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Bloc paravertébral • Eason MJ, Wyatt R: Paravertebral thoracic block-a reappraisal. Anaesthesia 1979; 34:638–42 Thoracic Paravertebral Block Manoj K. Karmakar Anesthesiology 2001; 95:771–80 Marret, Ann Thorac Surg 2005;79:2109 –14 Paravertebral Block With Ropivacaine 0.5% Versus Systemic Analgesia for Pain Relief After Thoracotomy Marret E, Ann Thorac Surg 2005;79:2109 –14 Paravertebral Ropivacaine, 0.3%, and Bupivacaine, 0.25%, Provide Similar Pain Relief After Thoracotomy Marta García Navlet et al. Journal Cardiothor Vasc Anesth Vol 20, 5 (October), 2006: pp 644-647 A comparison of the analgesic efficacy and side effects of paravertebral versus epidural blockade—A systematic review and meta-analysis of randomized trials. Davies RG Br J Anaesth 96:418-426, 2006 Bloc Paravertébral Oui Péri thoracique et chirurgie cardiaque ? Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Blomberg S et al. Anaesthesiol 1990;73:840–7. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Kock M, Blomberg S et al. Anesth Analg 1990;71:625–30. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Loick H et al. Anesth Analg 1999;88:701–9. • • • • Sympatholyse Baisse de la VO2 Effets anti-ischémiques Amélioration de la fonction diastolique • « In patients with multivessel ischemic heart disease, TEA partly normalizes the myocardial blood flow in response to sympathetic stimulation. » Nygård E et al. Circulation. 2005;111:2165-2170. PAC Mortalité Morbidité cardiaque IDM 1.7 % 2.4 % British Cardiac Society, Heart 2003 • Baisse du risque de 1 % 4600 patients • Méta-analyse. Liu SS, Anesthesiol 2004: 101 15 études, 1178 patients (PAC) Péri thoracique et chirurgie cardiaque ? Non AA, 103(6), December 2006, p 1592 The Use of Epidural Analgesia in Cardiac Surgery Should Be Encouraged Department of Anesthesiology; Montreal General Hospital; McGill University; Montreal, Canada; Hemmerling Department of Anesthesiology; University of Toronto; Ontario, Canada; Djaiani University of Chicago; Chicago, IL; Babb Department of Anesthesiology; University of Pittsburgh; Pittsburgh, PA; Williams For patients undergoing cardiac surgery, anesthesiologists should choose analgesic options that focus more on minimizing risk than maximizing the potential of unproven benefits. Mark A. Chaney, MD Department of Anesthesia and Critical Care University of Chicago Chicago, Illinois Péri thoracique et neurochirurgie ? Postoperative Analgesia After Major Spine Surgery: Patient-Controlled Epidural Analgesia Versus Patient-Controlled Intravenous Analgesia Schenk R, Anesth Analg 2006;103:1311–17 • Ropivacaïne 0.125 % + sufentanil 1 µg/ml • 14 ml/h, 5 ml, 15 min. Postoperative Analgesia After Anterior Correction of Thoracic Scoliosis: A Prospective Randomized Study , Comparing Continuous Double Epidural Catheter Technique With Intravenous Morphine. Blumenthal S, SPINE 2006; 31, 15: 1646–1651 • 2 KT perop, voie antérieure transforaminale (T4-5, T10-12) • J0: Remifentanil • J1 à 8H: Ropivacaïne 0.3 % 4-8 ml dans chaque KT, puis 4-10 ml/h • H+3: stop Remifentanil • Objectif: bloc sensitif T2-T12 Péri thoracique et neurochirurgie ? 2 KT valent mieux qu’un.