Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery

Abstract

Pawinee Pangthipampai, Manoj K Karmakar, Banchobporn Songthamwat, Jatuporn Pakpirom, Winnie Samy Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People’s Republic of ChinaCorrespondence: Manoj K KarmakarDepartment of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Room 0421D, 4/F, Main Clinical Block and Trauma Centre, Shatin, New Territories, Hong Kong, Special Administrative Region of the People’s Republic of ChinaTel [phone]Fax [phone]Email [email protected]: Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1–T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS.Patients and Methods: Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1– 0.5 μg.kg− 1.h− 1) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA.Results: The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0± 20.5 mg) as supplementary analgesia.Conclusion: USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.Keywords: anesthesia, analgesia, thoracic paravertebral block, mastectomy, breast, ultrasound

Keywords

• anesthesia
• analgesia
• thoracic paravertebral block
• mastectomy
• breast
• ultrasound.