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R D, Parameswari A, Venkitaraman B, Vakamudi M, Manickam A. A Randomized Clinical Study to Compare the Perioperative Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block Over Thoracic Epidural in Modified Radical Mastectomy. Cureus 2023; 15:e51103. [PMID: 38149062 PMCID: PMC10750254 DOI: 10.7759/cureus.51103] [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] [Accepted: 12/26/2023] [Indexed: 12/28/2023] Open
Abstract
Aim This study aims to compare the effectiveness of ultrasound-guided erector spinae block (ESB) with thoracic epidural (TE) in managing postoperative pain among breast cancer (BC) surgery patients. Methods A total of 42 patients were enrolled and randomly divided into two groups, each comprising 21 participants. Primary endpoints assessed included intraoperative fentanyl consumption, postoperative pain scores, and the need for rescue analgesia. Secondary endpoints encompassed intraoperative hemodynamic changes and the incidence of postoperative nausea and vomiting (PONV). Results The study found no significant difference in intraoperative fentanyl requirement (p=0.62) or postoperative pain scores measured using numerical rating scores (NRS) throughout the 48-hour postoperative period. None of the patients in either group required rescue analgesia. Notably, there was a statistically significant difference in postoperative nausea and vomiting at the two-hour mark, favoring the erector spinae block. Both groups exhibited comparable hemodynamic changes during intraoperative monitoring. Conclusions Our investigation concludes that the ESF offers equivalent analgesic efficacy to the thoracic epidural during both surgery and the postoperative period without inducing any significant hemodynamic instability. Considering the lower complication rate associated with paraspinal blocks compared to neuraxial blocks, the ESB presents itself as a promising alternative method for effective pain relief in mastectomy procedures.
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Affiliation(s)
- Deepshika R
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Aruna Parameswari
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | | | - Mahesh Vakamudi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Akilandeswari Manickam
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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The quality of recovery after erector spinae plane block in patients undergoing breast surgery: a randomized controlled trial. BMC Anesthesiol 2022; 22:222. [PMID: 35836116 PMCID: PMC9281119 DOI: 10.1186/s12871-022-01760-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The erector spinae plane (ESP) block has recently been shown to effectively alleviate postoperative pain and reduce opioid consumption in breast surgery patients. However, data are still limited concerning the quality of recovery in patients following this procedure. METHODS This study was a randomized controlled trial (RCT) performed in a university hospital. We randomly allocated patients to one of three groups: ESP, SHAM, and control (CON). Procedures in the ESP and SHAM blocks were performed ipsilaterally with 0.375% ropivacaine or 0.9% saline (0.4 mL/kg). Our primary outcome was the assessment of the patient's improvement with quality-of-recovery 40 (QoR-40) a day after surgery. Other outcome assessments included postoperative pain evaluation on the visual analog scale (VAS), 24-hour opioid consumption with patient-controlled analgesia (PCA), time to the first opioid demand, and global satisfaction with perioperative treatment. RESULTS Overall, patients in the ESP group had improved QoR-40 compared to the CON group, 186 [177-193] vs. 175 [165-183] (medians and interquartile ranges). Pain severity was significantly higher in the CON group compared to the ESP group at hours 2 (38 [23-53] vs. 20 [7-32]) and 4 (30 [18-51] vs. 19 [7-25]). Moreover, we observed lower oxycodone consumption after 24 hours with the PCA pump between the ESP (4 [2-8] mg) and the CON (9.5 [5-19]) groups. Patients in the CON group used PCA sooner than those in the ESP group. Participants in the ESP group were more satisfied with treatment than those in the CON group. We found no statistical difference between SHAM and the other groups. CONCLUSIONS Compared to the CON group, the ESP block improved the quality of recovery, alleviated pain intensity, and lowered opioid consumption in patients undergoing breast surgery. However, we did not observe this superiority in comparison with the SHAM group. TRIAL REGISTRATION NCT04726878 .
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Surya R, Joseph Gunasingh JL, Sethuraman RM, Asokan A, Thilak M. "Combination of Thoracic Epidural Anesthesia, Supraclavicular Brachial Plexus Block and Supraclavicular Nerve Block as Surgical Anesthesia for Modified Radical Mastectomy-A Case Series". A A Pract 2022; 16:e01591. [PMID: 35679142 DOI: 10.1213/xaa.0000000000001591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sensory innervation of the breast is complex, thereby making it difficult to perform any surgical procedure with a single regional anesthesia technique. Because of the involvement of pectoral muscles and extension of the incision into the axilla, a modified radical mastectomy makes it further challenging and requires multiple techniques. We have used a new combination of regional techniques in this case series and found that it provided complete surgical anesthesia with a smaller volume of local anesthetic.
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Affiliation(s)
- R Surya
- From the Department of Anesthesiology, Sri Venkateshwaraa Medical College Hospital & Research Centre, Ariyur, India
| | | | | | - Aswin Asokan
- From the Department of Anesthesiology, Sri Venkateshwaraa Medical College Hospital & Research Centre, Ariyur, India
| | - M Thilak
- Department of Anesthesiology, Sree Balaji Medical College & Hospital, BIHER, Chennai, India
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Kumar M, Karoo K, Sinha M, Nilima N. A randomised prospective single-blind pilot study to compare the analgesic efficacy of thoracic epidural block and erector spinae plane block in breast cancer surgery. Indian J Anaesth 2022; 66:S148-S153. [PMID: 35774237 PMCID: PMC9238232 DOI: 10.4103/ija.ija_982_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Aims: Thoracic epidural analgesia (TEA) is an effective analgesic technique for breast surgery, although it has many associated complications. Ultrasound (US)–guided erector spinae plane (ESP) block requires less technical expertise, is safe and may be an alternative to TEA. We aimed to compare the efficacy of TEA with US-guided continuous ESP block for post-operative analgesia in patients undergoing modified radical mastectomy (MRM) surgeries. Methods: Sixty-six female patients of age group 18–65 years, and American Society of Anesthesiologists (ASA) physical status I and II, undergoing MRM surgeries were recruited. Patients received TEA in Group Ep and US-guided ESP block in Group Er, before induction of general anaesthesia. Both the groups received 0.2% ropivacaine 15 mL, followed by 5 mL.h-1 infusion for 24 h. The primary outcome was the duration of analgesia. Secondary outcomes were total doses of rescue analgesics in 24 hours and visual analogue scale (VAS) scores at 0 h, 1 h, 2 h, 4 h, 8 h, 12 h, and 24 h. Results: The mean duration of analgesia was 21.72 ± 4.73 hours in Ep group and 20.60 ± 5.77 hours in Er group (P = 0.39). The total dose of rescue analgesics in the postoperative period was comparable between both the groups. There was no significant difference in VAS scores between the groups over 24 h. Conclusion: US-guided ESP block can be used as safe and easy to perform alternative analgesic technique over thoracic epidural analgesia for peri-operative pain management in breast cancer surgeries.
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Hoerner E, Gasteiger L, Ortler M, Pustilnik V, Mathis S, Brunner C, Neururer S, Schlager A, Egle D, Putz G. The impact of dexamethasone as a perineural additive to ropivacaine for PECS II blockade in patients undergoing unilateral radical mastectomy - A prospective, randomized, controlled and double-blinded trial. J Clin Anesth 2021; 77:110622. [PMID: 34872040 DOI: 10.1016/j.jclinane.2021.110622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE Dexamethasone is commonly used as an adjuvant to local anesthetics to prolong duration of peripheral nerve blocks with minimal side-effects. The present study investigates the efficacy of dexamethasone added to ropivacaine 0.2% as compared to ropivacaine 0.2% alone for pectoral nerves block II (PECS II) in unilateral radical mastectomy. DESIGN A prospective, randomized, controlled and double-blinded trial. SETTING The study was performed at Innsbruck Medical University Hospital, Austria, between January 2019 and October 2020. PATIENTS Sixty female patients with an American Society of Anesthesiologists Score I-II (18-90 years, BMI 18-35) scheduled for unilateral radical mastectomy without one-stage immediate autologous breast reconstruction were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. INTERVENTIONS Patients were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. MEASUREMENTS Primary outcome parameter was the cumulative opioid consumption during the first 72 postoperative hours. Secondary outcome parameters were the duration of analgesia and the course of the visual analogue scale (VAS) and the area under the curve VAS (AUC-VAS). MAIN RESULTS There was no difference in cumulative opioid consumption after 72 h between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (11.89 vs 11.90 morphine milligram equivalent, respectively; p 0.831). Duration of analgesia also did not differ significantly between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (12.75 versus 8.75 h, respectively; p 0.680). There also was no difference in the course of VAS and AUC-VAS. CONCLUSIONS Dexamethasone 8 mg when added to ropivacaine 0.2% for PECS II block in unilateral radical mastectomy was not found to reduce total opioid consumption over 72 postoperative hours or to prolong duration of analgesia as compared to pure ropivacaine 0.2%.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria.
| | - Michael Ortler
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Vitaliy Pustilnik
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Simon Mathis
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Christine Brunner
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Sabrina Neururer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria
| | - Andreas Schlager
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Guenther Putz
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
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Srivastava A, Jamil S, Khandelwal A, Raj M, Singh S. Thoracic Epidural Anesthesia for Modified Radical Mastectomy in a High-Risk Patient: A Case Report With Literature Review. Cureus 2021; 13:e15822. [PMID: 34306886 PMCID: PMC8295951 DOI: 10.7759/cureus.15822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
Surgery is one of the mainstays of treatment in breast cancers. Typically, modified radical mastectomy (MRM) is done under general anesthesia (GA). However, GA is not a reasonable choice in patients with multiple comorbidities and difficult airways. Thoracic epidural anesthesia (TEA) is a reasonable and safe alternative to GA as it involves blunting of stress response and avoidance of airway handling apart from hemodynamic stability, lower analgesic consumption, superior postoperative analgesia, reduced postoperative nausea and vomiting, earlier resumption of feeding, and shorter duration of hospitalization. We report a case of advanced breast cancer in a 57-year-old female with a co-existing difficult airway, bronchial asthma, and hypertension in whom MRM was conducted successfully under TEA. We also present a comprehensive review of literature on the use of TEA for MRM.
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Affiliation(s)
- Aarti Srivastava
- Anaesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, IND
| | - Shaista Jamil
- Anaesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, IND
| | - Ankur Khandelwal
- Anaesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, IND
| | - Manish Raj
- Anaesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, IND
| | - Shalley Singh
- Anaesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, IND
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The Effect of Ultrasound-Guided Erector Spinae Plane Block Combined with Dexmedetomidine on Postoperative Analgesia in Patients Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial. Pain Ther 2021; 10:475-484. [PMID: 33475952 PMCID: PMC8119550 DOI: 10.1007/s40122-020-00234-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/22/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction One of the most common malignancies in women worldwide is breast cancer. Erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy for breast cancer. The duration of nerve block analgesia is limited if local anesthetic agents are used alone. The purpose of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia during a single injection of local anesthetics. Methods In this double-blind, randomized study, 60 female American Society of Anesthesiologists (ASA) I–II patients undergoing modified radical mastectomy were randomized into two groups: ultrasound (US)-guided ESPB with 30 mL of 0.33% ropivacaine (group R) and US-guided ESPB with 30 mL of dexmedetomidine plus 0.33% ropivacaine (group DR). US-guided ESPB at the T3 vertebral level was performed preoperatively in all patients. The indicators were 1-, 6-, 12-, 24-, and 48-h visual analog scale (VAS) pain scores after surgery in the resting state and at 90-degree shoulder abduction. Other measures were a comparison of intraoperative sufentanil and remifentanil, postoperative nausea and vomiting (PONV), flurbiprofen consumption, the lengths of post-anesthesia care unit (PACU) stay and hospital stay, postoperative bradycardia, and hypotension. Results The VAS pain score was lower in group DR than group R at any time in the resting state, except at 1 h after surgery. The VAS pain score was lower in group DR than group R at 12 and 24 h in an active state after surgery (P < 0.05 for each time interval). The intraoperative dosages of remifentanil and sufentanil in group DR were lower than that in group R. The postoperative dosage of flurbiprofen in group DR was lower than that in group R (P = 0.038). The lengths of PACU stay were longer in group DR than in group R. No significant difference was found in PONV and hospital stay between the two groups. No sinus bradycardia or hypotension after surgery occurred in the two groups. Conclusions Dexmedetomidine as an adjunctive to ESPB can effectively relieve pain and significantly reduce the need for opioids during modified radical mastectomy for breast cancer. Trial Registration The study was registered in the Chinese Clinical Trial Registry (ChiCTR2000031134, principal investigator: Yao Lu, date of registration: 2020-3-22).
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Kochhar A, Banday J, Ahmad Z, Panjiar P, Vajifdar H. Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study. J Anaesthesiol Clin Pharmacol 2020; 36:182-186. [PMID: 33013032 PMCID: PMC7480315 DOI: 10.4103/joacp.joacp_72_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 12/09/2019] [Accepted: 12/27/2019] [Indexed: 12/03/2022] Open
Abstract
Background and Aims: The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery. Material and Methods: After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 – thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery. Results: There was significant reduction in the requirement of morphine (P < 0.001), isoflurane (P = 0.004) and vecuronium (P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced (P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine. Conclusions: The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.
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Affiliation(s)
- Anjali Kochhar
- Department of Anesthesia, Critical Care and Pain Medicine, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
| | - Jahanara Banday
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Zainab Ahmad
- Department of Anesthesia, Critical Care and Pain Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
| | - Pratibha Panjiar
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Homay Vajifdar
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
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Pectoral Nerve Block and Erector Spinae Plane Block and Post-Breast Surgery Complications. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.100893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Malawat A, Verma K, Jethava D, Jethava DD. Erector spinae plane block for complete surgical anaesthesia and postoperative analgesia for breast surgeries: A prospective feasibility study of 30 cases. Indian J Anaesth 2020; 64:118-124. [PMID: 32139929 PMCID: PMC7017659 DOI: 10.4103/ija.ija_639_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background and Aims: Several regional anaesthesia techniques have been described for carcinoma of the breast surgeries in the past but all of them failed to provide adequate surgical anaesthesia and are associated with multiple complications, thus limiting their use. This prospective study was designed to assess the efficacy of erector spinae plane (ESP) block to provide complete surgical anaesthesia without general anaesthesia (GA) and postoperative analgesia in patients undergoing modified radical mastectomy (MRM) surgery. Methods: Thirty females of the American Society of Anaesthesiologists physical status I, II or III scheduled for MRM were included in the study to receive unilateral ultrasound-guided ESP block preoperatively (25 ml of 0.5% bupivacaine with dexamethasone 8 mg on the operating side). The primary objective of the study was to evaluate the efficacy of ESP block to provide complete surgical anaesthesia in terms of total number of cases converted to GA. Results: Our study shows that ultrasound-guided single-shot ESP block provided complete surgical anaesthesia in all the patients within an average of 31.50 minutes and an average long-lasting postoperative analgesia of 41.73 hours following MRM. Conclusion: Our study proves that ESP block is a novel, predictable, secure, and safe option for carcinoma of the breast surgery. Thus, ESP block would surely provide a clinical advantage in these population group.
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Affiliation(s)
- Aman Malawat
- Department of Anaesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Jaipur, Rajasthan, India
| | - Kalpana Verma
- Department of Anaesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Jaipur, Rajasthan, India
| | - Durga Jethava
- Department of Anaesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Jaipur, Rajasthan, India
| | - Dharam D Jethava
- Department of Anaesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Jaipur, Rajasthan, India
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Schreiber KL, Belfer I, Miaskowski C, Schumacher M, Stacey BR, Van De Ven T. AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery. THE JOURNAL OF PAIN 2019; 21:294-305. [PMID: 31493489 DOI: 10.1016/j.jpain.2019.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/06/2019] [Accepted: 08/12/2019] [Indexed: 12/30/2022]
Abstract
Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% and 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the 5 dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks [ACTTION], American Academy of Pain Medicine [AAPM], American Pain Society [APS] Pain Taxonomy) to acute pain after breast surgery. Application of the AAAPT taxonomy yielded the following: 1) Core Criteria: Location, timing, severity, and impact of breast surgery pain were defined; 2) Common Features: Character and expected trajectories were established in relevant surgical subgroups, and common pain assessment tools for acute breast surgery pain identified; 3) Modulating Factors: Biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: Domains of impact were outlined and defined; 5) Neurobiologic Mechanisms: Putative mechanisms were specified ranging from nerve injury, inflammation, peripheral and central sensitization, to affective and social processing of pain. PERSPECTIVE: The AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of interindividual variation, and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain.
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Affiliation(s)
- Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Inna Belfer
- National Center for Complementary and Integrative Health, NIH, Bethesda, Maryland
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California
| | - Mark Schumacher
- Department of Anesthesia and Perioperative Care, Division of Pain Medicine, University of California, San Francisco, San Francisco, California
| | - Brett R Stacey
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Thomas Van De Ven
- Duke University Department of Anesthesiology, Division of Pain Medicine, Durham, North Carolina
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Versyck B, Geffen G, Chin K. Analgesic efficacy of the PecsIIblock: a systematic review and meta‐analysis. Anaesthesia 2019; 74:663-673. [DOI: 10.1111/anae.14607] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2019] [Indexed: 11/26/2022]
Affiliation(s)
- B. Versyck
- Department of Anaesthesia and Pain Medicine Catharina Hospital Eindhoven the Netherlands
| | - G.‐J. Geffen
- Department of Anaesthesia Radboud University Medical Center Nijmegen the Netherlands
| | - K.‐J. Chin
- Department of Anaesthesia Toronto Western Hospital University of Toronto ON Canada
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Versyck B, Groen G, Geffen G, Van Houwe P, Bleys RL. The pecs anesthetic blockade: A correlation between magnetic resonance imaging, ultrasound imaging, reconstructed cross‐sectional anatomy and cross‐sectional histology. Clin Anat 2019; 32:421-429. [DOI: 10.1002/ca.23333] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/06/2019] [Accepted: 01/12/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Barbara Versyck
- Department of AnesthesiologyCatharina Hospital Eindhoven The Netherlands
| | - Gerbrand Groen
- Anesthesiology Pain Center, Department of AnesthesiologyUniversity Medical Center Groningen, University of Groningen Groningen The Netherlands
| | - Geert‐Jan Geffen
- Department of AnesthesiologyRadboud University Medical Center Nijmegen The Netherlands
| | - Patrick Van Houwe
- Department of AnesthesiologyGZA Ziekenhuizen Campus Sint‐Augustinus Wilrijk Belgium
| | - Ronald Law Bleys
- Department of Functional AnatomyUniversity Medical Center Utrecht Utrecht The Netherlands
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Singh S, Kumar G, Akhileshwar. Ultrasound-guided erector spinae plane block for postoperative analgesia in modified radical mastectomy: A randomised control study. Indian J Anaesth 2019; 63:200-204. [PMID: 30988534 PMCID: PMC6423951 DOI: 10.4103/ija.ija_758_18] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Several locoregional techniques have been described for providing postoperative analgesia after breast surgery. The optimal technique should be easy to perform, reproducible and provide good analgesia. This randomised control study was designed to evaluate the postoperative analgesic effect of ultrasound-guided erector spinae plane (US-guided ESP) block for modified radical mastectomy (MRM) surgery. Methods A total of 40 females belonging to American Society of Anesthesiologists' 1 or 2 posted for MRM were randomly allocated into Group 1 (control group) and group 2 (ESP group). Patients in Group 1 received only general anaesthesia (GA) and were managed for pain postoperatively according to routine protocol, while group 2 (ESP group) patients received unilateral US-guided ESP block preoperatively (20 mL 0.5% bupivacaine to the operating side) followed by GA. The primary objective of study was to record postoperative 24 h cumulative morphine requirement. Differences between the two groups were analyzed using the Mann-Whitney U-test or a two-tailed Student's t-test. Results Postoperative morphine consumption was found to be significantly less in patients receiving US-guided ESP block compared to control group (1.95 ± 2.01 mg required in ESP group vs 9.3 ± 2. 36 mg required in control group, P value = 0.01)). All the patients in control group required supplemental morphine postoperatively compared to only two patients requiring that in US-guided ESP block group (P < 0.01). Conclusion US-guided ESP block when given prior to MRM surgery provided effective postoperative analgesia. CTRI registration no. - CTRI/2018/03/012712 registered in the clinical trial registry, India.
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Affiliation(s)
- Swati Singh
- Anaesthesia and Intensive Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Gunjan Kumar
- Anaesthesia and Intensive Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Akhileshwar
- Anaesthesia and Intensive Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Shah S, Hariharan U, Bhargava A. Recent trends in anaesthesia and analgesia for breast cancer surgery. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Matsumoto M, Flores EM, Kimachi PP, Gouveia FV, Kuroki MA, Barros ACSD, Sampaio MMC, Andrade FEM, Valverde J, Abrantes EF, Simões CM, Pagano RL, Martinez RCR. Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia. Sci Rep 2018; 8:7815. [PMID: 29777144 PMCID: PMC5959858 DOI: 10.1038/s41598-018-26273-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/08/2018] [Indexed: 12/24/2022] Open
Abstract
Surgery is the first-line treatment for early, localized, or operable breast cancer. Regional anesthesia during mastectomy may offer the prevention of postoperative pain. One potential protocol is the combination of serratus anterior plane block (SAM block) with pectoral nerve block I (PECS I), but the results and potential benefits are limited. Our study compared general anesthesia with or without SAM block + PECS I during radical mastectomy with axillary node dissection and breast reconstruction using evaluations of pain, opioid consumption, side effects and serum levels of interleukin (IL)-1beta, IL-6 and IL-10. This is a prospective, randomized controlled trial. Fifty patients were randomized to general anesthesia only or general anesthesia associated with SAM block + PECS I (25 per group). The association of SAM block + PECS I with general anesthesia reduced intraoperative fentanyl consumption, morphine use and visual analog pain scale scores in the post-anesthetic care unit (PACU) and at 24 h after surgery. In addition, the anesthetic protocol decreased side effects and sedation 24 h after surgery compared to patients who underwent general anesthesia only. IL-6 levels increased after the surgery compared to baseline levels in both groups, and no differences in IL-10 and IL-1 beta levels were observed. Our protocol improved the outcomes of mastectomy, which highlight the importance of improving mastectomy protocols and focusing on the benefits of regional anesthesia.
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Affiliation(s)
- Marcio Matsumoto
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.,Sao Paulo Servicos Medicos de Anestesia, Rua Adma Jafet, Jafet, 91 - Bela Vista, São Paulo - SP, 01308-050, Sao Paulo, Brazil
| | - Eva M Flores
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.,Sao Paulo Servicos Medicos de Anestesia, Rua Adma Jafet, Jafet, 91 - Bela Vista, São Paulo - SP, 01308-050, Sao Paulo, Brazil
| | - Pedro P Kimachi
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.,Sao Paulo Servicos Medicos de Anestesia, Rua Adma Jafet, Jafet, 91 - Bela Vista, São Paulo - SP, 01308-050, Sao Paulo, Brazil
| | - Flavia V Gouveia
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Mayra A Kuroki
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Alfredo C S D Barros
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Marcelo M C Sampaio
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Felipe E M Andrade
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - João Valverde
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.,Sao Paulo Servicos Medicos de Anestesia, Rua Adma Jafet, Jafet, 91 - Bela Vista, São Paulo - SP, 01308-050, Sao Paulo, Brazil
| | - Eduardo F Abrantes
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Claudia M Simões
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.,Sao Paulo Servicos Medicos de Anestesia, Rua Adma Jafet, Jafet, 91 - Bela Vista, São Paulo - SP, 01308-050, Sao Paulo, Brazil
| | - Rosana L Pagano
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil
| | - Raquel C R Martinez
- Hospital Sirio-Libanes, Rua Professor Daher Cutait, 69, 01308-060, Sao Paulo, Brazil.
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Nair AS, Seelam S, Naik V, Rayani BK. Opioid-free mastectomy in combination with ultrasound-guided erector spinae block: A series of five cases. Indian J Anaesth 2018; 62:632-634. [PMID: 30166661 PMCID: PMC6100268 DOI: 10.4103/ija.ija_314_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Suresh Seelam
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Vibhavari Naik
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Basanth K Rayani
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II. J Clin Anesth 2017. [DOI: 10.1016/j.jclinane.2017.03.054] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Babu S, Gupta BK, Gautam GK. A Comparative Study for Post Operative Analgesia in the Emergency Laparotomies: Thoracic Epidural Ropivacaine with Nalbuphine and Ropivacaine with Butorphanol. Anesth Essays Res 2017; 11:155-159. [PMID: 28298776 PMCID: PMC5341686 DOI: 10.4103/0259-1162.186593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Adequate postoperative pain therapy for emergency abdominal surgeries is important far beyond the perioperative period because sensitization to painful stimuli can cause postoperative morbidity. A prospective, double-blind, randomized study was carried out to compare the quality of postoperative analgesia and side-effect profile between epidurally administered butorphanol and nalbuphine as an adjuvant to 0.2% ropivacaine. MATERIALS AND METHODS A total of eighty patients, 43 men and 37 women between the age of 18 and 65 years of American Society of Anesthesiologists (ASA) Class I E and II E, who underwent intestinal perforation repair surgery were randomly allocated into two groups ropivacaine with butorphanol (RB) and ropivacaine with nalbuphine (RN), comprising of 40 patients each. Group RB received 0.2% ropivacaine containing 2 mg butorphanol while Group RN received 0.2% ropivacaine containing 10 mg nalbuphine through thoracic epidural catheter. Quality of analgesia, cardiorespiratory parameters, side-effects, and the need of rescue intravenous analgesia were observed. RESULTS The demographic profile and ASA Class were comparable between the groups. RN group had good quality of analgesia and stable cardiorespiratory parameters for the initial 6 h of postoperative period, after which they were comparable in both groups. Furthermore, the need of rescue analgesia was higher (20%) in the RB group during the first 6 h. The side-effect profile was comparable with a little higher incidence of nausea in both groups. CONCLUSION Thoracic epidurally administered ropivacaine with nalbuphine is more effective than ropivacaine with butorphanol for immediate postoperative pain relief in patients undergoing emergency exploratory laparotomy.
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Affiliation(s)
- Saravana Babu
- Department of Anaesthesiology and Critical Care Medicine, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
| | - Bikram Kumar Gupta
- Department of Anaesthesiology and Critical Care Medicine, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
| | - Gyanendra Kumar Gautam
- Department of Anaesthesiology and Critical Care Medicine, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India
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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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22
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Cheng GS, Ilfeld BM. An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery. PAIN MEDICINE 2016; 18:1344-1365. [DOI: 10.1093/pm/pnw172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Park SY, Chun HR, Kim MG, Lee SJ, Kim SH, Ok SY, Cho A. Transient Horner's syndrome following thoracic epidural anesthesia for mastectomy: a prospective observational study. Can J Anaesth 2015; 62:252-7. [PMID: 25560203 DOI: 10.1007/s12630-014-0284-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 11/24/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Transient Horner's syndrome is an uncommon complication of epidural anesthesia, though its exact incidence in thoracic epidural anesthesia is not clear. Therefore, this study prospectively evaluated the incidence of Horner's syndrome after thoracic epidural anesthesia for mastectomy. METHODS Patients scheduled for mastectomy, with or without breast reconstruction, were enrolled in this prospective observational study from September 2010 to December 2013. Intraoperative thoracic epidural anesthesia was established using 0.375% or 0.5% ropivacaine 15 mL with thoracic epidural analgesia continued postoperatively with a continuous infusion of 0.15% ropivacaine 2 mL·hr(-1) with fentanyl 8 μg·hr(-1). Signs of Horner's syndrome (miosis, ptosis, and hyperemia) were assessed at one and two hours as well as one, two, and three days postoperatively. RESULTS Thoracic epidural anesthesia was successful in 439 patients, with six (1.4%) of these patients acquiring Horner's syndrome. All signs of Horner's syndrome resolved gradually within 180 min of discontinuing the epidural infusion. In one patient with Horner's syndrome, a radiographic contrast injection confirmed that the drug had spread to the cervical epidural level. CONCLUSION The incidence of Horner's syndrome following thoracic epidural anesthesia and continuous thoracic epidural analgesia for mastectomy was 1.4%. The mechanism was consistent with cephalic spread of the epidural local anesthetic. This trial was registered at: Clinicaltrials.gov, number: NCT02130739.
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Affiliation(s)
- Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, 140-743, Korea,
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Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259:1056-67. [PMID: 24096762 DOI: 10.1097/sla.0000000000000237] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia. BACKGROUND It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality. METHODS We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint. RESULTS A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients. CONCLUSIONS In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.
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Kaya M, Oğuz G, Şenel G, Kadıoğulları N. Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block. J Anesth 2013; 27:862-7. [PMID: 23736824 DOI: 10.1007/s00540-013-1647-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 05/17/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM). METHODS Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded. RESULTS VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1. CONCLUSIONS The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.
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Affiliation(s)
- Menşure Kaya
- Department of Anesthesiology, Ankara Oncology Education and Research Hospital, 41/7 Yenimahalle, 06170, Ankara, Turkey,
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Swaminathan V, Spiliopoulos MK, Audisio RA. Choices in surgery for older women with breast cancer. Breast Care (Basel) 2012; 7:445-51. [PMID: 24715825 DOI: 10.1159/000345402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.
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Affiliation(s)
| | | | - Riccardo A Audisio
- Consultant Breast Oncological Surgeon, St Helens Teaching Hospital, St Helens, UK
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Guay J, Grabs D. A cadaver study to determine the minimum volume of methylene blue or black naphthol required to completely color the nerves relevant for anesthesia during breast surgery. Clin Anat 2010; 24:202-8. [DOI: 10.1002/ca.21085] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 09/17/2010] [Accepted: 09/24/2010] [Indexed: 11/11/2022]
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Kang KS, Kim CW, Ahn KR, Kim CS, Yoo S, Chung JH, Chung JW, Kim SH. A comparison of cervical epidural analgesia and intravenous patient-controlled analgesia after mastectomy with immediate latissimus dorsi flap breast reconstruction. Korean J Anesthesiol 2009; 56:669-674. [PMID: 30625808 DOI: 10.4097/kjae.2009.56.6.669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breast reconstruction following mastectomy has become increasingly popular in recent years. The purpose of this study was to compare the efficacy of cervical epidural patient-controlled analgesia (CEA) and intravenous patient-controlled analgesia (IV-PCA) for controlling the postoperative pain and the side effects after mastectomy with immediate Latissimus dorsi (LD) flap breast reconstruction. METHODS Sixty patients who were to undergo mastectomy with immediate LD flap breast reconstruction were randomly assigned to receive CEA [Group CEA, (n = 30), 0.15% ropivacaine + fentanyl 4 microg/ml] or IV-PCA [Group IV-PCA (n = 30) fentanyl 20 microg/kg + ketorolac 3 mg/kg] for postoperative pain control via a PCA pump (basal rate: 2 ml/h, bolus: 2 ml, lock out interval: 15 min) after their operation. Before general anesthesia, an epidural catheter was inserted at the cervical (C)7-thoracic (T)1 level in the patients of the CEA group. The resting visual analogue scale (VAS) for pain, the systolic blood pressure, the heart rate and the side effects were recorded for 48 hours after operation. RESULTS The VAS at rest was significantly lower in the CEA group than that in the IV-PCA group at 16 hours after surgery. The CEA group required less additional analgesics as compared with the group IV- PCA. There were no significant differences in the systolic blood pressure, the heart rate and the incidence of side effects between the two groups. CONCLUSIONS We conclude that cervical epidural analgesia, as compared with intravenous patient-controlled analgesia, provides effective pain control and it shows a similar incidence of side effects after mastectomy with immediate LD flap breast reconstruction.
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Affiliation(s)
- Kyu Sik Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Chang Won Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Ki Ryang Ahn
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Chun Sook Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Siehyeon Yoo
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Jin Hun Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Ji Won Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Sang Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
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Abstract
OBJECTIVE The aim of this study was to find out if ropivacaine with clonidine can be successfully used after radical retropubic prostatectomy. MATERIAL AND METHODS A total of 86 patients were randomized into two groups each consisting of 43 patients. Patients in group 1 received epidural bupivacaine/morphine/clonidine and those in group 2 ropivacaine and clonidine. If necessary analgesic, antiemetic or antihistamine drugs were administered. Pain on a visual analogue scale (VAS), motoric and sensoric disturbances, sedation, itching, nausea and vomiting, hypotension, need of antihistamines, naloxon, antiemetics, ephedrine, and analgesics were also documented. RESULTS Differences in sedation, itching, nausea and vomiting, motoric and sensoric disturbances, need of antihistamines, antiemetics, and ketoprofen were significant, the other parameters did not show any significant differences. CONCLUSIONS We recommend the use of ropivacaine with clonidine in the postoperative pain management after radical retropubic prostatectomy.
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Baek YH, Ok SY, Kim SI, Kim SC, Lee MH. Effects of Continuous Epidural Infusion after Thoracic Epidural Anesthesia for Mastectomy on Postoperative Pain, Nausea and Vomiting. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.4.396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Young Hee Baek
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Soonchunhang University College of Medicine, Seoul, Korea
| | - Si Young Ok
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Soonchunhang University College of Medicine, Seoul, Korea
| | - Soon Im Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Soonchunhang University College of Medicine, Seoul, Korea
| | - Sun Chong Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Soonchunhang University College of Medicine, Seoul, Korea
| | - Min Hyuk Lee
- Department of General Surgery, Soonchunhyang University Hospital, Soonchunhang University College of Medicine, Seoul, Korea
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Singh AP, Tewari M, Singh DK, Shukla HS. Cervical Epidural Anesthesia: A Safe Alternative to General Anesthesia for Patients Undergoing Cancer Breast Surgery. World J Surg 2006; 30:2043-7; discussion 2048-9. [PMID: 16927058 DOI: 10.1007/s00268-006-0117-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND General anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM. PATIENTS AND METHODS Fifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C(6)-C(7) or C(7)-T(1) epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter. RESULTS In 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2 pound, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery. CONCLUSIONS Cervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.
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Affiliation(s)
- A P Singh
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
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Suresh S. Thoracic Epidural Catheter Placement in Children. Reg Anesth Pain Med 2004. [DOI: 10.1097/00115550-200403000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kotake Y, Matsumoto M, Morisaki H, Takeda J. The effectiveness of continuous epidural infusion of low-dose fentanyl and mepivacaine in perioperative analgesia and hemodynamic control in mastectomy patients. J Clin Anesth 2004; 16:88-91. [PMID: 15110368 DOI: 10.1016/j.jclinane.2003.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2002] [Accepted: 05/01/2003] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVES To investigate, in mastectomy patients, the effectiveness of continuous cervical epidural block using a low-dose fentanyl infusion in combination with local anesthetics. DESIGN Prospective, observational study. SETTING 450-bed, university-affiliated hospital. PATIENTS 21 ASA physical status I and II female patients undergoing modified radical mastectomy. INTERVENTIONS An epidural catheter was inserted at the C(7)-Th(1) interspace before the induction of anesthesia. Anesthesia was maintained using a low concentration of sevoflurane with nitrous oxide-oxygen (N(2)O-O(2)). A mixture of 100 microg fentanyl and 49 mL of 1% mepivacaine was prepared, and 7 mL of this solution was epidurally injected before the initial incision. This same solution was continuously infused at a rate of 7 mL/hr (fentanyl 17.5 microg/hr) throughout the anesthesia, and at 2 mL/hr (fentanyl 5 microg/hr) postoperatively. MEASUREMENTS AND MAIN RESULTS Intraoperative mean arterial pressure (MAP) and heart rate (HR), postoperative pain and analgesic use, and the frequency of postoperative side effects of anesthesia, including nausea, dizziness, and respiratory depression, were recorded. The protocol described provided stable intraoperative hemodynamic control with no or low-dose nicardipine infusion. Sufficient postoperative analgesia was achieved in 18 of 21 patients. One patient reported postoperative nausea, and no other side effects were reported. CONCLUSIONS Continuous epidural infusion of the low-dose fentanyl mixture described above provides adequate intraoperative hemodynamic control and postoperative pain relief, with a low rate of side effects in mastectomy patients.
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Affiliation(s)
- Yoshifumi Kotake
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan.
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Lechner TJ, van Wijk MG, Maas AJ, van Dorsten FR, Drost RA, Langenberg CJ, Teunissen LJ, Cornelissen PH, van Niekerk J. Clinical results with the acoustic puncture assist device, a new acoustic device to identify the epidural space. Anesth Analg 2003; 96:1183-1187. [PMID: 12651681 DOI: 10.1213/01.ane.0000052382.04446.42] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Sixty patients scheduled for lumbar epidural anesthesia were included in a study in which we evaluated the efficacy of localizing the epidural space by means of an acoustic signal. A prototype of an acoustic puncture assist device, connected to the epidural needle by an extension tube, generated the pressure needed to perform the epidural puncture and translated this pressure into corresponding acoustic and visible signals. The device frees the anesthesiologist to handle the epidural needle with both hands and to detect the epidural space by means of these signals. In all 60 patients (100%), the epidural space was successfully located by using the acoustic signal. In all cases, this was confirmed by the pressure measurement, which proved to be a reliable indicator for correct identification of the epidural space. We conclude that it is possible to locate the epidural space by means of the acoustic puncture assist device. The method proved to be reliable, safe, and simple in this study. The benefits of this new epidural puncture technique include better needle control, teaching, control of correct catheter placement, and documentation. The last can be an important adjunct to anesthesia practice. IMPLICATIONS The authors demonstrate that it is possible to identify the epidural space by an acoustic and visible signal. An experimental setup constructed for this purpose makes the epidural puncture procedure audible and visible.
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Affiliation(s)
- Timo J Lechner
- Departments of *Anesthesiology and Pain Therapy and †Clinical Physics, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands
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Senard M, Joris J. [Use of ropivacaine for peridural postoperative analgesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:713-24. [PMID: 12494805 DOI: 10.1016/s0750-7658(02)00781-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice. DATA SOURCES Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block. STUDY SELECTION Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded. DATA EXTRACTION Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia. DATA SYNTHESIS 20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1. CONCLUSIONS Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.
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Affiliation(s)
- M Senard
- Service d'anesthésie-réanimation, CHU de Liège, domaine du Sart Tilman, B-4000 Liège, Belgique.
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Abstract
PURPOSE OF REVIEW The controversy over preemptive analgesia continues unabated, with studies both supporting and refuting its efficacy. The timing of an analgesic intervention and presence of a placebo control may have significant impact on the interpretation of results and may have led to the premature conclusion that preemptive analgesia is of limited clinical utility. A review of the recent literature using strict definitions of preemptive and preventive analgesia is required in order to clarify the broader issue of the benefits of perioperative analgesia. RECENT FINDINGS A total of 27 studies, published from April 2001 to April 2002, were found to evaluate preemptive (n = 12) or preventive analgesia (n = 15). Evidence for a benefit of preventive analgesia was strong, with 60% of studies finding reduced pain or analgesic consumption beyond the clinical duration of action of the analgesic intervention. Evidence for a benefit of preemptive analgesia was equivocal, with 41.7% of studies demonstrating that preincisional treatment reduces pain or analgesic consumption to a greater extent than does postincisional treatment. SUMMARY Studies that used a preventive design had a greater likelihood of finding a beneficial effect. The application of preventive perioperative analgesia (not necessarily preincisional) is associated with a significant reduction in pain beyond the clinical duration of action of the analgesic agent, in particular for the N-methyl-D-aspartate antagonists. The classical definition of preemptive analgesia should be abandoned in favor of preventive analgesia. This will broaden the scope of inquiry from a narrow focus on preincisional versus postincisional interventions to one that aims to minimize postoperative pain and analgesic requirements by reducing peripheral and central sensitization arising from noxious preoperative, intraoperative and postoperative inputs.
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Affiliation(s)
- Joel Katz
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Lechner TJM, van Wijk MGF, Maas AJJ. Clinical results with a new acoustic device to identify the epidural space. Anaesthesia 2002; 57:768-72. [PMID: 12133089 DOI: 10.1046/j.1365-2044.2002.02621.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fifty patients scheduled for surgery under lumbar epidural anaesthesia were included in a study to evaluate the possibility of localising the epidural space solely by means of an acoustic signal. With an experimental set-up, the pressure generated during the epidural puncture procedure was translated into a corresponding acoustic signal. One anaesthetist held the epidural needle with both hands and detected the epidural space by means of this acoustic signal. At the same time, a second anaesthetist applied the loss of resistance technique and functioned as control. In all patients the epidural space was located with the acoustic signal. This was confirmed by conventional loss of resistance in 49 (98%) of the patients; in one patient (2%) it was not. We conclude that it is possible to locate the epidural space using an acoustic signal alone.
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Affiliation(s)
- T J M Lechner
- Departm,ent of Anaesthesiology and Pain Therapy, Bosch Medicentrum, 5200 ME's-Hertogenbosch, The Netherlands.
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Nielsen KC, Steele SM. Outcome after regional anaesthesia in the ambulatory setting--is it really worth it? Best Pract Res Clin Anaesthesiol 2002; 16:145-57. [PMID: 12491549 DOI: 10.1053/bean.2002.0244] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Regional anaesthesia provides a continuum of perioperative care that includes perioperative pain management, decreased opioid requirements and decreased post-operative nausea and vomiting. In addition to these benefits, a wide variety of perioperative outcomes can be enhanced by utilizing regional anaesthesia in the ambulatory setting. Regional anaesthesia has been shown to improve the cardiovascular, pulmonary, gastrointestinal, coagulative, immunological and cognitive functions and to be of benefit in an economic context. These improvements are particularly advantageous in caring for elderly and high-risk patient populations undergoing surgery. In addition, regional anaesthesia can facilitate early recovery with excellent post-operative analgesia and few side-effects, which may decrease overall operative costs. This chapter identifies important perioperative outcomes that may be positively influenced by the use of regional anaesthesia in the ambulatory setting.
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Affiliation(s)
- Karen C Nielsen
- Department of Anesthesiology, Division of Ambulatory Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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