Anesth Analg 2002;94:355-359
© 2002 International Anesthesia Research Society
AMBULATORY ANESTHESIA
Paravertebral Blockade for Minor Breast Surgery
Michel A. Terheggen, MD*
,
Frank Wille, MD
,
Inne H. Borel Rinkes, MD, PhD
,
Trian I. Ionescu, MD, PhD, and
Johannes T. Knape, MD, PhD
*Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands; Department of Anesthesiology, Diakonessenhuis, Utrecht/Zeist, The Netherlands; Division for Perioperative Care, Anesthesia and Pain Medicine, University Medical Center, Utrecht, The Netherlands; and Department of Surgery, University Medical Center Utrecht, The Netherlands
Address correspondence and reprint requests to Michel A. M. B. Terheggen, Department of Anesthesiology, Ziekenhuis Rijnstate, Postbus 9555, 6800 TA Arnhem, the Netherlands. Address e-mail to mterhegg{at}euronet.nl
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Abstract
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Paravertebral blockade (PVB) has been advocated as a useful technique for breast surgery. We prospectively compared the efficacy of PVB via a catheter technique with the efficacy of general anesthesia (GA) for minor breast surgery. Thirty patients were randomized into two groups to receive either PVB or GA. Variables of efficacy were postoperative pain measured on a visual analog scale, postoperative nausea and vomiting (PONV), recovery time, and patient satisfaction. Postoperative visual analog scale scores in the PVB group were significantly lower in the early postoperative period (maximum, 12 vs 45 mm; P < 0.01). In both groups, PONV was nearly absent. There was no difference in recovery time. Patient satisfaction was better in the PVB group (2.8 vs 2.3; scale, 0–3; P < 0.01). There was one inadvertent epidural block and one inadvertent pleural puncture in the PVB group. Although PVB resulted in better postoperative pain relief, the advantages over GA were marginal in this patient group because postoperative pain was relatively mild and the incidence of PONV was small. Considering that the technique has a certain complication rate, we conclude that at present the risk/benefit ratio of PVB does not favor routine use for minor breast surgery.
IMPLICATIONS: This study confirms the previously reported superior pain relief after paravertebral blockade (PVB) for breast surgery. However, considering the relatively mild postoperative pain and therefore the limited advantage of PVB for these patients, the risk/benefit ratio does not favor the routine use of PVB for minor breast surgery.
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Introduction
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Diagnostic and minor therapeutic breast surgery is usually performed in an outpatient setting. The anesthetic technique should aim at fast recovery and adequate postoperative pain relief. This cannot always be achieved with general anesthesia (GA), which may be associated with considerable postoperative pain and a frequent incidence of postoperative nausea and vomiting (PONV) (1). GA is the most commonly used technique for breast surgery. Interest in paravertebral blockade (PVB) is increasing (2–9). This technique is characterized by unilateral regional blockade of several dermatomes without sympathicolysis and with effective blockade of pain stimuli (10,11). These unique characteristics are attributed to ipsilateral blockade of the spinal nerves and sympathetic chain, without blocking of the contralateral sympathetic chain (12). In a prospective, multicenter study, the technique seemed safe and reliable in 367 patients (13). PVB seems to be a solution for the problems of postoperative pain and PONV after breast surgery. Several groups have studied the technique in various settings and report a reduction in the incidence of both postoperative pain and PONV (14–17).
There have been no prospective randomized studies comparing PVB with GA in minor breast surgery. The goal of this study was to prospectively evaluate the efficacy of PVB compared with GA for this specific patient group in a day-case setting. The primary outcome was the severity of postoperative pain; secondary outcome measures were PONV, time until discharge, and patient satisfaction.
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Methods
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The study was approved by the hospital ethical committee. After extensive information about the procedures and written informed consent, 30 patients (ASA physical status I or II), aged 17–72 yr, were included in the study. All were scheduled for elective, outpatient, minor breast surgery. Minor breast surgery included lumpectomies, quadrantectomies (with or without a sentinel node procedure), and radiograph wire-localized breast biopsies. Patients with any contraindication for regional anesthesia, such as infection of the puncture site, anatomic deformities, or coagulation disorders, were excluded. No premedication was given. The patients were randomized into two groups by use of sealed envelopes. After arrival at the day-care unit, patients in Group 1 had an end-hole 20-gauge catheter placed into the paravertebral space through an 18-gauge Tuohy needle by using the technique described by Eason and Wyatt (10). The catheter was inserted at the T3-4 interspace and was advanced 1–2 cm into the paravertebral space. All PVB and GA procedures were performed by one of the investigators (MT or FW). Patients for whom a radiograph wire localization of a nonpalpable lesion was planned were given 15–20 mL of mepivacaine 2% with epinephrine 1:200,000 until adequate blockade was obtained in the surgical area. The dermatomal level of analgesia was determined by pinprick. After the localization procedure, before surgery, they received 15–20 mL of bupivacaine 0.5% with epinephrine 1:200,000 through the paravertebral catheter. Patients who were not planned for a localization procedure also received 15–20 mL of bupivacaine 0.5% with epinephrine 1:200,000 a half hour before surgery. Local anesthetics were administered after a negative aspiration test and a 2-mL test dose. During the operation, patients in this group were offered sedation with propofol by using a target-controlled infusion (TCI) system aiming at plasma levels of propofol of 1.5–3 µg/mL. After completion of surgery, the paravertebral catheter was removed in the operating room. Patients in Group 2 were anesthetized with fentanyl 1–1.5 µg/kg and propofol TCI, aiming at plasma levels of propofol of 3–5 µg/mL. After the insertion of a laryngeal mask airway, patients were allowed to breathe spontaneously a mixture of oxygen/nitrous oxide 1:2. In both groups, a bolus of 0.5 µg/kg fentanyl was administered if heart rate or mean arterial blood pressure increased more than 20% above baseline values. In the postoperative period, all patients received the same analgesic and antiemetic regimen: on request, 500 mg of rectal naproxen was given; if this proved insufficient after 30 min, morphine 0.15 mg/kg was administered (one third IV, two thirds IM). Nausea lasting more than 10 min or vomiting was treated with 4 mg ondansetron IV. Pain was scored with a 100-mm visual analog scale (VAS) by a trained recovery nurse who was not informed about the technique used. VAS scores were taken at 15 and 30 min and every 30 min until discharge.
PONV was scored by the same nurse, at the same intervals, by using a system in which two points were given when the patient had vomited in the past time interval, one point when the patient experienced nausea, and zero points when neither phenomenon was present. The amounts of administered analgesics and antiemetics were registered. Patients were discharged from the postanesthesia care unit (PACU) as soon as they reached an Aldrete score of 9 points and had an acceptable drain production. The recovery time was noted. Patient satisfaction was scored the day after operation by telephone, rating 0 to 3, varying from very unsatisfied to very satisfied. Pain experienced during the radiograph wire localization was scored retrospectively by using a 1–5 verbal numeric score. The duration of this procedure was recorded by the radiologist.
Data are expressed in mean values ± SD and were compared by using a two-sample Student’s t-test or Mann-Whitney U-test for nonparametric data. P < 0.05 was considered statistically significant. Data of patients with failures or complications were analyzed in the original groups according to the intention-to-treat principle.
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Results
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Fifteen patients were included in Group 1 (PVB), of whom 10 underwent radiograph wire localization, and 15 patients were included in Group 2 (GA), of whom 9 underwent a localization procedure. The average age in Group 1 was 48 ± 10 yr; in Group 2 the average age was 51 ± 12 yr. The average height was 165 ± 7 cm in Group 1 and 167 ± 6 cm in Group 2. The average weight was 72 ± 7 kg in Group 1 and 66 ± 10 kg in Group 2. Thirteen patients in Group 1 had ASA physical status I; Group 2 had 11 patients with ASA physical status I. The other patients all had ASA physical status II. No significant statistical differences in demographic characteristics were noted between the groups. The average time to establish an adequate PVB was 25 min. Amounts of local anesthetics used and the extents of the blockades are listed in Table 1.
Mean postoperative VAS scores were significantly lower in the PVB group, except after 120 min, when all patients were almost free of pain (Fig. 1). The maximum VAS score in the PVB group was 11 ± 15 mm, versus 44 ± 23 mm in the GA group (P < 0.001). Table 2 lists all other results: PONV was nearly absent in both groups. Only one patient, in the GA group, required antiemetic medication. Pain scores during the localization procedure were significantly lower in the PVB group. Patient satisfaction scores were significantly higher in the PVB group. Patients in the GA group required more analgesics; intraoperative fentanyl, postoperative naproxen, and morphine requirements were significantly larger in the GA group. There were no significant differences in recovery time between groups.
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Figure 1. Mean postoperative visual analog scale (VAS) pain scores in millimeters (0 = no pain to 100 = worst pain imaginable) reported by patients at 15, 30, 60, 90, and 120 min after arrival at recovery and at time of discharge from the recovery room after receiving paravertebral block (PVB) or general anesthesia (GA). *P < 0.01; **P <0.001. Error bars = SEM.
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One patient in the PVB group developed a bilateral blockade with transient mild dyspnea and mild hypotension. This occurred 10 min after a dose of 8 mL mepivacaine 2% with epinephrine 1:200,000. The lowest mean arterial pressure was 50 mm Hg. Mean arterial pressure was normalized within 5 min after a fluid challenge of 500 mL of colloid solution. Dyspnea resolved spontaneously in the same time. Although this patient had a surgical bilateral thoracic blockade, she received GA for the surgical procedure at her request. Her length of stay on the PACU was 135 min, and her patient satisfaction score was 2 (satisfied). Another patient in this group had an accidental pleural puncture. This was noted by the more than normal loss of resistance when advancing the needle over the transverse process. Interpleural placement of the needle was confirmed by the inward movement of fluid through the Tuohy needle with inspiration of the patient. The planned PVB was converted successfully to an interpleural blockade with 20 mL bupivacaine 0.5% with epinephrine 1:200,000. The patient had no clinical signs of pneumothorax. We let her stay in the PACU for 195 min. Her patient satisfaction score was 2 (satisfied). A pneumothorax could not be demonstrated by radiologic follow-up for 2 days. In the GA group there were no complications.
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Discussion
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The results of this study demonstrate that thoracic PVB results in superior postoperative pain relief compared with GA when used for minor breast surgery. This confirms the reported efficacy of PVB (2–9). In addition, there are other advantages of PVB for women undergoing breast surgery, such as a reduced incidence of PONV (14–17). New developments in oncologic breast surgery, such as sentinel node biopsy, have resulted in a more differentiated continuum of surgical procedures, ranging from a diagnostic lumpectomy to a modified radical mastectomy. Therefore, a more differentiated anesthetic approach should be applied, and thus we investigated the efficacy of PVB specifically for minor breast surgery.
Although we found a significant postoperative pain reduction in the PVB group, pain in the GA group was relatively mild and of short duration (Fig. 1). Also, we found no significant PONV when using propofol TCI in both groups. The relatively mild pain scores in the GA group underline the importance of evaluating PVB in specific patient groups. The absence of PONV contrasts with reports in the literature (1) and with recent observations of Klein et al. (16) and Pusch et al. (17). A possible explanation for this finding might be the difference in patient selection with both studies, because we limited our study to small surgical procedures. Another reason might have been our choice for propofol as a general anesthetic. A technique with an inhaled anesthetic may have shown other results, possibly more in favor of PVB. The fact that Pusch et al. also used propofol for GA, in contrast with the group of Klein et al., makes the influence of the choice of GA technique difficult to assess. Our study showed that only 4 of 15 patients in the GA group needed morphine postoperatively. This is another reason that postoperative pain experienced by these patients was relatively mild and might be another reason for the infrequent PONV occurrence in our study.
Although PVB leads to a reduction in postoperative pain, it was obvious that pain was not the sole limiting factor for discharge from the PACU. Length of stay was predominantly determined by other factors, such as surgical care and observation of drain production. Patients with a PVB who underwent a radiograph wire localization procedure experienced less pain during the procedure, but this did not reduce the time needed by the radiologist to perform the localization. The reduced pain during the localization procedure was an important factor for the higher patient satisfaction scores in the PVB group. We also noticed appreciation for PVB in study patients who later presented for definite oncologic breast surgery. They often refused to undergo the operation without a PVB.
In respect to the technique of PVB itself, there are several approaches to achieve the blockade. Several North American authors prefer a multiple-injection method, whereas most European authors prefer the large-volume, single-puncture technique. Good results have been reported from both methods (10,11,14–17). Our choice for the single-injection technique is based on the following considerations: A single injection gives less patient discomfort and might diminish the need for sedation during performance of the PVB. Furthermore, the single-puncture technique has been prospectively studied in 367 patients and seems to be safe and effective (13). As for now, no prospective studies concerning the safety and efficacy of the multiple-injection technique have been published. It might be logical to assume that a multiple-injection technique multiplies the probability of direct puncture-related complications with the number of punctures. Another consideration is that the single-puncture technique gives the opportunity to place a paravertebral catheter, as we did in this study. A catheter makes it possible to fractionate the amount of injected local anesthetic solution, which might play a role in increasing the safety of PVB. Also, a catheter makes it possible to reestablish neural blockade, as in our patients who underwent a radiograph wire localization procedure, or to apply a continuous technique. However, the large-volume single-puncture technique does have some disadvantages. The spread of local anesthetics can vary, as can be seen from the number of blocked dermatomes in Table 1. A disadvantage of using a catheter is the introduction of catheter-related complications. The patient in our study with a bilateral blockade is an example of such an event, for she had an inadvertent epidural placement of the catheter, as confirmed by radiograph contrast evaluation. Moreover, the small-volume multiple-injection technique seems to be a reliable and safe method, for it is practiced on a large scale in North America without reports of relevant disadvantages or complications. A prospective, large-number, multicenter comparison between these different techniques of PVB will be useful in answering the questions that arise from this discussion.
Because each regional technique has its failure rate and risk of complications, it is important to clearly identify specific patient groups in which the benefits outweigh these drawbacks. For women undergoing minor breast surgery, we conclude that the risk/benefit ratio of single-puncture large-dose PVB does not favor the routine use of this regional technique, because of the relatively mild postoperative pain and the near absence of PONV in this patient group.
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Acknowledgments
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The authors wish to thank their research professor Cor J. Kalkman, MD, PhD, for his support, time, and energy.
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Accepted for publication October 19, 2001.
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Abstract
Introduction
