Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial

BACKGROUND AND OBJECTIVE: Different anaesthetic techniques are used during breast surgery but are frequently associated with unsatisfactory postoperative analgesia. Paravertebral nerve blockade has recently been proposed as a favourable alternative for this type of surgical procedure, providing excellent pain relief and a reduced incidence of postoperative nausea and vomiting. The aim of the present study was to compare the use of a nerve-stimulator guided paravertebral nerve blockade technique to regular general anaesthesia for breast surgery. METHODS: Sixty patients were prospectively randomized to receive either paravertebral nerve blockade or general anaesthesia for breast surgery. The primary end-point of the study was to assess postoperative analgesia (visual analogue scale and supplemental opioid requirements); the incidence of postoperative nausea and vomiting and length of hospital stay were considered as secondary outcome measures. RESULTS: Visual analogue scores both at rest and at movement, as well as the need for supplemental opioid administration during the first 3 days postoperatively, were significantly lower in patients handled with para-vertebral nerve blockade compared to patients receiving general anaesthesia (P < 0.05). The number of patients free from nausea and vomiting after operation was significantly higher in the paravertebral nerve blockade group (93%) compared to the general anaesthesia group (67%) (P < 0.05). The use of paravertebral nerve blockade was also associated with a significantly shorter hospital stay (median 1 day) compared to general anaesthesia (2 days) (P < 0.01). Both the performance of the block and the intraoperative conditions was well accepted by the vast majority of patients treated by paravertebral nerve blockade (97%). CONCLUSION: The use of paravertebral nerve blockade was associated with improved postoperative pain relief, a reduced incidence of nausea and vomiting after operation and a shorter duration of hospital stay compared to general anaesthesia in patients undergoing breast surgery.     

Nerve stimulator-guided paravertebral blockade combined with sevoflurane sedation versus general anesthesia with systemic analgesia for postherniorrhaphy pain relief in children: a prospective randomized trial

BACKGROUND: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair. METHODS: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair. RESULTS: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05). CONCLUSIONS: Paravertebral nerve blockade was associated with improved postoperative pain relief; reduced analgesic consumption, and faster hospital discharge compared with a systemic analgesia protocol in children undergoing herniorrhaphy.     

Paravertebral blockade vs general anesthesia or spinal anesthesia for inguinal hernia repair

One hundred and fifty-five patients scheduled for inguinal hernia repair (IHR) were given the choice of either general anesthesia (GA) (n = 53) or spinal anesthesia (SP) (n = 47) or nerve stimulator guided paravertebral blockade (PVB) (n = 55). The incidence of postoperative nausea and vomiting (PONV), duration of hospital stay and need for postoperative analgesia were recorded. Apart from a difference in the age of patients in the GA group who were found to be slightly younger, all groups were found similar with regard to weight, height, duration of surgery, sex, type of hernia and ASA class. The incidence of PONV (0%) v/s 19% and 21% was significantly reduced in patients treated with the PVB compared to patients receiving SA and GA respectively. The length of hospital stay was also found to be shorter in the PVB group (mean 1.2 days) v/s SA (mean 2.4 days) and GA (mean 2.9 days). The need for supplemental postoperative analgesics was also found to be higher in both SA and GA when compared to PVB patients who were managed without any analgesics during the first 24 postoperative hours. The described technique appears to be an attractive alternative method to provide adequate anesthesia for IHR.     

Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases.

OBJECTIVE: To assess safety and efficacy of the regional anesthetic technique paravertebral block for operative treatment of breast cancer, and to compare postoperative pain, nausea, vomiting, and length of hospital stay in patients undergoing breast surgery using paravertebral block and general anesthesia. BACKGROUND: General anesthesia is currently the standard technique used for surgical treatment of breast cancer. Increasing hospital costs have focused attention on reducing the length of hospital stay for these patients. However, the side effects and complications of general anesthesia preclude ambulatory surgery for most patients undergoing breast surgery. In April 1994, the authors initiated the use of paravertebral block anesthesia for patients undergoing primary breast cancer surgery. A review of our early experience revealed that this regional anesthetic technique enables effective anesthesia for operative procedures of the breast and axilla, reduces postoperative nausea and vomiting, and provides prolonged postoperative sensory block that minimizes narcotic requirements. METHODS: A retrospective analysis of 145 consecutive patients undergoing 156 breast cancer operations using paravertebral block and 100 patients undergoing general anesthesia during a 2-year period was performed. Anesthetic effectiveness and complications, inpatient experience with postoperative pain, nausea, vomiting, and length of stay were measured. RESULTS: Surgery was successfully completed in 85% of the cases attempted by using paravertebral block alone, and in 91% of the cases, surgery was completed by using paravertebral block supplemented with local anesthetic. There was a 2.6% incidence of complications associated with block placement. Twenty percent of patients in the paravertebral group required medication for nausea and vomiting during their hospital stay compared with 39% in the general anesthesia group. Narcotic analgesia was required in 98% of general anesthesia patients, as opposed to 25% of patients undergoing paravertebral block. Ninety-six percent of patients having paravertebral block anesthesia were discharged within the day of surgery, compared with 76% of patients who had a general anesthetic. CONCLUSIONS: Paravertebral block can be used to perform major operations for breast cancer with minimal complications and a low rate of conversion to general anesthesia. Paravertebral block markedly improves the quality of recovery after breast cancer surgery and provides the patient with the option of ambulatory discharge.     

Paravertebral Block Anesthesia for Inguinal Hernia Repair

Choice of anesthesia for inguinal hernia repair remains a controversial topic. Local anesthesia has been described in the literature as the optimal technique, however general and spinal anesthesia are commonly used in practice despite well-known complications and side effects. The regional technique of paravertebral block has been successfully used at our institution for the operative treatment of breast cancer. Its attributes are prolonged sensory block with minimization of postoperative pain, reduction of nausea and vomiting, shortened hospital stay, patient satisfaction, and rapid return to normal activities. These features are desirable in the practice of ambulatory hernia surgery; hence we initiated the use of thoracic/lumbar paravertebral block for that surgical procedure. Paravertebral block anesthesia was performed on 30 consecutive patients. Block placement took an average of 12.3 minutes, in six cases repeat injection at one or two spinal levels was required due to incomplete blockade. Paravertebral block achieved effective anesthesia in 28 of 30 cases; conversion to general anesthesia was performed for two failed blocks. We are reporting postoperative data on the 28 completed blocks. Supplementation of intravenous sedation or injection of local anesthesia successfully treated transient intraoperative pain in 10 cases. Epidural extension of anesthesia resulting in lower limb numbness and motor weakness delayed the discharge of two patients. There were no other complications of anesthesia and no cases of urinary retention. TIme to onset of pain averaged 15 hours, while duration of sensory block was 13 hours. Patients were prescribed a standing order of naproxen 500 mg B.I.D. for 4 days regardless of pain; supplemental oral narcotic use during the 48 hours following surgery averaged 3.5 tablets, with 6 patients not requiring any narcotic. ninety-six percent of patients scheduled for ambulatory surgery were discharged from the postanesthesia care unit, with an average stay of 2.5 hours. Employed patients returned to work on day 5.5 (range 3-10 days); patients who were not employed returned to regular activities in 5.8 days (range 1-14 days). Eighty-two percent of patients reported being "very satisfied" with the anesthetic technique.     

Nerve Stimulator-guided Paravertebral Blockade Combined with Sevoflurane Sedation versus General Anesthesia with Systemic Analgesia for Postherniorrhaphy Pain Relief in Children: A Prospective Randomized Trial

Background: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair.

Methods: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair.

Results: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05).     

Single-injection paravertebral block compared to general anaesthesia in breast surgery

BACKGROUND: Breast surgery is frequently associated with post-operative nausea, vomiting, pain and painful restricted movement. Paravertebral block may be an alternative to general anaesthesia for this type of surgery. We studied the single-injection paravertebral block at the level of T4 and report a comparison of single-injection paravertebral block to general anaesthesia for breast surgery. METHODS: After written informed consent was obtained, 86 patients were enrolled in this prospective study. Forty-four women were randomly allocated to receive a single-injection paravertebral block at the level of T4, while 42 women received general anaesthesia. The surgical procedures varied from lumpectomy (wide local excision of a tumour) to modified radical mastectomy with axillary dissection. The block was performed according to the guidelines described by Eason and Wyatt using 0.3 ml x kg(-1) (maximum dose 150 mg) of bupivacaine 0.5%. The skin and the underlying tissues were infiltrated with local anaesthetic solution two fingers (about 3 cm) from the anatomical midline and level with the cephalad end of the vertebral spine. RESULTS: Time for performance of blocks lasted from 4 to 9 min. Recovery from anaesthesia or sedation was shortened, while postoperative pain scores (VAS), the incidence of vomiting and the requirement for analgesics were lower in the paravertebral group. Less painful restricted movement was observed in the paravertebral block group. Paravertebral block was inadequate in 6.8% of patients. Epidural spread with paraparaesis and Horner triad was assumed in one patient. CONCLUSION: Single-injection paravertebral block at the level of T4 represents a suitable alternative to general anaesthesia in women undergoing breast surgery.     

Ambulatory surgical management of breast carcinoma using paravertebral block.

OBJECTIVE: The authors describe an initial experience using paravertebral block for ambulatory or short-stay operations for breast cancer. BACKGROUND: Rising hospital costs have focused attention on limiting the length of stay for patients undergoing surgical treatment of breast cancer. Thus far, ambulatory surgery has been limited by side effects and complications of general anesthesia. Paravertebral block offers the potential benefit of effective analgesia, with limited postoperative nausea and vomiting. METHODS: The medical records of the first 15 patients with breast cancer who underwent 16 major operations for the treatment of breast cancer using paravertebral block were reviewed. Patients were either discharged directly from the recovery room or after overnight hospital admission. The effectiveness of anesthesia, surgical outcome, patient satisfaction, and hospital costs are reviewed. RESULTS: Paravertebral block achieved effective anesthesia for cancer operations of the breast and axilla; conversion to general anesthesia or supplementation with local anesthesia was not required. There was one postoperative hemorrhage, there were two seromas, and there was one superficial wound infection. Sensory block persisted for an average of 23 hours. Postoperative pain was effectively controlled, in fact, nine patients required no postoperative narcotic for pain control. Nausea and vomiting transiently afflicted three patients and prompted overnight observation in one patient originally scheduled for immediate discharge. Fourteen patients (93%) rated their experience as "very satisfactory." CONCLUSION: Breast operations for the surgical management of breast cancer using paravertebral block can be performed safely, with great patient satisfaction, and with potential for significant cost savings.     

Bilateral continuous paravertebral catheters for reduction mammoplasty

Surgical procedures of the breast can result in significant postoperative pain. Paravertebral nerve blocks have been used successfully in the management of analgesia after breast surgery but are limited by a single injection. This report describes the use of bilateral paravertebral catheters to provide extended analgesia for reduction mammoplasty. A 48-year-old female underwent bilateral paravertebral catheter placement at thoracic level 3 and local anesthetic injections followed by general anesthesia for elective reduction mammoplasty. She reported no pain following the operation and required no supplemental opioids for pain management during her overnight recovery. This case demonstrates a method for extended bilateral thoracic analgesia. The technique may offer an alternative to traditional outpatient analgesics for reduction mammoplasty.     

Thoracic and lumbar paravertebral blocks for outpatient lithotripsy

Paravertebral nerve block has been used for a variety of surgical procedures to provide unilateral anesthesia and postoperative analgesia. We report the successful application of this regional anesthesia modality for outpatient lithotripsy. Preoperatively, thoracic and lumbar paravertebral nerve blocks with 0.5% ropivacaine were placed with ultrasound and nerve stimulator guidance for two patients with ureteral calculi. One patient scheduled for cystoscopy and ureteroscopy with laser lithotripsy received general anesthesia intraoperatively. The second patient underwent extracorporeal shock wave lithotripsy with propofol intravenous sedation. Postoperatively, both patients reported pain scores of zero (Visual Analog Scale) for 24 hours and required no opioid rescue analgesia.     

A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children

The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93%vs 69%) and surgeon satisfaction (93%vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.     

Bilateral paravertebral blockade for conventional cardiac surgery

This prospective observational study aimed to assess the feasibility and efficacy of bilateral continuous paravertebral blockade combined with general anaesthesia in "on-pump" cardiac surgery. One hundred and eleven elective patients had two paravertebral catheters inserted: one either side of the midline within 2.5 cm of the spinous process of the third or fourth thoracic vertebrae, through which a mixture of ropivacaine and fentanyl was infused during and after surgery. In the first 47 patients, haemodynamic and analgesia data were recorded. In all patients, time to tracheal extubation, length of stay in the intensive care unit and the hospital, morbidity and mortality, and any complication attributable to the regional blockade were recorded. The technique was associated with good haemodynamic stability, good postoperative analgesia and short times to tracheal extubation, with few significant complications.     

Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series

Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low‐dose intra‐operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra‐operative pain, and all would choose this anaesthetic technique again. Surgeon‐reported operating conditions were ‘indistinguishable from general anaesthesia’ in most cases, and surgeons were ‘extremely satisfied’ or ‘satisfied’ with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra‐operative sedation is a feasible technique for breast surgery.     

局部神经阻滞麻醉在腹股沟无张力疝修补术中的应用

目的　寻找更合理的腹股沟无张力疝修补术的麻醉方法。方法　2001 年 5 月至 2003年5月,采用人工合成材料行腹股沟无张力疝修补手术618例,随机分两组,335例采用局部神经阻滞麻醉(局麻组),283例采用联合麻醉(对照组),分析两组的临床资料。结果　局麻组手术时间平均35 min。住院平均2 5 d,平均花费4326元。无切口感染,无尿潴留,6例阴囊积液。联合麻醉组手术时间(加麻醉时间)平均90 min。平均住院8 d,平均住院费6775元。无切口感染,32例术后尿潴留,15例阴囊积液。随访12~36个月,平均24个月,两组均无复发。结论　局部神经阻滞麻醉下的腹股沟无张力疝修补术是一种安全、可靠、简便、经济的方式。     

Comparison of local, spinal, and general anaesthesia for inguinal herniorrhaphy.

OBJECTIVE: To compare local, spinal, and general anaesthesia for inguinal hemiorraphy in otherwise healthy patients with respect to duration of operation, time in operating room, postoperative pain, complications, rehabilitation, and satisfaction. DESIGN: Prospective randomised controlled trial. SETTING: University hospital, Turkey. SUBJECTS: Seventy-five men with unilateral primary inguinal hernias, Nyhus type II and III, and ASA I and II. INTERVENTIONS: Lichtenstein repairs with standard local, spinal, or general anaesthesia. MAIN OUTCOME MEASURES: Duration of operation and anaesthesia, postoperative pain scores, analgesic requirements, complications, length of hospital stay, postoperative rehabilitation, and satisfaction. RESULTS: With local anaesthesia, we recorded shorter time spent in the operating room, lower incidence of nausea and urinary retention, and more satisfaction. In the local and spinal anaesthetic groups, postoperative analgesic requirements and length of hospital stay were less than in the general anaesthesia group. CONCLUSIONS: Local anaesthesia is suitable for day-case hernia repair with fewer postoperative problems and less analgesia requirement. Patients also reported greater satisfaction. Local anaesthesia may be preferred to other methods.     

局麻下善愈补片腹膜前间隙修补治疗成人脐疝的探讨

目的探讨局麻下国产善愈补片腹膜前间隙修补术治疗成人脐疝的应用价值。方法分析25例局麻下国产善愈补片腹膜前间隙修补成人脐疝的病例，观察麻醉效果、手术时间、住院时间及随访观察术后并发症及复发情况。结果全部采用局部浸润麻醉，手术时间35—85min，平均55min，术后0～2h下床活动，术后切EI疼痛较明显5例，术后切EI皮下积液1例，平均住院时间3．5d，术后平均随访11个月无复发，无明显异物感。结论局麻下国产善愈补片腹膜前间隙修补术是治疗成人脐疝的一种有效而可靠的术式，具有手术操作安全，手术适应证广，术后恢复快，并发症少、复发率低等优点。     

Bilateral ultrasound-guided continuous ilioinguinal-iliohypogastric block for pain relief after cesarean delivery

We present three cases in which continuous ilioinguinal-iliohypogastric nerve block with 0.2% ropivacaine, together with oral ibuprofen, was used to provide analgesia after cesarean delivery. The catheters were placed under ultrasound guidance in the plane between the internal oblique and transversus abdominis muscles on both sides of the abdomen. Numeric pain rating was used for the assessment of postoperative pain. Low pain scores, minimal use of supplemental opioid, and the absence of nausea and vomiting suggests that continuous ilioinguinal-iliohypogastric nerve blockade deserves further study as a possible component of multimodal analgesia after cesarean delivery.     

超声引导下双侧髂腹股沟-髂腹下神经连续阻滞用于剖宫产术后镇痛

本文中我们介绍3个采用了0．2％罗哌卡因行髂腹股沟-髂腹下神经连续阻滞用于剖宫产手术后镇痛,同时口服布洛芬的病例。在超声引导下,于腹部两侧的腹内斜肌和腹横肌之间分别置入连续性导管。用疼痛数字量表评估手术后疼痛。疼痛评分较低,需追加阿片类药物少及无恶心、呕吐的研究结果提示：髂腹股沟神经阻滞作为剖宫产手术后多模式镇痛的一个可能成分,值得进一步研究。     

Use of continuous paravertebral analgesia to facilitate neurologic assessment and enhance recovery after thoracoabdominal aortic aneurysm repair

Neurologic assessment after thoracic aortic aneurysm repair is important for detecting and treating late onset paraplegia. Traditional methods of pain control, such as patient-controlled IV analgesia and epidural analgesia, may interfere with neurologic assessment. We present a case of a patient who received continuous thoracic paravertebral analgesia that provided excellent analgesia while preserving the ability to monitor neurologic function. IMPLICATIONS: We provided postoperative continuous paravertebral analgesia in a patient after thoracoabdominal aneurysm repair requiring postoperative neurologic assessment. Paravertebral analgesia provides unilateral analgesia with fewer neurologic and hemodynamic side effects than central neuraxial blockade and should be considered for management of patients undergoing thoracic aortic aneurysm repair.