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© 2000 International Anesthesia Research Society
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Abstract |
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Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. Paravertebral nerve block (PVB) has the potential to offer long-lasting pain relief and fewer postoperative side effects when used for breast surgery. We compared thoracic PVB with general anesthesia for cosmetic breast surgery in a single-blinded, prospective, randomized study of 60 women scheduled for unilateral or bilateral breast augmentation or reconstruction. Patients were assigned (n = 30 per group) to receive a standardized general anesthetic (GA) or thoracic PVB (levels T1–7). Procedural data were collected, as well as verbal and visual analog pain and nausea scores. Verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea to GA alone.
Implications: Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.
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Introduction |
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Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. In the United States, nearly one in eight women will develop breast cancer and many will undergo a mastectomy with reconstruction (1). Many women will also undergo elective cosmetic surgery. Unfortunately, despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, vomiting, and chronic pain (2–4). The reasons for the intense nausea after breast surgery are multifactorial. One prominent factor is general anesthesia (GA), which is still associated with a 50% incidence of nausea and vomiting in breast surgery patients (3). These complications lead to patient suffering, extended postanesthesia care unit (PACU) stays, prolonged admissions, and additional hospital costs. Paravertebral nerve block (PVB) is an anesthetic technique that may reduce these complications, because it can uniquely eliminate cortical responses to thoracic dermatomal stimulation when compared with other forms of central neuraxial block (e.g., epidural anesthesia) (5). This profound block may offer an alternative to GA that also provides inhibition of painful stimuli, both of which may play a role in the pain and complications in these patients.
At our institution, PVB has been used to provide operative and immediate postoperative analgesia for breast cancer surgery (6). In initial nonrandomized trials, it has provided excellent unilateral chest wall anesthesia, a low frequency of postoperative nausea and vomiting, and low supplemental analgesic requirements (7). We report a randomized, prospective study comparing thoracic PVB with GA.
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Methods |
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Approval for the study was obtained from our institutional review board. Sixty patients, classified as ASA physical status I–III, aged 18 yr or older, gave written, informed consent to participate in this randomized, prospective, single-blinded trial. All patients were scheduled for unilateral or bilateral breast augmentation or reconstruction. Patient exclusion criteria included coagulopathy, infection at the site of block placement, and morbid obesity (twice the ideal body weight or >130 kg).
Patients were assigned by prerandomized, sealed envelopes to receive one of two different anesthetics: Group 1, GA (n = 30); and Group 2, PVB, thoracic level T1–7 (n = 30)
Patients randomized to receive GA were premedicated with 0.5–2.0 mg of midazolam IV. Anesthesia was induced with propofol 1.5–2 mg/kg IV and fentanyl 1–3 µg/kg IV. Succinylcholine 2 mg/kg IV was used to facilitate the intubation of the trachea. Anesthesia was maintained with isoflurane and nitrous oxide in oxygen. Fentanyl 1–2 µg/kg IV was administered at the discretion of the anesthesiologist. No further muscle relaxants were administered after tracheal intubation.
Patients randomized to receive a PVB were sedated in the sitting position by using 1–5 mg of midazolam IV and 100–250 µg of fentanyl IV. The blocks were performed, by using the technique described by Moore (8) and Katz (9), by one senior resident and attending anesthesiologists experienced in the technique. The superior aspects of the spinous processes of thoracic levels T1–7 were identified. The needle entry site was marked 2.5 cm lateral to each spinous process ipsilateral to the operative breast. When surgery involved both breasts, PVB was performed bilaterally. By using a 22-gauge, 3.5-inch Quincke spinal needle attached via extension tubing to a syringe, the needle was advanced anteriorly in the parasagittal plane (perpendicular to the back in all directions) until it contacted the transverse process. The needle was then withdrawn to the subcutaneous tissue and angled to walk off the caudad edge of the transverse process. From the caudad edge, it was then advanced anteriorly approximately 1 cm. After aspiration of the syringe, 4 mL of 0.5% bupivacaine with 1:400,000 fresh epinephrine was injected at each of the seven levels. The patient was then returned to the supine position and sensation was assessed by using pin-prick. After assuring adequate anesthesia, the patient was transferred to the operating room. Intraoperative sedation was provided with propofol 30–70 µg · kg-1 · min-1 IV, titrated to moderate sedation, with patients being arousable on command. Intermittent doses of 25 µg of fentanyl IV and 10 mg of propofol IV were given for supplemental sedation.
As a prophylactic antiemetic, all patients were treated with 4 mg of ondansetron IV, 30 min before the end of the procedure. At the conclusion of surgery, all patients were transferred to the PACU. Patients were medicated with either morphine 20–50 µg/kg IV or fentanyl (if there was a previous adverse reaction to morphine) 0.2–0.5 µg/kg IV repeated every 5 min as necessary to relieve severe pain, rated by using the visual analog scale (VAS) greater than 3. Results are reported as morphine equivalents (fentanyl 10 µg = morphine 1 mg). For nausea or vomiting, patients received 4 mg of ondansetron IV.
Procedural data were collected, including the time to perform the GA (the time from monitor placement until intubation) and the time to place the PVB (the time from monitor placement until positioned supine). The need for reblock and the need for intraoperative local anesthetic supplementation by the surgeon were noted. In addition, the total intraoperative fentanyl dose administered to each patient was recorded. A research assistant unaware of the anesthetic technique collected postoperative patient data.
Patients were asked to record their pain by using a verbal analog pain score (0 = no pain to 10 = worst pain imaginable) and a VAS (0 mm = no pain to 100 mm = worst pain imaginable). Nausea was measured by using a verbal rating score (0 = no nausea to 10 = vomiting). Verbal scores for pain were collected postoperatively at 30 min, 60 min, 24 h, 48 h, and 72 h. If patients were discharged from the hospital, VAS for pain was used to measure later time points. These measurements were recorded on written forms at 24, 48, and 72 h and submitted by mail. Nausea scores were collected at 30 min, 60 min, and 24 h. In addition, patients were asked to record when they first felt able to resume their daily routine.
Descriptive statistics for demographics, procedural data, and intraoperative narcotics were produced. In addition, pain and nausea scores were analyzed. Statistical analysis for this study used a continuity-corrected, Wilcoxon’s two-sample test with a 0.05 two-sided significance level to test whether the proportion of patients reporting pain and nausea in the GA group was statistically different from that in the PVB group. This test was also used to compare responses from the two groups for each variable. For the purposes of the power determination, the two groups were taken to be of equal size, n = 30 per group. Parametric data were reported as mean ± SD.
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Results |
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Sixty patients completed the study protocol. Only one patient in the PVB group had a failed block and required GA and, therefore, was omitted from analysis. There were no differences between the GA and PVB groups in age (44 ± 14 vs 48 ± 14 yr), weight (62 ± 12 vs 66 ± 12 kg), height (162 ± 8 vs 164 ± 4 cm) or ASA physical status. All patients were women. Three patients in the PVB group required reblock (bupivacaine 25 mg/level). The mean supplemental dose of bupivacaine was 58 ± 29 mg. Supplemental local anesthetic was not required intraoperatively. The mean time for anesthesia preparation was 4 ± 1 min in the GA group and 24 ± 7 min for the PVB group (P = 0.0001). Bilateral reconstruction was performed in 13 patients in the GA group and 18 patients in the PVB group (P = 0.43). The types of surgical procedures performed are listed in Table 1. The mean duration of surgery was 117 ± 68 min in the GA group and 104 ± 33 min in the PVB group (P = 0.3). The mean dose of propofol used for sedation in the PVB group was 305 ± 160 mg IV. The amount of intraoperative fen- tanyl was 277 ± 120 µg IV in the GA group and 235 ± 96 µg IV in the PVB group (P = 0.13)
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The verbal analog pain scores demonstrated statistically significant less pain at 30 min, 1, 24, and 72 h (Figure 1). The VAS scores, designed to test pain at the later time periods (24, 48, and 72 h after discharge) demonstrated a numeric reduction in pain scores at each time interval; however, differences between groups were not statistically significant (Figure 2). In the PACU, 17 of 30 patients in the GA group and 8 of 30 patients in the PVB group required supplemental analgesics (GA group, 5 ± 3 mg of morphine and 26 ± 37 µg of fentanyl; PVB group, 0 ± 1 mg of morphine and 4 ± 13 µg of fentanyl). The GA group used 3 times more supplemental narcotic (morphine equivalent) (3.6 ± 4.0 mg) versus the PVB group (0.8 ± 2.0 mg) (P = 0.001).
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Nausea scores are depicted in Figure 3. Despite lower mean nausea scores in the PVB group at 30 min, 1 h, and 24 h, only the measure at 24 h reached statistical significance (P = 0.04). In addition, there were no adverse events in either group requiring intervention by the anesthesia team. Both groups returned to work after an average of 10 days (P = 0.910).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The results of this study suggest that PVB provides improved analgesia during the first 24 hours after breast surgery when compared with GA (Figure 1). The improved analgesia may last as long as 72 hours after initial block.
These data were corroborated by a threefold increase in the GA group’s requirement for supplemental analgesics in the first hour in the PACU, compared with that used in the PVB group. The analgesic effect of PVB appears to last longer than would be predicted based on local anesthetic kinetics alone (10). The explanation for this prolonged effect is unclear. When compared with other forms of central neuraxial block (e.g., epidural anesthesia) (5), PVB has been shown to be uniquely effective in eliminating cortical responses to thoracic dermatomal stimulation. This may perhaps inhibit a central reflex involved in pain. However, further work is needed to clarify the etiology of this extended pain relief.
In addition, the data demonstrated lower nausea and vomiting scores at 30 minutes, 1 hour, and 24 hours in the PVB group; however, only the value at 24 hours was statistically significant (P = 0.04). The lower scores may, in part, be the result of improved analgesia and the need for less postoperative opioids. Despite the lack of statistical significance, the fact that the overall nausea scores were lower in the PVB group is encouraging. The incidence of nausea and vomiting in this patient population is particularly high. The fact that measurements at earlier times failed to meet statistical significance, may be attributable to the low overall nausea scores recorded by patients. This may, in part, be caused by the universal use of prophylactic antiemetics in the study or perhaps the small sample size.
Frequently, labor-intensive anesthetic techniques do not gain acceptance because of their requirement for operating room time. Clearly, significantly more time was involved (24 minutes) to place the PVB than the 4 minutes used to induce the general anesthetic (P = 0.0001). This is definitely a disadvantage for a technique that requires positioning and multiple injections. However, using a monitored preoperative holding area to place the blocks may be one way to avoid this problem. Another disadvantage of PVB is the potential inadvertent injection or spread into the epidural space. The paravertebral space lies directly adjacent to the intervertebral foramina and in close proximity to the epidural space. Further, because the space also contains vascular structures, aspiration for blood before injection is essential. This potential for spread emphasizes the lack of a definitive end point when entering the paravertebral space. Pleura of the lung extends down to the level of T-12. Another technical complication could be a pneumothorax from deep needle penetration at the thoracic level. Although these complications were not noted in this series of patients, further prospective studies on a large patient population are necessary to evaluate overall safety of the technique.
In conclusion, this study demonstrated improved postoperative analgesia from PVB at 30 minutes (P = 0.0005), 1 hour (P = 0.0001), and 24 hours (P = 0.04) and may last as long as 72 hours, when compared with GA alone, for cosmetic breast surgery. In addition, there was a trend of less postoperative nausea in those treated with a PVB; however, this was only statistically significant at 24 hours (P = 0.04). Despite the additional time required on behalf of the anesthesiologist, the technique offers patients postoperative benefits that may justify the increased effort. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea than GA alone.
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Acknowledgments |
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The authors are grateful to Cynthia Shimer, BS, for her expert technical assistance.
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References |
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- Chang J. A review of breast cancer chemoprevention. Biomed Pharmacother 1998;52:133–6.[Medline]
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Tasmuth T, von Smitten K, Hietanen P, et al. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol 1995;6:453–9.
[Abstract/Free Full Text] - Fujii Y, Tanaka H, Toyooka H. Prophylactic antiemetic therapy with granisetron-dexamethasone combination in women undergoing breast surgery. Acta Anaesthesiol Scand 1998;42:1038–42.[Web of Science][Medline]
- Quinn A, Brown J, Wallace P, Asbury A. Studies in postoperative sequelae. nausea and vomiting—still a problem. Anaesthesia 1994;49:62–5.[Web of Science][Medline]
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Richardson J, Jones J, Atkinson R. The effect of thoracic paravertebral blockade. Anesth Analg 1998;87:373–6.
[Abstract/Free Full Text] - Greengrass R, O’Brien F, Lyerly K, et al. Paravertebral block for breast cancer surgery. Can J Anaesth 1996;43:858–61.[Web of Science][Medline]
- Coveney E, Weltz C, Greengrass R, et al. Use of paravertebral block anesthesia in the surgical management of breast cancer. Ann Surg 1998;227:496–501.[Web of Science][Medline]
- Moore D. A handbook for use in clinical practice of medicine and surgery. 4th ed. Springfield, IL:Charles C. Thomas, 1965.
- Katz J. Atlas of regional anesthesia. 2nd ed. Norwalk, CA:Appleton and Lange, 1994.
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Cheung S, Booker P, Franks R, Pozzi M. Serum concentrations of bupivacaine during prolonged continuous paravertebral infusion in young infants. Br J Anaesth 1997;79:9–13.
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