Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study

BACKGROUND

Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients.

METHODS

Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated.

RESULTS

Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05).

CONCLUSIONS

US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TRIAL REGISTRATION

NCT04596787.

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).

Intraoperative pectoral block thoracic paravertebral block for postoperative analgesia after breast cancer surgery: A randomized controlled trial

BACKGROUND AND METHODS

With the increasing rate of breast cancer surgery, the pain management of these patients gains importance. The aim of this study is to compare the ultrasound (US) guided thoracic paravertebral block (TPV) versus intraoperative pectoral nerve block (PECS) with a low volume local anaesthetic for postoperative analgesia after breast cancer surgery. A total of 41 patients underwent mastectomy and sentinel lymph node biopsy or modified radical mastectomy were included in this randomized controlled, single-blinded trial. The patients were divided into two groups as PECS and TPV blocks. In the PECS group, 10 ml of 0.5% bupivacaine was administered to the fascial plane by the surgeon. In the TPV group, 25 ml of 0.25% bupivacaine at T3 level was administered by the anaesthetist under US-guidance. Visual analogue scale (VAS) scores and additional analgesic requirements were recorded at postoperative 0, 6, 12, 24 and 48 h.

RESULTS

In the TPV group, mean VAS score (VAS0) was significantly lower (p ˂ 0.001). In other time periods, there was no significant difference between the groups.

CONCLUSIONS

It was observed that intraoperative PECS block was as effective as TPV in providing postoperative analgesia and additional analgesic requirements were similar. This result suggests PECS block may be a good alternative to TPV.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.

METHODS

In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.

RESULTS

Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.

CONCLUSION

Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.

STUDY REGISTRATION

PROSPERO (CRD42020198244); registered 19 October 2020.

Thoracic Paravertebral Nerve Block with Ropivacaine and Adjuvant Dexmedetomidine Produced Longer Analgesia in Patients Undergoing Video-Assisted Thoracoscopic Lobectomy: A Randomized Trial

Purpose

This study evaluated the postoperative analgesic effect of ultrasound-guided single-point thoracic paravertebral nerve block (TPVB) combined with dexmedetomidine (DEX) in patients undergoing video-assisted thoracoscopic lobectomy.

Methods

Sixty adult patients of the American Society of Anesthesiologists (ASA) I-III were randomly assigned into three groups (n = 20 each). G group: patients received routine general anesthesia; PR group: patients received 0.5% ropivacaine; and PRD group: patients received 0.5% ropivacaine with 1 μg/kg DEX. TPVB was performed in the T5 space before surgery, and then, general anesthesia induction and video-assisted thoracoscopic lobectomy were performed. Analgesics were administered through the patient-controlled analgesia (PCA) device intravenously. The background infusion of each PCA device was set to administer 0.02 μg/kg/h sufentanil, with a lockout time of 15 min, and a total allowable volume is 100 ml.

Results

Compared to PR and G groups, the total sufentanil consumption after operation, the times of analgesic pump pressing, the pain score, and the incidence of postoperative nausea or vomiting in the PRD group were significantly reduced (p < 0.05). Also, the duration of first time of usage of the patient-controlled analgesia (PCA) was longer. The heart rate (HR) and mean arterial pressure (MAP) during operation were lower in the PRD group as compared with the other two groups in most of the time. However, hypotension and arrhythmia occurred in three groups with no statistically significant difference.

Conclusions

A small volume of TPVB with ropivacaine and DEX by single injection produced longer analgesia in patients undergoing video-assisted thoracoscopic lobectomy, reduced postoperative opioids consumption, and the incidence of side effects.

Analgesic and opioid sparing effects of preoperative thoracic paravertebral block: A double blind evaluation of 0.5% bupivacaine with adrenaline in patients scheduled for simple mastectomy

Background

Various regional anaesthetic techniques are used for post-mastectomy pain relief; however, thoracic paravertebral block (TPVB) has shown some advantages over other methods. This study sought to demonstrate the post-operative benefit of pre-operative TPVB in patients scheduled for simple mastectomy.

Methods

The study was carried out on 60 adult female patients with the American Society of Anesthesiologists physical status Class I to III scheduled for unilateral mastectomy. Pre-operatively, a nerve stimulator was used to locate the paravertebral space thereafter bupivacaine with adrenaline or saline was injected into the space. Post-operatively, intravenous morphine patient controlled analgesia was commenced in the two groups for 24 h after the surgery. In addition, intravenous paracetamol 15 mg/kg was administered 6 hourly for 24 h in both groups.

Results

The 24 h morphine consumption was significantly reduced in the bupivacaine group compared to the control group (P = 0.000). The Numerical pain rating score was significantly lower in the bupivacaine group than in the control group in the 1^st 6 h; P = 0.001. The time to first request for analgesia was significantly longer in the bupivacaine group than the control group (P = 0.000). Nausea was the major side effect detected and this was significantly higher in the control group (P = 0.024). The morphine sparing effect was 65.7% in the bupivacaine group.

Conclusion

The study showed that bupivacaine-based TPVB provided an effective post-operative analgesic and opioid-sparing effect for simple mastectomy when compared with a saline-based control group that received only intravenous morphine patient controlled analgesia and paracetamol.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study

BACKGROUND

Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge.

METHODS

The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression.

RESULTS

Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001).

CONCLUSION

Paravertebral blocks are associated with decreased pain score at the time of hospital discharge.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses

BACKGROUND AND OBJECTIVE

The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.

DATABASES AND DATA TREATMENT

We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.

RESULTS

Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.

CONCLUSIONS

Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed.

SIGNIFICANCE

This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.

Different Analgesic Routes of Magnesium Sulfate: Intravenous versus Pectoralis II Interfascial Plane Block for Breast Cosmetic Surgeries

Purpose

The purpose of the study is to evaluate the most effective analgesic route of magnesium sulfate (MgSO₄) either intravenous (i.v.) or pectoralis interfascial plane block.

Patients and Methods

Fifty adult female patients were divided into two equal groups: i.v. MgSO₄ and Pecs II block MgSO₄ (Pecs MgSO₄) group. After general anesthesia, in i.v. MgSO₄ group, the local anesthetic (LA) for Pecs II block was prepared by adding 3 mL saline to 57 mL bupivacaine 0.25% divided equally for each side. A bolus i.v. solution of MgSO₄ 10% 0.5 mL.kg^-1 diluted in saline in a total volume of 100 mL was given over 15 minutes. Then, the solution for continuous i.v. infusion; 30 mL MgSO₄ 10% and 70 mL saline was infused at the rate of 0.5 mL.kg^-1.h^-1 intraoperatively. For PecsMgSO₄ group, LA formed of 3 mL MgSO₄ 10% added to 57 mL bupivacaine 0.25%. Whereas, 100 mL saline was given as bolus i.v. followed by continuous infusion of 100 mL normal saline at the rate of 0.5 mL.kg^-1.h^-1.

Results

In the group received MgSO₄-bupivacaine Pecs II block, there was a nonsignificant decrease in postoperative morphine consumption compared to i.v. administration of MgSO₄. The two groups were comparable in the intensity of pain and sedation scores.

Conclusion

The use of bupivacaine Pecs II block enhanced with addition of MgSO₄ to pectoralis interfascial plane block or intravenously in patients underwent breast cosmetic surgeries under general anesthesia was associated with comparable results of the postoperative morphine requirements, intensity of postoperative pain, and extension of the duration of postoperative analgesia. The intraoperative hemodynamic effects i.v. MgSO₄ were superior to the pectoralis interfascial plane route of administration.

Variables associated with length of stay in patients undergoing mastectomy and delayed-immediate breast reconstruction with tissue expander

Delayed-immediate reconstruction with the placement of tissue expanders at the time of mastectomy is a common approach to breast reconstruction. The purpose of this study was to identify variables associated with increased LOS in patients that underwent bilateral or unilateral mastectomy with tissue expander placement. Bilateral procedure, a diagnosis of anxiety or depression, and age >55 years were independently associated with increased LOS. More recent year of surgery and Friday surgery were associated with decreased LOS.

Thoracic Paravertebral Block with Adjuvant Dexmedetomidine in Video-Assisted Thoracoscopic Surgery: A Randomized, Double-Blind Study

Background: The addition of the adjuvant dexmedetomidine to a nerve block improves the quality of the block and reduces perioperative opioid consumption. The aim of this study was to assess the effect of dexmedetomidine as an adjuvant for the thoracic paravertebral block (TPVB) in postoperative pain control after video-assisted thoracoscopic surgery (VATS). Methods: Sixty-six males, aged 15–40 years, with spontaneous pneumothorax scheduled for VATS wedge resection were enrolled. Following surgery, ultrasound-guided TPVB was performed on the T3 and T5 levels with 30 mL of 0.5% ropivacaine, plus adjuvant dexmedetomidine 50 μg or normal saline. The primary outcome was cumulative fentanyl consumption at 24 h. Pain severity, the requirement for additional rescue analgesics, hemodynamic variations, and side effects were also evaluated. Results: Median postoperative cumulative fentanyl consumption at 24 h was significantly lower in the dexmedetomidine group (122.6 (interquartile range (IQR) 94.5–268.0) μg vs. 348.1 (IQR, 192.8–459.2) μg, p-value = 0.001) with a Hodges–Lehman median difference between groups of 86.2 (95% confidence interval (CI), 4.2–156.4) mg. Coughing numeric rating scale (NRS) was lower in the dexmedetomidine group at postoperative 2, 4, 8, and 24 h. However, resting NRS differed significantly only after 4 h postoperative. Conclusions: Dexmedetomidine as an adjunct in TPVB provided effective pain relief and significantly reduced opioid requirement in VATS.

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.

Intraoperative Techniques for the Plastic Surgeon to Improve Pain Control in Breast Surgery

Supplemental Digital Content is available in the text.

In recent years, there has been a growing emphasis placed on reducing length of hospital stay and health costs associated with breast surgery. Adequate pain control is an essential component of enhanced recovery after surgery. Postoperative pain management strategies include use of narcotic analgesia, non-narcotic analgesia, and local anesthetics. However, these forms of pain control have relatively brief durations of action and multiple-associated side effects. Intraoperative regional blocks have been effectively utilized in other areas of surgery but have been understudied in breast surgery. The aim of this article was to review various intraoperative techniques for regional anesthesia and local pain control in breast surgery and to highlight areas of future technique development.

Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis

PURPOSE

Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds.

METHODS

A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control.

RESULTS

The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds.

CONCLUSION

Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

Are Cure Rates for Breast Cancer Improved by Local and Regional Anesthesia?

BACKGROUND AND OBJECTIVES

Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA.

METHODS

We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching.

RESULTS

Median age of the 1107 patients who met study criteria was 64 years (range, 24-97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR "free" rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55-1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83-3.63; P = 0.15).

CONCLUSIONS

Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Randomised controlled pilot study to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: TOPIC feasibility study protocol

INTRODUCTION

Open chest surgery (thoracotomy) is considered the most painful of surgical procedures. Forceful wound retraction, costochondral dislocation, posterior costovertebral ligament disruption, intercostal nerve trauma and wound movement during respiration combine to produce an acute, severe postoperative pain insult and persistent chronic pain many months after surgery is common. Three recent systematic reviews conclude that unilateral continuous paravertebral blockade (PVB) provides analgesia at least equivalent to thoracic epidural blockade (TEB) in the postoperative period, has a lower failure rate, and symptom relief that lasted months. Crucially, PVB may reduce the development of subsequent chronic pain by intercostal nerve protection or decreased nociceptive input. The overall aim is to determine in patients who undergo thoracotomy whether perioperative PVB results in reducing chronic post-thoracotomy pain (CPTP) compared with TEB. This pilot study will evaluate feasibility of a substantive trial.

METHODS AND ANALYSIS

TOPIC is a randomised controlled trial comparing the effectiveness of TEB and PVB in reducing CPTP. This is a pilot study to evaluate feasibility of a substantive trial and study processes in 2 adult thoracic centres, Heart of England NHS Foundation Trust (HEFT) and University Hospital of South Manchester NHS Foundation Trust (UHSM). The primary objective is to establish the number of patients randomised as a proportion of those eligible. Secondary objectives include evaluation of study processes. Analyses of feasibility and patient-reported outcomes will primarily take the form of simple descriptive statistics and where appropriate, point estimates of effects sizes and associated 95% CIs.

ETHICS AND DISSEMINATION

The study has obtained ethical approval from NHS Research Ethics Committee (REC number 14/EM/1280). Dissemination plan includes: informing patients and health professionals; engaging multidisciplinary professionals to support a proposal of a definitive trial and submission for a full HTA application dependent on the success of the study.

TRIAL REGISTRATION NUMBER

ISRCTN45041624; Pre-results.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction

BACKGROUND

Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use.

METHODS

The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded.

RESULTS

A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05).

CONCLUSIONS

Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review

Objectives

The addition of a perioperative continuous paravertebral nerve block (cPVB) to a single-injection thoracic paravertebral nerve block (tPVB) has demonstrated improved analgesia in breast surgery. However, its use following isolated post-mastectomy reconstruction using a latissimus dorsi flap (LDF) has not previously been examined.

Methods

We performed a retrospective review of patients who underwent salvage breast reconstruction with a unilateral LDF by a single surgeon. Preoperatively, all patients received a single-injection tPVB with 0.5% ropivacaine. Additionally, patients had the option for catheter placement to receive a continuous 0.2% ropivacaine infusion with intermittent boluses. Infusions commenced in the recovery room and the catheters were removed on the morning of discharge. The primary endpoint was the mean pain numeric rating scale (NRS) scores for the 24-hour period beginning at 7:00 on post-operative day 1.

Results

A total of 22 patients were included in this study (11-cPVB and 11-tPVB). The mean NRS pain score of cPVB patients (3.5 (standard deviation (SD) 1.8) was lower than that of the single-injection tPVB patients (4.4 (SD 2.1), however this difference was not statistically significant (P = 0.31). The length of hospital stay and opioid use was not statistically different between groups.

Conclusions

Patients receiving a cPVB in addition to tPVB after LDF reconstruction experienced similar pain to those receiving tPVB alone. A larger, randomized clinical trial is warranted to fully determine the benefits of using cPVB in addition to tPVB for this procedure.

Efficacy of dexmedetomidine as an adjuvant in paravertebral block in breast cancer surgery

PURPOSE

This study evaluated the analgesic efficacy of dexmedetomidine in combination with bupivacaine for single-shot paravertebral block (PVB) in patients undergoing major breast cancer surgery.

METHODS

This prospective, randomized double blind study was conducted in 45 ASA I/II/III females, aged ≥18 years, undergoing modified radical mastectomy or breast conservation surgery with axillary lymph node dissection. Patients in group PB (paravertebral-bupivacaine) received PVB with 0.5 % bupivacaine 0.3 ml/kg with 1 ml normal saline; group PBD (paravertebral-bupivacaine-dexmedetomidine) received PVB with 0.5 % bupivacaine 0.3 ml/kg and dexmedetomidine 1 μg/kg in a volume of 1 ml; and group C (control) patients were given a sham block (a subcutaneous injection with 2 ml normal saline) before receiving general anesthesia (GA). All patients received analgesia by fentanyl intraoperatively and morphine patient-controlled analgesia postoperatively.

RESULTS

The control group patients required more intraoperative fentanyl than the other two groups. Patients receiving dexmedetomidine had lower morphine consumption (p < 0.001), pain scores and incidence of postoperative nausea/vomiting (p = 0.011); longer time to first analgesic request; earlier time to mobilize; and better satisfaction scores. Heart rate and blood pressure values during the intraoperative period were also lower at many time points in this group. However, the incidence of hypotension and bradycardia were statistically similar in all groups.

CONCLUSIONS

PVB using dexmedetomidine 1 µg/kg added to 0.5 % bupivacaine in patients undergoing major breast cancer surgery under GA provides analgesia of longer duration with decreased postoperative opioid consumption and lower incidence of nausea/vomiting compared to PVB with bupivacaine alone or no PVB.

Can acute pain treatment reduce postsurgical comorbidity after breast cancer surgery? A literature review

Regional analgesia, opioids, and several oral analgesics are commonly used for the treatment of acute pain after breast cancer surgery. While all of these treatments can suppress the acute postsurgical pain, there is growing evidence that suggests that the postsurgical comorbidity will differ in accordance with the type of analgesic used during the surgery. Our current study reviewed the effect of analgesics used for acute pain treatments on the major comorbidities that occur after breast cancer surgery. A considerable number of clinical studies have been performed to investigate the relationship between the acute analgesic regimen and common comorbidities, including inadequate quality of recovery after the surgery, persistent postsurgical pain, and cancer recurrence. Previous studies have shown that the choice of the analgesic modality does affect the postsurgical comorbidity. In general, the use of regional analgesics has a beneficial effect on the occurrence of comorbidity. In order to determine the best analgesic choice after breast cancer surgery, prospective studies that are based on a clear definition of the comorbidity state will need to be undertaken in the future.

[Clinical application of thoracic paravertebral anesthetic block in breast surgeries]

INTRODUCTION

optimum treatment for postoperative pain has been of fundamental importance in surgical patient care. Among the analgesic techniques aimed at this group of patients, thoracic paravertebral block combined with general anesthesia stands out for the good results and favorable risk-benefit ratio. Many local anesthetics and other adjuvant drugs are being investigated for use in this technique, in order to improve the quality of analgesia and reduce adverse effects.

OBJECTIVE

evaluate the effectiveness and safety of paravertebral block compared to other analgesic and anesthetic regimens in women undergoing breast cancer surgeries.

METHODS

integrative literature review from 1966 to 2012, using specific terms in computerized databases of articles investigating the clinical characteristics, adverse effects, and beneficial effects of thoracic paravertebral block.

RESULTS

on the selected date, 16 randomized studies that met the selection criteria established for this literature review were identified. Thoracic paravertebral block showed a significant reduction of post-operative pain, as well as decreased pain during arm movement after surgery.

CONCLUSION

thoracic paravertebral block reduced postoperative analgesic requirement compared to placebo group, markedly within the first 24hours. The use of this technique could ensure postoperative analgesia of clinical relevance. Further studies with larger populations are necessary, as paravertebral block seems to be promising for preemptive analgesia in breast cancer surgery.

Treatment of postmastectomy pain with ambulatory continuous paravertebral nerve blocks: a randomized, triple-masked, placebo-controlled study

BACKGROUND

We aimed to determine with this randomized, triple-masked, placebo-controlled study if benefits are afforded by adding a multiple-day, ambulatory, continuous ropivacaine paravertebral nerve block to a single-injection ropivacaine paravertebral block after mastectomy.

METHODS

Preoperatively, 60 subjects undergoing unilateral (n = 24) or bilateral (n = 36) mastectomy received either unilateral or bilateral paravertebral perineural catheter(s), respectively, inserted between the third and fourth thoracic transverse process(es). All subjects received an initial bolus of ropivacaine 0.5% (15 mL) via the catheter(s). Subjects were randomized to receive either perineural ropivacaine 0.4% or normal saline using portable infusion pump(s) [5 mL/h basal; 300 mL reservoir(s)]. Subjects remained hospitalized for at least 1 night and were subsequently discharged home where the catheter(s) were removed on postoperative day (POD) 3. Subjects were contacted by telephone on PODs 1, 4, 8, and 28. The primary end point was average pain (scale, 0-10) queried on POD 1.

RESULTS

Average pain queried on POD 1 for subjects receiving perineural ropivacaine (n = 30) was a median (interquartile) of 2 (0-3), compared with 4 (1-5) for subjects receiving saline (n = 30; 95% confidence interval difference in medians, -4.0 to -0.3; P = 0.021]. During this same period, subjects receiving ropivacaine experienced a lower severity of breakthrough pain (5 [3-6] vs 7 [5-8]; P = 0.046) as well. As a result, subjects receiving perineural ropivacaine experienced less pain-induced physical and emotional dysfunction, as measured with the Brief Pain Inventory (lower score = less dysfunction): 14 (4-37) versus 57 (8-67) for subjects receiving perineural saline (P = 0.012). For the subscale that measures the degree of interference of pain on 7 domains, such as general activity and relationships, subjects receiving perineural saline reported a median score 10 times higher (more dysfunction) than those receiving ropivacaine (3 [0-24] vs 33 [0-44]; P = 0.035). In contrast, after infusion discontinuation, there were no statistically significant differences detected between treatment groups.

CONCLUSIONS

After mastectomy, adding a multiple-day, ambulatory, continuous ropivacaine infusion to a single-injection ropivacaine paravertebral nerve block results in improved analgesia and less functional deficit during the infusion. However, no benefits were identified after infusion discontinuation.

Continuous paravertebral block for postoperative pain compared to general anaesthesia and wound infiltration for major oncological breast surgery

We hypothesized that improved acute postoperative pain relief will be achieved using general anaesthesia (GA) either in combination with continuous thoracic paravertebral block (GA-cPVB) or single shot (GA-sPVB) as compared to GA supplemented by local wound infiltration (GA-LWI) after unilateral major breast cancer surgery.

A randomised controlled trial was conducted in 46 adult women in a day-care or short-stay hospital setting after major breast cancer surgery. Pain-intensity was measured using an 11-point visual analogue scale (VAS) until postoperative day 2. GA-sPVB was stopped due to slow inclusion.

No significant difference in VAS score was noted between GA-LWI (VAS median 0.5 (interquartile range 0.18–2.00)) and GA-cPVB, (VAS 0.3 (0.00–1.55, p = 0.195)) 24 hours after surgery or at any point postoperatively until postoperative day 2.

We conclude that both GA-LWI and GA-cPVB anaesthetic techniques are equally effective in treatment of acute postoperative pain after major oncological breast surgery. As GA-LWI is easily to perform with fewer complications and it is more cost-effective it should be preferred over GA-cPVB.

Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting

BACKGROUND

Mastectomy is associated with postoperative nausea and pain. We evaluated whether paravertebral block (PVB) use altered opioid use, antiemetic use, and length of stay in patients undergoing mastectomy.

METHODS

We performed a retrospective cohort analysis of all patients who underwent mastectomy with or without PVB from 2008 to 2010. Patient demographics, operative procedure, intraoperative medications, postoperative opioid and antiemetic use, and length of stay were reviewed. Statistical analysis included univariable and multivariable analysis.

RESULTS

A total of 605 patients were identified, of whom 526 patients were evaluable. A total of 294 patients underwent mastectomy without PVB (132 bilateral), and 232 patients underwent mastectomy with PVB (148 bilateral). Immediate reconstruction was performed in 203 (39 %) patients. Need for any postoperative antiemetic was less frequent in the PVB group (39 vs. 57 %, p < 0.0001). Day of surgery opioid use was lower in the PVB group than the non-PVB group (mean ± SD 40.1 ± 15.2 vs. 47.6 ± 17.7 morphine equivalents, p < 0.0001). Decreased opioid use was seen in unilateral mastectomy without reconstruction and bilateral mastectomy with and without immediate reconstruction. The proportion of patients discharged within 36 h of surgery was significantly higher in the PVB group (55 vs. 42 %, p = 0.0031). On multivariable analysis controlling for year of surgery, patient age and surgeon, PVB use affected antiemetic use and opioid use but not hospital length of stay.

CONCLUSIONS

PVB results in decreased opioid use and decreased need for postoperative antiemetic medication in patients undergoing mastectomy. The greatest benefit is seen in patients undergoing bilateral mastectomy with immediate breast reconstruction.

Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Background:

Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.

Methods:

Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.

Results:

Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P &lt; 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.

Conclusion:

Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Comparison of paravertebral and interpleural block in patients undergoing modified radical mastectomy

Background:

Paravertebral and inter pleural blocks (IPB) reduce post-operative pain and decrease the effect of post-operative pain on lung functions after breast surgery. This study was designed to determine their effect on lung functions and post-operative pain in patients undergoing modified radical mastectomy.

Materials and Methods:

A total of 120 American Society of Anesthesiologists physical status 1 and 2 patients scheduled to undergo breast surgery were randomly allocated to receive IPB (Group IPB, n = 60) or paravertebral block (PVB) (Group PVB, n = 60) with 20 ml of 0.5% bupivacaine pre-operatively. A standard protocol was used to provide general anesthesia. Lung function tests, visual analog scale (VAS) for pain at rest and movement, analgesic consumption were recorded everyday post-operatively until discharge.

Results:

Lung functions decreased on 1^st post-operative day and returned to baseline value by 4^th post-operative day in both groups. VAS was similar in both groups. There was no significant difference in the consumption of opioids and diclofenac in both groups. Complete block was achieved in 48 patients (80%) in paravertebral group and 42 patients (70%) in inter pleural group.

Conclusion:

To conclude, lung functions are well-preserved in patients undergoing modified radical mastectomy under general anesthesia supplemented with paravertebral or IPB. IPB is as effective as PVB for post-operative pain relief. PVB has the added advantage of achieving a more complete block.

Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block

PURPOSE

In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM).

METHODS

Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded.

RESULTS

VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1.

CONCLUSIONS

The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.

Guided paravertebral blocks with versus without clonidine for women undergoing breast surgery: a prospective double-blinded randomized study

BACKGROUND

Paravertebral blocks (PVBs) have been introduced as an alternative to general anesthesia for breast cancer surgeries. The addition of clonidine as an adjuvant in PVBs may enhance quality and duration of analgesia and significantly reduce the consumption of analgesics after breast surgery. In this prospective randomized double-blind study, we assessed the significance of adding clonidine to the anesthetic mixture for women undergoing mastectomy.

METHODS

Sixty patients were randomized equally into 2 groups, both of which received PVB block, either with or without clonidine. Analgesic consumption was noted up to 2 weeks after the operation. A visual analog scale was used to assess pain postoperatively during the hospital stay, and a numeric rating scale was used when patients were discharged.

RESULTS

Analgesic consumption was significantly lower in the clonidine group 48 hours postoperatively with 95% confidence interval (CI) for the difference (-69.5% to -6.6%). Pain scores at rest showed significant reduction in the clonidine group during the period from 24 to 72 hours postoperatively with 95% CI for the ratios of 2 means (1.09-3.61), (2.04-9.04), and (2.54-16.55), respectively, with shoulder movement at 24, 48, and 72 hours postoperatively 95% CI for the ratio of 2 means (1.10-3.15), (1.32-6.38), and (1.33-8.42), respectively. The time needed to resume daily activity was shorter in the clonidine group compared with the control group with 95% CI for the ratio of 2 means (1.14-1.62).

CONCLUSION

The addition of clonidine enhanced the analgesic efficacy of PVB up to 3 days postoperatively for patients undergoing breast surgery.

A Double-blind Randomized Trial of Wound and Intercostal Space Infiltration with Ropivacaine during Breast Cancer Surgery

Background:

The efficacy of local anesthetic wound infiltration for the treatment of acute and chronic postoperative pain is controversial and there are no detailed studies. The primary objective of this study was to evaluate the influence of ropivacaine wound infiltration on chronic pain after breast surgery.

Methods:

In this prospective, randomized, double-blind, parallel-group, placebo-controlled study, 236 patients scheduled for breast cancer surgery were randomized (1:1) to receive ropivacaine or placebo infiltration of the wound, the second and third intercostal spaces and the humeral insertion of major pectoralis. Acute pain, analgesic consumption, nausea and vomiting were assessed every 30 min for 2 h in the postanesthesia care unit and every 6 h for 48 h. Chronic pain was evaluated 3 months, 6 months, and 1 yr after surgery by the brief pain inventory, hospital anxiety and depression, and neuropathic pain questionnaires.

Results:

Ropivacaine wound infiltration significantly decreased immediate postoperative pain for the first 90 min, but did not decrease chronic pain at 3 months (primary endpoint), or at 6 and 12 months postoperatively. At 3 months, the incidence of chronic pain was 33% and 27% (P = 0.37) in the ropivacaine and placebo groups, respectively. During follow-up, brief pain inventory, neuropathic pain, and anxiety increased over time in both groups (P &lt; 0.001) while depression remained stable. No complications occurred.

Conclusion:

This multicenter, prospective study shows that ropivacaine wound infiltration after breast cancer surgery decreased immediate postoperative pain but did not decrease chronic pain at 3, 6, and 12 months postoperatively.

Use of preoperative paravertebral block decreases length of stay in patients undergoing mastectomy plus immediate reconstruction

BACKGROUND

A prior study in patients undergoing breast surgery with and without the use of paravertebral blocks (PVB) found no significant difference in patient length of stay (LOS). However, patients undergoing bilateral procedures and those undergoing immediate reconstructions were excluded. We sought to determine if the use of PVB in patients undergoing unilateral or bilateral mastectomy plus immediate reconstruction decreases patient LOS.

METHODS

We undertook a retrospective review of patients who had mastectomies with immediate reconstructions with and without the use of preoperative PVB. Outcomes including LOS, postoperative nausea and vomiting, and time to oral narcotics were compared between groups.

RESULTS

Mean LOS for the PVB group was 42 h. This was significantly less than the mean LOS of 47 h for the nonblock group (p = .0015). The significantly lower LOS for the PVB group was true for patients undergoing bilateral procedures (p = .045), unilateral procedures (p = .0031), tissue expander placement (p = .0114), and immediate implant placement (p = .037). Mean time to conversion to oral narcotics was significantly shorter in the PVB group (15 h) compared with the nonblock group (20 h) (p < .001). The incidence of postoperative nausea in the PVB group (42.8 %) was also significantly less than in the nonblock group (54.7 %) (p = .031).

CONCLUSIONS

The routine use of preoperative PVB in patients undergoing mastectomy plus immediate reconstruction significantly decreased patient LOS. In addition to improved pain control from the block itself, quicker conversion to oral narcotics because of less postoperative nausea likely contributed to a decreased LOS.

The role of regional anaesthesia techniques in the management of acute pain

Regional anaesthesia and analgesia techniques are used to effectively manage acute pain after a variety of surgeries. With the rapid growth of ultrasound-guided procedures, anaesthetists are re-examining regional anaesthesia and analgesia and their roles in pain management. In this evolving field previous published data may not reflect current practice. Therefore, a narrative review of recent literature was undertaken to establish the current utility and efficacy of regional anaesthesia and analgesia for the management of acute pain following surgery. Only prospective randomised controlled trials published between March 2009 and March 2011 with outcome measures of analgesia efficacy were included. Sixty-five randomised controlled trials were identified involving 4841 patients. Regional techniques for the management of knee (26%), abdominal (26%) and shoulder (14%) surgery were most frequently studied. The review provides further evidence that regional anaesthesia and analgesia can offer excellent analgesia with acceptable side-effects for the management of postsurgical pain. In addition, the results of this review support the use of ultrasound guidance when performing regional techniques and continuous catheter techniques to prolong analgesia.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]

INTRODUCTION

Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements.

MATERIAL AND METHODS

An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block.

RESULTS

In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II.

CONCLUSIONS

Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.

A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection

Background

The effect of local infiltration after breast surgery is controversial. This prospective double blind randomized study sought to document the analgesic effect of local anaesthetic infiltration after breast cancer surgery.

Methods

Patients scheduled for mastectomy or tumorectomy and axillary nodes dissection had immediate postoperative infiltration of the surgical wound with 20 ml of ropivacaine 7.5 mg.ml^-1 or isotonic saline. Pain was assessed on a visual analogue scale at H2, H4, H6, H12, H24, H72, and at 2 month, at rest and on mobilization of the arm. Patient'comfort was evaluated with numerical 0-3 scales for fatigue, quality of sleep, state of mood, social function and activity.

Results

Twenty-two and 24 patients were included in the ropivacaine and saline groups respectively. Postoperative pain was lower at rest and on mobilization at 2, 4 and 6 hour after surgery in the ropivacaine group. No other difference in pain intensity and patient 'comfort scoring was documented during the first 3 postoperative days. Patients did not differ at 2 month for pain and comfort scores.

Conclusion

Single shot infiltration with ropivacaine transiently improves postoperative pain control after breast cancer surgery.

Trial registration number

NCT01404377

Paravertebral blocks in breast cancer surgery: is there a difference in postoperative pain, nausea, and vomiting?

BACKGROUND

The purpose of this study was to evaluate postoperative pain and postoperative nausea and vomiting (PONV) in patients with paravertebral blocks (PVB) undergoing breast cancer surgery with or without axillary staging.

METHODS

An Institutional Review Board approved, retrospective chart review from January 2007 to December 2009 was performed at a single institution. Charts were reviewed for type of breast cancer surgery, axillary staging, PVB, PONV, postoperative pain score, dosages of pain medication and antiemetic medication given in the Post Anesthesia Care Unit (PACU), and during the postoperative days (POD). The study population consisted of females with a diagnosis of breast cancer undergoing breast cancer surgery, with or without axillary staging. Patients were excluded if they: had simultaneous myocutaneous tissue flap breast reconstruction, had additional surgical procedures, used continuous delivery postoperative pain medications, had a history of chronic pain, or had a history of chronic antiemetics prior to surgery. All patients received standard perioperative medications per the anesthesia department.

RESULTS

A total of 419 patients underwent breast cancer surgery during the given time period of which 337 patients were able to be included in the study. Of these patients, 241 of the 337 patients had PVB and 96 patients did not have PVB. The mean age was 59.5 years. The mean BMI was 28.7 kg/m(2). Also, 45.5% of the patients who had PVB (110) had a mastectomy, while 41.1% of patients in the non-PVB cohort (39) had a mastectomy. In addition, 45 patients with PVB had immediate tissue expander reconstruction and only 14 patients in the non-PVB group. Of patients with PVB, 53.3% (129) had a sentinel lymph node biopsy (SLN) and 33.5% (81) had full axillary dissections. Of patients in the non-PVB, 35.8% (34) had no axillary staging and 44.2% (42) underwent SLN. Also, 229 patients with PVB and 78 patients without PVB had a general anesthetic. Only 3.3% of patients with PVB and 4.2% of patients without PVB had postoperative nausea (P = 0.746). One patient with PVB and no patients without PVB reported emesis in the PACU (P = 1). There was no difference in morphine equivalents (P = 0.234) or in pain scores (P = 0.521) between the 2 groups in the PACU. There was no difference in amount of morphine equivalents given on POD0 (P = 0.8) or POD1 (P = 0.079). The reconstruction patients with PVB used less opioid analgesic on POD1 compared with the non-PVB reconstruction group (P = 0.02).

CONCLUSIONS

Patients undergoing breast cancer surgery who have paravertebral blocks have similar postoperative nausea and vomiting and similar postoperative pain scores compared with patients without paravertebral blocks. PVB may have an important role in decreasing postoperative pain and opioid analgesic usage in patients electing to have immediate breast reconstruction with tissue expanders.

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.