Paravertebral blocks in immediate breast reconstruction following mastectomy

Abstract

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.

Study of ultrasound-guided ropivacaine combined with butorphanol continuous paravertebral block to prevent pain syndrome by evaluating ccl2 gene expression after radical mastectomy

“…Hemodynamic instability or compromise, surgical stress response, poor postoperative pain control and delayed spontaneous respiratory recovery, many inflammatory mediators produced by white blood cells and endothelial cells can all cause pain, and such pain can be offset by endogenous opioids in peripheral termination of the nerve (29,30). Inflammation occurs in the trauma area, leading to the activation of pain receptors (31, 32).…”

Paravertebral Blocks in Tissue Expander Breast Reconstruction: A Propensity-Matched Analysis of Perioperative Opioid Consumption and Patient-Reported Outcomes

“…This finding is consistent with other studies on PVBs in implant-based reconstruction, which have also shown that opioid consumption is slightly reduced in patients receiving blocks. 15,17,25 For example, Stein et al 25 found that opioid use was 11 MMEs lower among patients who received PVBs than among those who did not. Our study, however, is the first to utilize propensity score matching to improve the comparability of patients who do or do not receive PVBs, thus providing more definitive evidence for the effect of PVBs on opioid consumption.…”

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction

“…Examples include TAP blocks, 21,22 Nmethyl-D-aspartate antagonists (gabapentin), 23 continuous local anesthesia pumps (On Q PUMP), 4,9 and paravertebral blocks. [24][25][26][27][28][29] Studies on the effect of TAP block on recovery after microvascular reconstruction have shown positive outcomes. [5][6][7][8] Therefore, our ERAS initially used TAP block with liposomal bupivacaine to target the donor site.…”

“…Apart from these baseline components, ERAS protocols can have certain unique components that account for improved outcomes. Examples include TAP blocks, 21,22 N -methyl- d -aspartate antagonists (gabapentin), 23 continuous local anesthesia pumps (On Q PUMP), 4,9 and paravertebral blocks 24–29 . Studies on the effect of TAP block on recovery after microvascular reconstruction have shown positive outcomes 5–8 .…”