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Clairoux A, Soucy-Proulx M, Idrissi M, Richebé P. Regional anesthesia did not prevent chronic neuropathic pain after oncologic breast surgery. Can J Anaesth 2023; 70:284-285. [PMID: 36526921 PMCID: PMC9757628 DOI: 10.1007/s12630-022-02374-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ariane Clairoux
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal, Montreal, QC, Canada.
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada.
| | - Maxim Soucy-Proulx
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Moulay Idrissi
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal, Montreal, QC, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal, Montreal, QC, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
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Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis. Sci Rep 2023; 13:1402. [PMID: 36697462 PMCID: PMC9876953 DOI: 10.1038/s41598-023-28727-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
Thoracic sympathetic nerve block (TSNB) has been widely used in the treatment of neuropathic pain. To reduce block failure rates, TSNB is assisted with several modalities including fluoroscopy, computed tomography, and ultrasonography. The present study describes our experience assessing the usefulness of thoracoscopy in TSNB for predicting compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis. From September 2013 to October 2021, TSNB was performed under local anesthesia using a 2-mm thoracoscope in 302 patients with severe primary hyperhidrosis. Among the 302 patients, 294 were included for analysis. The target level of TSNB was T3 in almost all patients. The mean procedure time was 21 min. Following TSNB, the mean temperature of the left and right palms significantly changed from 31.5 to 35.3 °C and from 31.5 to 34.8 °C, respectively. With TSNB, primary hyperhidrosis was relieved in all patients. Pneumothorax occurred in six patients, in which no chest tube insertion was required. One patient developed hemothorax and was discharged the next day after small-bore catheter drainage. Transient ptosis developed in 10 patients and improved within a day in all patients. Our experiences showed that thoracoscopic TSNB is accurate, safe, and feasible to block the thoracic sympathetic nerve in patients with severe primary hyperhidrosis.
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Clairoux A. In reply: Regional anesthesia techniques for surgical anesthesia in breast cancer procedures. Can J Anaesth 2022; 69:1428-1429. [PMID: 36056277 PMCID: PMC9438869 DOI: 10.1007/s12630-022-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ariane Clairoux
- Département d'anesthésie, CIUSSS de l'Est-de-l'Île-de-Montréal, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada.
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Clairoux A, Soucy-Proulx M, Pretto F, Courgeon V, Caron-Goudreau M, Issa R, Bélanger MÈ, Brulotte V, Verdonck O, Idrissi M, Fortier A, Richebé P. Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery. Can J Anaesth 2022; 69:485-493. [PMID: 34997554 PMCID: PMC8741138 DOI: 10.1007/s12630-021-02182-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ariane Clairoux
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada.
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada.
| | - Maxim Soucy-Proulx
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - François Pretto
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Victoria Courgeon
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Maxime Caron-Goudreau
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Rami Issa
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Marie-Ève Bélanger
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Véronique Brulotte
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Moulay Idrissi
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Annik Fortier
- Department of Statistics, Montreal Health Innovations Coordinating Center (MHICC), Montreal, QC, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montreal, 5415, Boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
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Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3932. [PMID: 34796086 PMCID: PMC8594660 DOI: 10.1097/gox.0000000000003932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022]
Abstract
Introduction: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. Methods: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. Results: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. Conclusions: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.
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Agarwal S, Bharati SJ, Bhatnagar S, Mishra S, Garg R, Gupta N, Kumar V, Khan MA. The comparison of the efficacy of ultrasound-guided paravertebral block versus erector spinae plane block for postoperative analgesia in modified radical mastectomy: A randomized controlled trial. Saudi J Anaesth 2021; 15:137-143. [PMID: 34188631 PMCID: PMC8191270 DOI: 10.4103/sja.sja_990_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The ultrasound (US)-guided erector spinae plane (ESP) block is a new regional anesthetic technique that offers significant advantages over paravertebral block as it is easy and safe to perform. We aim to compare the efficacy of US-guided paravertebral block with ESP block for postoperative analgesia in modified radical mastectomy (MRM). METHODS Eighty female patients of age group 18-70 years, belonging to physical status American Society of Anesthesiologists (ASA) I and II, undergoing MRM were included in the study. In Group P, patients received paravertebral block and in Group E, patients received ESP block before induction of general anesthesia. Both the groups received 0.5% 20 mL ropivacaine. The time to first rescue analgesia and total doses of rescue analgesics were recorded in the postoperative period. Numeric Rating Scale (NRS) scores at 0 min, 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h were noted, and patient satisfaction was evaluated at 24 h. Unpaired t-test or the Mann-Whitney U test was used to compare quantitative variables while Chi-square test or Fisher's exact test was used to compare qualitative variables. RESULTS The time for the first analgesic request was 232.5 min (140-1200) in ESP group as compared to paravertebral group in which the duration was 205 min (135-1190) (P value = 0.29). The total dose of rescue analgesics and NRS scores in postoperative period were comparable. However, the time to perform ESP block was significantly shorter than that of paravertebral block. CONCLUSION ESP block can be used as a safe and easy to perform alternative analgesic technique over paravertebral block in breast cancer surgeries.
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Affiliation(s)
- Shilpi Agarwal
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
- Address for correspondence: Dr. Sachidanand Jee Bharati, Additional Professor, Department of Onco-Anesthesiology and Palliative Medicine, DR Brairch, AIIMS, New Delhi, India. E-mail:
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, DR BRAIRCH, AIIMS, New Delhi, India
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Singh UP, Kumar S, Mishra S, Tripathi M, Kumar V, Malviya D. Comparison of Ultrasound-Guided Thoracic Paravertebral Block Using Ropivacaine and Balanced General Anesthesia in Breast Surgeries. Anesth Essays Res 2021; 14:448-453. [PMID: 34092857 PMCID: PMC8159062 DOI: 10.4103/aer.aer_113_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Despite the latest advances in breast surgery, the procedure is frequently associated with postoperative pain, nausea, and vomiting, which leads not only to increased patient's suffering but also to a prolongation of hospital stays and related costs. Thoracic paravertebral block (TPVB) has been successfully used to provide analgesia for multiple thoracic and abdominal procedures in both children and adults. Methods Forty patients were allocated for this observational, comparative study and divided into two groups of 20 each, namely thoracic paravertebral group (Group P) study group and general anesthesia (GA) group (Group G), control group, and observations made for duration of procedure, visual analog score, rescue analgesia, surgeon and patient's satisfaction, postoperative complications, and duration of postanesthesia care unit (PACU) stay in both the groups. Results We found that there was a statistically significant difference in duration of procedure, more time was taken in performing TPVB. Pain was better controlled in Group P and requirement of rescue analgesia was higher in Group G patients, postoperative complications such as shivering, nausea, vomiting, and duration of PACU stay were more in patients receiving GA. Conclusion Hence, we conclude that ultrasound-guided TPVB appears to be safe, reliable, and effective technique for breast surgeries with several advantages over GA in terms of long-lasting pain relief, fewer complications, and shorter hospital stay.
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Affiliation(s)
- Ujjwal P Singh
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sumit Kumar
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shilpi Mishra
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manoj Tripathi
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Virendra Kumar
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Deepak Malviya
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Kar P, Ramachandran G. Pain relief following sternotomy in conventional cardiac surgery: A review of non neuraxial regional nerve blocks. Ann Card Anaesth 2021; 23:200-208. [PMID: 32275036 PMCID: PMC7336989 DOI: 10.4103/aca.aca_241_18] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques.
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Affiliation(s)
- Prachi Kar
- Department of Anesthesia and Intensive Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Gopinath Ramachandran
- Department of Anesthesia and Intensive Care, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Chhabra A, Roy Chowdhury A, Prabhakar H, Subramaniam R, Arora MK, Srivastava A, Kalaivani M. Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery. Cochrane Database Syst Rev 2021; 2:CD012968. [PMID: 33629404 PMCID: PMC8521097 DOI: 10.1002/14651858.cd012968.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia. OBJECTIVES To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality. SEARCH METHODS On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome. MAIN RESULTS Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias. AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.
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Affiliation(s)
- Anjolie Chhabra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Apala Roy Chowdhury
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh Kumar Arora
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anurag Srivastava
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Santonastaso DP, de Chiara A, Russo E, Gamberini E, Lucchi L, Sibilio A, Bagaphou C, Zani G, Righetti R, Rispoli M, Fusari M, Agnoletti V. A possible future for anaesthesia in breast surgery: thoracic paravertebral block and awake surgery. A prospective observational study. TUMORI JOURNAL 2020; 107:125-131. [PMID: 32842912 DOI: 10.1177/0300891620951626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
| | - Annabella de Chiara
- Anaesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena (FC), Italy
| | - Emanuele Russo
- Anaesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena (FC), Italy
| | - Emiliano Gamberini
- Anaesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena (FC), Italy
| | - Leonardo Lucchi
- Day Surgery-Breast Unit, AUSL Romagna, M. Bufalini Hospital, Cesena (FC), Italy
| | - Andrea Sibilio
- General Surgery Unit, AUSL Romagna, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Claude Bagaphou
- Anaesthesia and Intensive Care Unit, USL Umbria 1 Ospedale di Città di Castello, Città di Castello (PG), Italy
| | - Gianluca Zani
- Anaesthesia and Intensive Care Unit, AUSL Romagna, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Roberto Righetti
- Anaesthesia and Intensive Care Unit, AUSL Romagna, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Marco Rispoli
- Anaesthesia and Intensive Care Unit, Vincenzo Monaldi Hospital, Napoli, Italy
| | - Maurizio Fusari
- Anaesthesia and Intensive Care Unit, AUSL Romagna, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Vanni Agnoletti
- Anaesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena (FC), Italy
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11
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Choi EK, Kim JI, Park SJ. A Randomized Controlled Trial Comparing Analgesic Efficacies of an Ultrasound-Guided Approach with and without a Combined Pressure Measurement Technique for Thoracic Paravertebral Blocks After Open Thoracotomy. Ther Clin Risk Manag 2020; 16:727-734. [PMID: 32821109 PMCID: PMC7418159 DOI: 10.2147/tcrm.s263353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose Ultrasound-guided thoracic paravertebral block (TPVB) is an established means for providing postoperative analgesia in thoracic surgery. However, there are conflicting results regarding the efficacy of post-thoracotomy pain management of ultrasound-guided TPVB when compared with that using traditional landmark approach. We therefore conducted a comparative study to evaluate the analgesic efficacy of TPVB when pressure measurement during needle advancement is combined with an ultrasound-guided approach. Patients and Methods The patients scheduled for lobectomy through thoracotomy were randomly allocated to receive either the ultrasound-guided approach only group (U group) or the ultrasound-guided approach combined with pressure measurement group (UP group) (n = 36 per group). Before thoracic muscle closure, 0.375% ropivacaine (20 mL) was administered as a bolus, followed by a continuous infusion of 0.2% ropivacaine (0.1 mL/kg/hr) in both groups. Postoperative pain was assessed using the visual analogue scale (VAS) pain score while resting and coughing. Local anesthetics and pethidine usage and sensory block area were also evaluated. Results The UP group showed significantly lower VAS scores, local anesthetics and pethidine usage, and a wider sensory block area than the U group. Conclusion A combined technique with ultrasound guidance and pressure measurement provided a superior analgesic effect over that of an ultrasound-guided approach alone for the management of post-thoracotomy pain.
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Affiliation(s)
- Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ji-Il Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sang-Jin Park
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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12
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Lepot A, Elia N, Tramèr MR, Rehberg B. Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses. Eur J Pain 2020; 25:5-22. [PMID: 32816362 DOI: 10.1002/ejp.1648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Ariane Lepot
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Martin Richard Tramèr
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benno Rehberg
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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13
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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14
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Yuan YJ, Zhou P, Xia F, Zhang XB, He SS, Guo DY, Xing YH, Zhao HW. Intranasal dexmedetomidine combined with local anesthesia for conscious sedation during breast lumpectomy: A prospective randomized trial. Oncol Lett 2020; 20:77. [PMID: 32863910 PMCID: PMC7436885 DOI: 10.3892/ol.2020.11938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022] Open
Abstract
Breast lumpectomy is usually performed under general or local anesthesia. To the best of our knowledge, whether conscious sedation with intranasal dexmedetomidine and local anesthesia is an effective anesthetic technique has not been studied. Thus, the present study aimed to investigate the effectiveness of conscious sedation with intranasal dexmedetomidine combined with local anesthesia in breast lumpectomy, and to identify its optimal dose. A prospective randomized, double-blinded, placebo-controlled, single-center study was designed, and patients undergoing breast lumpectomies were recruited based on the inclusion and exclusion criteria. All patients were randomly allocated to four groups: i) Local anesthesia with 0.9% intranasal saline (placebo); local anesthesia with ii) 1 µg.kg−1; iii) 1.5 µg.kg−1; or iv) 2 µg.kg−1 intranasal dexmedetomidine. The sedation status, pain relief, vital signs, adverse events, and satisfaction of patient and surgeon were recorded. Patients in the three dexmedetomidine groups were significantly more sedated and experienced less pain compared with the placebo group 45 min after intranasal dexmedetomidine administration and during 30 min in the post-anesthesia care unit. Patients in the 1.5 µg.kg−1 group were more sedated compared with the 1 µg.kg−1 group (without reaching statistical significance), whereas the 1.5 µg.kg−1 group exhibited a similar level of sedation 45 min after intranasal dexmedetomidine administration compared with the 2 µg.kg−1 group. In addition, patients in the 1 and 1.5 µg.kg−1 group experienced no adverse hemodynamic effects. Patient and surgeon satisfaction were greater in the 1.5 µg.kg−1 group compared with the 1 and 2 µg.kg−1 groups. Taken together, the results of the present study suggested that conscious sedation with intranasal dexmedetomidine and local anesthesia may be an effective anesthetic for breast lumpectomy surgery, and that the optimal dose for intranasal dexmedetomidine administration may be 1.5 µg.kg−1, as it resulted in good sedation and patient satisfaction without adverse effects.
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Affiliation(s)
- Ya-Jing Yuan
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Peng Zhou
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Fei Xia
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Xiao-Bei Zhang
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Shan-Shan He
- Department of Breast Reconstruction, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Dong-Yong Guo
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Yu-Hong Xing
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Hong-Wei Zhao
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
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15
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Kuş A, Yörükoğlu UH, Aksu C, Çınar S, Cantürk NZ, Gürkan Y. [The effect of thoracic paravertebral block on seroma reduction in breast surgery - a randomized controlled trial]. Rev Bras Anestesiol 2020; 70:215-219. [PMID: 32536425 DOI: 10.1016/j.bjan.2019.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 12/16/2019] [Accepted: 12/31/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked. OBJECTIVE With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery. METHODS Forty ASA I-II female patients aged 18-65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively. RESULTS AND CONCLUSIONS Mean seroma formation at postoperative 24th hour was 112.5±53.3 mL in the control group and 74.5±47.4 mL in the TPVB group (p=0.022). NRS scores were similar between two groups (p=0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6±4 mg in the TPBV group, and 16.6±6.9 mg in the control group (p <0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.
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Affiliation(s)
- Alparslan Kuş
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
| | - Ufuk H Yörükoğlu
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia.
| | - Can Aksu
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
| | - Saffet Çınar
- Kocaeli University Hospital, Department of General Surgery, Kocaeli, Turquia
| | - Nuh Zafer Cantürk
- Kocaeli University Hospital, Department of General Surgery, Kocaeli, Turquia
| | - Yavuz Gürkan
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
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16
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Kuş A, Yörükoğlu UH, Aksu C, Çınar S, Cantürk NZ, Gürkan Y. The effect of thoracic paravertebral block on seroma reduction in breast surgery – a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32536425 PMCID: PMC9373638 DOI: 10.1016/j.bjane.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked. Objective With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery. Methods Forty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and Control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively. Results and conclusions Mean seroma formation at postoperative 24th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.
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Affiliation(s)
- Alparslan Kuş
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
| | - Ufuk H Yörükoğlu
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia.
| | - Can Aksu
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
| | - Saffet Çınar
- Kocaeli University Hospital, Department of General Surgery, Kocaeli, Turquia
| | - Nuh Zafer Cantürk
- Kocaeli University Hospital, Department of General Surgery, Kocaeli, Turquia
| | - Yavuz Gürkan
- Kocaeli University Hospital, Department of Anesthesiology and Reanimation, Kocaeli, Turquia
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17
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Aspects of Anesthesia for Breast Surgery during Pregnancy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1252:107-114. [DOI: 10.1007/978-3-030-41596-9_14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Freys SM, Pogatzki-Zahn E. Pain therapy to reduce perioperative complications. Innov Surg Sci 2019; 4:158-166. [PMID: 33977126 PMCID: PMC8059349 DOI: 10.1515/iss-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
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Affiliation(s)
- Stephan M. Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
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19
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Klingensmith JD, Haggard AL, Ralston JT, Qiang B, Fedewa RJ, Elsharkawy H, Geoffrey Vince D. Tissue classification in intercostal and paravertebral ultrasound using spectral analysis of radiofrequency backscatter. J Med Imaging (Bellingham) 2019; 6:047001. [PMID: 31720315 DOI: 10.1117/1.jmi.6.4.047001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 10/14/2019] [Indexed: 12/23/2022] Open
Abstract
Paravertebral and intercostal nerve blocks have experienced a resurgence in popularity. Ultrasound has become the gold standard for visualization of the needle during injection of the analgesic, but the intercostal artery and vein can be difficult to visualize. We investigated the use of spectral analysis of raw radiofrequency (RF) ultrasound signals for identification of the intercostal vessels and six other tissue types in the intercostal and paravertebral spaces. Features derived from the one-dimensional spectrum, two-dimensional spectrum, and cepstrum were used to train four different machine learning algorithms. In addition, the use of the average normalized spectrum as the feature set was compared with the derived feature set. Compared to a support vector machine (SVM) (74.2%), an artificial neural network (ANN) (68.2%), and multinomial analysis (64.1%), a random forest (84.9%) resulted in the most accurate classification. The accuracy using a random forest trained with the first 15 principal components of the average normalized spectrum was 87.0%. These results demonstrate that using a machine learning algorithm with spectral analysis of raw RF ultrasound signals has the potential to provide tissue characterization in intercostal and paravertebral ultrasound.
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Affiliation(s)
- Jon D Klingensmith
- Southern Illinois University Edwardsville, Department of Electrical and Computer Engineering, Edwardsville, Illinois, United States
| | - Asher L Haggard
- Southern Illinois University Edwardsville, Department of Electrical and Computer Engineering, Edwardsville, Illinois, United States
| | - Jack T Ralston
- Southern Illinois University Edwardsville, Department of Electrical and Computer Engineering, Edwardsville, Illinois, United States
| | - Beidi Qiang
- Southern Illinois University Edwardsville, Department of Mathematics and Statistics, Edwardsville, Illinois, United States
| | - Russell J Fedewa
- Cleveland Clinic Foundation, Department of Biomedical Engineering, Cleveland, Ohio, United States
| | - Hesham Elsharkawy
- Cleveland Clinic Foundation, Department of General Anesthesia and Pain Management, Outcomes Research, and Anesthesiology Institute, Cleveland, Ohio, United States
| | - David Geoffrey Vince
- Cleveland Clinic Foundation, Department of Biomedical Engineering, Cleveland, Ohio, United States
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20
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Franco CD. The sensory innervation of the chest wall and its implications. Reg Anesth Pain Med 2019; 45:480-481. [DOI: 10.1136/rapm-2019-101055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 11/04/2022]
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21
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Zhang H, Miao Y, Qu Z. Refining a great idea: the consolidation of PECS I, PECS II and serratus blocks into a single thoracic fascial plane block, the SAP block—a concern on the muscle pain. Reg Anesth Pain Med 2019; 45:480. [DOI: 10.1136/rapm-2019-101042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 11/04/2022]
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Abo-Zeid MA, Ghareeb S, Abdelhalim MM. Different Analgesic Routes of Magnesium Sulfate: Intravenous versus Pectoralis II Interfascial Plane Block for Breast Cosmetic Surgeries. Anesth Essays Res 2019; 13:411-416. [PMID: 31602054 PMCID: PMC6775850 DOI: 10.4103/aer.aer_114_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Maha A Abo-Zeid
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Sameh Ghareeb
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - M M Abdelhalim
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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23
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Franco CD, Inozemtsev K. Refining a great idea: the consolidation of PECS I, PECS II and serratus blocks into a single thoracic fascial plane block, the SAP block. Reg Anesth Pain Med 2019:rapm-2019-100745. [PMID: 31558684 DOI: 10.1136/rapm-2019-100745] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 11/04/2022]
Abstract
The popularity of ultrasound-guided nerve blocks has impacted the practice of regional anesthesia in profound ways, improving some techniques and introducing new ones. Some of these new nerve blocks are based on the concept of fascial plane blocks, in which the local anesthetic is injected into a plane instead of around a specific nerve. Pectoralis muscles (PECS) and serratus blocks, most commonly used for post op analgesia after breast surgery, are good examples. Among the nerves targeted by PECS/serratus blocks are different branches of the brachial plexus that traditionally have been considered purely motor nerves. This unsubstantiated claim is a departure from accepted anatomical knowledge and challenges our understanding of the sensory innervation of the chest wall. The objective of this Daring Discourse is to look beyond the ability of PECS/serratus blocks to provide analgesia/anesthesia of the chest wall, to concentrate instead on understanding the mechanism of action of these blocks and, in the process, test the veracity of the claim. After a comprehensive review of the evidence we have concluded that (1) the traditional model of sensory innervation of the chest wall, which derives from the lateral branches of the upper intercostal nerves and does not include branches of the brachial plexus, is correct. (2) PECS/serratus blocks share the same mechanism of action, blocking the lateral branches of the upper intercostal nerves, and so their varied success is tied to their ability to reach them. This common mechanism agrees with the traditional innervation model. (3) A common mechanism of action supports the consolidation of PECS/serratus blocks into a single thoracic fascial plane block with a point of injection closer to the effector site. In a nod to transversus abdominus plane block, the original inspiration for PECS blocks, we propose naming this modified block, the serratus anterior plane block.
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Affiliation(s)
- Carlo D Franco
- Anesthesiology, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA
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Sun L, Li Q, Wang Q, Ma F, Han W, Wang M. Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study. BMC Anesthesiol 2019; 19:101. [PMID: 31185919 PMCID: PMC6560727 DOI: 10.1186/s12871-019-0768-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/24/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG. METHODS This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016-2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events. RESULTS Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups. CONCLUSIONS Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA.
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Affiliation(s)
- Lixin Sun
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Qiujie Li
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Qiang Wang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Fuguo Ma
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
| | - Wei Han
- Department of Respiratory Medicine, Qingdao Municipal Hospital, 1 Jiaozhou Road, Qingdao, 266011, Shandong, China.
| | - Mingshan Wang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, 266011, Shandong, China
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Hassan ME, Mahran E. Effect of adding magnesium sulphate to bupivacaine on the clinical profile of ultrasound-guided thoracic paravertebral block in patients undergoing modified radical mastectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2014.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Essam Mahran
- Department of Anaesthesia, ICU , National Cancer Institute , Cairo University , Egypt
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Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.10.006] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Stein MJ, Waltho D, Ramsey T, Wong P, Arnaout A, Zhang J. Paravertebral blocks in immediate breast reconstruction following mastectomy. Breast J 2019; 25:631-637. [PMID: 31087471 DOI: 10.1111/tbj.13295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative pain remains a major challenge following immediate breast reconstruction with 40% of patients experiencing acute pain and up to 60% developing chronic pain. Paravertebral blocks (PVB's) have emerged as a promising adjunct to standard analgesic protocols. The aim of this study was to assess the utility of PVB's in immediate breast reconstruction following mastectomy. METHODS A retrospective review of patients undergoing immediate breast reconstruction following mastectomy was performed. The primary outcome was postoperative pain measured by total oral morphine equivalent usage and self reported pain scores and secondary outcomes were length of stay in the PACU, complications, and OR delay. RESULTS Of 298 patients undergoing immediate breast reconstruction, 112(38%) underwent standard analgesic protocols and 186(62%) underwent PVB in addition to the standard protocol. PVB's were associated with reductions in average postoperative pain scores (2.8 vs 3.3, P = 0.002), total opiate consumption (52 units vs 63 units, P = 0.038) and time spent in the PACU 92 vs 142 minutes, P = 0.0228) compared to patients who had general anesthesia alone. The overall complication rate was 3.7% (7/186 patients), all which were minor complications such as headache, bloody tap, vasovagal episode and temporary weakness. The use of PVBs delayed the OR start time on average by 15 minutes (34 vs 49 minutes). CONCLUSIONS The present study offers one of the largest retrospective cohort studies to date evaluating the utility of PVB's in immediate breast reconstruction following mastectomy. We demonstrate that, PVB's in immediate breast reconstruction are associated with reductions in postoperative pain, narcotic usage and length of stay in PACU, but are associated with delays to the start time of the case. Anesthesiologists, plastic surgeons and hospital administrators must continue to work together to ensure this important and necessary service is administered in an efficient and cost effective manner.
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Affiliation(s)
- Michael J Stein
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Dan Waltho
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsey
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Patrick Wong
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Angel Arnaout
- Division of General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jing Zhang
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Eldemrdash AM, Abdelzaam ESM. By Ultrasonic-Guided Erector Spinae Block, Thoracic Paravertebral Block versus Serratus Anterior Plane Block by Articaine with Adrenaline during Breast Surgery with General Anesthesia: A Comparative Study of Analgesic Effect Post-Operatively: Double Blind Randomized, Controlled Trial. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/ojanes.2019.94008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Single-Injection Versus Multiple-Injection Technique of Ultrasound-Guided Paravertebral Blocks: A Randomized Controlled Study Comparing Dermatomal Spread. Reg Anesth Pain Med 2018; 42:575-581. [PMID: 28665874 DOI: 10.1097/aap.0000000000000631] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to investigate the extent of dermatomal spread following an ultrasound-guided thoracic paravertebral block (PVB) when equal volumes of local anesthetic are injected at 1 versus 5 vertebral levels. METHODS Seventy patients undergoing a unilateral mastectomy were randomized to receive either single or multiple injections of a PVB under real-time ultrasound guidance using a parasagittal approach. The patients in the single-injection group received a PVB at T3-T4 level with 25 mL of 0.5% ropivacaine and 4 subcutaneous sham injections. Patients in the multiple-injection group received 5 injections of a PVB from T1 to T5 level. Five milliliters of 0.5% ropivacaine was injected at each level. Evaluation of the sensory block was carried out 20 minutes following the completion of the PVB. RESULTS The median (interquartile range) dermatomal spread was not significantly different for the single-injection group (5 [4-6]) compared with the multiple-injection group (5 [5-6]), with a median difference of 0 segments (95% confidence interval, -1 to 0 segments; P = 0.22). The median time to performance of the single-injection PVB was shorter compared with the multiple-injection group (10 minutes), with a mean difference of -4 minutes (95% confidence interval, -6 to -3 minutes; P < 0.001). CONCLUSIONS An ultrasound-guided single-injection PVB provides equivalent dermatomal spread and duration of analgesia compared with a multiple-injection PVB. The single-injection technique takes less time to perform and hence may be preferred over a multiple-injection technique.The trial was registered prospectively at ClinicalTrials.gov (NCT02852421) on July 15, 2016.
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Gölboyu BE, Ekinci M, Baysal PK, Yeksan AN, Çelik EC, Bilgi Z, Aksun M. Síndrome de Horner transitória após bloqueio paravertebral em injeção única. Braz J Anesthesiol 2018; 68:518-520. [DOI: 10.1016/j.bjan.2017.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/23/2016] [Indexed: 10/19/2022] Open
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Gölboyu BE, Ekinci M, Baysal PK, Yeksan AN, Çelik EC, Bilgi Z, Aksun M. Transient Horner's syndrome after single shot paravertebral block. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 28526464 PMCID: PMC9391816 DOI: 10.1016/j.bjane.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background Thoracic paravertebral block can provide analgesia for unilateral chest surgery and is associated with a low complication rate. Horner syndrome also referred to as oculosympathetic paresis, is a classic neurologic constellation of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis resulting from disruption of the sympathetic pathway supplying the head, eye, and neck. Case report We present a patient with an ipsilateral transient Horner syndrome after ultrasound guided single shot of 15 mL 0.25% levobupivacaine for thoracic paravertebral block at T5–6 level. Conclusions It should be kept in mind that even a successful ultrasound guided single shot thoracic paravertebral block can be complicated with Horner syndrome due to unpredictable distribution of the local anesthetic.
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Klingensmith JD, Haggard A, Fedewa RJ, Qiang B, Cummings K, DeGrande S, Vince DG, Elsharkawy H. Spectral Analysis of Ultrasound Radiofrequency Backscatter for the Detection of Intercostal Blood Vessels. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1411-1422. [PMID: 29681422 DOI: 10.1016/j.ultrasmedbio.2018.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 02/23/2018] [Accepted: 03/12/2018] [Indexed: 06/08/2023]
Abstract
Spectral analysis of ultrasound radiofrequency backscatter has the potential to identify intercostal blood vessels during ultrasound-guided placement of paravertebral nerve blocks and intercostal nerve blocks. Autoregressive models were used for spectral estimation, and bandwidth, autoregressive order and region-of-interest size were evaluated. Eight spectral parameters were calculated and used to create random forests. An autoregressive order of 10, bandwidth of 6 dB and region-of-interest size of 1.0 mm resulted in the minimum out-of-bag error. An additional random forest, using these chosen values, was created from 70% of the data and evaluated independently from the remaining 30% of data. The random forest achieved a predictive accuracy of 92% and Youden's index of 0.85. These results suggest that spectral analysis of ultrasound radiofrequency backscatter has the potential to identify intercostal blood vessels. (jokling@siue.edu) © 2018 World Federation for Ultrasound in Medicine and Biology.
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Affiliation(s)
- Jon D Klingensmith
- Department of Electrical and Computer Engineering, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA.
| | - Asher Haggard
- Department of Electrical and Computer Engineering, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA
| | - Russell J Fedewa
- Department of Biomedical Engineering, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Beidi Qiang
- Department of Mathematics and Statistics, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA
| | - Kenneth Cummings
- Anesthesiology Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sean DeGrande
- Anesthesiology Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - D Geoffrey Vince
- Department of Biomedical Engineering, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hesham Elsharkawy
- Anesthesiology Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Should thoracic paravertebral blocks be used to prevent chronic postsurgical pain after breast cancer surgery? A systematic analysis of evidence in light of IMMPACT recommendations. Pain 2018; 159:1955-1971. [DOI: 10.1097/j.pain.0000000000001292] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Comparison of Paravertebral Block by Anatomic Landmark Technique to Ultrasound-Guided Paravertebral Block for Breast Surgery Anesthesia. Reg Anesth Pain Med 2018; 43:385-390. [DOI: 10.1097/aap.0000000000000746] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Priya S, Bamba C. Comparison of Morphine and Clonidine as Adjuvants in Paravertebral Block. Anesth Essays Res 2018; 12:459-463. [PMID: 29962616 PMCID: PMC6020574 DOI: 10.4103/aer.aer_27_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND General anesthesia (GA) has been considered as the gold standard for breast cancer surgery. The problem of postoperative pain as well as the high incidence of nausea and vomiting has led to the search for a better modality for pain management with fewer side effects. In the last few years, paravertebral block (PVB) has gained immense popularity either in combination with GA or by itself for the anesthetic management of patients undergoing breast surgery. CONTEXT Paravertebral block in breast surgery. AIMS This study aims to evaluate the efficacy and duration of postoperative analgesia provided by ultrasound (USG)-guided PVB with bupivacaine and morphine versus bupivacaine and clonidine in patients undergoing modified radical mastectomy (MRM). SUBJECT AND METHODS In the study, 70 patients who were scheduled for MRM were enrolled and randomly divided into Group M (n = 35) and Group C (n = 35). Both groups received USG-guided PVB at T2-T3 after administering GA. Group M received 2 mg/kg 0.5% bupivacaine with 0.05 mg/kg morphine and Group C received 2 mg/kg 0.5% bupivacaine with 1 μg/kg clonidine in the block. Postoperatively, pain intensity was recorded using the visual analog scale (VAS) (0-10 scale) at 1, 2, 6, 18, and 24 h duration when patients were resting and during a standardized movement. Modified Post Anaesthesia Discharge Scoring System was assessed at 1, 2, 6, 18 and 24 h after surgery. RESULTS In this study conducted on 70 patients, VAS scores (both at rest and on movement) were found comparable at postoperative 1, 2, 6, 18, and 24 h (P > 0.05). There was no statistical difference in comparing postanesthesia discharging scoring in both the groups. No incidence of postoperative nausea and vomiting was seen in any group. CONCLUSIONS Morphine and clonidine in PVB are equally effective, and there is no superiority of one agent over the other. Hence, both drugs may be used with equal efficacy as adjuvants to bupivacaine in PVB for providing postoperative analgesia.
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Affiliation(s)
- Surabhi Priya
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Charu Bamba
- Department of Anaesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Head LK, Lui A, Boyd KU. Efficacy and safety of bilateral thoracic paravertebral blocks in outpatient breast surgery. Breast J 2018; 24:561-566. [DOI: 10.1111/tbj.13008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/18/2017] [Accepted: 08/01/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Linden K. Head
- Division of Plastic and Reconstructive Surgery; Department of Surgery; University of Ottawa; Ottawa ON Canada
| | - Anne Lui
- Department of Anesthesiology and Pain Medicine; University of Ottawa; Ottawa ON Canada
| | - Kirsty Usher Boyd
- Division of Plastic and Reconstructive Surgery; Department of Surgery; University of Ottawa; Ottawa ON Canada
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Impact of pectoral nerve block on postoperative pain and quality of recovery in patients undergoing breast cancer surgery. Eur J Anaesthesiol 2018; 35:215-223. [DOI: 10.1097/eja.0000000000000762] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Chhabra A, Prabhakar H, Subramaniam R, Arora MK, Srivastava A, Kalaivani M. Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery. Hippokratia 2018. [DOI: 10.1002/14651858.cd012968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anjolie Chhabra
- All India Institute of Medical Sciences; Department of Anaesthesiology, Pain Medicine and Critical Care; Ansari Nagar New Delhi India 110029
| | - Hemanshu Prabhakar
- All India Institute of Medical Sciences; Department of Neuroanaesthesiology and Critical Care; Ansari Nagar New Delhi India 110029
| | - Rajeshwari Subramaniam
- All India Institute of Medical Sciences; Department of Anaesthesiology, Pain Medicine and Critical Care; Ansari Nagar New Delhi India 110029
| | - Mahesh Kumar Arora
- All India Institute of Medical Sciences; Department of Anaesthesiology, Pain Medicine and Critical Care; Ansari Nagar New Delhi India 110029
| | - Anurag Srivastava
- All India Institute of Medical Sciences; Department of Surgery; Ansari Nagar New Delhi India 110029
| | - Mani Kalaivani
- All India Institute of Medical Sciences; Department of Biostatistics; Ansari Nagar New Delhi India
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Abstract
PURPOSE OF REVIEW Breast surgery, performed for medical or cosmetic reasons, remains one of the most frequently performed procedures, with over 500,000 cases performed annually in the USA alone. Historically, general anesthesia (GA) has been widely accepted as the gold-standard technique, while epidural anesthesia was largely considered too invasive and thus unnecessary for breast surgery. Over the past years, paravertebral block (PVB) has emerged as an alternative analgesic or even anesthetic technique. Substantial evidence supports the use of PVB for major breast surgery. RECENT FINDINGS In patients receiving PVB, immediate and long-term analgesia is superior to systemic analgesia while opioid use and typical adverse effects of systemic analgesia such as nausea and vomiting are decreased. The benefits may also include an improved oncological survival with PVB after mastectomy for malignancy. PVB offers clinically significant benefits for perioperative care of patients undergoing breast surgery. The benefits of continuous PVB are most firmly supported for major breast surgery and include both effective short-term pain control and reduction in burden of chronic pain. On the other hand, minor breast surgery should be effectively manageable using multimodal analgesia in the majority of patients, with PVB reserved as analgesic rescue or for patients at high risk of excessive perioperative pain.
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Župčić M, Graf Župčić S, Duzel V, Šimurina T, Šakić L, Fudurić J, Peršec J, Milošević M, Stanec Z, Korušić A, Barišin S. A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone. Croat Med J 2017; 58:270-280. [PMID: 28857520 PMCID: PMC5577647 DOI: 10.3325/cmj.2017.58.270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.
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Affiliation(s)
- Miroslav Župčić
- Miroslav Župčić, Anesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Dubrava, Av. G. Šuška 6, 10000 Zagreb, Croatia,
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Fentie DY, Gebremedhn EG, Denu ZA, Gebreegzi AH. Efficacy of single-injection unilateral thoracic paravertebral block for post open cholecystectomy pain relief: a prospective randomized study at Gondar University Hospital. Local Reg Anesth 2017; 10:67-74. [PMID: 28744155 PMCID: PMC5513842 DOI: 10.2147/lra.s133946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cholecystectomy can be associated with considerable postoperative pain. While the benefits of paravertebral block (PVB) on pain after thoracotomy and mastectomy have been demonstrated, not enough investigations on the effects of PVB on pain after open cholecystectomy have been conducted. We tested the hypothesis that a single-injection thoracic PVB reduces pain scores, decreases opioid consumption, and prolongs analgesic request time after cholecystectomy. Methods Of 52 patients recruited, 50 completed the study. They were randomly allocated into two groups: the paravertebral group and the control group. The outcome measures were the severity of pain measured on numeric pain rating scale, total opioid consumption, and first analgesic request time during the first postoperative 24 hours. Result The main outcomes recorded during 24 hours after surgery were Numerical Rating Scale (NRS) pain scores (NRS, 0–10), cumulative opioid consumption, and the first analgesic request time. Twenty four hours after surgery, NRS at rest was 4 (3–6) vs 5 (5–7) and at movement 4 (4–7) vs 6 (5–7.5) for the PVB and control groups, respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four hours after surgery, median (25th–75th percentile) cumulative morphine consumption was 0 (0–2) vs 2.5 (2–4) mg (P<0.0001) and cumulative tramadol consumption was 200 (150–250) mg vs 300 (200–350) mg in the paravertebral and in the control group, respectively (P=0.003). After surgery, the median (25th–75th percentile) first analgesic requirement time was prolonged in the PVB group in statistically significant fashion (P<0.0001). Conclusion and recommendations Single-shot thoracic PVB as a component of multi-modal analgesic regimen provided superior analgesia when compared with the control group up to 24 postoperative hours after cholecystectomy, and we recommend this block for post cholecystectomy pain relief.
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Affiliation(s)
- Demeke Yilkal Fentie
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Endale Gebreegziabher Gebremedhn
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zewditu Abdissa Denu
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Hailekiros Gebreegzi
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Odom EB, Mehta N, Parikh RP, Guffey R, Myckatyn TM. Paravertebral Blocks Reduce Narcotic Use Without Affecting Perfusion in Patients Undergoing Autologous Breast Reconstruction. Ann Surg Oncol 2017; 24:3180-3187. [PMID: 28718036 DOI: 10.1245/s10434-017-6007-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Autologous breast reconstruction offers excellent long term outcomes after mastectomy. However, maintaining adequate postoperative analgesia remains challenging. Use of paravertebral blocks (PVBs) reduces postoperative narcotic use and length of stay, and enhanced recovery protocols with mixed analgesia methods are gaining popularity, but few studies have explored the intraoperative effects of these interventions. METHODS Patients who underwent abdominally based autologous breast reconstruction between 2010 and 2016 were compiled into a retrospective database. We used electronic medical records to determine demographics, as well as perioperative and intraoperative vital signs and narcotic, anxiolytic, crystalloid, colloid, blood product, and vasopressor requirements, and postoperative complications. Results were compared between patients who had a PVB and those who did not and those who had a PVB alone and those who followed our enhanced recovery protocol using standard statistical methods and adjusting for preoperative values. RESULTS A total of 170 patients were included in the study. Sixty-six had a PVB, and 104 did not. Of the 66 who had a PVB, 19 followed our enhanced recovery protocol. Patients who did not have a PVB required 171.6 mg of total narcotic medication in the perioperative period, those with a PVB alone required 146.9 mg, and those who followed the ERAS protocol 95.2 mg (p = 0.01). There was no difference in intraoperative mean arterial pressure, time with mean arterial pressure <80% of baseline, vasopressor use, or fluid requirement. There was no difference in complication rate. CONCLUSIONS PVBs and an enhanced recovery protocol reduce the use of narcotic medications in autologous breast reconstruction without impacting intraoperative hemodynamics. Breast reconstruction after mastectomy restores body image and improves health-related quality of life, satisfaction with appearance and physical, psychosocial, and sexual well-being (Donovan et al. in J Clin Oncol 7(7):959-968, 1989; Eltahir et al. in Plast Reconstr Surg 132(2):201e-209e, 2013; Jagsi et al. in Ann Surg 261(6):1198-1206, 2015). For patients pursuing breast reconstruction, there are two major options: prosthetic (tissue expander/implant) or autologous reconstruction. However, while providing exceptional long-term outcomes, postoperative pain and length of hospital stay remains a major challenge preventing more widespread adoption of autologous breast reconstruction (Albornoz et al. in Plast Reconstr Surg 131(1):15-23, 2013; Gurunluoglu et al. in Ann Plast Surg 70(1):103-110, 2013; Kulkarni et al. in Plast Reconstr Surg 132(3):534-541, 2013; Sbitany et al. in Plast Reconstr Surg 124(6):1781-1789, 2009). Acute postoperative pain contributes to prolonged hospital stays, increased narcotic use, and associated risks of the aforementioned.
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Affiliation(s)
- Elizabeth B Odom
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Nili Mehta
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rajiv P Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan Guffey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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Wynne R, Lui N, Tytler K, Koffsovitz C, Kirwa V, Riedel B, Ryan S. The Trajectory of Postoperative Pain Following Mastectomy with and without Paravertebral Block. Pain Manag Nurs 2017; 18:234-242. [PMID: 28601480 DOI: 10.1016/j.pmn.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 11/21/2016] [Accepted: 03/08/2017] [Indexed: 11/18/2022]
Abstract
Evidence to support the argument that general anesthesia (GA) with paravertebral block (PVB) provides better pain relief for mastectomy patients than GA alone is contradictory. The aim of this study was to explore pain and analgesia after mastectomy with or without PVB during acute inpatient recovery. A retrospective study was conducted in a single hospital providing specialist cancer services in metropolitan Melbourne, Australia. We explored pain and concomitant analgesic administration in 80 consecutive women recovering from mastectomy who underwent GA with (n = 40) or without (n = 40) PVB. A pain management index (PMI) was derived to illustrate the efficacy of management from day of surgery (DOS) to postoperative day (POD) 3. Patients who reported no pain progressively increased from DOS (n = 12, 15%) to POD 3 (n = 54, 67.5%). Most patients were administered analgesics as a combination of acetaminophen and a strong opioid on DOS (n = 53, 66.2%), POD 1 (n = 45, 56.2%), POD 2 (n = 33, 41.2%), and POD 3 (n = 21, 26.2%). Less than 6% of patients on any POD were administered multimodal anlagesics. PMI scores indicate some pain in the context of receiving weak and strong opioids for GA patients and more frequent use of nonopioid analgesics in PVB patients during recovery. These findings highlight the need for data describing patterns of analgesic administration in addition to reports of postoperative pain to determine the most effective means of avoiding postoperative pain in patients who require mastectomy.
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Affiliation(s)
- Rochelle Wynne
- School of Nursing & Midwifery, Deakin University, Geelong, Australia.
| | - Natalie Lui
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kristen Tytler
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Carol Koffsovitz
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Victor Kirwa
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Shane Ryan
- Department of Anaesthesia, Peter MacCallum Cancer Centre, Melbourne, Australia
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Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty. Plast Reconstr Surg 2017; 139:20e-28e. [DOI: 10.1097/prs.0000000000002842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gupta K, Srikanth K, Girdhar KK, Chan V. Analgesic efficacy of ultrasound-guided paravertebral block versus serratus plane block for modified radical mastectomy: A randomised, controlled trial. Indian J Anaesth 2017; 61:381-386. [PMID: 28584346 PMCID: PMC5444215 DOI: 10.4103/ija.ija_62_17] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background and Aims: Modified radical mastectomy (MRM) may be associated with severe post-operative pain, leading to chronic pain syndrome. We compared the post-operative analgesic profile of two ultrasound-guided nerve blocks: Paravertebral block (PVB) and serratus plane block (SPB). Methods: This double-blind, randomised study was conducted on fifty adult females, scheduled for MRM with axillary dissection. After inducing general anaesthesia with intravenous midazolam 1 mg, fentanyl 1.5 mcg/kg, propofol 1–2 mg/kg and vecuronium 0.1 mg/kg, patients were administered either ultrasound-guided thoracic PVB at T4 (n = 25) or SPB at 5th rib (n = 25) with 20 ml of 0.5% bupivacaine, both as a single level injection. Time to first rescue analgesia and morphine consumption in 4, 6, 24, 48 and 72 h by PCA pump, visual analogue scale score and any adverse effects were recorded. Quantitative variables were compared using the unpaired t-test or the Mann–Whitney U test between the two groups. Qualitative variables were compared using the Chi-square test or Fisher's exact test. Results: The duration of analgesia (mean ± Standard deviation [SD]) was significantly longer in the PVB group compared to SPB group (346 ± 57 min vs. 245.6 ± 58 min, P < 0.001). The post-operative 24 h morphine consumption (mean ± SD) was significantly higher in the SPB group (9.7 ± 2.1 mg) compared to PVB group (6.5 ± 1.5 mg) (P < 0.001). Conclusion: Ultrasound-guided SPB is an alternative analgesic technique to thoracic PVB for MRM although PVB provides a longer duration of analgesia.
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Affiliation(s)
- Kapil Gupta
- Department of Anaesthesia, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Kadapa Srikanth
- Department of Anaesthesia, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Kiran Kumar Girdhar
- Department of Anaesthesia, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Vincent Chan
- Department of Anaesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag 2016; 6:603-618. [DOI: 10.2217/pmt-2015-0008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Gloria S Cheng
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian M Ilfeld
- University of California San Diego, San Diego, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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