Double-lumen tube placement: protecting the good lung.

Correspondence Post-thoracotomy epidural vs paravertebral analgesia Editor.-I read with interest the article by Richardson and colleagues on post-thoracotomy pain.' The authors compared thoracic paravertebral bupivacaine (bolus of 0. 5 6 followed by infusion of 0.5%) with thoracic epidural bupivacaine (bolus of 0.25% followed by infusion of 0.25%). Both groups received PCA morphine. The paravertebral group had significantly lower pain scores. better preservation of respiratory function, lower incidence of chest infections, and less nausea, vomiting and hypotension. Thus the authors concluded that with these regimens, paravertebral block was superior to epidural bupivacaine. As many believe that thoracic epidural can provide superior analgesia. these are impressive findings. 1 feel it is important to emphasize that Richardson and colleagues uscd 0.259 bupivacaine without opioids in the epidural group, which is an uncommon practice. A combination of local anaesthetic and opioid administered epidurally has been shown to be syner-gistic.' Even though the optimal drug combination has yet to be determined, 91% of anaesthetists in the UK use a combination of bupivacaine with either fentanyl or diamorphine.' Choosing to administer only local anaesthetic epidurally effectively handicapped the epidural group in comparison with the paravertebral group. It is conceivable that a combination of an opioid and dilute 0. I % bupivacaine would have resulted in a significantly better outcome in the epidural group. The authors reasoned against using a local anaesthetic-opioid combination regimen for the epidural group on the basis that all patients returned to the general ward and they were unsure how to provide additional rescue opioid analgesia, as a combination of neuraxial and systemic opioids (for example) is known to be a major risk factor of respiratory depression. It is worth noting that 39% of respondents to a survey of thoracic epidural analgesia practice allowed patients to return to a general ward without specific additional nursing resources.' Inadequate analgesia with a correctly placed epidural catheter can generally be managed with an epidural top-up; systemic opioids are usually not needed. The use of epidural morphine, including top-ups, has been shown to be safe on surgical wards.' Paravertebral analgesia is an attractive alternative to epidural analgesia: it is a relatively easy technique and is free of the risk of major neurological injury. We need a study comparing the two methods of analgesia where each technique is individually optimized. Otherwise I am left wondering whether paravertebral analgesia is really as good or maybe even better than thoracic …