A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction

Wolf, Omer; Clemens, Mark W.; Purugganan, Ronaldo V.; Crosby, Melissa A.; Kowalski, Alicia M.; Kee, Spencer Stephen; Li, Jun; Goravanchi, Farzin

doi:10.1097/01.prs.0000481070.79186.0d

Cited by 33 publications

(26 citation statements)

References 19 publications

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“…Sixteen trials reported on potential harm related to paravertebral blocks (Abdallah et al., 2014; Arunakul & Ruksa, 2010; Bhuvaneswari et al., 2012; Boughey et al., 2009; Dabbagh & Elyasi, 2007; Das et al., 2012; Fallatah & Mousa, 2016; Jin et al, 2016; Kairaluoma et al., 2004; Kamal Abdel‐halim, 2011; Klein et al., 2000; Moller et al., 2007; Naja et al., 2003; Pusch et al., 1999; Terheggen et al, 2002; Wolf et al., 2016). Harm reported included epidural spread of the local anaesthetic in two patients (Pusch et al., 1999), a pleural puncture in one (Terheggen et al, 2002), an intoxication due to local anaesthetics in one (Kairaluoma et al., 2004), vascular punctures without subsequent haematoma in two (Fallatah & Mousa, 2016), and one patient described pain at the site of injection for more than 1 month postoperatively (Fallatah & Mousa, 2016).…”

Section: Resultsmentioning

confidence: 99%

“…PVB ropivacaine 2 mg/kg then continuous infusion of saline, level not described (57) 2. PVB ropivacaine 2 mg/kg then continuous infusion of ropivacaine 0.25% 0.1 ml/kg/hr, level not described 60 Kamal Abdel-halim, 2011;Klein et al, 2000;Moller et al, 2007;Naja et al, 2003;Pusch et al, 1999;Terheggen et al, 2002;Wolf et al, 2016). Harm reported included epidural spread of the local anaesthetic in two patients (Pusch et al, 1999), a pleural puncture in one (Terheggen et al, 2002), an intoxication due to local anaesthetics in one (Kairaluoma et al, 2004), vascular punctures without subsequent haematoma in two (Fallatah & Mousa, 2016), and one patient described pain at the site of injection for more than 1 month postoperatively (Fallatah & Mousa, 2016).…”

Section: Safety Datamentioning

confidence: 97%

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Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Lepot

Elia

Tramèr

et al. 2020

European Journal of Pain

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Background and objective: The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery. Databases and data treatment: We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE. Results: Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available. Conclusions: Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed. Significance: This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.

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Section: Resultsmentioning

confidence: 99%

Section: Safety Datamentioning

confidence: 97%

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Lepot

Elia

Tramèr

et al. 2020

European Journal of Pain

View full text Add to dashboard Cite

show abstract

“…Preoperative paravertebral block (PVB) reduces postoperative pain . Patients in our study undergoing bilateral procedures were more likely to undergo preoperative PVB, possibly explaining the association on univariate analysis and lack thereof on multivariate analysis.…”

Section: Discussionmentioning

confidence: 99%

Variables associated with length of stay in patients undergoing mastectomy and delayed‐immediate breast reconstruction with tissue expander

et al. 2019

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Delayed‐immediate reconstruction with the placement of tissue expanders at the time of mastectomy is a common approach to breast reconstruction. The purpose of this study was to identify variables associated with increased LOS in patients that underwent bilateral or unilateral mastectomy with tissue expander placement. Bilateral procedure, a diagnosis of anxiety or depression, and age >55 years were independently associated with increased LOS. More recent year of surgery and Friday surgery were associated with decreased LOS.

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“…Paravertebral nerve blocks have been shown to reduce patient reported pain scores both in early and late hospital admission. A recent randomized control trial by Wolf et al was the first to prospectively demonstrate reduced postoperative pain and opioid consumption in 14 patients undergoing immediate breast reconstruction . Fahy et al found a reduction in antiemetic and opiate use and Coopey et al demonstrated decreased length of stay in their retrospective cohort of woman undergoing immediate reconstruction.…”

Section: Discussionmentioning

confidence: 99%

“…In recent years, the use of Paravertebral Nerve Block's (PVBs) has gained increasing popularity. They have been shown to decrease pain, length of stay in hospital, and opiate use in patients with breast cancer undergoing both prosthetic, [22][23][24][25][26][27] and autologous microvascular breast reconstruction. 28 There is limited data illustrating the efficacy of paravertebral blocks in immediate breast reconstruction following mastectomy.…”

Section: Introductionmentioning

confidence: 99%

Paravertebral blocks in immediate breast reconstruction following mastectomy

et al. 2019

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Background Postoperative pain remains a major challenge following immediate breast reconstruction with 40% of patients experiencing acute pain and up to 60% developing chronic pain. Paravertebral blocks (PVB's) have emerged as a promising adjunct to standard analgesic protocols. The aim of this study was to assess the utility of PVB's in immediate breast reconstruction following mastectomy. Methods A retrospective review of patients undergoing immediate breast reconstruction following mastectomy was performed. The primary outcome was postoperative pain measured by total oral morphine equivalent usage and self reported pain scores and secondary outcomes were length of stay in the PACU, complications, and OR delay. Results Of 298 patients undergoing immediate breast reconstruction, 112(38%) underwent standard analgesic protocols and 186(62%) underwent PVB in addition to the standard protocol. PVB's were associated with reductions in average postoperative pain scores (2.8 vs 3.3, P = 0.002), total opiate consumption (52 units vs 63 units, P = 0.038) and time spent in the PACU 92 vs 142 minutes, P = 0.0228) compared to patients who had general anesthesia alone. The overall complication rate was 3.7% (7/186 patients), all which were minor complications such as headache, bloody tap, vasovagal episode and temporary weakness. The use of PVBs delayed the OR start time on average by 15 minutes (34 vs 49 minutes). Conclusions The present study offers one of the largest retrospective cohort studies to date evaluating the utility of PVB's in immediate breast reconstruction following mastectomy. We demonstrate that, PVB's in immediate breast reconstruction are associated with reductions in postoperative pain, narcotic usage and length of stay in PACU, but are associated with delays to the start time of the case. Anesthesiologists, plastic surgeons and hospital administrators must continue to work together to ensure this important and necessary service is administered in an efficient and cost effective manner.

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A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction

Abstract: Therapeutic, II.

Cited by 33 publications

References 19 publications

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Variables associated with length of stay in patients undergoing mastectomy and delayed‐immediate breast reconstruction with tissue expander

Paravertebral blocks in immediate breast reconstruction following mastectomy

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