Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases

Paravertebral Versus EPidural Analgesia in Minimally Invasive Esophageal ResectioN (PEPMEN): A Randomized Controlled Multicenter Trial

OBJECTIVE

To compare the quality of recovery in patients receiving epidural or paravertebral analgesia for minimally invasive esophagectomy (MIE).

BACKGROUND

Paravertebral analgesia may be a promising alternative to epidural analgesia, avoiding potential side effects and improving postoperative recovery.

METHODS

This randomized controlled superiority trial was conducted across 4 Dutch centers with esophageal cancer patients scheduled for transthoracic MIE with intrathoracic anastomosis, randomizing patients to receive either epidural or paravertebral analgesia. The primary outcome was Quality of Recovery (QoR-40) on the third postoperative day (POD). Secondary outcomes included quality of life, postoperative pain, opioid consumption, inotropic/vasopressor medication use, hospital stay, complications, readmission, and mortality.

RESULTS

From December 2019 to February 2023, 192 patients were included: 94 received epidural and 98 paravertebral analgesia. QoR-40 score on POD3 was not different between groups (mean difference: 3.7, 95% CI: -2.3 to 9.7; P =0.268). Epidural patients had significantly higher QoR-40 scores on POD1 and 2 (mean difference: 7.7, 95% CI: 2.3-13.1; P =0.018 and mean difference: 7.3, 95% CI: 1.9-12.7; P =0.020) and lower pain scores (median 1 vs 2; P <0.001 and median 1 vs 2; P =0.033). More epidural patients required vasopressor medication on POD1 (38.3% vs 13.3%; P <0.001). Urinary catheters were removed earlier in the paravertebral group (median POD3 vs 4; P <0.001). No significant differences were found in postoperative complications or hospital/intensive care unit stay.

CONCLUSIONS

This randomized controlled trial did not demonstrate the superiority of paravertebral over epidural analgesia regarding the quality of recovery on POD3 after MIE. Both techniques are effective and can be offered in clinical practice.

Subpectoral plexus block to enhance surgical anesthesia produced by a multilevel thoracic paravertebral block for primary breast cancer surgery: a prospective randomized double-blind study

BACKGROUND AND OBJECTIVES

The efficacy of a multilevel thoracic paravertebral block (6m-TPVB at T1-T6), as the sole anesthetic, for primary breast cancer surgery (PBCS) has been questioned. Current literature suggests that a significant number of patients may report pain during various stages of surgery, notably during the detachment of the breast base from the pectoralis major muscle and its fascia. Given that the pectoral muscles are innervated by nerves from the subpectoral plexus (C5-T1), which are not affected by a 6m-TPVB alone, we propose that an additional "subpectoral plexus block" (SPPB) may enhance the surgical anesthesia.

METHODS

60 patients undergoing PBCS under a 6m-TPVB were randomized to receive an SPPB (Gp-A, n=30) or a sham block (Gp-B, n=30). Midazolam (1-3 mg) and ketamine (10-20 mg) were administered intravenously for sedation and analgesia before the block placement and an infusion of dexmedetomidine (0.1-0.5 mcg/kg/h) was used to maintain conscious sedation during surgery. The 6m-TPVB was ultrasound guided, and 4-5 mL of 0.5% ropivacaine with 1:200 000 epinephrine was injected at each vertebral level (total volume used 25 mL). The SPPB was also ultrasound guided, and 5 mL of 0.25% ropivacaine was injected each near the origin of the thoracoacromial artery in the pectoserratus plane and between the two pectoral muscles (interpectoral plane) in Gp-A, at the level of the third rib. In Gp-B, 3-5 mL of normal saline (sham block) was injected into the pectoralis major muscle. Surgery commenced about 25-30 min after the completion of the SPPB. Ketamine (10-20 mg IV bolus) was used for rescue analgesia (our primary outcome variable) if the patient complained of pain during surgery to an arbitrary maximum of 100 mg, or the anesthesia was deemed inadequate, after which it was converted to general anesthesia.

RESULTS

The two study groups were comparable with respect to demographic data, total dose of midazolam and dexmedetomidine used, duration of surgery, and overall patient satisfaction. Ketamine, as rescue analgesia, was required to complete surgery in both study groups, but fewer patients in Gp-A (56.7%) required rescue analgesia than in Gp-B (93.3%, p=0.002). Ketamine requirement (median (IQR)) was also significantly lower (p<0.001) in Gp-A (10 (0-40) mg) than in Gp-B (50 (20-70) mg). The surgeons were more (p=0.02) satisfied (mean±SD numeric rating scale, 0-100) with surgical conditions in Gp-A (77.29±10.63) than in Gp-B (65.83±21.38).

CONCLUSION

A SPPB enhances the surgical anesthesia produced by a 6m-TPVB for primary breast cancer surgery.

TRIAL REGISTRATION NUMBER

https://www.chictr.org.cn/showprojEN.html?proj=5368, Trial ID No: ChiCTR-TRC-14004200; Date of Registration: 25 January 2014, Study commencement date: 28 February 2014.

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Comparison of the Efficacy Between Ultrasound-Guided Paravertebral Block and Erector Spinae Block for Postoperative Analgesia in Percutaneous Nephrolithotomy Using Levobupivacaine: A Prospective and Randomized Study

Introduction Various techniques have been developed in the current era of regional anesthesia practice. With the advent of ultrasound, the visualization of needle and pleura in real time enables a better outcome with negligible adverse events. This study was designed to compare the efficacy between ultrasound-guided erector spinae plane block (ESPB) and paravertebral block (PVB) in percutaneous nephrolithotomy (PCNL) for the duration of postoperative analgesia with levobupivacaine, a local anesthetic with higher lipid solubility, making it more potent and resulting in a longer duration of action. Methods This prospective randomized single-blinded study enrolled 50 patients of ASA grades I and II, aged between 20 and 60 years, who were scheduled for PCNL under general anesthesia. Patients were divided into two groups of 25 each: group ESPB and group PVB, and 25 mL of 0.25% levobupivacaine was administered to both groups. They were primarily evaluated for the duration of postoperative analgesia. Total rescue analgesic requirements, hemodynamic parameters, and any adverse effects were also assessed. Results Both ESPB and PVB provided a significant duration of analgesia postoperatively. Demographic characteristics in both groups were comparable. The duration of postoperative analgesia in group ESPB was 746 ± 58.6 minutes when compared to group PVB, which is 768 ± 68.6 minutes (p = 0.08). Intravenous (IV) paracetamol was used as a rescue analgesic. The doses used were also comparable in both groups, with the visual analog score (VAS) being high after around 12 hours of surgery. The total rescue analgesic requirement was similar in both groups (group ESPB, 2.0 ± 1.6; group PVB, 2.2 ± 1.4; p = 0.51). There were no significant hemodynamic or other adverse effects in either group. Conclusion We conclude that both ESPB and PVB using isobaric levobupivacaine 0.25% as a local anesthetic are equally efficacious in providing effective postoperative analgesia in patients undergoing PCNL under general anesthesia.

The Bibliometric and Visualized Analysis of Research for Hospital Medication Management Based on the Web of Science Database

Objective

Identify the collaborations between authors, countries, and institutions, respectively, and explore the hot issues and prospects for research on hospital medication management.

Materials and Methods

Publications on hospital medication management were retrieved from the Web of Science Core Collection. Bibliometric analyses were performed using CiteSpace 6.1.R3, HistCite 2.1, and VOSviewer 1.6.16. The network maps were created between authors, countries institutions, and keywords.

Results

A total of 18,723 articles related to hospital medication management studies were identified. Rapid growth in the number of publications since 2017. The high papers were published in AM J HEALTH-SYST PH, while JAMA-J AM MED ASSOC was the most co-cited journal. Manias E and WHO ranked first in the author and cited author. There were active collaborations among the top authors. Bates DW was the key author in this field. The authors have active collaborations in adverse drug events, acute coronary syndrome, in-hospital major bleeding, and so on. The US was the leading contributor in this field. The UK, Australia, and China are also very active. Active cooperation between countries and between institutions was observed. The main hot topics included matters related to outcome indicators, hospital pharmacy service behaviors, and medication use in pain management. More recent keywords focus on chronic disease medication management and clinical medication management.

Conclusion

Hospital medication management studies have significantly increased after 2017. There was active cooperation between authors, countries, and institutions. The application of hospital medication management in the emergency department and the relationship between medication management and medication adherence are current research hotspots. In addition, with the continuous progress of society, chronic diseases have become an important factor affecting people's health, and medication management is becoming more and more subdivided, so the direction of chronic disease medication management as well as precise medication may become the development direction of future research.

Safety and Complications of Landmark-based Paravertebral Blocks: A Retrospective Analysis of 979 Patients and 4983 Injections

OBJECTIVE

This study aimed to determine the incidence of complications after landmark-based paravertebral blocks for breast surgery.

METHODS

The medical records of patients who received a paravertebral block for breast surgery between 2019 and 2022 were reviewed. Patient age, sex, type of procedure, number of injections, volume of injected anesthetic, and possible complications were noted. A record was identified as a possible serious block-related complication if there was concern or treatment for local anesthetic systemic toxicity, pneumothorax, altered mental status, or intrathecal/epidural spread. Other complications recorded were immediate postblock hypotension and nausea/vomiting requiring treatment and unanticipated postsurgical admission. Patients receiving ultrasound-guided paravertebral blocks were excluded from this study.

RESULTS

Over a 3-year period, 979 patients received paravertebral blocks using the landmark technique for breast surgery, totaling 4983 injections. Overall, 6 patients required assessment for postblock issues (0.61%), including hypotension (2 patients), nausea (3 patients), and hypotension + altered mental status (1 patient). This latter patient was identified as having a serious complication related to the paravertebral block (0.1%). This patient had unintentional intrathecal spread and altered mental status that required mechanical ventilation. The incidence of block-related hypotension and nausea requiring treatment was thus 0.31% and 0.31% respectively. Four patients required unanticipated admission, but none were for block-related reasons. No patients in this study were found to have local anesthetic systemic toxicity or pneumothorax.

CONCLUSION

Our study suggests that landmark-based paravertebral blocks for breast surgery result in a very low complication rate and are a safe technique for postsurgical analgesia.

Analgesia for rib fractures: a narrative review

PURPOSE

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

SOURCE

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

PRINCIPAL FINDINGS

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

CONCLUSION

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Postoperative analgesic options after spine surgery: finding the optimal treatment strategies

INTRODUCTION

Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes.

AREAS COVERED

This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques.

EXPERT OPINION

Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery.

DESIGN

A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation).

SETTING

Randomized controlled trials (RCTs).

PARTICIPANTS

Adults and children undergoing heart surgery.

INTERVENTIONS

Any kind of PRA compared to no RA or placebo or neuraxial anesthesia.

MEASUREMENTS AND MAIN RESULTS

In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials.

CONCLUSIONS

Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.

A Comparative Study of Morphine and Clonidine as an Adjunct to Ropivacaine in Paravertebral Block for Modified Radical Mastectomy

Background General anesthesia (GA) is a standard for breast malignant surgery. The issue of postoperative pain as well as the high occurrence of nausea and vomiting have prompted the quest for a superior methodology for tormenting the executives with fewer complications. Over the most recent couple of years, paravertebral block (PVB) has acquired huge fame either in combination with GA or alone for anesthetic management. In this study, we aim to evaluate the efficacy of morphine and clonidine as an adjunct to ropivacaine in PVB in breast cancer patients undergoing modified radical mastectomy. Methods In this study, a total of 90 patients were divided into the following three groups (30 each) based on a computer-generated random table. Group C (control): PVB with 0.25% ropivacaine (19 ml) 1 ml saline; Group M: PVB with 0.25% ropivacaine (19 ml) + 20 microgram/kg body weight morphine; Group N: PVB with 0.25% ropivacaine (19 ml) + 1.0 microgram/kg body weight clonidine. The postoperative pain intensity was recorded using the visual analog scale (VAS), and sedation was observed by the Ramsay Sedation Scale (RSS) score. Results The VAS was similar at zero hours, two hours, and four hours in the postoperative period among all the groups. There was a significant (p = 0.003) difference in VAS from six hours to 20 hours in the postoperative period among the groups. A significant (p < 0.05) difference was observed among the groups at eight hours to 20 hours. The first requirement of analgesia was significantly (p = 0.001) higher in Group N (7.70 ± 1.74) than in Group C (4.43 ± 1.43) and Group M (7.33 ± 2.21). Conclusion Morphine in the PVB provides better postoperative analgesia. The consumption of rescue analgesia was significantly reduced in the morphine group as compared to the clonidine group. The procedure also proved to be safe as no complication was encountered in the PVB in our study.

Preemptive parasternal intercostal nerve block for patients undergoing off-pump coronary artery bypass grafting: a double-blind, randomized, controlled trial

Background

Parasternal intercostal nerve block has been increasingly used for postoperative analgesia and has shown that this technique can provide effective postoperative analgesia. This study aimed to investigate the effect of preemptive parasternal intercostal nerve block on the opioid and vasoactive drug dose required for intraoperative hemodynamic stability and postoperative analgesia in patients undergoing off-pump coronary artery bypass grafting.

Methods

In this prospective, randomized controlled study, 64 participants aged 45-75 years scheduled for off-pump coronary artery bypass grafting at The Second Xiangya Hospital of Central South University. Patients were randomized into two groups and preoperatively administered ropivacaine (group R) and saline (group S), in the parasternal intercostal spaces with ultrasound-guided bilateral nerve block.

Results

The primary outcome was intraoperative sufentanil and vasopressor dosage. The secondary outcomes were intraoperative hemodynamics, postoperative pain scores, and anesthesia recovery, postoperative use of rescue dezocine, stay in intensive care unit, and length of hospital stay. The consumption of intraoperative sufentanil and vasopressor was significantly lower in group R than in group S. The visual analog score in group R was significantly lower than that in group S up to 12 h postoperatively. The time to anesthesia recovery was significantly less in group R than in group S. Most patients in group S required rescue dezocine, whereas most patients in group R did not. The hemodynamic variables were stable in all patients.

Conclusions

A preemptive parasternal intercostal nerve block effectively reduced the required intraoperative sufentanil and norepinephrine dose and provided adequate analgesia for the first 12 h after surgery. Therefore, a preemptive parasternal intercostal nerve block is a good option for patients undergoing off-pump coronary artery bypass grafting.

Clinical trial registration

chictr.org.cn, identifier ChiCTR1800017210.

Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis

Thoracic sympathetic nerve block (TSNB) has been widely used in the treatment of neuropathic pain. To reduce block failure rates, TSNB is assisted with several modalities including fluoroscopy, computed tomography, and ultrasonography. The present study describes our experience assessing the usefulness of thoracoscopy in TSNB for predicting compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis. From September 2013 to October 2021, TSNB was performed under local anesthesia using a 2-mm thoracoscope in 302 patients with severe primary hyperhidrosis. Among the 302 patients, 294 were included for analysis. The target level of TSNB was T3 in almost all patients. The mean procedure time was 21 min. Following TSNB, the mean temperature of the left and right palms significantly changed from 31.5 to 35.3 °C and from 31.5 to 34.8 °C, respectively. With TSNB, primary hyperhidrosis was relieved in all patients. Pneumothorax occurred in six patients, in which no chest tube insertion was required. One patient developed hemothorax and was discharged the next day after small-bore catheter drainage. Transient ptosis developed in 10 patients and improved within a day in all patients. Our experiences showed that thoracoscopic TSNB is accurate, safe, and feasible to block the thoracic sympathetic nerve in patients with severe primary hyperhidrosis.

Visualization analysis of thoracic paravertebral block in breast surgery based on bibliometrics

Background

Breast surgery is one of the most common surgeries in the world, and pain after breast surgery is very common, representing one of the key factors affecting the quality of life after surgery. With the development of clinical techniques, thoracic paravertebral block (TPVB) has gradually become the preferred regional anesthesia technique for postoperative breast analgesia.

Methods

Using Web of Science as the data source, medical articles about the application of TPVB in breast surgery published from 1900 to 2022 were retrieved and imported into CiteSpace and VOSviewer software. Using bibliometrics and knowledge mapping visualization methods, the literature was analyzed from the aspects of publication, author, institution, country, high-frequency keywords, keyword clustering, emergence words, and so on.

Results

A total of 299 articles were included. according to the yearly numbers of articles, the trend is increasing annually. The most published authors in this field are Susan M. Steele, Roy A. Greengrass, Brian M. Ilfeld, Karmakar Manoj Kumar, and Stephen M. Klein. The League of European Research Universities, University of Toronto, and Duke University are the 3 institutions with the largest number of publications, and their cooperation degree is relatively low. Articles of American origin predominated. TPVB is the major keyword associated with the application of TPVB in breast surgery, which appears most frequently and has a high research interest.

Conclusions

The trend and characteristics of TPVB application research in breast surgery were visualized, and the studies in this field are generally increasing annually in number, providing useful bibliometric analysis for researchers to further explore in this field.

Analgesic efficacy of the superficial versus deep serratus plane blocks for mastectomy with axillary clearance: A randomized controlled trial

BACKGROUND

The serratus plane block is an effective technique for providing analgesia to patients undergoing breast surgery.

METHODS

This prospective, double-blind, randomized study enrolled 60 female patients scheduled for unilateral mastectomy and axillary clearance. The patients received either a superficial serratus plane block or deep serratus plane block. Dermatomal spread was recorded 30 minutes after block administration. Postoperatively, pain visual analog scale (VAS) scores were documented at recovery (time 0), at 30 minutes; and in the ward hourly for 4 hours, and 4-hourly until 24 hours postoperatively. The time to first analgesic rescue and cumulative morphine consumption using patient-controlled analgesia morphine (PCAM) were recorded.

RESULTS

The results showed lower VAS scores at rest (at 1, 2, 3, and 4 hours postoperatively), and during movement (at 1, 2, 3, 4, 8, and 24 hours postoperatively) in the superficial serratus plane block group, P < .005. Similarly, cumulative morphine usage was lower in the superficial serratus plane group, P < .005. The time to the first rescue analgesic was also significantly longer in the superficial group, P < .001. More patients in the superficial serratus plane group achieved greater dermatomal spread at T2 and T7 than those in the deep group.

CONCLUSIONS

Superficial serratus plane block provides better analgesic efficacy than deep serratus plane block in mastectomy and axillary clearance.

Comparison between erector spinae plane block and paravertebral block regarding postoperative analgesic consumption following breast surgery: a randomized controlled study

BACKGROUND

Pain control following breast surgery is of utmost importance in order to reduce the chance of chronic pain development, and facilitate early rehabilitation. The erector spinae plane block (ESPB) is a recently developed regional anaesthesia procedure successfully used for different types of surgical procedures including thoracic and abdominal surgeries.

METHODS

A double-blind, randomized, controlled trial was conducted on 90 patients who were scheduled for modified radical mastectomy (MRM). Patients were randomly categorized into groups I (women who underwent ESPB), II (women who underwent paravertebral block (PVB), and III (women who underwent general anaesthesia).

RESULTS

The ESPB (4.9 ± 1.2 mg) and PVB (5.8 ± 1.3 mg) groups had significantly lower total morphine consumption than the control group had (16.4 ± 3.1 mg; p < 0.001). Notably, patients in the ESPB group had insignificantly lower morphine consumption than those in the PVB group had (p = 0.076). Moreover, patients in the ESPB and PVB groups had a significantly longer time to first required anaesthesia than those in the control group (7.9 ± 1.2 versus 7.5 ± 0.9 versus 2 ± 1.2 h, respectively; p < 0.001). The postoperative visual analog scale scores were lower in the ESPB and PVB groups than in the control group on the first 24 h after the procedure (p < 0.001).

CONCLUSION

ESPB and PVB provide effective postoperative analgesia for women undergoing MRM. The ESPB appears to be as effective as the PVB.

TRIAL REGISTRATION

The study was registered before the enrolment of the first patient at the Pan African Clinical Trial Registry ( www.pactr.org ) database. Identification number for the registry is (PACTR202008836682092).

Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery

BACKGROUND

The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus's impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge.

METHODS

We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vs intrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N = 106) and consecutive patients-moving backwards-from 28 February 2020 to 6 December 2019 (prepandemic group; N = 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU).

RESULTS

The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99-170] min vs prepandemic group, 191 [164-234] min; P < 0.001) as was the incidence of PONV (3% vs 11%; P = 0.03) and median [IQR] PACU durations of stay (29 [21-39] min vs 46 [37-63] min; P < 0.001).

CONCLUSIONS

Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

Transverse thoracic muscle plane block as a routine strategy for cardiac enhanced recovery after surgery in sternotomy: A retrospective analysis

ABSTRACT

The aim of this study is to retrospectively analyze and evaluate the effect of transverse thoracic muscle plane (TTP) block as a routine analgesic strategy for cardiac enhanced recovery after surgery in sternotomy.Patients received TTP block after general anesthesia and tracheal intubation were included in this study. The baseline clinical data of the patients, intraoperative use of sufentanil, internal mammary artery separating time, the postoperative duration of invasive ventilation, visual analogue scale, the compression times of patient-controlled intravenous analgesia in the first 3 days after surgery, and postoperative nausea and vomiting were recorded.A total of 104 cases was included and divided to G group (without TTP block) and TTP group (with TTP). Sufentanil use (sufentanil dose/min, sufentanil dose/kg body weight, sufentanil dose/[min kg]) in TTP group was significantly lower than that of G group. In G group, intraoperative use of sufentanil was correlated to the duration of anesthesia (P = .035). The postoperative visual analogue scale pain scores and the compression times of patient-controlled intravenous analgesia in the TTP group were significantly decreased compared with G group (P < .01). The postoperative duration of invasive ventilation of patients with normal and mildly impaired pulmonary function was significantly correlated to the use of sufentanil (P = .027, .009).TTP block has certain analgesic effect and can reduce sufentanil use in medium-length cardiac surgery and postoperative use of opioids. It is indicated that TTP block can be used as a routine enhanced recovery after surgery strategy for sternotomy in cardiac surgery.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

PURPOSE OF REVIEW

Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important.

RECENT FINDINGS

With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve.  Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.

Use of Paravertebral Block as an Alternative to General Anesthesia for Breast Surgeries: A Randomized Control Study

BACKGROUND

General anaesthesia (GA) is the conventional technique used for surgical treatment of breast lumps. However, various side effects and complications of GA, such as postoperative pain, nausea, vomiting, and increased hospital stay increase morbidity in patients. Regional anaesthesia using multiple injection paravertebral block is an ideal alternative to GA for breast surgeries.

METHODS

Sixty female patients posted for unilateral breast surgery were randomly divided into two groups, Group P for paravertebral block and group G for GA, and compared on the basis of time taken for induction of anaesthesia, postoperative pain relief on basis of Visual Analogue Scale (VAS) score, postoperative nausea and vomiting (PONV) and duration of hospital stay.

RESULTS

Duration of surgery in group P was 64.75±18.07 and 67.32±17.64 in group G respectively (P>0.05). Time for inducing anaesthesia was significantly longer in group P (17.15±3.92min) compared to group G (5.90±1.75min) with P<0.05. Significant difference (P<0.001) was observed in the mean duration of postoperative analgesia of group P (298.34±67.02min) and group G (107.68±27.28min). The VAS scores in immediate postoperative period and after two and four hours in the postoperative period were significantly higher in group G (P<0.05). The incidence of postoperative nausea and vomiting was significantly higher in group G (13 out of 30 patients) than group P (four out of 28 patients) with P<0.05.

CONCLUSION

The efficacy and safety of paravertebral block for operative treatment of breast tumors, excellent analgesia in early postoperative period, requirement of significantly lesser amount of postoperative analgesics, decreased incidence of PONV and negligible complications along with early ambulation and hospital discharge makes it an afferent cost-effective block of choice for unilateral breast surgeries.

Comparison of Ultrasound-Guided Thoracic Paravertebral Block Using Ropivacaine and Balanced General Anesthesia in Breast Surgeries

Background and Aims

Despite the latest advances in breast surgery, the procedure is frequently associated with postoperative pain, nausea, and vomiting, which leads not only to increased patient's suffering but also to a prolongation of hospital stays and related costs. Thoracic paravertebral block (TPVB) has been successfully used to provide analgesia for multiple thoracic and abdominal procedures in both children and adults.

Methods

Forty patients were allocated for this observational, comparative study and divided into two groups of 20 each, namely thoracic paravertebral group (Group P) study group and general anesthesia (GA) group (Group G), control group, and observations made for duration of procedure, visual analog score, rescue analgesia, surgeon and patient's satisfaction, postoperative complications, and duration of postanesthesia care unit (PACU) stay in both the groups.

Results

We found that there was a statistically significant difference in duration of procedure, more time was taken in performing TPVB. Pain was better controlled in Group P and requirement of rescue analgesia was higher in Group G patients, postoperative complications such as shivering, nausea, vomiting, and duration of PACU stay were more in patients receiving GA.

Conclusion

Hence, we conclude that ultrasound-guided TPVB appears to be safe, reliable, and effective technique for breast surgeries with several advantages over GA in terms of long-lasting pain relief, fewer complications, and shorter hospital stay.

Safety of treatment options available for postoperative pain

IntroductionPostoperative pain is one of the most common adverse events after surgery and has been shown to increase the risk of other complications. On the other hand, liberal opioid use in the perioperative period is also associated with risk of adverse events. The current consensus is therefore to provide multimodal, opioid minimizing analgesia after surgery.Areas CoveredIn this review, we will discuss the benefits and risks associated with non-opioid analgesics, including non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, α-2 agonists, and corticosteroids. In addition, we will discuss the general and block-specific risks associated with regional anesthestic techniques.Expert OpinionAdverse events associated with non-opioid analgesics are rare outside their specific contraindicated patient groups, especially when dosed appropriately. α-2 agonists can cause transient hypotension and bradycardia, and gabapentinoids may cause sedation in higher risk patient populations. Regional anesthesia techniques are generally safe when done by an experienced practitioner. We therefore encourage the development of standardized multimodal analgesic protocols, which may facilitate opioid minimization and lead to better patient outcomes.

Anatomic Landmark Technique Thoracic Paravertebral Nerve Block as a Sole Anesthesia for Modified Radical Mastectomy in a Resource-Poor Setting: A Clinical Case Report

Mastectomy is mostly performed as definitive management for resectable breast cancer. Implementing paravertebral nerve block for patients with metastasis features of cancer to lungs and other organs, patients with co-morbidity, geriatrics, and malnourished individuals will eliminate the risks and complications of general anesthesia. Though thoracic paravertebral block is an established technique as postoperative pain management for breast surgery, there is no conclusive evidence on its use as a sole anesthetic for modified radical mastectomy. In this case report, we present a 33-year-old woman who underwent a successful modified radical mastectomy for stage IIIb breast cancer associated with clinical and radiological features of metastasis to the lung under a multiple injection landmark technique paravertebral nerve block. We believe that the anatomic landmark technique paravertebral nerve block can be used as an alternative anesthetic technique for modified radical mastectomy in a resource-limited setting for patients who are expected to have a high risk of perioperative complications under general anesthesia.

Moving Toward Opioid-Free Breast Surgery: Regional Blocks and a Novel Technique

Perioperative pain control is of increasing importance as awareness regarding the risks of under-controlled pain and opioid abuse rise. Enhanced recovery protocols and multimodal analgesia, including regional blocks, are useful tools for the plastic surgeon. The thoracic paravertebral block, pectoralis nerve I and pectoralis nerve II blocks, and proximal intercostal blocks are 3 described methods that provide regional anesthesia for breast surgery. The widespread use of these methods may be limited by the requirements for ultrasound equipment and anesthesiologists skilled in regional blocks. This article describes a novel technique of the intercostal field block under direct visualization that is safe and efficient.

Management of non-invasive tumours, benign tumours and breast cancer during the COVID-19 pandemic: recommendations based on a Latin American survey

Introduction

The COVID-19 pandemic has changed health systems across the world, both in general hospitals and in oncology institutes or centres.For cancer specialists, particularly breast cancer (BC), the COVID-19 pandemic represents a combination of challenges since the hospital resources and staff have become more limited; this has obliged oncology specialists to seek a consensus and establish which patients with BC require more urgent attention and which patients can wait until there is a better control of this pandemic. The health system in Latin America has some special characteristics; in some of the countries, there are shortages which limit access to several specialities (surgery, clinical oncology and radiotherapy) in some regions.

Objective

After a systematic review of the most recent literature regarding the management of BC during the COVID-19 pandemic, the main objective is to understand the position of the different Latin American Societies of Mastology in terms of available alternatives for the treatment of BC.

Methods

After carrying out a comprehensive and exhaustive search of the most recent guides on the management of BC during the COVID-19 pandemic, the board members of the Latin American Federation of Mastology invited, via email, different specialists, all experts in BC care, to complete an anonymous survey online.The survey was distributed between 30 and 10 May 2020. The survey included 27 questions on four topics: demographic information, consultations, imaging and treatment of BC.The questionnaire was sent and then distributed to various health specialists including breast surgeons, clinical oncologists, radiation oncologists and radiologists via the Presidents of the different Latin American Societies of Mastology in 18 countries. The results are summarised as tallies based on the number of responses to each question.

Results

A total of 499 responses were received. The majority of the respondents were males (275 (55.11%)); 290 participants were over 45 years (58.11%).The questionnaire presented those surveyed with three possible answers (agree, disagree and neither agree nor disagree). The results reflect that there was consensus in the majority of situations presented. Only seven questions revealed disagreement among those responding. The results are presented as recommendations.

Conclusion

The management of patients with BC presents unique challenges during the current world health situation produced by COVID-19 pandemic. Breast care specialists (surgical oncologists, breast care clinicians, clinical oncologists, radiation oncologists and radiologists) from 18 countries in Central and South America submitted through their responses and recommendations for the treatment of BC during the COVID-19 pandemic.

A Randomized Controlled Trial Comparing Analgesic Efficacies of an Ultrasound-Guided Approach with and without a Combined Pressure Measurement Technique for Thoracic Paravertebral Blocks After Open Thoracotomy

Purpose

Ultrasound-guided thoracic paravertebral block (TPVB) is an established means for providing postoperative analgesia in thoracic surgery. However, there are conflicting results regarding the efficacy of post-thoracotomy pain management of ultrasound-guided TPVB when compared with that using traditional landmark approach. We therefore conducted a comparative study to evaluate the analgesic efficacy of TPVB when pressure measurement during needle advancement is combined with an ultrasound-guided approach.

Patients and Methods

The patients scheduled for lobectomy through thoracotomy were randomly allocated to receive either the ultrasound-guided approach only group (U group) or the ultrasound-guided approach combined with pressure measurement group (UP group) (n = 36 per group). Before thoracic muscle closure, 0.375% ropivacaine (20 mL) was administered as a bolus, followed by a continuous infusion of 0.2% ropivacaine (0.1 mL/kg/hr) in both groups. Postoperative pain was assessed using the visual analogue scale (VAS) pain score while resting and coughing. Local anesthetics and pethidine usage and sensory block area were also evaluated.

Results

The UP group showed significantly lower VAS scores, local anesthetics and pethidine usage, and a wider sensory block area than the U group.

Conclusion

A combined technique with ultrasound guidance and pressure measurement provided a superior analgesic effect over that of an ultrasound-guided approach alone for the management of post-thoracotomy pain.

Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery

Purpose

Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1–T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS.

Patients and Methods

Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1–0.5 µg.kg⁻¹.h⁻¹) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA.

Results

The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia.

Conclusion

USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.

[The effect of thoracic paravertebral block on seroma reduction in breast surgery - a randomized controlled trial]

BACKGROUND

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

OBJECTIVE

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

METHODS

Forty ASA I-II female patients aged 18-65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24^th hour postoperatively.

RESULTS AND CONCLUSIONS

Mean seroma formation at postoperative 24^th hour was 112.5±53.3 mL in the control group and 74.5±47.4 mL in the TPVB group (p=0.022). NRS scores were similar between two groups (p=0.367) at postoperative 24^th hour but mean morphine consumption at postoperative 24^th hour was 5.6±4 mg in the TPBV group, and 16.6±6.9 mg in the control group (p <0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

The effect of thoracic paravertebral block on seroma reduction in breast surgery – a randomized controlled trial

Background

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

Objective

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

Methods

Forty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and Control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively.

Results and conclusions

Mean seroma formation at postoperative 24th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

Paravertebral block: anatomy and relevant safety issues

Paravertebral block, especially thoracic paravertebral block, is an effective regional anesthetic technique that can provide significant analgesia for numerous surgical procedures, including breast surgery, pulmonary surgery, and herniorrhaphy. The technique, although straightforward, is not devoid of potential adverse effects. Proper anatomic knowledge and adequate technique may help decrease the risk of these effects. In this brief discourse, we discuss the anatomy and technical aspects of paravertebral blocks and emphasize the importance of appropriate needle manipulation in order to minimize the risk of complications. We propose that, when using a landmark-based approach, limiting medial and lateral needle orientation and implementing caudal (rather than cephalad) needle redirection may provide an extra margin of safety when performing this technique. Likewise, recognizing a target that is not in close proximity to the neurovascular bundle when using ultrasound guidance may be beneficial.

Regional Catheters for Postoperative Pain Control: Review and Observational Data

Context

Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures.

Evidence Acquisition

This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences.

Results

As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other.

Conclusions

Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.

Subarachnoid block with continuous TAP catheter analgesia produces less chronic pain and better functional outcome after inguinal hernioplasty: a randomized controlled observer-blinded study

BACKGROUND AND OBJECTIVES

The major concern after inguinal hernioplasty is chronic postsurgical pain and impaired quality of life due to central sensitization. Preoperative, intraoperative, and postoperative pre-emptive analgesia using regional techniques may help prevent the development of central sensitization. This study evaluated the effect of regional anesthesia followed by continuous regional analgesia on postoperative pain and functional outcome following inguinal hernioplasty.

METHODS

Seventy-two consecutive patients scheduled to undergo open mesh inguinal hernioplasty were randomly allocated to one of three groups: subarachnoid block alone (group SAB), general anesthesia alone (group GA), or subarachnoid block combined with a continuous transverse abdominis plane block (group TAP). Pain and functional outcome was assessed before and 6 months following the surgery using the Core Outcome Measures Index score adapted for patients with hernia (COMI-hernia). During the first 72 hours postoperatively, pain was assessed at rest and during five different activities using the numerical rating scale.

RESULTS

Six months following the surgery, the COMI-hernia score was lower in group TAP than in group GA or group SAB (0.54±0.41 vs 0.88±0.43 and 1.00±0.54, respectively; p<0.02). Pain at rest (p<0.02) and during activities (p<0.001) was lowest in group TAP during the first 72 hours postoperatively.

CONCLUSIONS

A subarachnoid block combined with continuous postoperative analgesia via a transverse abdominis plane catheter provided better pain control and functional outcome 6 months following inguinal hernioplasty as well as better postoperative analgesia.

CLINICAL TRIAL REGISTRATION

CTRI/2016/09/007238.

Paravertebral blocks in immediate breast reconstruction following mastectomy

BACKGROUND

Postoperative pain remains a major challenge following immediate breast reconstruction with 40% of patients experiencing acute pain and up to 60% developing chronic pain. Paravertebral blocks (PVB's) have emerged as a promising adjunct to standard analgesic protocols. The aim of this study was to assess the utility of PVB's in immediate breast reconstruction following mastectomy.

METHODS

A retrospective review of patients undergoing immediate breast reconstruction following mastectomy was performed. The primary outcome was postoperative pain measured by total oral morphine equivalent usage and self reported pain scores and secondary outcomes were length of stay in the PACU, complications, and OR delay.

RESULTS

Of 298 patients undergoing immediate breast reconstruction, 112(38%) underwent standard analgesic protocols and 186(62%) underwent PVB in addition to the standard protocol. PVB's were associated with reductions in average postoperative pain scores (2.8 vs 3.3, P = 0.002), total opiate consumption (52 units vs 63 units, P = 0.038) and time spent in the PACU 92 vs 142 minutes, P = 0.0228) compared to patients who had general anesthesia alone. The overall complication rate was 3.7% (7/186 patients), all which were minor complications such as headache, bloody tap, vasovagal episode and temporary weakness. The use of PVBs delayed the OR start time on average by 15 minutes (34 vs 49 minutes).

CONCLUSIONS

The present study offers one of the largest retrospective cohort studies to date evaluating the utility of PVB's in immediate breast reconstruction following mastectomy. We demonstrate that, PVB's in immediate breast reconstruction are associated with reductions in postoperative pain, narcotic usage and length of stay in PACU, but are associated with delays to the start time of the case. Anesthesiologists, plastic surgeons and hospital administrators must continue to work together to ensure this important and necessary service is administered in an efficient and cost effective manner.

The impact of intravenous dexamethasone on the efficacy and duration of analgesia of paravertebral block in breast cancer surgery: a randomized controlled trial

Purpose

The study aimed at the evaluation of the impact of intravenous (IV) dexamethasone on efficacy and duration of analgesia of paravertebral block (PVB) in patients undergoing modified radical mastectomy (MRM).

Patients and methods

This randomized, double-blind controlled trial included 50 patients with breast cancer scheduled for unilateral MRM. Ultrasound-guided PVB was performed in out-of-plane technique. The technique was repeated at each segment from C7 to T6. The participants were randomly allocated to one of two groups. Group BD (n=25) received IV 8 mg dexamethasone diluted with 8 mL of normal saline to reach 10 mL solution, while Group B received IV 10 mL normal saline. Top-up local infiltration analgesia into the surgical field was performed by the surgeon if needed using lidocaine 1% intraoperatively. Propofol infusion of 50-100 µg/kg/min was maintained throughout the surgery. The time to administration of the first postoperative analgesic dose, pain intensity as visual analog scale (VAS) score, number of patients who required rescue morphine analgesia, total morphine consumption, postoperative nausea and vomiting (PONV) impact scale, and the overall satisfaction of patients with pain management were measured.

Results

Fifty patients were randomized and analyzed. The time to first rescue analgesic dose was significantly longer in Group DB (P<0.001). The VAS scores were significantly lower in Group DB compared to Group B up to 12 hours postoperatively. Morphine consumption was lower in Group DB compared to Group B. PONV Impact Scale score was significantly higher in Group B.

Conclusion

Systemic dexamethasone increased the efficacy and duration of the single-shot multilevel PVB in breast cancer surgery.

Trial registration

ISRCTN registry, study ID: ISRCTN15920148.

Patient-controlled paravertebral analgesia for video-assisted thoracoscopic surgery lobectomy

Background

Paravertebral block has been proven to be an efficient method to provide post-thoracotomy pain management. This study aimed to compare patient-controlled paravertebral analgesia (PCPA) and intravenous patient-controlled analgesia (IVPCA) in terms of analgesic efficiency, respiratory function, and adverse effects after video-assisted thoracoscopic surgery (VATS) lobectomy.

Patients and methods

The prospective randomized trial study was carried out on 60 patients who underwent VATS lobectomy (randomly allocated 30 patients in each group). In the PCPA group, an initial dose of 0.3 mL/kg of 0.125% bupivacaine with fentanyl 2 µg/mL was administered, followed by a 3 mL/h continuous infusion with patient-controlled analgesia (2 mL bolus, 10-minute lockout interval, 25 mL/4 h limit). In the IVPCA group with morphine 1 mg/mL solution, an infusion device was programmed to deliver a 1.0 mL demand bolus with no basal infusion rate, with a 10-minute lockout interval and a maximum of 20 mL/4 h period. Postoperative pain was assessed by visual analog scale at rest and on coughing. Arterial blood gas and spirometry were monitored and recorded for the first 3 postoperative days. Side effects to include were also recorded.

Results

The PCPA group had statistically significant lower pain scores (P<0.0001) at rest at all times. Lower pain scores on coughing were statistically significant in PCPA group in the first 4 hours. Postoperative spirometry showed that both the groups had comparable recovery trajectories for their pulmonary function. Arterial blood gas analysis showed pH and PaCO₂ were in a normal range in both the groups. The incidence of headache was higher in the IVPCA group (13.3% vs 0%; P=0.038).

Conclusion

PCPA effectively managed pain after VATS lobectomy, with lower pain scores, similar respiratory function, and fewer side effects than standard IVPCA treatment.

Single-Injection Versus Multiple-Injection Technique of Ultrasound-Guided Paravertebral Blocks: A Randomized Controlled Study Comparing Dermatomal Spread

BACKGROUND AND OBJECTIVES

The objective of this study was to investigate the extent of dermatomal spread following an ultrasound-guided thoracic paravertebral block (PVB) when equal volumes of local anesthetic are injected at 1 versus 5 vertebral levels.

METHODS

Seventy patients undergoing a unilateral mastectomy were randomized to receive either single or multiple injections of a PVB under real-time ultrasound guidance using a parasagittal approach. The patients in the single-injection group received a PVB at T3-T4 level with 25 mL of 0.5% ropivacaine and 4 subcutaneous sham injections. Patients in the multiple-injection group received 5 injections of a PVB from T1 to T5 level. Five milliliters of 0.5% ropivacaine was injected at each level. Evaluation of the sensory block was carried out 20 minutes following the completion of the PVB.

RESULTS

The median (interquartile range) dermatomal spread was not significantly different for the single-injection group (5 [4-6]) compared with the multiple-injection group (5 [5-6]), with a median difference of 0 segments (95% confidence interval, -1 to 0 segments; P = 0.22). The median time to performance of the single-injection PVB was shorter compared with the multiple-injection group (10 minutes), with a mean difference of -4 minutes (95% confidence interval, -6 to -3 minutes; P < 0.001).

CONCLUSIONS

An ultrasound-guided single-injection PVB provides equivalent dermatomal spread and duration of analgesia compared with a multiple-injection PVB. The single-injection technique takes less time to perform and hence may be preferred over a multiple-injection technique.The trial was registered prospectively at ClinicalTrials.gov (NCT02852421) on July 15, 2016.

Ketorolac May Increase Hematoma Risk in Reduction Mammaplasty: A Case-control Study

Background:

Ketorolac is a potent nonsteroidal anti-inflammatory drug that has valuable analgesic properties but also a hypothetical risk of increased bleeding due to inhibition of platelet activation. The clinical significance of this risk, however, is unclear when it is used after reduction mammaplasty. Our study objective was to therefore examine the association between ketorolac exposure and hematoma occurrence after breast reduction surgery. We hypothesized that there was no association between ketorolac exposure and hematoma occurrence in breast reduction surgery.

Methods:

A case-control design was used. Data from charts of all reduction mammaplasties that developed hematomas requiring surgical evacuation (cases) at our university-based hospitals were retrieved and matched to data from charts of reduction mammaplasty patients who did not indicate this complication (controls). Matching occurred in a 1:1 ratio based on 4 criteria: age, body mass index, institution, and preexisting hypertension. Charts were reviewed for retrospective information on exposure to ketorolac. Odds ratio (OR) was calculated with an OR > 1 favoring an association.

Results:

From 2002 to 2016, 40 cases of hematoma met inclusion criteria and were matched with 40 controls (N = 80). Cases had a significantly lower body mass index than controls; however, the other baseline patient demographics were similar between the 2 groups. There was an association between hematoma formation and exposure to ketorolac (OR, 2.4; 95% confidence interval, 0.8–7.4; P = 0.114) and a trend for greater risk of hematoma formation, although this was not statistically significant.

Conclusions:

Based on this level 3 evidence, there appears to be an association between perioperative ketorolac exposure and hematoma after breast reduction surgery, but it was not statistically significant. Although this study was adequately powered, the OR of 2.4 was associated with a wide confidence interval. A larger sample size may increase the precision of the results and may also make the association definitive.

Paravertebral Blocks for Same-Day Breast Surgery

PURPOSE OF REVIEW

Breast surgery, performed for medical or cosmetic reasons, remains one of the most frequently performed procedures, with over 500,000 cases performed annually in the USA alone. Historically, general anesthesia (GA) has been widely accepted as the gold-standard technique, while epidural anesthesia was largely considered too invasive and thus unnecessary for breast surgery. Over the past years, paravertebral block (PVB) has emerged as an alternative analgesic or even anesthetic technique. Substantial evidence supports the use of PVB for major breast surgery.

RECENT FINDINGS

In patients receiving PVB, immediate and long-term analgesia is superior to systemic analgesia while opioid use and typical adverse effects of systemic analgesia such as nausea and vomiting are decreased. The benefits may also include an improved oncological survival with PVB after mastectomy for malignancy. PVB offers clinically significant benefits for perioperative care of patients undergoing breast surgery. The benefits of continuous PVB are most firmly supported for major breast surgery and include both effective short-term pain control and reduction in burden of chronic pain. On the other hand, minor breast surgery should be effectively manageable using multimodal analgesia in the majority of patients, with PVB reserved as analgesic rescue or for patients at high risk of excessive perioperative pain.