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

Evidence-based review of enhancing postoperative recovery after breast surgery

BACKGROUND

The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery.

METHODS

Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS.

RESULTS

Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies.

CONCLUSION

This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.

Interventions to Alleviate Symptoms Related to Breast Cancer Treatments and Areas of Needed Research

Treatments for breast cancer produce a host of side effects, which can become debilitating. Some cancer treatment-related side effects occur in up to 90% of patients during treatment and can persist for months or years after treatment has ended. As the number of breast cancer survivors steadily increases, the need for cancer control intervention research to alleviate side effects also grows. This review provides a general overview of recent clinical research studies of selected topics in the areas of symptom management for breast cancer with a focus on cognitive difficulties, fatigue, cardiotoxicity, bone loss, insomnia, and cancer pain. We review both pharmacological and behavioral intervention clinical research studies, conducted with breast cancer patients and survivors. Additionally, clinical perspectives on symptom management and recommendations for areas of needed research are provided.

Double-blinded, placebo-controlled, prospective randomized trial evaluating the efficacy of paravertebral block with and without continuous paravertebral block analgesia in outpatient breast cancer surgery

BACKGROUND

Paravertebral block (PVB) is an effective alternative to general anesthesia for breast cancer surgery. Continuous paravertebral block (CPVB) anesthesia may extend postoperative analgesia at home and improve quality of early postoperative recovery of breast cancer patients.

PURPOSE

This double-blinded randomized trial was conducted to compare degree of pain, nausea, mood, level of symptom distress, and time to return to normal daily activity between PVB and PVB + CPVB in patients undergoing outpatient breast cancer surgery.

PATIENTS AND METHODS

Between July 2003 and April 2008 we randomly assigned 94 (73 evaluable) patients in a 1:1:1 ratio with early breast cancer to single injection PVB followed by CPVB infusion of 0.1% or 0.2% ropivacaine vs placebo (saline) for 48 hours postoperatively for unilateral breast cancer surgery without reconstruction. The primary study endpoint was the degree of pain, nausea, mood state, level of symptom distress, and recovery time.

RESULTS

Of the 468 patients assessed for eligibility, 94 consented and 21 with incomplete data or follow-up were excluded, leaving 73 subjects for analysis. There was no clinically significant difference in degree of postoperative pain, nausea, mood state, level of symptom distress, or return to normal activity among the three study groups.

CONCLUSION

The current study does not support the routine use of continuous paravertebral catheter anesthesia in patients undergoing operative treatment for breast cancer.

Role of regional anesthesia in the ambulatory environment

The use of local anesthetics in ambulatory surgery offers multiple benefits in line with the goals of modern-day outpatient surgery. A variety of regional techniques can be used for a wide spectrum of procedures; all are shown to reduce postprocedural pain; reduce the short-term need for opiate medications; reduce adverse effects, such as nausea and vomiting; and reduce the time to dismissal compared with patients who do not receive regional techniques. Growth in ambulatory procedures will likely continue to rise with future advances in surgical techniques, changes in reimbursement, and the evolution of clinical pathways that include superior, sustained postoperative analgesia. Anticipating these changes in practice, the role of, and demand for, regional anesthesia in outpatient surgery will continue to grow.

[Multiple-injection thoracic paravertebral block for reconstructive breast surgery]

OBJECTIVE

To describe the use of multiple-injection thoracic paravertebral blockade, with intravenous sedation, for anesthesia during reconstructive breast surgery.

MATERIAL AND METHODS

Descriptive, prospective study in 100 scheduled operations for major reconstructive breast surgery. The paravertebral block was performed by means of 3 injections at the lower edges of the vertebral apophyses at T3-5. We recorded time performing the procedure, latency (time until block onset), dermatomes blocked, degree of effectiveness, conversion to general anesthesia, postoperative complications and pain, and patient satisfaction.

RESULTS

Dermatomes T3, T4, and T5 were blocked in 99% of the patients. The block took 7.39 minutes to perform and latency was 7.37 minutes. Postoperative analgesia with anti-inflammatory drugs was adequate for most patients. There were 3 cases of epidural diffusion, 10 patients with hypotension, 12 with postoperative nausea or vomiting, and 3 with symptoms of epidural blockade. Intravascular puncture occurred, without complications, in 3 cases. There were no cases of pneumothorax or intrathecal injection. Ninety-one percent of the patients declared they were satisfied or very satisfied with the technique.

CONCLUSIONS

Triple-injection paravertebral blocks, in which 3 fractions of the total anesthetic dose are delivered to block dermatomes T3-5 is an effective technique that is easy to perform and leads to few complications. Most patients express a high degree of satisfaction with this anesthetic technique.

Paravertebral block provides significant opioid sparing after hand-assisted laparoscopic nephrectomy: an expanded case report of 30 patients

PURPOSE

We report our experience of paravertebral block (PVB) on analgesic requirements and dynamic pain in patients presenting for hand-assisted laparoscopic nephrectomy (HALN) and compare our results with conventional opioid therapy.

PATIENTS AND METHODS

From October 2006 to May 2008, 30 patients (male:female ratio, 17:13) scheduled for HALN received paravertebral analgesia preoperatively. Postoperative opioid requirements and dynamic visual analog scale pain scores were determined in the recovery room and every 8 hours for 48 hours postoperatively. Data were obtained from medical records and patient interview.

RESULTS

The paravertebral analgesia was completed in all 30 patients with a mean visual analog scale score of 3.08 (0-10). Cumulative morphine equivalent doses were 11.82 mg (0-41 mg), whereas in two other studies, it ranged from 24 to 54 mg.

CONCLUSION

PVBs provided excellent analgesia with significant opioid sparing in this pilot series of 30 patients with HALN. Utilization of multimodal analgesia incorporating PVB is recommended for patients presenting for HALN.

Regional anesthesia and obesity

PURPOSE OF REVIEW

Worldwide, the number of overweight and obese patients has increased dramatically. As a result, anesthesiologists routinely encounter obese patients daily in their clinical practice. The use of regional anesthesia is becoming increasingly popular for these patients. When appropriate, a regional anesthetic offers advantages and should be considered in the anesthetic management plan of obese patients. The following is a review of regional anesthesia in obesity, with special consideration of the unique challenges presented to the anesthesiologist by the obese patient.

RECENT FINDINGS

Recent studies report difficulty in achieving peripheral and neuraxial blockade in obese patients. For example, there is an increased incidence of failed blocks in obese patients compared with similar, normal weight patients. Despite difficulties, regional anesthesia can be used successfully in obese patients, even in the ambulatory surgery setting.

SUMMARY

Successful peripheral and neuraxial blockade in obese patients requires an anesthesiologist experienced in regional techniques, and one with the knowledge of the physiologic and pharmacologic differences that are unique to the obese patient.

Improved postoperative pain control using thoracic paravertebral block for breast operations

Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. We report our institutional experience with PVB over the initial 8 months of use. All patients undergoing breast operations at the ambulatory care building from September 09, 2005 to June 28, 2005 were reviewed. Comparison was performed between patients receiving PVB and those who did not. Pain scores were assessed immediately, 4 hours, 8 hours and the morning after surgery. 178 patients received PVB and 135 patients did not. Patients were subdivided into three groups: Group A-segmental mastectomy only (n = 89), Group B-segmental mastectomy and sentinel node surgery (n = 111) and Group C-more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.

[Tumescent infiltrative anaesthesia for mastectomy: about six cases]

OBJECTIVE

To assess safety and efficacy of tumescent infiltration of the supraclavicular nerve and the anterior and lateral branches of the intercostal nerves in major breast surgery.

METHODS

A retrospective analysis of six selected patients undergoing mastectomy was performed. A mixture composed of 150mg ropivacaine, 400mg of lidocaine and 0.5mg epinephrine diluted in 500ml Ringer's were administered subcutaneously as follows: 80ml along the parasternal line from the second to the sixth intercostal space, 80ml along the mid axillary line from the second to the sixth intercostal space, 80ml along the infraclavicular line, 80ml in the space between the pectoralis muscle and the mammary gland and 80ml in the axilla in case of axillary dissection.

RESULTS

This technique achieved effective analgesia in six patients associated with sedation or light anaesthesia; conversion to general anaesthesia or supplementation with local anaesthesia was not required. No complication was observed. No emesis was noted.

CONCLUSION

This technique provides adequate peroperative analgesia and is a technically low-risk procedure. Further evaluation of this technique is recommended.

Evidence-based surgical care and the evolution of fast-track surgery

BACKGROUND

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

OBJECTIVE

To assess, synthesize, and discuss implementation of "fast-track" recovery programs.

DATA SOURCES

Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

DATA SYNTHESIS

Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

CONCLUSION

Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

Bilateral thoracic paravertebral block for abdominoplasty

Thoracic bilateral paravertebral block is a technique commonly used in the ambulatory setting for numerous plastic surgery procedures. Paravertebral block has not been reported with abdominoplasty surgery. This case series explores this anesthetic technique in the inpatient and day patient setting.

A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks

Regional analgesia has entered cardiac anesthesia in the form of spinal or epidural analgesia. However, the risk of spinal or epidural hematoma is a constant worry. Alternative regional techniques might be applicable in cardiac surgery. The purpose of this study is to present a novel technique of bilateral single-shot paravertebral blocks (BSS-PVB) for cardiac surgery via median sternotomy and compare its efficacy versus high thoracic epidural analgesia (TEA). Fifty-two patients were compared in this prospective cohort audit. In 26 patients, cardiac surgery was performed using low-dose fentanyl/BSS-PVB (bilateral blocks of 3 mL bupivacaine 0.5% each, T1-7) and general anesthesia; in another 26 patients, TEA (bupivacaine 0.125% at 10 mL/hour) and general anesthesia were used. Patients were assigned to cohorts according to their preoperative data and types of surgery. All patient data are shown as mean +/- SD; pain scores were compared between groups using the t test immediately, 6 hours, and 24 hours after surgery (P < .05). In the BSS-PVB-group (19 men, 7 women), mean age was 65 +/- 11 years, weight 74 +/- 16 kg, ejection fraction 59% +/- 12%, and duration of surgery 130 +/- 27 minutes; in the TEA-group (17 men, 9 women), mean age was 63 +/- 10 years, weight 75 +/- 16 kg, ejection fraction 58% +/- 12%, and duration of surgery 113 +/- 27 minutes. These data and preoperative comorbidity variables were not significantly different between the two groups. In each group, 18 patients underwent off-pump coronary artery bypass grafting, 3 on-pump and 5 mitral valve replacements. All patients were successfully immediately extubated. Postoperative pain scores were at any point significantly lower with TEA, immediately at 2.4 +/- 2.2 versus 3.7 +/- 2.6, at 6 hours at 1.1 +/- 1.5 versus 2.4 +/- 1.8, and at 24 hours at 1.0 +/- 1.4 versus 2.3 +/- 1.6 (0 = no pain, 10 = maximum pain). There was no complications related to epidural catheter placement or BSS-PVB. Using both techniques, immediate extubation after cardiac surgery is feasible; TEA provides better pain relief after cardiac surgery than BSS-PVB.

Day case breast augmentation under paravertebral blockade: a prospective study of 100 consecutive patients

BACKGROUND

An increasing trend toward day surgery management requires plastic surgeons not only to be cognizant of block techniques, but also to assess their safety and efficacy objectively. Paravertebral block offers benefits by enhancing surgical anesthesia and postoperative analgesia. This study aimed to assess the safety and efficacy of paravertebral block for day patients undergoing submuscular breast augmentation. The primary outcome measure was the rate of block failure. The secondary outcome measures included recovery room stay, pain management, and block complications. On the basis of a literature review and audit results, the study objective also aimed to propose safe guidelines for ambulatory paravertebral block patients undergoing breast surgery.

METHODS

A total of 100 patients undergoing 172 single-level paravertebral blocks (72 bilateral blocks) and sedation for submuscular breast augmentation were studied prospectively. A single-injection paravertebral block was performed at the T4 level using a loss of resistance technique. Surgical, anesthetic, and recovery room details were recorded. Analyses were performed to determine the association between recovery room times, body mass index, pain scores, and requirements for opioids, antiemetics, and vasopressors.

RESULTS

The findings showed that 87% of the blocks were successful for surgical anesthesia and 94% of the blocks were successful for postoperative analgesia. The pain score for 74% of the subjects was 3 or less. Antiemetics were given for 10% of the patients with significantly longer recovery room times. Vasopressors were required for 6% of the patients. A surgically caused pneumothorax resulted in the only unplanned admission.

CONCLUSION

The study findings suggest that paravertebral block is a safe and effective technique for day case submuscular breast augmentation.

Specific nerve blocks: an update

Recently there has been a considerable increase in interest in regional anesthesia and neural blockade. Many traditional nerve block techniques have been significantly modified to better fit the realm of both inpatient and outpatient surgery. The introduction of long acting local anesthetics with better safety profile as well as better equipment for continuous neuronal blockade has further increased the utility of peripheral nerve blocks. A significant effort has also been invested in studying and improving the safety of various techniques. These developments, coupled with an increased emphasis on teaching of regional blocks by organized anesthesia societies are likely to result in a wider use of these techniques in years to come.

Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery

We reported earlier that preincisional paravertebral block (PVB) provides significant immediate postoperative analgesia after breast cancer surgery. In the same patients (n = 60), a 1-yr follow-up was performed to find out whether PVB could also reduce the prevalence of postoperative chronic pain. The follow-up consisted of a 14-day symptom diary and telephone interviews 1, 6, and 12 mo after surgery. The 14-day consumption of analgesics was similar in the 30 PVB and the 30 control patients. However, 1 mo after surgery, the intensity of motion-related pain was lower (P = 0.005) in the PVB group. Six months after surgery, the prevalence of any pain symptoms (P = 0.029) was lower in the PVB group. Finally, at 12 mo after surgery, in addition to the prevalence of pain symptoms (P = 0.003) and the intensity of motion-related pain (P = 0.003), the intensity of pain at rest (P = 0.011) was lower in the PVB group. These findings were independent of whether or not axillary dissection had been performed. The incidence of neuropathic pain was low (two and three patients in the PVB and control groups, respectively). In addition to providing acute postoperative pain relief, preoperative PVB seems to reduce the prevalence of chronic pain 1 yr after breast cancer surgery.

Paravertebral Block: An Improved Method of Pain Control in Percutaneous Transhepatic Biliary Drainage

BACKGROUND AND PURPOSE

Percutaneous transhepatic biliary drainage remains a painful procedure in many cases despite the routine use of large amounts of intravenous sedation. We present a feasibility study of thoracic paravertebral blocks in an effort to reduce pain during and following the procedure and reduce requirements for intravenous sedation.

METHODS

Ten consecutive patients undergoing biliary drainage procedures received fluoroscopically guided paravertebral blocks and then had supplemental intravenous sedation as required to maintain patient comfort. Levels T8-T9 and T9-T10 on the right were targeted with 10-20 ml of 0.5% bupivacaine. Sedation requirements and pain levels were recorded.

RESULTS

Ten biliary drainage procedures in 8 patients were performed for malignancy in 8 cases and for stones in 2. The mean midazolam use was 1.13 mg i.v., and the mean fentanyl requirement was 60.0 microg i.v. in the block patients. Two episodes of hypotension, which responded promptly to volume replacement, may have been related to the block. No serious complications were encountered. The mean pain score when traversing the chest wall, liver capsule, and upon entering the bile ducts was 0.1 on a scale of 0 to 10, with 1 patient reporting a pain level of 1 and 9 reporting 0. The mean peak pain score, encountered when manipulating at the common bile duct level or when addressing stones there, was 5.4 and ranged from 0 to 10.

CONCLUSIONS

Thoracic paravertebral block with intravenous sedation supplementation appears to be a feasible method of pain control during biliary interventions.

Efficacité des techniques d'analgésie locorégionale après chirurgie du sein : une méta-analyse

OBJECTIVE

To evaluate the effectiveness of locoregional analgesic techniques (thoracic paravertebral block (TPVB), wound infiltration (WI)) after breast surgery.

STUDY DESIGN

Meta-analysis.

METHODS

Searches of Medline and Cochrane were performed using the search terms "breast surgery" and "local anaesthetics" and "infiltration" or "paravertebral block". Manual searches were also performed. Two independent investigators assessed the publications and extracted the data. Inclusion criteria were randomised controlled trials that evaluated effectiveness of single-injection TPVB or WI with local anaesthetics after breast surgery. Postoperative pain scores evaluated by visual analogic scale (VAS) during the first six hours (H6), at twelve hours (H12) and incidence of postoperative nausea and vomiting (PONV) were collected.

RESULTS

Nine studies met inclusion criteria with five trials that evaluated paravertebral block (N=253) and 4 studies that evaluated wound infiltration (N=174). TPVB decreased significantly VAS at H6 (Weighted mean difference (WMD)=-18 [-5;-32] ; P=0.007) and at H12 (WMD=-12[-20;-4] ; P=0.001) and the risk of PONV (relative risk=0.39 [0.26; 0.57] ; P<0.00001). WI did not decrease significantly VAS for postoperative pain and PONV.

CONCLUSION

Single injection TPVB in contrast to WI is effective for analgesia after breast surgery and decreases PONV.

Cervical Epidural Anesthesia: A Safe Alternative to General Anesthesia for Patients Undergoing Cancer Breast Surgery

BACKGROUND

General anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM.

PATIENTS AND METHODS

Fifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C(6)-C(7) or C(7)-T(1) epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter.

RESULTS

In 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2 pound, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery.

CONCLUSIONS

Cervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.

Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine

BACKGROUND AND OBJECTIVE

No clinical trials comparing the characteristics of sensory blockade caused by various local anaesthetics in thoracic paravertebral blockade have been published. The aim of this prospective study was a clinical assessment of sensory blockade after paravertebral injection of ropivacaine or bupivacaine in patients undergoing modified radical mastectomy.

METHODS

Seventy ASA I-II patients were randomized to receive a single injection of ropivacaine 0.5% (n = 35) or bupivacaine 0.5% (n = 35) at the T4 level. General anaesthesia with propofol and fentanyl was provided during the procedure and patients were not intubated. The following parameters were analysed: duration and dynamics of the sensory blockade and the patient's and surgeon's assessment.

RESULTS

Both ropivacaine and bupivacaine provided a similar level of analgesia. Ropivacaine was characterized by more rapid onset - after only 5 min 53% of patients in this group had the extent of sensory blockade wide enough to perform modified radical mastectomy in comparison to only 20% after bupivacaine (P 9 segments blocked) was noted more often in the ropivacaine group (88% vs. 65%, P < 0.05), lasted longer and appeared to be wider than sensory blockade produced by bupivacaine. Regression of sensory blockade was initially similar, but after 24 h sensory blockade in the ropivacaine group still had a potential to provide analgesia for modified radical mastectomy in 81% of patients in comparison to only 50% of such patients in the bupivacaine group (P < 0.05). Degree of postoperative pain, performance of the cardiovascular system, consumption of medications and complications were all similar between the study groups.

CONCLUSIONS

Both agents provide satisfactory conditions for mastectomy, but ropivacaine seems to be superior to bupivacaine for thoracic paravertebral blockade during breast cancer surgery.

Paravertebral Blocks Provide Superior Same-Day Recovery over General Anesthesia for Patients Undergoing Inguinal Hernia Repair

Inguinal herniorrhaphy is commonly performed on an outpatient basis under nerve blocks or local or general anesthesia (GA). Our hypothesis is that use of paravertebral blocks (PVB) as the sole anesthetic technique will result in shorter time to achieve home readiness and improved same-day recovery over a 'fast-track' GA. Fifty patients were randomly assigned to receive either PVB or GA under standardized protocols (PVB = 0.75% ropivacaine, followed by propofol sedation; GA = dolasetron 12.5 mg, propofol induction, rocuronium, endotracheal intubation; desflurane; bupivacaine 0.25% for field block). Eligibility for postanesthetic care unit (PACU) bypass and data on time-to-postoperative pain, ambulation, home readiness, and incidence of adverse events were collected. More patients in the PVB group (71%) met the criteria to bypass the postanesthetic care unit compared with patients in the GA group (8%; P < 0.001). Only 3 (13%) of patients in the PVB group requested treatment for pain while in the hospital, compared with 12 (50%) patients in the GA group, despite infiltration with local anesthetic (P = 0.005). Patients in the PVB group were able to ambulate earlier (102 +/- 55 minutes) than those in the GA group (213 +/- 108 minutes; P < 0.001). Time-to-home readiness and discharge times were shorter for patients in the PVB group (156 +/- 60 and 253 +/- 37 minutes) compared with those in the GA group (203 +/- 91 and 218 +/- 93 minutes) (P < 0.001). Adverse events (e.g., nausea, vomiting, sore throat) and pain requiring treatment in the first 24 hours occurred less frequently in patients who had received PVB than in those who had received GA. In outpatients undergoing inguinal herniorrhaphy, PVB resulted in faster time to home readiness and was associated with fewer adverse events and better analgesia before discharge than GA.

Lumbar plexus blockade with ropivacaine for postoperative pain management in elderly patients undergoing urologic surgeries

BACKGROUND/AIMS

We evaluated the effectiveness and safety of lumbar plexus blockade with ropivacaine for postoperative pain relief in elderly patients undergoing flank incision for urological surgery.

METHODS

60 urological patients (>65 years old) were chosen randomly for paravertebral lumbar blockade. Postoperatively ropivacaine was used in group I (n = 30) and bupivacaine was administered in group II (n = 30) for lumbar plexus blockade. Heart rates, systolic and diastolic blood pressures, peripheral oxygen saturations, analgesia levels with visual analogue scales (VAS) were measured postoperatively at 5 and 30 min and 1, 3, 6, 8,and 12 h. Patient satisfaction scores and complications were recorded.

RESULTS

The hemodynamic parameters of the groups were in the normal ranges (p > 0.05). VAS were significantly decreased at 60 min in both groups (p < 0.05) and no important increase was observed during the first 8 h (p > 0.05). After the 8-hour measurement, analgesic was given to 7 patients in group I and 6 patients in group II (p < 0.05). There were no complications (p > 0.05). Patient satisfaction scores were found to be higher for all patients (p > 0.05).

CONCLUSION

In elderly patients, lumbar plexus blockade with ropivacaine can be a simple, safe and effective analgesic technique especially in the early postoperative period after urologic surgeries with flank incision.

Peripheral Nerve Block Techniques for Ambulatory Surgery

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial

BACKGROUND AND OBJECTIVE

Different anaesthetic techniques are used during breast surgery but are frequently associated with unsatisfactory postoperative analgesia. Paravertebral nerve blockade has recently been proposed as a favourable alternative for this type of surgical procedure, providing excellent pain relief and a reduced incidence of postoperative nausea and vomiting. The aim of the present study was to compare the use of a nerve-stimulator guided paravertebral nerve blockade technique to regular general anaesthesia for breast surgery.

METHODS

Sixty patients were prospectively randomized to receive either paravertebral nerve blockade or general anaesthesia for breast surgery. The primary end-point of the study was to assess postoperative analgesia (visual analogue scale and supplemental opioid requirements); the incidence of postoperative nausea and vomiting and length of hospital stay were considered as secondary outcome measures.

RESULTS

Visual analogue scores both at rest and at movement, as well as the need for supplemental opioid administration during the first 3 days postoperatively, were significantly lower in patients handled with para-vertebral nerve blockade compared to patients receiving general anaesthesia (P < 0.05). The number of patients free from nausea and vomiting after operation was significantly higher in the paravertebral nerve blockade group (93%) compared to the general anaesthesia group (67%) (P < 0.05). The use of paravertebral nerve blockade was also associated with a significantly shorter hospital stay (median 1 day) compared to general anaesthesia (2 days) (P < 0.01). Both the performance of the block and the intraoperative conditions was well accepted by the vast majority of patients treated by paravertebral nerve blockade (97%).

CONCLUSION

The use of paravertebral nerve blockade was associated with improved postoperative pain relief, a reduced incidence of nausea and vomiting after operation and a shorter duration of hospital stay compared to general anaesthesia in patients undergoing breast surgery.

Post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients

AIM

This study aimed to evaluate patient information provided, the management of post-operative symptoms and post-operative care, and patient satisfaction with ambulatory breast surgery over a 1-year period.

METHODS

From January to December 2000, all breast cancer patients undergoing conservative breast surgery were offered surgery as an outpatient procedure at the Ambulatory Surgery Unit.

RESULTS

Two hundred and thirty six patients underwent outpatient surgery. None were readmitted during the first night or the first week. Two hundred and nineteen patients completed a questionnaire. One hundred and sixty nine patients (group 1) underwent wide local excision (WLE) and 50 (group 2), WLE and axillary lymphadenectomy. Patients in group 2 experienced more pain at discharge from the hospital (p < or = 0.01) and during the first week after discharge (p < or = 0.00001) than patients in group 1. The mean overall satisfaction score was 8.97 on a scale of 1-10. Post-operative information provided by the surgeon before discharge from the hospital was rated 8.90 on a scale of 1-10 while information provided by the nurse was rated 9.33 (p < 0.0001).

CONCLUSION

Ambulatory surgery for breast cancer patients is safe and popular with patients, however, post-operative pain presents problem.

Peripheral Nerve Blocks and Continuous Catheter Techniques

Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.

Single-Injection Paravertebral Block Before General Anesthesia Enhances Analgesia After Breast Cancer Surgery With and Without Associated Lymph Node Biopsy

Paravertebral block (PVB) seems to decrease postoperative pain and postoperative nausea and vomiting (PONV) after breast surgery, but the studies have not been placebo controlled. We studied 60 patients scheduled for breast cancer surgery randomly given single-injection PVB at T3 with bupivacaine 5 mg/mL (1.5 mg/kg) or saline before general anesthesia. The patient and attending investigators were blinded; the PVB or the sham block was performed behind a curtain by an anesthesiologist not involved in the study. The patients given PVB with bupivacaine needed 40% less IV opioid medication (primary outcome variable) in the postanesthesia care unit, had a longer latency to the first opioid dose, and had less pain at rest after 24 h than the control patients (P < 0.01). They also had less PONV in the postanesthesia care unit (P < 0.05), were less sedated until 90 min (P < 0.05), and performed better in the digit symbol substitution test at 90 min and the ocular coordination test 60-120 min after surgery (P < 0.05). The average peak bupivacaine plasma concentration was 750 ng/mL. One patient had bilateral convulsions immediately after bupivacaine injection. We conclude that PVB before general anesthesia for breast cancer surgery reduced postoperative pain, opioid consumption, and occurrence of PONV and improved recovery from anesthesia.