paravertebral blockade vs. general anesthesia or spinal anesthesia for inguinal hernia repair. Middle East J Anesthesiol. 2001;16:201–10.PubMedGoogle Scholar
  5. 5.
    Naja ZM, Raf M, El-Rajab M, Daoud N, Ziade FM, Al-Tannir MA, Lonnqvist PA. A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children. Anaesthesia. 2006;61:1064–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Naja 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.CrossRefPubMedGoogle Scholar
  7. 7.
    Bhattacharya P, Mandal MC, Mukhopadhyay S, Das S, Pal PP, Basu SR. Unilateral paravertebral block: an alternative to conventional spinal anaesthesia for inguinal hernia repair. Acta Anaesthesiol Scand 2010;54:246–51.CrossRefPubMedGoogle Scholar
  8. 8.
    Fredman B, Zohar E, Philipov A, Olsfanger D, Shalev M, Jedeikin R. The induction, maintenance and recovery characteristics of spinal versus general anesthesia in elderly patients. J Clin Anesth. 1998;10:623–30.CrossRefGoogle Scholar
  9. 9.
    Neufeld KJ, Leoutsakos JM, Sieber FE, Wanamaker BL, Chambers JJ, Rao V, Schretlen DJ, Needham DM. Outcomes of early delirium diagnosis after general anesthesia in elderly. Anesth Analg. 2013;117:471–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Steinmetz J, Rasmussen LS. The elderly and general anesthesia. Minerva Anestesiol. 2010;76:745–52.PubMedGoogle Scholar
  11. 11.
    Liu J, Yuan W, Wang X, Royse CF, Gong M, Zhao Y, Zhang H. Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery. Clin Interv Aging. 2014;9:341–50.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Özkan D, Akkaya T, Cömert A, Balkc N, Özdemir E, Gümüs H, Ergül Z, Kaya O. Paravertebral block in inguinal hernia surgeries: two segments or four segments? Reg Anesth Pain Med. 2009;34:312–15.CrossRefPubMedGoogle Scholar
  13. 13.
    Hadzic A, Kerimoglu B, Loreio D, Karaca PE, Claudio RE, Yufa M, Wedderburn R, Santos AC, Thys DM. Paravertebral blocks provide superior same-day recovery over general anesthesia for patients undergoing inguinal hernia repair. Anesth Analg. 2006; 102:1076–81.CrossRefPubMedGoogle Scholar
  14. 14.
    Wassef MR, Randazzo T, Ward W. The paravertebral nerve root block for inguinal herniorrhaphy—a comparison with the field block approach. Reg Anesth Pain Med. 1998;23:451–6.PubMedGoogle Scholar
  15. 15.
    Klein SM, Pietrobon R, Nielsen KC, Steele SM, Warner DS, Moylan JA, Eubanks SW, Greengrass RA. Paravertebral somatic nerve block compared with peripheral nerve blocks for outpatient inguinal herniorrhaphy. Reg Anesth Pain Med. 2002;27:476–80.CrossRefPubMedGoogle Scholar
  16. 16.
    Klein SM, Greengrass RA, Weltz CR, Warner DS. Paravertebral somatic nerve block for outpatient inguinal Herniorrhaphy: An expanded case report of 22 patients. Reg Anesth Pain Med. 1998;23:306–10.PubMedGoogle Scholar
  17. 17.
    Weltz CR, Klein SM, Arbo JE, Greengrass RA. Paravertebral block anesthesia for inguinal hernia repair. World J Surg. 2003;27:425–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Naja MZ, Ziade MF, Lönnqvist PA. Nerve stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol. 2003;20:897–903.CrossRefPubMedGoogle Scholar
  19. 19.
    Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tayara K, Younes F, Lönnqvist PA. Thoracic paravertebral block: influence of the number of injections. Reg Anesth Pain Med. 2006; 31:196–201.PubMedGoogle Scholar
  20. 20.
    Conzen P, Peter K. Inhalation anaesthesia at the extremes of age: geriatric anaesthesia. Anaesthesia. 1995;50(S):29–33.CrossRefPubMedGoogle Scholar
  21. 21.
    Agarwal A, Kishore K. Complications and controversies of regional anesthesia: a review. Indian J Anaesth. 2009;53:543–53.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Allen DJ, Chae-Kim SH, Trousdale DM. Risk and complications of neuraxial anesthesia and the use of anticoagulation in the surgical patient. BUMC Proc 2002;15:369–73.Google Scholar
  23. 23.
    Bay-Nielsen M, Kehlet H. Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Acta Anaesthesiol Scand 2008;52:169–74.CrossRefPubMedGoogle Scholar
  24. 24.
    Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003;362:853–58.CrossRefPubMedGoogle Scholar
  25. 25.
    Saito T, Gallagher ET, Cutler S, Tanuma K, Yamada K, Saito N, Maruyama K, Carlsson C. Extended unilateral anesthesia: New technique or unilateral anesthesia? Reg Anesth. 1996;21:304–7.PubMedGoogle Scholar
  26. 26.
    Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lonnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004; 59:459–63.CrossRefPubMedGoogle Scholar
  27. 27.
    Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998; 81: 230–38.CrossRefPubMedGoogle Scholar
  28. 28.
    Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010;85:18–26.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Cepeda MS, Farrar JT, Baumgarten M, Boston R, Carr DB, Strom BL. Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther 2003;74:102–12.CrossRefPubMedGoogle Scholar
  30. 30.
    Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Clin Pharmacol Ther 2001;87:608–24.Google Scholar
  31. 31.
    Awad IT, Duggan EM. Posterior lumbar plexus block: anatomy, approaches and techniques. Reg Anesth Pain Med 2005;30:143–9.PubMedGoogle Scholar
  32. 32.
    Klaassen Z, Marshall E, Tubbs RS, Louis RG, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat 2011;24:454–46.CrossRefPubMedGoogle Scholar
  33. 33.
    Kirchmair L, Lirk P, Colvin J, Mitterschiffthaler G, Moriggl B. Lumbar plexus and psoas major muscle: Not always as expected. Reg Anesth Pain Med 2008;33:109–114.PubMedGoogle Scholar
  34. 34.
    Pandhare SR, Gaikwad AP. Anatomical study of ilioinguinal nerve and its clinical correlation. Int J Curr Res Rev. 2013;5:69–75.Google Scholar
  35. 35.
    Al-Dabbagh A. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat 2002;24:102–7.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2018

Authors and Affiliations

  1. 1.Anesthesia and Pain Management DepartmentMakassed General HospitalBeirutLebanon
  2. 2.Surgery DepartmentMakassed General HospitalBeirutLebanon
  3. 3.Faculty of Public HealthLebanese UniversityBeirutLebanon
  4. 4.American University of Beirut Medical CenterBeirutLebanon

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