Martina Bachmann

Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery.

We reported earlier that preincisional paravertebral block (PVB) provides significant immediate postoperative analgesia after breast cancer surgery. In the same patients (n = 60), a 1-yr follow-up was performed to find out whether PVB could also reduce the prevalence of postoperative chronic pain. The follow-up consisted of a 14-day symptom diary and telephone interviews 1, 6, and 12 mo after surgery. The 14-day consumption of analgesics was similar in the 30 PVB and the 30 control patients. However, 1 mo after surgery, the intensity of motion-related pain was lower (P = 0.005) in the PVB group. Six months after surgery, the prevalence of any pain symptoms (P = 0.029) was lower in the PVB group. Finally, at 12 mo after surgery, in addition to the prevalence of pain symptoms (P = 0.003) and the intensity of motion-related pain (P = 0.003), the intensity of pain at rest (P = 0.011) was lower in the PVB group. These findings were independent of whether or not axillary dissection had been performed. The incidence of neuropathic pain was low (two and three patients in the PVB and control groups, respectively). In addition to providing acute postoperative pain relief, preoperative PVB seems to reduce the prevalence of chronic pain 1 yr after breast cancer surgery.

Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy.

Paravertebral block (PVB) seems to decrease postoperative pain and postoperative nausea and vomiting (PONV) after breast surgery, but the studies have not been placebo controlled. We studied 60 patients scheduled for breast cancer surgery randomly given single-injection PVB at T3 with bupivacaine 5 mg/mL (1.5 mg/kg) or saline before general anesthesia. The patient and attending investigators were blinded; the PVB or the sham block was performed behind a curtain by an anesthesiologist not involved in the study. The patients given PVB with bupivacaine needed 40% less IV opioid medication (primary outcome variable) in the postanesthesia care unit, had a longer latency to the first opioid dose, and had less pain at rest after 24 h than the control patients (P < 0.01). They also had less PONV in the postanesthesia care unit (P < 0.05), were less sedated until 90 min (P < 0.05), and performed better in the digit symbol substitution test at 90 min and the ocular coordination test 60–120 min after surgery (P < 0.05). The average peak bupivacaine plasma concentration was 750 ng/mL. One patient had bilateral convulsions immediately after bupivacaine injection. We conclude that PVB before general anesthesia for breast cancer surgery reduced postoperative pain, opioid consumption, and occurrence of PONV and improved recovery from anesthesia.

Randomised comparison of hyperbaric articaine and hyperbaric low-dose bupivacaine along with fentanyl in spinal anaesthesia for day-case inguinal herniorrhaphy.

Background and objective Low-dose mixture of hyperbaric bupivacaine and fentanyl is commonly used in day-case spinal anaesthesia. Using hyperbaric articaine, the onset may be faster and duration more predictable than with bupivacaine–fentanyl. We compared these two spinal anaesthetics for inguinal herniorrhaphy. Methods Adult patients were randomised to spinal anaesthesia with hyperbaric articaine 84 mg (group A, n = 40) or hyperbaric bupivacaine 7 mg along with fentanyl 10 &mgr;g (group B+F, n = 40). A blinded observer tested the block characteristics. Aiming at sensory block spread to T10 dermatome, the operating table was tilted head-end up or down 10° (once or twice), as required. Postoperative telephone interviews were performed. Results All patients in group A had a sensory block to T10 in a median time of 4 (range 2–20) min. In group B+F, the median onset time of T10 analgesia was 10 (2–30) min (P < 0.001), but T10 analgesia was not reached in seven of 40 B+F patients. A head-up tilt was needed in 37 of 40 group A patients to prevent from too extensive cephalad spread of block, and 34 of 40 group B+F patients needed a head-down tilt to enhance cephalad spread of analgesia. To treat hypotension, 6.4 mg of ephedrine was required, on average, in group A and 1.8 mg in group B+F (P = 0.01). Median time to recovery from sensory block was significantly shorter in group A (2.5 h) than in group B+F (3 h; P = 0.002). General anaesthesia was needed in three patients (group A, two patients: sensory block too short; group B+F, one patient: sensory block too limited). Conclusion Hyperbaric articaine leads to faster onset of block and faster recovery than bupivacaine along with fentanyl. Hypotension is more common with articaine. The onset and extension of the spinal block are unpredictable when using these techniques.