A Comparison of Ultrasound-assisted Paravertebral Block and General Anesthesia for Outpatient Breast Cancer Surgery, a Prospective Randomized Trial
The optimal anesthetic technique for breast cancer surgery allows for good postoperative
pain relief and rapid discharge. Breast cancer surgery with potential axillary dissection is
often performed under general anesthesia due to the potential for poor analgesia with local
anesthetic infiltration at the surgical site alone. General anesthesia can be associated
with increased post-operative pain, nausea, and delayed discharge when compared to regional
anesthesia for breast and other types of procedures (1,2).
The paravertebral block is a technique that has been used perioperatively for breast (3,4),
thoracic (5), abdominal (6), and hernia surgeries (7). It has also been used for pain
control after rib fractures and penetrating trauma (8,9). The paravertebral block is
performed by injecting local anesthetic above or below the transverse processes of the
vertebral bodies where the spinal nerve roots emerge from the intervertebral foramina. The
most common technique is to insert a needle 2.5 centimeters lateral to the spinous process
at each level and "walk off" the transverse process. Injections at one or multiple levels
block the somatic and sympathetic innervation to these dermatomes (10).
Rare complications of thoracic paravertebral blocks include epidural spread, intrathecal
injection, and Horner's Syndrome (1,11,12). One of the most feared complications of the
traditional technique is pleural puncture, which has an incidence of 0.64% to 6.7% in the
published literature (3,11,13).
Ultrasound guidance in regional anesthesia is gaining widespread popularity. This
technology provides visualization of key anatomic structures and has been shown to decrease
block placement and onset times (14,15) and improve patient comfort (15). Ultrasound-guided
blocks are associated with success rates of greater than 90% (15,16). In the thoracic
region, ultrasound can be used to identify the vertebral transverse processes, as well as
the ribs and the pleura of the lungs (17). In this way, pleural puncture can be avoided
during paravertebral block placement.
To date there have been no published prospective, randomized trials comparing the multiple
injection thoracic paravertebral technique using ultrasound guidance to general anesthesia
in breast cancer surgery patients.
Our hypothesis is that paravertebral block anesthesia will result in shorter Post Anesthesia
Care Unit (PACU) stays and decreased Visual Analog Scale (VAS) scores when compared to
general anesthesia in patients undergoing breast cancer surgery. Secondary endpoints will
include the need for postoperative opioids and the presence of nausea and/or vomiting.
Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Treatment
Time in minutes until the patient is declared ready for discharge from the Post Anesthesia Care Unit (PACU)
Until PACU discharge
Tiffany Tedore, M.D.
New York Presbyterian Hospital Weill Cornell Medical Center
United States: Institutional Review Board
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