Roy A. Greengrass

Thoracic paravertebral block for breast surgery.

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.

Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump.

Continuous interscalene brachial plexus blockade traditionally requires a hospital stay for local anesthetic infusion, and achieving consistent catheter insertion may be difficult. Incorporating long-acting pain relief from a continuous peripheral nerve block, with a reliable method of catheter insertion, and a self-contained infusion system would be a valuable asset for short-stay care. We compared the efficacy of single injection interscalene brachial plexus blockade to a continuous peripheral nerve block, with an insulated Tuohy system and a disposable infusion pump. Forty adult patients scheduled for open rotator cuff repair were entered in this randomized, double-blinded, placebo-controlled study. Patients received an interscalene brachial plexus blockade and a continuous peripheral nerve catheter as their primary anesthetic and then, were assigned to receive one of two different postoperative infusions: either 0.2% ropivacaine at 10 mL/h via a disposable infusion pump or normal saline at 10 mL/h via a disposable infusion pump (n = 18–20 per group). Visual analog pain scores and postoperative morphine consumption were measured for 24 h. The ropivacaine group showed less pain than the placebo group (P = 0.0001) between 12 and 24 h after the initial injection of local anesthetic. In addition, initial interscalene blockade was successful in all patients and all redosed catheters were functional after 24 h with the continuous catheter insertion system. We conclude that it is possible to achieve a high rate of successful catheter placement and analgesia by using the continuous catheter insertion system and a disposable infusion pump in the ambulatory setting. This method of analgesia may offer improved pain relief after outpatient rotator cuff repair. Implications This study demonstrates that it is possible to achieve successful interscalene brachial plexus continuous catheter insertion and a high degree of persistent analgesia by using a catheter insertion system and a disposable infusion pump administering 0.2% ropivacaine.

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.

Continuous peripheral nerve block for ambulatory surgery.

Background and Objectives Adenosine is an endogenous compound that may have analgesic effects. Results from clinical trials are not consistent, however, and there is a need for large-scale, randomized, placebocontrolled studies to clarify the role of adenosine in the treatment of pain states, including acute nociceptive pain and pain involving central sensitization. Methods The analgesic and antihyperalgesic effect of systemic adenosine on the heat/capsaicin sensitization model of experimental pain was investigated in 25 healthy human volunteers. Sensitization was produced by heating the skin to 45°C for 5 minutes, followed by a 30-minute application of 0.075% capsaicin cream, and maintained by periodically reheating the sensitized skin to 40°C for 5 minutes at 40-minute intervals. Subjects received intravenous adenosine 60 μg/kg/min or saline for 85 minutes. Areas of secondary hyperalgesia to von Frey hair and brush stimulation, heat-pain detection thresholds (HPDTs) in normal and sensitized skin, and painfulness of stimulation with 45°C for 1 minute (LTS) in normal skin were quantified before, during, and after study drug infusion. Results Systemic adenosine had no effect on the area of secondary hyperalgesia to von Frey hair or brush stimulation, HPDT in normal or sensitized skin, or painfulness of LTS in normal skin. Conclusion We conclude that adenosine has no effect on acute nociceptive pain induced by heat stimulation or on secondary hyperalgesia induced by heat/capsaicin sensitization in healthy volunteers.

Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine.

Discharging patients with a long-acting peripheral nerve block remains controversial. Concerns about accidental injury of the limb or surgical site because of an insensate extremity are common despite a lack of data on the subject. We report a study examining the efficacy and complications of discharge after long-acting block. This prospective study included 1791 patients receiving an upper or lower extremity nerve block with 0.5% ropivacaine and discharged the day of surgery. Efficacy (conversion to general anesthesia and opioid use), persistent motor or sensory weakness, complications, satisfaction, and unscheduled health care visits were assessed in the postanesthesia care unit (PACU) and at 24 h and 7 days postoperatively using a detailed questionnaire. There were 2382 blocks placed: 1119 upper extremity blocks and 1263 lower extremity blocks. Efficacy was demonstrated by a small conversion to general anesthesia (1%–6%) and a lack of patients requiring opioids in the PACU (89%–92%). A large percentage of patients continued to use opioids at 7 days (17%-22%). Despite the requirement for opioids, satisfaction with the anesthesia experience was high at 24 h and 7 days (Liekert scale [1–5] mean at 24 h, 4.88 ± 0.44; mean at 7 days, 4.77 ± 0.69) and most (98%) would choose the same anesthetic again. Thirty-seven patients (1.6%) were identified with symptoms or complaints at 7 days. After review, 6 of them (0.25%) had a persistent paresthesia that may have been related to the block or discharge. We conclude that long-acting peripheral nerve blockade may be safely used in the ambulatory setting with a high degree of efficacy, safety, and satisfaction. This technique is associated with an infrequent incidence of neurologic complications and injuries. Given the frequent incidence of persistent pain at 7 days, prolongation of the analgesia would be beneficial.

A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block

The onset time and duration of action of ropivacaine during an interscalene block are not known.The potentially improved safety profile of ropivacaine may allow the use of higher concentrations to try and speed onset time. We compared bupivacaine and ropivacaine to determine the optimal long-acting local anesthetic and concentration for interscalene brachial plexus block. Seventy-five adult patients scheduled for outpatient shoulder surgery under interscalene block were entered into this double-blind, randomized study. Patients were assigned (n = 25 per group) to receive an interscalene block using 30 mL of 0.5% bupivacaine, 0.5% ropivacaine, or 0.75% ropivacaine. All solutions contained fresh epinephrine in a 1:400,000 concentration. At 1-min intervals after local anesthetic injection, patients were assessed to determine loss of shoulder abduction and loss of pinprick in the C5-6 dermatomes. Before discharge, patients were asked to document the time of first oral narcotic use, when incisional discomfort began, and when full sensation returned to the shoulder. The mean onset time of both motor and sensory blockade was <6 min in all groups. Duration of sensory blockade was similar in all groups as defined by the three recovery measures. We conclude that there is no clinically important difference in times to onset and recovery of interscalene block for bupivacaine 0.5%, ropivacaine 0.5%, and ropivacaine 0.75% when injected in equal volumes. Implications: In this study, we demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 0.75% fails to improve the onset or duration of interscalene brachial plexus block. (Anesth Analg 1998;87:1316-9)

Influence of Obesity on Surgical Regional Anesthesia in the Ambulatory Setting: An Analysis of 9,038 Blocks

Background: Regional anesthesia is increasing in popularity for ambulatory surgical procedures. Concomitantly, the prevalence of obesity in the United States population is increasing. The objective of the present investigation was to assess the impact of body mass index (BMI) on patient outcomes after ambulatory regional anesthesia. Methods: This study was based on prospectively collected data including 9,038 blocks performed on 6,920 patients in a single ambulatory surgery center. Patients were categorized into three groups according to their BMI (<25 kg/m2, 25–29 kg/m2, ≥30 kg/m2). Block efficacy, rate of acute complications, postoperative pain (at rest and with movement), postoperative nausea and vomiting, rate of unscheduled hospital admissions, and overall patient satisfaction were assessed. Linear and logistic multivariable analyses were used to obtain the risk-adjusted effect of BMI on these outcomes. Results: Of all patients 34.8% had a BMI <25 kg/m2, 34.0% were overweight (BMI 25–29 kg/m2), and 31.3% were obese (BMI ≥ 30 kg/m2). Patients with BMI ≥30 kg/m2 were 1.62 times more likely to have a failed block (P = 0.04). The unadjusted rate of acute complications was higher in obese patients (P = 0.001). However, when compared with patients with a normal BMI, postoperative pain at rest, unanticipated admissions, and overall satisfaction were similar in overweight and obese patients. Conclusions: The present investigation shows that obesity is associated with higher block failure and complication rates in surgical regional anesthesia in the ambulatory setting. Nonetheless, the rate of successful blocks and overall satisfaction remained high in patients with increased BMI. Therefore, overweight and obese patients should not be excluded from regional anesthesia procedures in the ambulatory setting.

Paravertebral block for breast cancer surgery

PurposeMajor breast cancer surgery is associated with a high incidence of postoperative nausea, vomiting and pain. Regional anaesthesia, with intraoperative sedation, would seem an ideal alternative to general anaesthesia for this type of surgery. We report our initial experience using paravertebral blocks (PVB) to provide anaesthesia for major breast surgery.MethodsTwenty-five patients agreeing to have surgery performed under paravertebral blocks were studied. Procedures performed varied from simple lumpectomy with axillary dissection to modified radical mastectomy with axillary dissection. During monitored sedation, blocks opposite spinous processes of C7– T6 were performed using bupivacaine 0.5% with epinephrine, 3– 4 ml per segment. Patients were evaluated for 72 hr and were requested to document:(i) when sensation returned (ii) incidence and frequency of nausea or vomiting (iii) degree of discomfort and medication taken.ResultsTwenty patients had blocks that required no supplementation. Five patients had blocks that were incomplete. No complications were attributed to the blocks. Post-operatively, patients with successful blocks had minimal nausea, vomiting and pain. No patients found the procedure unsatisfactory. Patients with successful blocks were all very satisfied.ConclusionOur initial results show that PVB for breast cancer surgery can be successfully performed in a majority of patients with few side effects. All patients with successful blocks were returned to the ambulatory care unit, bypassing the recovery room. That breast cancer surgery under regional anaesthesia can be safely performed as an ambulatory procedure has the potential for accomplishing major cost-saving.RésuméObjectifLa chirurgie majeure du sein est associée à une incidence élevée de nausées, de vomissements et de douleurs postopératoires. L’anesthésie régionale avec sédation semblerait une solution de rechange idéale pour réaliser cette chirurgie. Les auteurs décrivent leur expérience initiale avec des blocs paravertébraux (BPV) pour l’anesthésie de la chirurgie mammaire majeure.MéthodesL’étude portait sur vingt-cinq patientes consentantes à une interventions sous blocs paravertébraux. Les interventions variaient de l’ablation d’une masse avec dissection axillaire à la mastectomie radicale modifée avec dissection axillaire. Pendant une sédation sous moniteur, des blocs étaient effectués latéralement aux apophyses épineuses de C7- T6 avec 3 à 4 ml de bupivacaine 0,5% adrénalinée par segment. Les patientes étaient évaluées pendant 72 h et on leur demandait de signaler: i) le moment du retour de la sensation ii) l’incidence et la fréquence des nausées ou des vomissements iii) le degré d’inconfort et la prise de médicaments.RésultatsVingt patientes sous bloc n’ont pas eu besoin d’analgésie supplémentaire. Pour cinq patientes le bloc était incomplet. Aucune complication n’était attribuable aux blocs. En postopératoire, les patientes aux blocs réussis avaient peu de nausées, de vomissements et de douleurs. Aucune des patientes ne s’est déclarée insatisfaite. Les patientes dont les blocs avaient réussi étaient toutes très satisfaites.ConclusionCes résultats initiaux montrent que les BPV réalisés pour une chirurgie mammaire peuvent fonctionner avec peu d’effets secondaires chez une majorité de patientes. Toutes les patientes chez qui les blocs avaient réussi sont retournées à l’unité des soins ambulatoires, sans arrêt à la salle de réveil. La chirurgie du cancer du sein peut être réalisée sous anesthésie régionale en toute sécurité en chirurgie ambulatoire et peut permettre de réaliser des économies importantes.

Ambulatory surgical management of breast carcinoma using paravertebral block.

ObjectiveThe authors describe an initial experience using paravertebral block for ambulatory or short-stay operations for breast cancer. BackgroundRising 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. MethodsThe 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. ResultsParavertebral 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.” ConclusionBreast 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.

Major ambulatory surgery with continuous regional anesthesia and a disposable infusion pump

CONTINUOUS peripheral nerve blockade can provide prolonged postoperative analgesia. By infusing local anesthetic through a catheter, neural blockade can be achieved that lasts longer than a single-injection block. 1,2 Traditionally, this method of pain relief has required a cumbersome infusion pump and a hospital stay. Reconstructive surgery of the foot or ankle can result in severe postoperative pain that is difficult to treat. Frequently, patients having such procedures require large doses of intravenous narcotics, which make early hospital discharge difficult. By using an anesthetic method that can provide improved analgesia and obviate a prolonged hospital stay, ambulatory surgery may be facilitated. We describe two patients undergoing major ankle surgery. Both patients were discharged to their homes with a continuous Sciatic nerve block and a disposable infusion pump.