Efficacy and safety of bilateral thoracic paravertebral blocks in outpatient breast surgery

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery: A meta-analysis

BACKGROUND

The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis.

METHODS

Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software.

RESULTS

Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = -0.65) and morphine (total: SMD = -2.23; patient-controlled analgesia: SMD = -1.45) as well as intraoperative requirement for fentanyl (SMD = -1.60), and lower the pain score at 1 (SMD = -0.30), 2 (SMD = -1.45), 4 (SMD = -2.36), 6 (SMD = -0.63), 8 (SMD = -2.47), 12 (SMD = -0.81), 24 (SMD = -1.78), 36 (SMD = -0.92), and 48 (SMD = -0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup (P < .05) relative to local anesthesia subgroup (P >.05).

CONCLUSION

DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.

A possible future for anaesthesia in breast surgery: thoracic paravertebral block and awake surgery. A prospective observational study

INTRODUCTION

Quadrantectomy is a surgical procedure traditionally performed under general anaesthesia with intraoperative and postoperative opioid-based analgesia. The use of locoregional anaesthesia techniques in breast surgery has become widespread and allows excellent management of intraoperative and postoperative pain with reduced opioid consumption. We chose thoracic paravertebral block as regional anaesthesia technique in breast surgery to investigate the possibility of carrying out this surgery with the patient awake.

METHODS

A prospective observational study on 50 patients was designed. The primary outcome for this study was the possibility to carry out the surgery with only the paravertebral block associated with mild sedation without general anaesthesia. Forty minutes before the start of the surgery, an ultrasound-guided thoracic paravertebral block was performed at two thoracic levels, and for each level, 7 mL of ropivacaine 0.7% was injected. Sedation was obtained with target-controlled infusion of propofol.

RESULTS

Forty-nine patients underwent the operation awake; in one case, we had to place an I-gel and perform general anaesthesia. No patient needed intraoperative or postoperative opioids. The numeric rating scale, recorded at 0, 2, 6, 12, 24, and 36 hours, was greater than 3 in only five patients.

CONCLUSIONS

We believe that if in the future we try to make quadrantectomy an intervention in which the anaesthesia is exclusively regional, therefore with a patient awake and collaborating, it will not be possible to ignore the use of thoracic paravertebral block.

The effectiveness of additional thoracic paravertebral block in improving the anesthetic effects of regional anesthesia for proximal humeral fracture surgery in elderly patients: study protocol for a randomized controlled trial

BACKGROUND

The innervation of the shoulder-upper-extremity area is complicated and unclear. Regional anesthesia with a brachial plexus and cervical plexus block is probably inadequate for the proximal humeral surgery. Missing blockade of the T1-T2 nerves may be the reason. We conduct this prospective randomized controlled trial (RCT) to explore whether an additional T2 thoracic paravertebral block (TPVB) can improve the success rate of regional anesthesia for elderly patients in proximal humeral fracture surgery.

METHODS/DESIGN

The patients aged 65 years or older, referred for anterior-approach proximal humeral fracture surgery, will be enrolled. Each patient will be randomly assigned 1:1 to receive a combined interscalene brachial plexus with superficial cervical plexus block (IC) (combined interscalene brachial plexus with superficial cervical plexus block) or an IC block combined with thoracic paravertebral block (ICTP) block (combined thoracic paravertebral block with brachial plexus and superficial cervical plexus block). The primary outcome is the success rate of regional anesthesia without rescue analgesic methods. The secondary outcomes are as follows: sensory block at the surgical area, proportion of patients who need rescue anesthesia (intravenously administered remifentanil or conversion to general anesthesia), cumulative doses of intraoperative vasoactive medications and adverse events. The total sample size is estimated to be 80 patients.

DISCUSSION

This RCT aims to confirm whether an additional T2 TPVB can provide better anesthetic effects of regional anesthesia with brachial and cervical plexus block in elderly patients undergoing proximal humeral surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03919422. Registered on 19 April 2019.