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REGIONAL ANESTHESIA

Continuous Thoracic Epidural Anesthesia with 0.2% Ropivacaine Versus General Anesthesia for Perioperative Management of Modified Radical Mastectomy

Nabil W. Doss, MD^*, Joseph Ipe, MD^*, Thomas Crimi, MD^*, Sanjeev Rajpal, MD, Steven Cohen, MD, Richard J. Fogler, MD, Rafik Michael, MD^*, and Jonas Gintautas, MD, PhD, MBA

Departments of *Anesthesiology and Surgical Services, The Brookdale University Hospital and Medical Center, Brooklyn, New York

Address correspondence and reprint requests to Nabil W. Doss, MD, The Brookdale University Hospital and Medical Center, 1 Brookdale Plaza, Brooklyn, NY 11212.

Abstract

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5–10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1–2 mg of midazolam or 50–100 µg/mL of fentanyl followed by 50–150 mg of propofol and was maintained with sevoflurane and 50% N₂O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

Implications: Ropivacaine 0.2%, a new, long-acting local anesthetic used for continuous thoracic epidural anesthesia, is a safe and reliable alternative to general anesthesia for patients undergoing breast surgery because of cancer. It facilitates recovery from anesthesia, significantly reduces postoperative pain, nausea, and vomiting, and positively contributes to the patient’s overall outcome.

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