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Table of Content - Volume 3 Issue 1 -July2017
A study of the efficacy of paravertebral block in the patients of breast surgeries at tertiary health care centre
Pravin C Jadhav1*, Vaishnavi V Kulkarni2, Pushpa I Agrawal3, Surekha Shinde4
1Assistant Professor, 2,3Associate Professor, Department of Anaesthesiology, Dr. V. M. Government Medical College, Solapur, Maharashtra, INDIA. Email: pravin01jadhav@gmail.com
Abstract Background: Breast cancer is perhaps the most common cancer in women that requires frequent surgical intervention. Until recently breast surgeries were typically performed under general anaesthesia by intravenous and inhalational anesthetic agents. Although G.A. provides desired state of unconsciousness, it does not eliminate the surgical stress response during intubation. It may cause postoperative nausea, vomiting and pain so prolongs recovery time. Using thoracic paravertebral block has emerged as a suitable alternative to GA, as it offers good surgical anaesthesia along with prolonged post-operative analgesia. Aim and objective: To assess the efficacy of paravertebral block in the patients of breast surgeries. Material and Methods: Study of thoracic paravertebral block (TPVB) in 40 patients of benign or malignant breast diseases. The PVB was given according to guidelines describe by Eason and Wyatt (1979). Efficacy of analgesia was assessed as Onset of analgesia. Result: Mean time for onset of analgesia was 8.325±130 min. In present study block was excellent in 28 patients out of 40. Intraoperatively there were no significant (P>0.05) changes in pulse rate, SABP, DABP and SPO2 at various periods. Mean duration of postoperative analgesia was 7.025±1.187 hour. Conclusion: Paravertebral block for breast surgery is very safe and effective technique with good postoperative analgesia Key Words: paravertebral block, Breast Surgery.
INTRODUCTION G.A. provides desired state of unconsciousness, it does not eliminate the surgical stress response. It may aggravate immune suppression and may cause postoperative nausea, vomiting and pain. It prolongs recovery time, lengthens hospital stay and increases hospital cost1 Many patients of carcinoma breast have associated medical illnesses and poor general condition making them high risk for general anaesthesia. Regional anaesthesia using thoracic paravertebral block has emerged as a suitable alternative to GA, as it offers good surgical anaesthesia along with prolonged post operative analgesia2. Thoracic paravertebral block appears promising due to reduction in postoperative pain, decreased opioid consumption with reduction in PONV, drowsiness and it is cost effective. In addition, it is an effective means of providing improved pulmonary function and finally decreased duration of stay in post anaesthesia care unit (PACU). More recently there has been renewed interest in this technique for treatment of acute and chronic pain. Because of ability to provide long lasting unilateral anaesthesia, PVB has been successfully used to provide analgesia for multiple thoracic and abdominal procedures. Therefore, we studied on thoracic paravertebral block for breast surgery. MATERIAL AND METHODS In our study, we selected forty female patients between age group of 25 to 65 years who were posted for unilateral breast surgery. Present study was conducted during the period of 2010-2012. Inclusion Criteria
Exclusion Criteria
Pre-anaesthetic evaluation was done with detail medical, surgical and anaesthetic history, clinical examination and investigations (Hb%, WBC count, Bleeding time, Clotting time, Urine examination, BSL, KFT,ECG,X ray chest ) Local anaesthetic sensitivity test was done prior to surgery. Informed written consent was taken from patient and their relatives. The day prior to surgery all patients received Tab Diazepam 10mg HS and Tab Ranitidine 150 mg HS for anxiolysis and acid prophylaxis respectively. On the operative day Inj. Glycopyrrolate 0.004 mg/kg iv., Inj. Midazolam 0.03mg/kg iv, Inj. Ranitidine 50 mg iv, Inj. Metaclopramide 10 mg iv was given as premedication. Non-invasive monitor applied in the form of ECG,NIBP and SP02 Pulse rate and Blood pressure was recorded in supine position. The paravertebral block was given according to guidelines described by Eason and Wyatt3 (1979). Test dose of 2%Lignocinewith Adrenaline 3ccwas given and then 0.4ml/kg of 0.5% Bupivacaine was injected in paravertebral space in small aliquots with repeated aspiration tests. Efficacy of analgesia was assessed as Onset of analgesia (Time was noted from initial bolus drug injection to loss of pinprick sensation at dermatome T4.)Number of segments blocked (area of loss of pinprick sensation was noted.) Duration of anaesthesia (time was taken from initial bolus dose to the requirement of first top up dose.) Top up dose was given after two segment regression or complain of pain. Injection. Bupivacaine 0.5% 4 to 6 ml was given as a top up dose. Quality of Analgesia Excellent: when no sedation or analgesic supplementation was required Good: When sedation was required. Fair: when analgesic like ketamine was required Poor: If the surgery was not possible the block was rated as unsuccessful and G.A. was given. Hemodynamic parameters in the form of pulse rate and blood pressure were recorded Before premedication, After premedication, before block and After block at interval of 10 min till the end of surgery. Intraoperatively oxygen saturation was monitored for every ten minutes. In the recovery room, pulse rate, blood pressure and SPO2 was recorded at ten minutes interval for two hours and patient was observed for any complications of the block. Each patient was enquired about pain after surgery using visual analogue score (VAS).Duration of post-operative analgesia was noted. All data collected and analysed statistically.
RESULTS Most of the patients were of the age group 56 to 65 years mean age was 50.1±11.1 years.55% of the patients were of the weight group of 45 to 55 Kgs. Mean weight was 52±6.3 Kgs. Out of 40 patients, 35 patients underwent MRM (Modified Radical Mastectomy) while 5 patients underwent fibroadenoma excision.
Table 1: Distribution of patients according to ASA Grade
Table 2: Distribution of patients according to time of onset
Time of onset which was noted from initial bolus drug injection to loss of pinprick sensation at dermatome T4. Mean time for onset of analgesia was 8.325±130 min. Most of the segments blocked were T1 to T6 (75%). Mean duration of Surgery was 136.4±29.335 min.
Table 3: Distribution of patients according to Duration of Anesthesia
Table 3 Shows duration of Anaesthesia. Time taken from initial bolus dose to the requirement of first top up dose. Mean duration of anaesthesia was 71.775±12.026 min.
Table 4: Distribution of patients according to Quality of Analgesia
Table 4 shows quality of analgesia. The paravertebral block was excellent in 28 patients (70%).
Table 5: Preoperative values of various parameters
Table 5 shows the preoperative values of various parameters in the form of pulse rate, SABP, DABP and SPO2. Table 6: Changes in the pulse rate,SABP,DABP and SPO2 from baseline at various periods
Table 6 Shows mean changes in the pulse rate SABP, DABP and SPO2from baseline at various periods. This table shows insignificant (P>0.05) changes in pulse rate, SABP, DABP and SPO2 at various periods. Most of the patients had no complications (95%) and 5% patients complaints of nausea.
Table 7: Duration of post-operative analgesia
Mean duration of post operative analgesia was 7.025±1.187.
DISCUSSION Our study material and methods correlate with study did by Eason and Wyatt3(1979), Pusch F et al (1999)4andAdityakumar et al (2009)5 In our study bolus dose of 0.5% inj. Bupivacaine was 20.605±2.470ml.In our study we given 0.5% Bupivacaine 0.4 ml/kg body weight, injected in paravertebral space with repeated aspiration test. Karmakar, Manoj et al (2001)6 Suggest current evidences that a single-sight injection of 0.375-0.5% Bupivacaine,15-20ml or 0.3 ml/kg is as effective as multiple-sight injection of 0.5% bupivacaine producing unilateral anaesthesia over 4 to 5 thoracic dermatome6. Easson and Wyatt3 (1979) found that at least four intercostals spaces could be covered by a single 15-ml injection of 0.375% bupivacaine. Pusch F et al (1999)4 studied single-injection unilateral PVB given at the level of T4, as a sole anaesthetic technique, for patients undergoing breast surgery for breast malignancy. The time of onset for block from initial bolus drug injection to loss of pinprick sensation at dermatome T4 was 8.325±1.3085 min. Adityakumar et al (2009)5 found onset of sensory block occurred in 7-10 min31.Coveney et al ( 1998)2 reported that in the PVB group the onset of sensory loss typically occurred 10 minutes after injection of 0.5% Bupivacaine2. In our study the extend of block was maximum in T1-T6. Easson and Wyatt3 (1979) found that at least four intercoastal spaces could be covered by a single 15-ml injection of 0.375% bupivacaine. D’Ercole et al (1999) 7.reported that after block placement, loss of sensation to pinprick over the T1-6 dermatomes on the left anterior chest wall was observed. In our study mean duration of analgesia was 71.775±12.026 minute. Mean Top up dose was required 1.11±0.32. Weltz et al (1995)8 anaesthesia was found to be adequate and supplementation was not required in any of the patient. In our study Mean duration for breast surgery was 136.4±29.335min.In our study duration of surgery correlate with studies had done by El Nasr (2002) 9, Naja (2003)10, Pusch et al (1999)4 and Coveney et al (1998)2. In our study PVB have been successful in 90% patients so our study correlate with study did by Naja et al (2003)10, Greengrass et al (1998)7, Pusch et al (1999)4 and Weltz et al (1995)8. Intraoperatively there was no significant change in pulse rate, SABP,DABP and SPO2.Similarily El Nasr9 (2002) reported that the heart rate and blood pressure did not differ between patients in the PVB group and GA group for the duration of the study (p>0.05 for both). Naja10 (2003) andPusch4 (1999) reported no change in intraoperative heart rate and blood pressure between patients in the PVB group and those undergoing GA. In our study 2 patients out of 40 (5%) complaints of nausea, thirty five out of 40 patients (95%) had no complaints. Our study correlated with study did by Greengrass et al (1998)7, Weltz et al (1995)8. Mean duration of postoperative analgesia was 7.025±1.187hr.Similarily Adityakumar et al (2009) 5found median duration for first dose of analgesia was 9 hours after operation.
CONCLUSION Paravertebral block for breast surgery is very safe and effective technique with good postoperative analgesia without any significant haemodynamic changes and complication.
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