Complication rate of ultrasound-guided paravertebral block for breast surgery

A Comparison of the Effectiveness of the Serratus Anterior Plane Block and Erector Spinae Plane Block to that of the Paravertebral Block in the Surgical Treatment of Breast Cancer-A Randomized, Prospective, Single-Blinded Study

Background/Objectives: The paravertebral block (PVB) is a well-studied, effective method of analgesia for breast surgery. Alternative techniques involving the blockage of intercostal nerve branches are the serratus anterior plane block (SAPB) and the erector spinae plane block (ESPB). However, no studies comparing both fascial blocks to PVB in breast surgery have been published to date. We evaluated the effectiveness of ESPB and SAPB vs. PVB, expressed as the requirement for intraoperative fentanyl, pain intensity at rest and during coughing, and morphine consumption on the first postoperative day. Additional aims were to perform an evaluation of the safety of the block types used. Materials and Methods: A total of 77 women and 1 man with stage I and II clinical breast cancer, aged 18-85 years, were randomized into one of three study groups: SAPB, PVB, and ESPB. Results: There were no statistically significant differences in fentanyl consumption during surgery with respect to the type of block used (p = 0.4246). Morphine consumption in the postoperative period was highest in the ESPB group, averaging 9.4 mg. There was a statistically significant difference in pain intensity from 4 pm on the day of surgery to 8 am the following morning. No complications related to the blocks were observed on the first postoperative day. Conclusions: Both the serratus anterior plane block and the erector spinae plane block were as effective as the paravertebral block in achieving intraoperative analgesia. The serratus anterior plane block was equally as effective as the paravertebral block in achieving postoperative analgesia. The erector spinae plane block was significantly less effective in achieving postoperative analgesia than both the paravertebral block and serratus anterior plane block.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Impact of Regional Nerve Blocks on Postoperative Delirium or Cognitive Dysfunction following Thoracic Surgery: A Systematic Review and Meta-Analysis

Regional nerve blocks (NBs) mitigate the occurrence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) in adult patients undergoing thoracic surgery. This study aimed to determine the exact effect of NBs on POCD and POD. Electronic databases, including PubMed, EMBASE, CINAHL, Scopus, and Web of Science, were searched for studies. The primary outcome was the incidence of POD or POCD. The secondary outcome was pain scores assessed 24 and 48 h postoperatively. We calculated the log odds ratio (LOR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). The LOR was converted to an odds ratio (OR). In the analysis of 1010 patients from seven randomized controlled trials, POD and POCD rates were 14.1% and 16.7%, respectively, in the NB group, and higher, at 27.3% and 35.2%, in the control group. NBs reduced the incidence of POD (OR, 0.44; 95%CI 0.30 to 0.64; p < 0.001; I2 = 0.00%) and POCD (OR, 0.43; 95%CI 0.24 to 0.76; p < 0.001; I2 = 0.00%). NBs reduced pain scores at 24 h (SMD, -2.60; 95%CI -3.90 to -1.30, p < 0.001; I2 = 97.68%) and 48 h (SMD, -1.80; 95%CI -3.18 to -0.41, p = 0.01; I2 = 98.14%) postoperatively. NBs mitigated the occurrence of POD and POCD in adult patients after thoracic surgery.

Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes

BACKGROUND

The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction.

METHODS

A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups.

RESULTS

The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery.

CONCLUSIONS

PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison between ultrasound-guided multi-injection intertransverse process and thoracic paravertebral blocks for major breast cancer surgery: a randomized non-inferiority trial

BACKGROUND

This study investigated whether a novel multi-injection intertransverse process block could provide non-inferior analgesia and recovery quality following major breast cancer surgery compared with the multi-injection thoracic paravertebral block.

METHODS

Eighty-eight females who underwent mastectomy plus sentinel or axillary lymph node dissection were randomized to receive either intertransverse process block or thoracic paravertebral block, both performed at T2-6 with 5 mL of 0.5% ropivacaine per level. The primary outcome was the worst resting pain score (11-point Numerical Rating Scale) within 30 min in the recovery room. The secondary outcome was recovery quality (15-item quality of recovery scale) 24 hours after surgery, which was tested following a gatekeeping procedure.

RESULTS

The worst resting pain scores were 0 (0, 1) in the intertransverse process block group vs 0.5 (0, 2) in the thoracic paravertebral block group, with a median difference of 0 (95% CI 0 to 0); the upper 95% CI limit was lower than the prespecified non-inferiority margin of 1 point (non-inferiority p<0.001). Aggregate scores of recovery quality at 24 hours postoperatively were 137.5 (126.5, 142.8) and 137.5 (127.8, 145.0) for the intertransverse process and thoracic paravertebral block groups, respectively, with a median difference of -1 (95% CI -6 to 3); the lower 95% CI limit was larger than the prespecified non-inferiority margin of -8 (non-inferiority p=0.006).

CONCLUSIONS

Compared with a multi-injection thoracic paravertebral block, the multi-injection intertransverse process block provided non-inferior analgesia within 30 min in the recovery room and recovery quality at 24 hours following major breast cancer surgery in females.

TRIAL REGISTRATION NUMBER

ChiCTR2000037963.

Efficacy of Ultrasound-Guided Thoracic Paravertebral Block on Postoperative Quality of Recovery in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Double-Blind Placebo-Controlled Trial

Purpose

This study aimed to examine the effectiveness of ultrasound-guided thoracic paravertebral block on postoperative quality of recovery in patients undergoing percutaneous nephrolithotomy.

Patients and Methods

In this randomized, double-blind, placebo-controlled trial, we enrolled patients scheduled for unilateral percutaneous nephrolithotomy. Patients were randomly allocated to receive thoracic paravertebral block either with 20 mL of 0.5% ropivacaine (PVB group) or an equal volume of saline (control group). The primary outcome was the quality of patient recovery at 24 h postoperatively, assessed using the 15-item Quality of Recovery scale. The secondary outcomes included the area under the curve of pain scores over time, time to first rescue analgesia, and postoperative 24 h morphine consumption.

Results

We analyzed the data of 70 recruited participants. The median Quality of Recovery-15 score at 24 h postoperatively was 127 (interquartile range, 117-133) in the PVB group, which was significantly higher than 114 (interquartile range, 109-122) in the control group, with a median difference of 10 points (95% confidence interval, 5-14; P<0.001). The area under the curve of pain scores over time was lower in patients receiving thoracic PVB than in those receiving saline block (P<0.001). The median time to first rescue analgesia in the PVB group (10.8 h, interquartile range 7.1-22.8 h) was longer than that in the control group (1.9 h, interquartile range 0.5-4.3 h) (P<0.001). Similarly, the median postoperative 24-hour morphine consumption was nearly half as low in the PVB group as in the control group (P<0.001). The occurrence of postoperative nausea and vomiting, and pruritus were significantly higher in the control group (P=0.016 and P=0.023, respectively).

Conclusion

Preoperative ultrasound-guided single injection of thoracic paravertebral block with ropivacaine improved the postoperative quality of recovery and analgesia in patients undergoing percutaneous nephrolithotomy.

A French nationwide survey on the practice of regional anaesthesia for breast cancer surgery

BACKGROUND

To assess the impact of recent recommendations concerning regional anaesthesia for breast cancer surgery, a nationwide practice survey was carried out.

METHODS

This cross-sectional electronic survey, conducted in 2021, collected answers from a panel of anaesthetists currently working in French practicing centres. It addressed the sets of techniques they practiced for every type of surgical procedure and their perceptions of the difficulties and risks associated with these techniques.

RESULTS

The practice of regional anaesthesia was generally high (70%), involving all the current types of blocks. Surgeon-done infiltration was popular for lumpectomy only. For the other current procedures, the pectoralis nerve blocks were preferred to the paravertebral block, which was favoured for mastectomies, when a lymph node harvesting was planned, or for immediate or delayed pedicle flap. Catheters were mostly used for mastectomies with pedicle flap. The erector spinae plane block was emergent. Whatever the type of block, regional anaesthesia was preferentially started before surgery. Despite some deviations such as the adjunction of unlabelled molecules, the practice fitted well with the European recommendations, but training and within-centre guidance lacked standardisation. For each block, actual practice, perceived difficulty and risk were inter-correlated, but paravertebral block - either practiced or not - was considered as more difficult and riskier to perform than any other.

CONCLUSIONS

These encouraging results do not dispense with the need to improve anaesthetic practices both in quantity and quality. Such improvement in the anatomic fit to the procedure and in the timing of blocks will also have to be considered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thoracic Paravertebral Block Combined with General Anaesthesia or General Anaesthesia Alone for Thoracoscopic Lung Adenocarcinoma Surgery: A Retrospective Study

Purpose

To investigate the effects of ultrasound-guided thoracic paravertebral block combined with general anaesthesia or general anaesthesia alone for thoracoscopic lung adenocarcinoma surgery, and to provide new thoughts for improving the clinical outcomes.

Methods

This was a retrospective study. Data were retrieved for 195 patients with lung adenocarcinoma undergoing elective radical lobectomy via video-assisted thoracoscopy between January 2018 and August 2019 in The Second Hospital of Shandong University, including 86 patients who received thoracic paravertebral block (TPVB) combined with general anaesthesia (group TG), and 109 patients who received general anaesthesia alone (group GA). All patients were given self-controlled intravenous analgesia pump for 48 h after surgery. The primary outcome was the recurrence-free survival 2 years postoperatively (the time between surgery and the earliest date of recurrence, metastasis or lung cancer-cause death). The secondary outcomes included the average numeric rating scale (NRS) scores within 48 h postoperatively, the first time of postoperative ambulation, duration of chest tube drainage, length of postoperative hospitalization, perioperative opioid consumption and the postoperative side effects.

Results

There were no statistical differences in the recurrence-free survival 2 years postoperatively between groups (Multivariate hazard ratio 0.706, 95% CI 0.126–3.941, P=0.691). The average NRS scores within 48 h postoperatively were significantly lower in group TG (P<0.05). The first time of postoperative ambulation, duration of chest tube drainage, and length of postoperative hospitalization in group TG were significantly reduced (P<0.05). Opioid consumption was significantly decreased in group TG (P<0.01). Finally, the incidence of postoperative nausea and vomiting (PONV) was significantly lower in group TG (P<0.05).

Conclusion

TPVB for thoracoscopic lung adenocarcinoma surgery did not improve the recurrence-free survival 2 years postoperatively compared with general anaesthesia alone, but it significantly enhanced the postoperative analgesia effect, reduced opioid consumption as well as side effects, and accelerated postoperative early recovery.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-2100050454).

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases

Purpose

Presumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery.

Patients and Methods

We included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018–July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration).

Results

We did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed.

Conclusion

Ultrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

Regional Anesthesia Techniques for Pain Management for Laparoscopic Surgery: a Review of the Current Literature

Purpose of Review

The field of regional anesthesia has evolved tremendously in the last 15 years. New anesthesia protocols for ambulatory surgery and enhanced recovery after surgery have been developed as well. The focus of these techniques and protocols has centered on patient satisfaction and pain control while minimizing the use of opioids. The field of ambulatory surgery and anesthesia continues to evolve, and regional anesthesia and its plane techniques are at the center of these changes.

Recent Findings

Recent research has shown that regional techniques contribute to better pain control and patient experience and may decrease patient readmission rates. The safety of these techniques has been validated when performed by experienced practitioners. New techniques such as the erector spinae block (ESP) have been studied in the setting of laparoscopic surgery with promising results.

Summary

Regional anesthesia techniques for patients presenting for laparoscopic surgery are safe and seem to provide benefits. Those are related to patient experience, pain control, and readmission rates. Different techniques can be applied to a specific type of intervention. Application of these techniques depend on the clinical picture and patient. Future research may help us clarify how these techniques may improve patient satisfaction and operating room efficiency. New regional blocks may also develop based on what we know today.

Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

Serratus anterior plane block (SAPB) provides effective thoracic analgesia. This systematic review and meta-analysis was conducted to assess the safety and efficacy of SAPB for postoperative analgesia after breast surgery.

Methods

A systematic literature search was performed using Embase, PubMed, Web of Science, and the Cochrane Library for eligible randomised controlled trials. The primary outcomes involved the administration of intraoperative and postoperative opioids. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for rating the quality of evidence for making recommendations.

Results

Overall, 13 studies comprising 826 patients met the inclusion criteria (412 in the SAPB group and 414 in the control group). Patients treated with SAPB exhibited a significantly lower postoperative opioid consumption (mean difference, −38.51 mg of oral morphine equivalent; 95% confidence interval (CI), −60.97 to −16.05; P < 0.01; I² = 100%), whereas no difference was observed in the intraoperative opioid consumption (mean difference, −9.85 mg of oral morphine equivalent; 95% CI, −19.52 to −0.18; P=0.05; I² = 94%). In addition, SAPB significantly decreased the occurrence of postoperative nausea and vomiting (risk ratio, 0.32; 95% CI, 0.19–0.55; P < 0.05;I² = 38%) and reduced pain scores during the postoperative period (1 h: standardised mean difference (SMD), −1.23; 95% CI, −2.00 to −0.45; I² = 92%; 2 h: SMD, −0.71; 95% CI, −1.00 to −0.41; I² = 48%; 4 h: SMD, −1.52; 95% CI, −2.77 to −0.27; I² = 95%; 6 h: SMD, −0.80; 95% CI, −1.51 to −0.08; I² = 81%; 8 h: SMD, −1.12; 95% CI, −1.98 to −0.27; I² = 92%; 12 h: SMD, −0.78; 95% CI, −1.21 to −0.35; I² = 83%; and 24 h: SMD, −0.71; 95% CI, −1.20 to −0.23; I² = 87%; P < 0.05 for all).

Conclusion

SAPB was safe and effective after breast surgery to relieve postsurgical pain. However, additional well-developed trials are required to validate these findings.

Ultrasound-Guided Thoracic Paravertebral Block Enhances the Quality of Recovery After Modified Radical Mastectomy: A Randomized Controlled Trial

PURPOSE

Ultrasound-guided thoracic paravertebral block (TPVB) has become increasingly popular for postoperative analgesia after breast surgery. We designed this prospective, randomized, double-blind, placebo-controlled trial to test the hypothesis that TPVB is superior to placebo in improving the patient quality of recovery following modified radical mastectomy.

PATIENTS AND METHODS

Sixty-eight female patients undergoing elective unilateral modified radical mastectomy were enrolled. Patients were randomized to receive preoperative ultrasound-guided TPVB with 0.5% ropivacaine (TPVB group, n=34) or 0.9% saline (Control group, n=34). The primary outcome was quality of recovery, measured 24 h after surgery using the 40-item Quality of recovery questionnaire (QoR-40). Secondary outcomes were the area under the curve of the visual analog scale pain scores over 24 h, postoperative 24-h morphine consumption, time to first rescue analgesia, length of post-anesthesia care unit stay, postoperative nausea and vomiting, and patient satisfaction.

RESULTS

The global QoR-40 score 24 h postoperatively (median [interquartile range]) was 173 [170-177] in the TPVB group and 161 [160-164] in the control group (P<0.001), respectively, with a median difference (95% confidence interval) of 11 (9-14). Compared with the control group, preoperative TPVB decreased the area under the curve of the visual analog scale pain scores over 24 h, reduced postoperative 24-h morphine consumption, prolonged the time to first rescue analgesia, shortened the length of post-anesthesia care unit stay, lessened postoperative nausea and vomiting, and improved the patient satisfaction.

CONCLUSION

A single preoperative injection of TPVB with ropivacaine enhances the quality of recovery and postoperative analgesia in patients following modified radical mastectomy.

Safety of treatment options available for postoperative pain

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

Inadvertent mental excitement after ultrasound-guided bilateral thoracic paravertebral block: a case report

Background

Bilateral Paravertebral block has been used successfully for postoperative pain relief in thoracic, abdominal, and pelvic regions. Despite the need for relatively large doses of local anaesthetics, there are few reports of systemic toxicity. Here we reported a case of local anaesthetic toxicity after ultrasound-guided bilateral thoracic paravertebral block before general anaesthesia leading to mental. To our knowledge, the onset of this patient has never been reported previously, and we will discuss the potential risk factors and preventive measures for such patients in the future.

Case information

A 38-year-old female patient presented for elective open resection of liver tumor, when bilateral 7th thoracic (T7) paravertebral blocks were performed under the guidance of ultrasound with 0.5% ropivacaine (3 mg/kg) in the anesthesia preparation area. After 20 minutes, the patient suddenly became extremely excited and requested to suspend the operation, because Guanyin Bodhisattva just told her that the operation would put her life in danger.

Conclusion

Although the dose of ropivacaine was up to 3 mg/kg for lumbar epidural, or 4.3 mg/kg for major nerve block based on the manufacturer's recommendation, we believe that the bolus dosage of 0.5% ropivacaine 3 mg/kg was high for bilateral thoracic paravertebral block in this patient.