Bilateral Continuous Thoracic Paravertebral Block Versus IV Fentanyl Infusion for Perioperative Analgesia in Patients Undergoing Cardiac Surgery Through Median Sternotomy

Bilateral Continuous Thoracic Paravertebral Block Versus IV Fentanyl Infusion for Perioperative Analgesia in Patients Undergoing Cardiac Surgery Through Median Sternotomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bilateral Continuous Thoracic Paravertebral Block Versus IV Fentanyl Infusion for Perioperative Analgesia in Patients Undergoing Cardiac Surgery Through Median Sternotomy Dina Kassim, Samaa Rashwan, Youssef Mohamed, Ihab Omar, Ahmed El-Shaarawy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5353197/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jun, 2025 Read the published version in Beni-Suef University Journal of Basic and Applied Sciences → Version 1 posted 10 You are reading this latest preprint version Abstract Background In patients who are undergoing open cardiac surgery, thoracic paravertebral block (TPVB) is advantageous for pain management. Our objective was to compare this type of block with intravenous Fentanyl analgesia in those patients. Methods This prospective, randomized study included 44 patients who underwent open heart surgery through a median sternotomy. Participants were randomly divided into two equal groups (each with 22 subjects). Group Ⅰ (Fentanyl group) (n = 22): received fentanyl infusion 2µg/kg/h after placing the endotracheal tube and stopped at the end of surgery. Group Ⅱ (TPVB group) (n = 22): Bilateral thoracic paravertebral catheters were inserted preoperative. Before induction, there was a maximum of 20 ml per side for each catheter, which received a bolus dose of 0.3ml/kg 0.25% bupivacaine. Continuous infusion of 0.25% bupivacaine at a rate of 0.1 ml/kg/h was administered through each catheter following intubation. The infusion was subsequently discontinued at the conclusion of the procedure. Results Critical-Care Pain Observation Tool (CCPOT) was lower in patients of group Ⅱ (TPVB group) than in patients of group Ⅰ (fentanyl group); in group Ⅱ at 8hs, 12hs, and 24hs postoperative were 2,3,3 respectively, whereas median CCPOT in group Ⅰ at 8hs, 12hs, and 24hs postoperative were 3,4,4 respectively (p value < 0.05). In comparison to group Ⅰ, there was a substantial decrease in the intraoperative fentanyl requirements of group Ⅱ (343.6 µg ± 44.1 and 926.8 µg ± 117.4) (p-value < 0.05). In comparison to group I (9 mg 2), the TPVB group's postoperative opioid requirements were significantly lower (6.2 mg 2.3). P-value was less than 0.05. Conclusion Compared with IV fentanyl infusion, Bilateral continuous thoracic paravertebral block was determined to be more effective in the operative and postoperative analgesia of patients who underwent heart surgery via median sternotomy. thoracic paravertebral block cardiac surgery pain fentanyl infusion Introduction Advances in cardiac surgery and postoperative care greatly affect outcomes and patients' quality of life. Lung collapse, atelectasis, or hypoxemia may occur after surgery due to inadequate postoperative pain management ( 1 ). Moreover, it can lead to chronic pain or frozen shoulder syndromes ( 2 ). Effective intraoperative anesthesia and adequate postoperative analgesia are provided by paravertebral nerve blocks (PVBs), which have significantly fewer adverse effects than centrally acting painkillers ( 3 ). Most published data on unilateral PVB ( 4 ) reported that it cannot be used in midline incisions ( 5 ). Therefore, bilateral (BPVB) has been successfully applied to median sternotomy in cardiac surgery and midline incisions in the abdominal and pelvic regions ( 6 ). Furthermore, according to reports, the administration of high doses of opioid-like fentanyl led to satisfactory postoperative pain relief ( 7 ). However, it may lead to respiratory depression and a prolonged stay in the intensive care unit ( 8 ). In order to evaluate the relative efficacy of intravenous fentanyl infusion and continuous bilateral thoracic paravertebral block in the context of operative and postoperative pain in patients undergoing heart surgery via median sternotomy, this study was conducted. Methods Ethics approval and consent to participate : This study was conducted from October 2019 to December 2021 after the approval of the Department of Anesthesiology and the local research and ethical committee (on October 9, 2018). It was registered at ClinicalTrials.gov on April 3, 2019 (ClinicalTrials.gov ID: NCT03903367). Written informed consent was obtained from all participants and is available upon request. Funding: No external source of funding. For 44 patients aged 18 to 65 who underwent elective open-heart surgery via median sternotomy, we obtained written informed consent. The patients were excluded if they had chest trauma, unstable hemodynamics, contraindications to local anesthetic drugs or to perform TPVB, patients with impaired left ventricular function, coagulation abnormalities, opioid abuse, history of chronic pain, psychic problems, and BMI ≥ 30. The patients were prepared preoperatively by history taking, physical examination, and routine investigations such as CBC, coagulation profile, renal profile, liver profile, ABG, CXR, Echocardiography, and Coronary angiography. On arrival at the operating theatre, an intravenous cannula (18G) was inserted, and IV 250 to 500 ml crystalloid fluids were infused, arterial line and central venous line were inserted under sedation (3-5 mg midazolam), and a complete aseptic condition, the monitor was attached to the patients to take preoperative readings of heart rate, O2 saturation, blood pressure, end-tidal CO2, and electrocardiogram. The urinary catheter was inserted following the induction of anesthesia. Following laryngoscopy and endotracheal intubation, the patient was administered midazolam 0.1 mg/kg, fentanyl 3-5 µg/kg, propofol up to 1-2 mg, and atracurim 0.5 mg/kg. Anesthesia was induced 3-5 minutes after preoxygenation with 100% O2. Anaesthesia was sustained at a 100% oxygen level; isoflurane was titrated according to the desired depth of anesthesia and atracurium infusion 5-10 mic/kg/min. - A computer-generated permuted block randomization sequence was employed to randomize the patients into two groups. Group Ⅰ (Fentanyl group) (n = 22): GA was administered, and fentanyl infusions were initiated at a rate of 2µg/kg/h following intubation and were discontinued at the conclusion of the surgery. Group Ⅱ (paravertebral group) (n=22): In the preoperative phase, ultrasound-guided bilateral thoracic paravertebral catheters were inserted at the level of T4. A 0.3ml/kg 0.25% bupivacaine bolus dose was administered in each catheter, with a total of 20 ml administered on each side. General anesthesia was administered for 15-20 minutes prior to the commencement of a continuous infusion of 0.1 ml/kg/h 0.25% bupivacaine, which was terminated once the procedure was complete. After 24 hours, the catheters were eliminated. When there was an increase ≥20% in the mean blood pressure (MBP) or heart rate (HR) from the baseline was observed, an incremental dose of fentanyl (2 µg/kg) was administered. The patients were transferred to the ICU after the completion of the surgery, where they were reconnected to the mechanical ventilator. The Critical-Care Pain Observation Tool (CPOT) was used to evaluate postoperative pain. The patient was considered pain free if CPOT≤ 2, if CPOT≥3 the patient received intravenous morphine 2-3 mg. Ultrasound-guided TPVB Procedure: The back of the patient was exposed, and skin white was applied by lidocaine 1% at the site of injection using an ultrasound Philips HD5 machine and linear ultrasound probe (4-16 MHz) in complete aseptic conditions. In the transverse approach, the transverse process was visualized by moving the probe medially after aligning it over the long axis of the rib. This was accomplished by tilting the probe to identify the internal intercostal membrane, parietal pleura, and external intercostal muscle. From the lateral to medial direction, In-plane introduction of the needle was performed at the probe's lateral end. The needle tip was positioned near the costotransverse ligament in the paravertebral space. The local anesthetic spread should cause displacement of the pleura anteriorly. The catheters were inserted after the bolus dose of local anaesthetic was injected to create a space for the catheter, via an 18G Tuohy needle, 3-4 cm distal to needle tip then the catheters were tunneled and fixed in place by adhesive tape. age, sex, weight, height, type of operation, left ventricular ejection fraction, Euro score II, and operative data were all recorded. time required for aortic cross-clamp, total bypass time, total operative time, and the necessity of inotropic support. Before the induction of anesthesia, the mean arterial blood pressure and heart rate were measured and recorded. Subsequently, they were measured and recorded 1 minute prior to the skin incision, 3 minutes after the skin incision, 1 minute prior to the sternotomy, and 3 minutes after the sternotomy. At 8, 12, and 24 hours after admission to the ICU, the Critical-Care Pain Observation Tool (CPOT) was the initial outcome. The second outcome was the time required for tracheal extubation, the total 24-hour morphine requirement, and the intraoperative fentanyl requirements, Chest tube drainage volume, duration of ICU stay, and complications associated with paravertebral block, such as pneumothorax and blood vessel or dural puncture. The Statistical Analysis: In order to determine the sample size, the comparison of CCPOT at 24h postoperative between patients who underwent sternotomy treated with bilateral continuous paravertebral block and those treated with IV fentanyl infusion, due to the fact that it was the primary result of our studies. As reported in a previous publication (9), In the paravertebral block-treated group, the median and interquartile range of the 24-hour postoperative visual analogue scale (VAS) were approximately 6 (1–11), whereas in the fentanyl group, it was approximately 7 (1–23, respectively). The median was considered in replacement of the mean and estimated the SD from the range. Accordingly, for each group, it was determined that a minimum of 22 patients was the appropriate sample size. The data were statistically described in terms of mean and standard deviation (₱SD), median and range, or frequencies and percentages. The normal distribution of numerical data was evaluated using the Kolmogorov-Smirnov test. The numerical variables were compared using the student t-test. A statistically significant P-value was defined as one that was less than 0.05. IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft Windows was employed to conduct all statistical analyses. Results This randomized comparative study included 44 patients divided into 2 groups (n=22 per group). All patients completed the study as shown in the flow diagram. Gender, age, body weight, body height, and Euro score Ⅱ did not demonstrate any statistically significant differences among the study groups (P value >0.05) (Table 1); The operational data, which encompassed the type of operation, aortic cross-clamp time (ACCT), total operative time (TOT), total bypass time (TBT), and inotropic support, did not exhibit a statistically significant difference between the two groups (p-value > 0.05) (Table 2) There was no statistically significant difference in hemodynamic variation between the two groups (p-value > 0.05) (Table 3), CCPOT was lower in patients of group Ⅱ (TPV) than in patients of group Ⅰ (fentanyl group); in group Ⅱ at 8hs, 12hs, and 24hs post-operative were 2,3,3 respectively, whereas median CCPOT in group Ⅰ at 8hs, 12hs, and 24hs post-operative were 3,4,4 respectively (p-value < 0.05) (Table 4) In comparison to group Ⅰ, group Ⅱ experienced a statistically significant decrease in intraoperative fentanyl consumption (343.6 µg ± 44.1 and 926.8 µg ± 117.4, respectively, p-value < 0.05). Additionally, group Ⅱ (TPV group) experienced a statistically significant reduction in postoperative morphine consumption (6.2 mg ± 2.3 versus 9 mg ± 2 for group I), p-value < 0.05 as in table 4 There was a statistically significant reduction in the time for tracheal extubation in patients of TPV group, 5.9 hrs ± 1.9 hours versus 11 hrs ± 3.3 hours for group I (p-value < 0.05) (Table 4). The postoperative ICU stay for the TPVB group patients was statistically significantly shorter, 2.5 days ± 0.8 days versus 3.2 days ± 0.8 days for group I (P value 0.004%) (Table 4). Discussion This study demonstrated that bilateral continuous (TPVB) using bupivacaine provided better perioperative analgesia, shorter extubation time, and earlier discharge from the ICU than continuous intravenous fentanyl infusion in patients who underwent heart surgery via median sternotomy. This could be attributed to the somatic and sympathetic block that the local anesthetic induces when injected into the paravertebral region, which is advantageous for thoracic surgery incisions (2). TPVB was reported to treat post-sternotomy pain without the adverse effects of systemic opioids or epidural blocks with lower hemodynamic effect and retain respiratory functions (10). The investigation of Sun L, et al (11) evaluated the effectiveness of bilateral TPVB in conjunction with general anesthesia (GA) in patients undergoing off-pump coronary artery bypass grafting (OPCABG). The results of the study determined that the intake of morphine and rescue analgesia was lower when bilateral TPVB was used in conjunction with GA in (OPCABG) than when GA was used alone, which is consistent with our findings in the current study. Carmona P, et al (12) determined that continuous paravertebral analgesia is a safe and acceptable method that enables early extubation and provides more effective pain control than intravenous analgesia in cardiac surgery via thoracotomy. Furthermore, Dhole S, et al (13) reported that the use of thoracic PVB after thoracotomy provides effective analgesia. This point was further supported by the fact that the VAS pain scores at rest and during coughing were substantially lower than those of intravenous opioids, as well as the fact that there were significantly fewer side effects. In contrast to our results, Olivier JF, et al (14) determined that thoracic epidural analgesia (TEA) offers superior pain relief following cardiac surgery compared to a bilateral single-shot paravertebral block (PVB). Biswas, et al (15) demonstrated that continuous thoracic paravertebral block was found to be less effective than epidural block in alleviating post-thoracotomy pain, according to the report. Nevertheless, the epidural group exhibited a higher incidence of sympatholytic complications. As a result, they advised the use of paravertebral block for post-thoracotomy pain in situations where a thoracic epidural is not practicable. Zengin and Alagoz (16) concluded that Thoracic epidural analgesia (TEA) provided effective postoperative analgesia and stable hemodynamics in elderly patients after thoracotomy more than TPVB. El Shora, et.al ( 17) found that thoracic epidural analgesia was not more efficacious than ultrasound-guided paravertebral block in the context of sternotomy pain following cardiac surgery. Conclusions The perioperative pain management in cardiac surgery was more effective with the bilateral continuous thoracic paravertebral block than with systemic fentanyl infusion. It is a technique that is straightforward and effortless to learn, safe to execute, and enables early mobilization and discharge. Study Limitations: The present investigation is a single-center investigation that involves a limited number of patients. The need for comparing bilateral thoracic paravertebral block with other procedures such as bilateral erector spinal block in cardiac surgery through midline incision. Declarations Funding: No external source of funding. Author Contribution DK, SR, YM, IO, and AE: 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; 3) final approval of the version to be published DK, SR, and YM: Data collection, analysis, and methodology development.IO, AE, and YM: manuscript writing. References Leal-Noval SR, Marquez-Vacaro JA, García-Curiel A. Nosocomial pneumonia in patients undergoing heart surgery. Critical Care Med. 2010; 28:935–940. Richardson J, Lönnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice.British Journal of Anaesthesia. 2011; 106 (2): 164–171. Helms O, Mariano J, Hentz JG. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized double-blind placebo-controlled study. Journal of Cardio-thoracic Surgery. 2011; 40:902–906. Rivedal DD, Nayar HS, Israel JS. Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mamoaplasty. journal of surgical research. 2018; 228: 307–313. Bonica JJ. The management of pain with analgesic block. The Management of Pain. London: Henry Kimpton. 1953; 166–84. Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001; 95: 771–80. Hutchins JL, Grandelis AJ, Kaizer AM. Thoracic paravertebral block versus thoracic epidural analgesia for postoperative pain control in open pancreatic surgery: A randomized controlled trial. Journal of Clinical Anesthesia. 2018; 48:41–45. Macintyre PE and Schug SA. Acute pain management: a practical guide. Boca Raton. CRC press. 2014; 4:100–106. Asida SM, Youssef IA, Mohamed AK, Abdelrazik AN. Post-thoracotomy pain relief: Thoracic paravertebral block compared with systemic opioids. Egyptian Journal of Anaesthesia. 2012; 28: 55–60. Singh S, Jacob M, Hasnain S. Comparison between continuous thoracic epidural block and continuous thoracic paravertebral block in the management of thoracic trauma. Medical journal armed forces India. 2017; 73:146–151. Sun L, Li Q, Wang Q, Ma F, Han W, Wang M. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting. BMC Anesthesiology. 2019; 19–101. Carmona P, Llagunes J, Casanova I. Continuous paravertebral analgesia versus intravenous analgesia in minimally invasive cardiac surgery by mini-thoracotomy. Rev Esp Anestesiol Reanim. 2012; 59(9):476–82. Dhole S, Mehta Y, Saxena H. 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(3):288–92. Olivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T. A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10(5): E357-62. Biswas S, Verma R, Bhatia VK, Chaudhary AK, Chandra G, Prakash R. Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief. J Clin Diagn Res. 2016;10(9): UC08-UC12. doi: 10.7860/JCDR/2016/19159.8489. Epub 2016 Sep 1. Retraction in: J Clin Diagn Res. 2020;14(7): ZZ01. Zengin M, Alagoz A. Comparison of Thoracic Epidural Analgesia and Thoracic Paravertebral Block Applications in the Treatment of Acute Pain After Thoracotomy in Geriatric Patients. Cureus. 2021;13(10): e18982. doi: 10.7759/cureus.18982 . PMID: 34820237; PMCID: PMC8606221. El Shora HA, El Beleehy AA, Abdelwahab AA, Ali GA, Omran TE, Hassan EA, Arafat AA. Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial. Thorac Cardiovasc Surg. 2020;68(5):410–416. doi: 10.1055/s-0038-1668496 . Epub 2018 Aug 16. PMID: 30114712. Tables Table (1): Demographic data and Euroscore Group I (n = 22) Group II (n = 22) p value Mean SD Mean SD Age (years) 35.6 9.8 35.6 9.8 > 0.999 Weight (Kg) 72.9 9.3 72.9 9.3 > 0.999 Height (cm) 167.2 4.0 167.2 4.0 > 0.999 Euroscor Ⅱ 0.851 0.3067 0.851 0.3067 > 0.999 Number % Number % P value Gender: •Female • Male 13 59.1% 12 54.5% 0.761 9 40.9% 10 45.5% Table (2): Operative data Group I (n = 22) Group II (n = 22) p value Number % Number % Type of operation: ASD 2 9.090% 3 13.60% > 0.999 AVR 8 36.36% 7 31.80% MVR 5 22.72% 6 27.30% TVR 3 13.60% 3 13.60% AVR, TVR 3 18.1% 1 4.50% AVR, MVR 1 4.5% 2 9.10% Mean SD Mean SD P value ACCT (minutes) 68.9 17.2 67.7 16.7 0.812 TBT (minutes) 91.3 18.4 89.1 19.1 0.701 TOT (minutes) 233.6 42.1 228.2 40.9 0.665 Number % Number % Inotropic support: No inotropes 2 9.09% 2 9.1% > 0.999 Adrenalin 9 40.9% 11 50.0% Noradrenalin 2 9.09% 1 4.5% Dobutamine 2 9.09% 5 22.7% Adrenalin, Noradrenalin 3 13.6% 1 4.5% ACCT : aortic cross clamp time; TBT : total bypass time; TOT : total operative time. AVR : Aortic Valve Replacement; MVR: Mitral Valve Replacement: TVR : Tricuspid Valve Replacement, ASD: Atrial Septal Defect Table (3): Hemodynamic parameters Group I (n = 22) Group II (n = 22) p value Mean SD Mean SD HR Base line 84.6 10.2 81.1 10.0 0.264 HR 1 min before skin incision 68.5 7.8 67.5 7.2 0.677 HR 3min after skin incision 71.0 5.7 69.7 5.7 0.448 HR 1 min before sternotomy 71.8 4.8 73.1 5.0 0.376 HR 3 min after sternotomy 78.2 6.4 75.7 5.3 0.168 MAP Base line 87.6 9.2 85.2 9.4 0.395 MAP 1 min before skin incision 73.2 6.1 75.7 7.9 0.248 MAP 3 min after skin incision 77.2 10.4 80.8 11.1 0.274 MAP 1 min before sternotomy 77.9 8.9 83.5 10.6 0.065 MAP 3 min after sternotomy 83.3 9.9 85.4 7.7 0.440 HR: heart rate (beats/min) MAP: mean arterial blood pressure (mmHg) Group I: Fentanyl group. Group II: Thoracic paravertebral group (TPVB). Table (4): CCPOT and Postoperative data Group I (n = 22) Group II (n = 22) p value Median Range Median Range CCPOT 8h 3 2 - 4 2 1 - 4 0.015 CCPOT 12h 4 2 - 6 3 2 - 4 0.000 CCPOT 24h 4 2 - 5 3 2 - 4 0.001 Mean SD Mean SD P value IO fentanyl dose (ug) 926.8 117.4 343.6 44.1 0.000 Morphine 24h (mg) 9.0 2.0 6.2 2.3 0.000 Extubation time (hours) 11.0 3.3 5.9 1.9 0.000 ICU stay (days) 3.2 0.8 2.5 0.8 0.004 Chest tube drain (ml) 255.5 102.5 248.2 100.9 0.814 CCPOT : Critical-Care Pain Observation Tool; IO : intraoperative Group I : Fentanyl group trail II: Thoracic paravertebral group (TPVB) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Jun, 2025 Read the published version in Beni-Suef University Journal of Basic and Applied Sciences → Version 1 posted Editorial decision: Revision requested 22 Feb, 2025 Reviewers agreed at journal 07 Feb, 2025 Reviews received at journal 30 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviewers agreed at journal 15 Dec, 2024 Reviewers agreed at journal 03 Dec, 2024 Reviewers invited by journal 25 Nov, 2024 Editor assigned by journal 17 Nov, 2024 Submission checks completed at journal 17 Nov, 2024 First submitted to journal 29 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5353197","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":391077077,"identity":"1a37bd36-c74f-4b7c-8dc2-452924d23f9d","order_by":0,"name":"Dina Kassim","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Dina","middleName":"","lastName":"Kassim","suffix":""},{"id":391077078,"identity":"f0d84c2e-187c-42be-84bd-45cf14aeaba6","order_by":1,"name":"Samaa Rashwan","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Samaa","middleName":"","lastName":"Rashwan","suffix":""},{"id":391077079,"identity":"6646fe82-35aa-4fe0-807a-03ae7090aad3","order_by":2,"name":"Youssef Mohamed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYNACGyBmb2x8/KMCyGBmbiBCSxoQ8xw+bMxwBqSFkVgtEmlp0oxtIB4BLQbHe4w/fEi4J8fPkGMgXTivNpq/HajlR8U23FrOnDGTnJFQbCzZcMbAeOa247kzDjM2MPacuY1by40cM2beHwmJGw72GCTwbjuW2wDUwszYhleL8ec/CUAth3kMDvDOOZY7nwgtBtIMIC3H2BKbeRtqcjcQ0iJ55liZZE9CgrFkD/NhxhnHDuRuBGo5iM8vfMebN3/4kZAgxy//sP3Hh5q63HnnDx988KMCtxaFA6j8w2DyAIY6JCDfgMqvw6d4FIyCUTAKRigAABBTYlaSrAA1AAAAAElFTkSuQmCC","orcid":"","institution":"Beni-Suef University","correspondingAuthor":true,"prefix":"","firstName":"Youssef","middleName":"","lastName":"Mohamed","suffix":""},{"id":391077080,"identity":"4ae2a95d-5d0c-4c02-80f5-46c865b2b95d","order_by":3,"name":"Ihab Omar","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Ihab","middleName":"","lastName":"Omar","suffix":""},{"id":391077081,"identity":"1293fddb-c163-46f7-b8f7-02f6f4e16422","order_by":4,"name":"Ahmed El-Shaarawy","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"El-Shaarawy","suffix":""}],"badges":[],"createdAt":"2024-10-29 09:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5353197/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5353197/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43088-025-00637-7","type":"published","date":"2025-06-03T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84242677,"identity":"3a063066-4c84-438a-b3b3-727326c1f760","added_by":"auto","created_at":"2025-06-09 16:11:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1062642,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5353197/v1/73057a4b-5726-4e5a-bca8-7bfa4018a49e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bilateral Continuous Thoracic Paravertebral Block Versus IV Fentanyl Infusion for Perioperative Analgesia in Patients Undergoing Cardiac Surgery Through Median Sternotomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdvances in cardiac surgery and postoperative care greatly affect outcomes and patients' quality of life. Lung collapse, atelectasis, or hypoxemia may occur after surgery due to inadequate postoperative pain management (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Moreover, it can lead to chronic pain or frozen shoulder syndromes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Effective intraoperative anesthesia and adequate postoperative analgesia are provided by paravertebral nerve blocks (PVBs), which have significantly fewer adverse effects than centrally acting painkillers (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Most published data on unilateral PVB (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) reported that it cannot be used in midline incisions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Therefore, bilateral (BPVB) has been successfully applied to median sternotomy in cardiac surgery and midline incisions in the abdominal and pelvic regions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Furthermore, according to reports, the administration of high doses of opioid-like fentanyl led to satisfactory postoperative pain relief (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, it may lead to respiratory depression and a prolonged stay in the intensive care unit (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn order to evaluate the relative efficacy of intravenous fentanyl infusion and continuous bilateral thoracic paravertebral block in the context of operative and postoperative pain in patients undergoing heart surgery via median sternotomy, this study was conducted.\u003c/p\u003e "},{"header":"Methods","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study was conducted from October 2019 to December 2021 after the approval of the Department of Anesthesiology and the local research and ethical committee (on October 9, 2018). It was registered at ClinicalTrials.gov on April 3, 2019 (ClinicalTrials.gov ID: NCT03903367).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWritten informed consent was obtained from all participants and is available upon request.\u003c/li\u003e\n \u003cli\u003eFunding: No\u0026nbsp;external source of funding.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor 44 patients aged 18 to 65 who underwent elective open-heart surgery via median sternotomy, we obtained written informed consent. The patients were excluded if they had chest trauma, unstable hemodynamics, contraindications to local anesthetic drugs or to perform TPVB, patients with impaired left ventricular function, coagulation abnormalities, opioid abuse, history of chronic pain, psychic problems, and BMI \u0026ge; 30.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patients were prepared preoperatively by history taking, physical examination, and routine investigations such as CBC, coagulation profile, renal profile, liver profile, ABG, CXR, Echocardiography, and Coronary angiography.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn arrival at the operating theatre, an intravenous cannula (18G) was inserted, and IV 250 to 500 ml crystalloid fluids were infused, arterial line and central venous line were inserted under sedation (3-5 mg midazolam), and a complete aseptic condition, the monitor was attached to the patients to take preoperative readings of heart rate, O2 saturation, blood pressure, end-tidal CO2, and electrocardiogram. The urinary catheter was inserted following the induction of anesthesia. Following laryngoscopy and endotracheal intubation, the patient was administered midazolam 0.1 mg/kg, fentanyl 3-5 \u0026micro;g/kg, propofol up to 1-2 mg, and atracurim 0.5 mg/kg. Anesthesia was induced 3-5 minutes after preoxygenation with 100% O2. Anaesthesia was sustained at a 100% oxygen level; isoflurane was titrated according to the desired depth of anesthesia and atracurium infusion 5-10 mic/kg/min.\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp; A computer-generated permuted block randomization sequence was employed to randomize the patients into two groups.\u003c/p\u003e\n\u003cp\u003eGroup Ⅰ (Fentanyl group) (n = 22): GA was administered, and fentanyl infusions were initiated at a rate of 2\u0026micro;g/kg/h following intubation and were discontinued at the conclusion of the surgery. Group Ⅱ (paravertebral group) (n=22): In the preoperative phase, ultrasound-guided bilateral thoracic paravertebral catheters were inserted at the level of T4. A 0.3ml/kg 0.25% bupivacaine bolus dose was administered in each catheter, with a total of 20 ml administered on each side. General anesthesia was administered for 15-20 minutes prior to the commencement of a continuous infusion of 0.1 ml/kg/h 0.25% bupivacaine, which was terminated once the procedure was complete. After 24 hours, the catheters were eliminated. \u0026nbsp;When there was an increase \u0026ge;20% in the mean blood pressure (MBP) or heart rate (HR) from the baseline was observed, an incremental dose of fentanyl (2 \u0026micro;g/kg) was administered.\u003c/p\u003e\n\u003cp\u003eThe patients were transferred to the ICU after the completion of the surgery, where they were reconnected to the mechanical ventilator. The Critical-Care Pain Observation Tool (CPOT) was used to evaluate postoperative pain. The patient was considered pain free if CPOT\u0026le; 2, if CPOT\u0026ge;3 the patient received intravenous morphine 2-3 mg.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Ultrasound-guided TPVB Procedure:\u0026nbsp;\u003c/strong\u003eThe back of the patient was exposed, and skin white was applied by lidocaine 1% at the site of injection using an ultrasound Philips HD5 machine and linear ultrasound probe (4-16 MHz) in complete aseptic conditions. In the transverse approach, the transverse process was visualized by moving the probe medially after aligning it over the long axis of the rib. This was accomplished by tilting the probe to identify the internal intercostal membrane, parietal pleura, and external intercostal muscle.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the lateral to medial direction, In-plane introduction of the needle was performed at the probe\u0026apos;s lateral end. The needle tip was positioned near the costotransverse ligament in the paravertebral space. The local anesthetic spread should cause displacement of the pleura anteriorly. The catheters were inserted after the bolus dose of local anaesthetic was injected to create a space for the catheter, via an 18G Tuohy needle, 3-4 cm distal to needle tip then the catheters were tunneled and fixed in place by adhesive tape.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eage, sex, weight, height, type of operation, left ventricular ejection fraction, Euro score II, and operative data were all recorded. time required for aortic cross-clamp, total bypass time, total operative time, and the necessity of inotropic support. Before the induction of anesthesia, the mean arterial blood pressure and heart rate were measured and recorded. Subsequently, they were measured and recorded 1 minute prior to the skin incision, 3 minutes after the skin incision, 1 minute prior to the sternotomy, and 3 minutes after the sternotomy. At 8, 12, and 24 hours after admission to the ICU, the Critical-Care Pain Observation Tool (CPOT) was the initial outcome. The second outcome was the time required for tracheal extubation, the total 24-hour morphine requirement, and the intraoperative fentanyl requirements, Chest tube drainage volume, duration of ICU stay, and complications associated with paravertebral block, such as pneumothorax and blood vessel or dural puncture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Statistical Analysis:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to determine the sample size, the comparison of CCPOT at 24h postoperative between patients who underwent sternotomy treated with bilateral continuous paravertebral block and those treated with IV fentanyl infusion, due to the fact that it was the primary result of our studies. As reported in a previous publication (9), In the paravertebral block-treated group, the median and interquartile range of the 24-hour postoperative visual analogue scale (VAS) were approximately 6 (1\u0026ndash;11), whereas in the fentanyl group, it was approximately 7 (1\u0026ndash;23, respectively). The median was considered in replacement of the mean and estimated the SD from the range. Accordingly, for each group, it was determined that a minimum of 22 patients was the appropriate sample size. The data were statistically described in terms of mean and standard deviation (₱SD), median and range, or frequencies and percentages. The normal distribution of numerical data was evaluated using the Kolmogorov-Smirnov test. The numerical variables were compared using the student t-test. A statistically significant P-value was defined as one that was less than 0.05. IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft Windows was employed to conduct all statistical analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis randomized comparative study included 44 patients divided into 2 groups (n=22 per group). All patients completed the study as shown in the flow diagram.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1734433204.jpeg\" alt=\"image\" style=\"width: 445px;\"\u003e\u003c/p\u003e\n\u003cp\u003eGender, age, body weight, body height, and Euro score Ⅱ did not demonstrate any statistically significant differences among the study groups (P value \u0026gt;0.05) \u0026nbsp;(Table 1); The operational data, which encompassed the type of operation, aortic cross-clamp time (ACCT), total operative time (TOT), total bypass time (TBT), and inotropic support, did not exhibit a statistically significant difference between the two groups (p-value \u0026gt; 0.05) (Table 2) There was no statistically significant difference in hemodynamic variation between the two groups (p-value \u0026gt; 0.05) (Table 3), CCPOT was lower in patients of group Ⅱ (TPV) than in patients of group Ⅰ (fentanyl group); in group Ⅱ at 8hs, 12hs, and 24hs post-operative were 2,3,3 respectively, whereas median CCPOT in group Ⅰ at 8hs, 12hs, and 24hs post-operative were 3,4,4 respectively (p-value \u0026lt; 0.05) (Table 4)\u003c/p\u003e\n\u003cp\u003eIn comparison to group Ⅰ, group Ⅱ experienced a statistically significant decrease in intraoperative fentanyl consumption (343.6 µg ± 44.1 and 926.8 µg ± 117.4, respectively, p-value \u0026lt; 0.05). Additionally, group Ⅱ (TPV group) experienced a statistically significant reduction in postoperative morphine consumption (6.2 mg ± 2.3 versus 9 mg ± 2 for group I), p-value \u0026lt; 0.05 as in table 4 There was a statistically significant reduction in the time for tracheal extubation in patients of TPV group, 5.9 hrs ± 1.9 hours versus 11 hrs ± 3.3 hours for group I (p-value \u0026lt; 0.05) (Table 4). The postoperative ICU stay for the TPVB group patients was statistically significantly shorter, 2.5 days ± 0.8 days versus 3.2 days ± 0.8 days for group I (P value 0.004%) (Table 4).\u003c/p\u003e\n\n\n\n\n\n\n\n"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that bilateral continuous (TPVB) using bupivacaine provided better perioperative analgesia, shorter extubation time, and earlier discharge from the ICU than continuous intravenous fentanyl infusion in patients who underwent heart surgery via median sternotomy. This could be attributed to the somatic and sympathetic block that the local anesthetic induces when injected into the paravertebral region, which is advantageous for thoracic surgery incisions (2).\u0026nbsp;\u003c/p\u003e\u003cp\u003eTPVB was reported to treat post-sternotomy pain without the adverse effects of systemic opioids or epidural blocks with lower hemodynamic effect and retain respiratory functions (10). \u0026nbsp;\u003c/p\u003e\u003cp\u003eThe investigation of\u003cstrong\u003e\u0026nbsp;Sun L, et al\u0026nbsp;\u003c/strong\u003e(11) evaluated the effectiveness of bilateral TPVB in conjunction with general anesthesia (GA) in patients undergoing off-pump coronary artery bypass grafting (OPCABG). The results of the study determined that the intake of morphine and rescue analgesia was lower when bilateral TPVB was used in conjunction with GA in (OPCABG) than when GA was used alone, which is consistent with our findings in the current study.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCarmona P, et al\u0026nbsp;\u003c/strong\u003e(12) determined that continuous paravertebral analgesia is a safe and acceptable method that enables early extubation and provides more effective pain control than intravenous analgesia in cardiac surgery via thoracotomy.\u003c/p\u003e\u003cp\u003eFurthermore,\u003cstrong\u003e\u0026nbsp;Dhole S, et al\u0026nbsp;\u003c/strong\u003e(13) reported that the use of thoracic PVB after thoracotomy provides effective analgesia. This point was further supported by the fact that the VAS pain scores at rest and during coughing were substantially lower than those of intravenous opioids, as well as the fact that there were significantly fewer side effects.\u0026nbsp;\u003c/p\u003e\u003cp\u003eIn contrast to our results, \u003cstrong\u003eOlivier JF, et al\u0026nbsp;\u003c/strong\u003e(14) determined that thoracic epidural analgesia (TEA) offers superior pain relief following cardiac surgery compared to a bilateral single-shot paravertebral block (PVB).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBiswas, et al\u003c/strong\u003e (15) demonstrated that continuous thoracic paravertebral block was found to be less effective than epidural block in alleviating post-thoracotomy pain, according to the report. Nevertheless, the epidural group exhibited a higher incidence of sympatholytic complications. As a result, they advised the use of paravertebral block for post-thoracotomy pain in situations where a thoracic epidural is not practicable.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eZengin and Alagoz\u003c/strong\u003e (16) concluded that Thoracic epidural analgesia (TEA) provided effective postoperative analgesia and stable hemodynamics in elderly patients after thoracotomy more than TPVB. \u003cstrong\u003eEl Shora, et.al (\u003c/strong\u003e17) found that thoracic epidural analgesia was not more efficacious than ultrasound-guided paravertebral block in the context of sternotomy pain following cardiac surgery.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe perioperative pain management in cardiac surgery was more effective with the bilateral continuous thoracic paravertebral block than with systemic fentanyl infusion. It is a technique that is straightforward and effortless to learn, safe to execute, and enables early mobilization and discharge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations:\u0026nbsp;\u003c/strong\u003eThe present investigation is a single-center investigation that involves a limited number of patients. The need for comparing bilateral thoracic paravertebral block with other procedures such as bilateral erector spinal block in cardiac surgery through midline incision.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo external source of funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDK, SR, YM, IO, and AE: 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; 3) final approval of the version to be published DK, SR, and YM: Data collection, analysis, and methodology development.IO, AE, and YM: manuscript writing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeal-Noval SR, Marquez-Vacaro JA, Garc\u0026iacute;a-Curiel A. Nosocomial pneumonia in patients undergoing heart surgery. Critical Care Med. 2010; 28:935\u0026ndash;940.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichardson J, L\u0026ouml;nnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice.British Journal of Anaesthesia. 2011; 106 (2): 164\u0026ndash;171.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelms O, Mariano J, Hentz JG. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized double-blind placebo-controlled study. Journal of Cardio-thoracic Surgery. 2011; 40:902\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRivedal DD, Nayar HS, Israel JS. Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mamoaplasty. journal of surgical research. 2018; 228: 307\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonica JJ. The management of pain with analgesic block. The Management of Pain. London: Henry Kimpton. 1953; 166\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarmakar MK. Thoracic paravertebral block. Anesthesiology. 2001; 95: 771\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutchins JL, Grandelis AJ, Kaizer AM. Thoracic paravertebral block versus thoracic epidural analgesia for postoperative pain control in open pancreatic surgery: A randomized controlled trial. Journal of Clinical Anesthesia. 2018; 48:41\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacintyre PE and Schug SA. Acute pain management: a practical guide. Boca Raton. CRC press. 2014; 4:100\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsida SM, Youssef IA, Mohamed AK, Abdelrazik AN. Post-thoracotomy pain relief: Thoracic paravertebral block compared with systemic opioids. Egyptian Journal of Anaesthesia. 2012; 28: 55\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh S, Jacob M, Hasnain S. Comparison between continuous thoracic epidural block and continuous thoracic paravertebral block in the management of thoracic trauma. Medical journal armed forces India. 2017; 73:146\u0026ndash;151.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun L, Li Q, Wang Q, Ma F, Han W, Wang M. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting. BMC Anesthesiology. 2019; 19\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmona P, Llagunes J, Casanova I. Continuous paravertebral analgesia versus intravenous analgesia in minimally invasive cardiac surgery by mini-thoracotomy. Rev Esp Anestesiol Reanim. 2012; 59(9):476\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhole S, Mehta Y, Saxena H. 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(3):288\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T. A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10(5): E357-62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiswas S, Verma R, Bhatia VK, Chaudhary AK, Chandra G, Prakash R. Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief. J Clin Diagn Res. 2016;10(9): UC08-UC12. doi: 10.7860/JCDR/2016/19159.8489. Epub 2016 Sep 1. Retraction in: J Clin Diagn Res. 2020;14(7): ZZ01.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZengin M, Alagoz A. Comparison of Thoracic Epidural Analgesia and Thoracic Paravertebral Block Applications in the Treatment of Acute Pain After Thoracotomy in Geriatric Patients. Cureus. 2021;13(10): e18982. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.18982\u003c/span\u003e\u003cspan address=\"10.7759/cureus.18982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34820237; PMCID: PMC8606221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Shora HA, El Beleehy AA, Abdelwahab AA, Ali GA, Omran TE, Hassan EA, Arafat AA. Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial. Thorac Cardiovasc Surg. 2020;68(5):410\u0026ndash;416. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0038-1668496\u003c/span\u003e\u003cspan address=\"10.1055/s-0038-1668496\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2018 Aug 16. PMID: 30114712.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable (1): Demographic data and Euroscore\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight (Kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeight (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e167.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e167.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Euroscor Ⅱ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0.851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.3067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.3067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eP value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026bull;Female\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026bull; Male\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e59.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e54.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.761\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e40.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e45.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2): Operative data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eType of operation:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eASD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.090%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAVR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMVR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTVR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAVR, TVR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAVR, MVR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;P value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eACCT (minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.812\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTBT (minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e91.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e89.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTOT (minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e233.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e228.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eInotropic support:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eNo inotropes\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt; 0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAdrenalin\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eNoradrenalin\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDobutamine\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAdrenalin, Noradrenalin\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eACCT\u003c/strong\u003e: aortic cross clamp time; \u003cstrong\u003eTBT\u003c/strong\u003e: total bypass time; \u003cstrong\u003eTOT\u003c/strong\u003e: total operative time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVR\u003c/strong\u003e: Aortic Valve Replacement; MVR: Mitral Valve Replacement:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTVR\u003c/strong\u003e: Tricuspid Valve Replacement, ASD: Atrial Septal Defect\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3): Hemodynamic parameters\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR Base line\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e84.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.264\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR 1 min before skin incision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.677\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR 3min after skin incision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e71.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e69.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.448\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR 1 min before sternotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e71.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e73.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR 3 min after sternotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e78.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAP Base line\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e87.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAP 1 min before skin incision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e73.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAP 3 min after skin incision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e77.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e80.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAP 1 min before sternotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e77.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e83.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAP 3 min after sternotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e85.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHR: heart rate (beats/min) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; MAP: mean arterial blood pressure (mmHg)\u003c/p\u003e\n\u003cp\u003eGroup I: Fentanyl group. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Group II: Thoracic paravertebral group (TPVB).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4): CCPOT and Postoperative data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003eGroup I\u003c/p\u003e\n \u003cp\u003e(n = 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 26px;\"\u003e\n \u003cp\u003eGroup II\u003c/p\u003e\n \u003cp\u003e(n = 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 13px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eCCPOT 8h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1 - 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eCCPOT 12h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eCCPOT 24h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2 - 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003eP value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eIO fentanyl dose (ug)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e926.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e117.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e343.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e44.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eMorphine 24h (mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eExtubation time (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eICU stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33px;\"\u003e\n \u003cp\u003eChest tube drain (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e255.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e102.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e248.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e100.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCCPOT\u003c/strong\u003e: Critical-Care Pain Observation Tool; \u003cstrong\u003eIO\u003c/strong\u003e: intraoperative\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;I\u003c/strong\u003e: Fentanyl group \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003etrail II:\u0026nbsp;\u003c/strong\u003eThoracic paravertebral group (TPVB)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"beni-suef-university-journal-of-basic-and-applied-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jbas","sideBox":"Learn more about [Beni-Suef University Journal of Basic and Applied Sciences](https://bjbas.springeropen.com)","snPcode":"43088","submissionUrl":"https://submission.springernature.com/new-submission/43088/3","title":"Beni-Suef University Journal of Basic and Applied Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"thoracic paravertebral block, cardiac surgery pain, fentanyl infusion","lastPublishedDoi":"10.21203/rs.3.rs-5353197/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5353197/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn patients who are undergoing open cardiac surgery, thoracic paravertebral block (TPVB) is advantageous for pain management. Our objective was to compare this type of block with intravenous Fentanyl analgesia in those patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective, randomized study included 44 patients who underwent open heart surgery through a median sternotomy. Participants were randomly divided into two equal groups (each with 22 subjects). Group Ⅰ (Fentanyl group) (n\u0026thinsp;=\u0026thinsp;22): received fentanyl infusion 2\u0026micro;g/kg/h after placing the endotracheal tube and stopped at the end of surgery. Group Ⅱ (TPVB group) (n\u0026thinsp;=\u0026thinsp;22): Bilateral thoracic paravertebral catheters were inserted preoperative. Before induction, there was a maximum of 20 ml per side for each catheter, which received a bolus dose of 0.3ml/kg 0.25% bupivacaine. Continuous infusion of 0.25% bupivacaine at a rate of 0.1 ml/kg/h was administered through each catheter following intubation. The infusion was subsequently discontinued at the conclusion of the procedure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCritical-Care Pain Observation Tool (CCPOT) was lower in patients of group Ⅱ (TPVB group) than in patients of group Ⅰ (fentanyl group); in group Ⅱ at 8hs, 12hs, and 24hs postoperative were 2,3,3 respectively, whereas median CCPOT in group Ⅰ at 8hs, 12hs, and 24hs postoperative were 3,4,4 respectively (p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In comparison to group Ⅰ, there was a substantial decrease in the intraoperative fentanyl requirements of group Ⅱ (343.6 \u0026micro;g\u0026thinsp;\u0026plusmn;\u0026thinsp;44.1 and 926.8 \u0026micro;g\u0026thinsp;\u0026plusmn;\u0026thinsp;117.4) (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In comparison to group I (9 mg 2), the TPVB group's postoperative opioid requirements were significantly lower (6.2 mg 2.3). P-value was less than 0.05.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCompared with IV fentanyl infusion, Bilateral continuous thoracic paravertebral block was determined to be more effective in the operative and postoperative analgesia of patients who underwent heart surgery via median sternotomy.\u003c/p\u003e","manuscriptTitle":"Bilateral Continuous Thoracic Paravertebral Block Versus IV Fentanyl Infusion for Perioperative Analgesia in Patients Undergoing Cardiac Surgery Through Median Sternotomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 11:09:43","doi":"10.21203/rs.3.rs-5353197/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-22T17:10:15+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"168097159778886884906488143534301047779","date":"2025-02-07T11:48:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-30T19:37:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49244541345363346767026182723390347524","date":"2025-01-21T13:52:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265410848805621783593067903295098594178","date":"2024-12-15T10:06:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231473146475398267558771937533374671698","date":"2024-12-03T07:59:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-25T20:19:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-17T22:30:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-17T22:29:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Beni-Suef University Journal of Basic and Applied Sciences","date":"2024-10-29T09:51:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"beni-suef-university-journal-of-basic-and-applied-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jbas","sideBox":"Learn more about [Beni-Suef University Journal of Basic and Applied Sciences](https://bjbas.springeropen.com)","snPcode":"43088","submissionUrl":"https://submission.springernature.com/new-submission/43088/3","title":"Beni-Suef University Journal of Basic and Applied Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"37a8ba9e-f3e3-4adf-8841-27564867d451","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:05:35+00:00","versionOfRecord":{"articleIdentity":"rs-5353197","link":"https://doi.org/10.1186/s43088-025-00637-7","journal":{"identity":"beni-suef-university-journal-of-basic-and-applied-sciences","isVorOnly":false,"title":"Beni-Suef University Journal of Basic and Applied Sciences"},"publishedOn":"2025-06-03 15:57:12","publishedOnDateReadable":"June 3rd, 2025"},"versionCreatedAt":"2024-12-17 11:09:43","video":"","vorDoi":"10.1186/s43088-025-00637-7","vorDoiUrl":"https://doi.org/10.1186/s43088-025-00637-7","workflowStages":[]},"version":"v1","identity":"rs-5353197","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5353197","identity":"rs-5353197","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}