|Year : 2019 | Volume
| Issue : 4 | Page : 1191-1196
Comparative study between thoracic epidural and ultrasound-guided thoracic paravertebral block in perioperative pain management for mastectomy
Safaa M Helal, Ahmed A Abdel Aziz, Khaled A Gab-Allah, Eman G Ramadan
Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||23-Apr-2018|
|Date of Decision||04-Jun-2018|
|Date of Acceptance||09-Jun-2018|
|Date of Web Publication||31-Dec-2019|
Eman G Ramadan
Shebeen El-Kom, Menoufia
Source of Support: None, Conflict of Interest: None
To compare between ultrasound-guided thoracic paravertebral block (PVB) and thoracic epidural block in patients undergoing mastectomy for pain control, intraoperative hemodynamics, and postoperative patient satisfaction.
Thoracic PVB and thoracic epidural appears promising when combined with general anesthesia in reduction of postoperative pain.
Patients and methods
Between mid-2016 and December 2017, this prospective clinical study included 60 female patients scheduled for a unilateral mastectomy in Menoufia University Hospitals and divided into two groups, 30 each. Patients in group A were given single shot ultrasound-guided PVB at T4 level using 0.3 ml/kg of 0.5% bupivacaine. Patients in group B were given single shot epidural block at T4 level using 2 ml/segment of 0.5% bupivacaine.
A total of 60 patients were included, of them, 30 patients received PVB and 30 received thoracic epidural. Heart rate was significantly higher in paravertebral group than in thoracic epidural group (P < 0.001). Mean arterial blood pressure was significantly higher in paravertebral group than in thoracic epidural (P < 0.001). The mean score measured using a seven-point Likert-like verbal rating scale for patient satisfaction in paravertebral group was 6.2 ± 0.85, compared with 4.9 ± 1.03 in epidural group; there was a highly significant statistical difference (P < 0.001). There was no significant statistical difference among the studied groups with respect to fentanyl requirements and postoperative visual analogue scale.
Ultrasound-guided PVB is an effective technique showing greater hemodynamics stability and pain control compared with epidural analgesia for mastectomy.
Keywords: epidural block, general anesthesia, hemodynamic stability mastectomy, thoracic paravertebral block, ultrasound guided
|How to cite this article:|
Helal SM, Abdel Aziz AA, Gab-Allah KA, Ramadan EG. Comparative study between thoracic epidural and ultrasound-guided thoracic paravertebral block in perioperative pain management for mastectomy. Menoufia Med J 2019;32:1191-6
|How to cite this URL:|
Helal SM, Abdel Aziz AA, Gab-Allah KA, Ramadan EG. Comparative study between thoracic epidural and ultrasound-guided thoracic paravertebral block in perioperative pain management for mastectomy. Menoufia Med J [serial online] 2019 [cited 2020 Jan 24];32:1191-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1191/274218
| Introduction|| |
Breast surgery is usually performed under general anesthesia, and is associated with considerable postoperative nausea and vomiting (PONV) along with physical, psychological, and immunological depression. So there is a search for an optimal regional techniques for breast surgeries that would reduce PONV and also provide postoperative sensory block, minimizing analgesic requirements to reduce postoperative pain after breast surgery . Ultrasound- guided thoracic paravertebral block (PVB) and thoracic epidural appears promising because of reduction in postoperative pain, decreased opioid consumption with reduction in PONV, drowsiness, risk of respiratory depression, and cost saving. There is a decrease in the incidence of chronic postsurgical pain, thereby improving the healing capacity of the wound . When thoracic epidural analgesia was used; the incidence of pain, nausea, vomiting, and length of hospital stay was reduced. However, possible serious complications of continuous epidural analgesia including hypotension, respiratory depression, infection, or even catheter migration to the subarachnoid space, may occur . Thoracic PVB has been used in thoracic and breast surgeries with minimal complications . The aim of our study was to compare between ultrasound-guided thoracic PVB and thoracic epidural block in patients undergoing mastectomy.
| Patients and Methods|| |
Sixty female patients of American Society of Anesthesiologists I–II aged 40–65 years, were scheduled for a unilateral breast surgery in Menoufia University Hospitals and were enrolled in this clinical study after approval of the local ethical committee and after taking an informed written consent. They were divided into two groups:
- Group A: 30 patients were given single shot PVB at T4 level using 0.3 ml/kg of 0.5% bupivacaine
- Group B: 30 patients were given single shot epidural block at T4 level using 2 ml/segment of 0.5% bupivacaine.
All the patients associated with severe respiratory, endocrine disease, bleeding disorders, allergy to any of the study drug, kyphoscoliosis, presence of local infection, chronic pain syndrome, chronic analgesic use, BMI greater than 35, known pregnancy, lactating mothers, and psychiatric disease were excluded from the study.
Patients were evaluated a day before surgery using personal data, history of any medical conditions, or drug allergies, examined generally and locally at the site of anaesthetic injection. All routine investigations were noted (ECG, hemoglobin, coagulation profile). Patients were thoroughly explained about the procedures and were made well conversant with the visual analogue scale (VAS) . All patients had to fast for 6 h before surgery.
After establishment of an intravenous access, all patients were preloaded with lactated Ringer's solution as maintenance fluid. Baseline vital parameters like pulse rate, noninvasive blood pressure, continuous ECG, respiratory rate, and peripheral arterial oxygen saturation were monitored using Nihon Kohden Lifescope BSM-3000 series Bedside Monitor (Nihon, Nishiochiai, Shinjuku-ku, Tokyo 161-8560, Japan) and noted. Patients were given incremental doses of intravenous midazolam before block placement to decrease anxiety during the procedure while maintaining a meaningful patient contact. After the block is achieved, we proceeded to general anesthesia. Intraoperative, all patients were monitored with five leads ECG, noninvasive blood pressure, pulse oximetry and end-tidal CO2, train-of-four, and entropy monitoring to exclude awareness under anesthesia. Monitoring has been continued and recorded at 5 min interval in the intraoperative and at 1 h interval for 6 h in the postoperative period.
Group A: the block was placed in a seated position. After sterilization, identification of the level of T4, painting and draping, skin was infiltrated with local anesthetic using 25-G 1.5-inch needle. A linear superficial ultrasound transducer (5–12 MHz) (M turbo ultrasound system SN WK2WHL) was used for ultrasound guidance (Philips Amsterdam, Netherlands). Sonar setting was fixed as we included only patients with BMI less than 35, so there was no change in depth of the block. The endpoint of a successful block is anterior displacement of the pleura. So, 0.3 ml/kg of 0.5% bupivacaine solution was then injected after repeated negative aspiration for blood, air, or cerebrospinal fluid, irrespective of paresthesia.
Group B: after identification of the level of T4, painting and draping, skin was infiltrated with local anesthetic and 2 ml/segment of 0.5% bupivacaine was injected after confirmation of epidural space.
Results were collected, tabulated, and statistically analyzed by an IBM compatible personal computer with SPSS statistical package (version 20, Released 2011, IBM SPSS statistics for windows; SPSS Inc., IBM Corp., Armonk, NY). Two types of statistical analysis were done: (a) descriptive statistics, for example, was expressed in mean (X̄) and SD. (b) Analytic statistics, for example, Student's t test done, it is a test of significance used for comparison of quantitative variables between two groups of normally distributed data. Although, Mann–Whitney's test was used for comparison of quantitative variables between two groups of unevenly distributed data. P value less than 0.05 was considered statistically significant.
| Results|| |
Patients' demographic data (age, BMI, type of surgery, and duration of surgery) were comparable between the two groups [Table 1]. With respect to the mean blood pressure (BP), during surgery there was a significant statistical difference among the studied groups as the patients receiving thoracic epidural (group B) showed a significant fall in BP leading to a significant P value at different intervals, such as 15, 20, 30, 40, 50 min, 1, and 1 h postoperative. In patients receiving ultrasound-guided thoracic PVB (group A) there was no significant fall in BP leading to more stability in hemodynamics than group B [Table 2]. With respect to the heart rate (HR), there was a fall in the epidural group than the paravertebral group (80.30 ± 3.09) and (81.17 ± 3.28), respectively, to statistically significant extent as the P value was P < 0.001. Total intraoperative fentanyl requirements, and the time towards first dose of rescue analgesic were comparable between the two groups [Table 3]. In terms of VAS score there was no significant difference between both techniques [Table 4]. The mean score was measured using a seven-point Likert-like verbal rating scale  for patient satisfaction in paravertebral group was 6.2 ± 0.85, compared with 4.9 ± 1.03 in epidural group; which was highly significant. There was no statistical difference among the studied groups in terms of VAS score [Table 5].
|Table 2: Comparison between the studied groups with respect to intraoperative heart rate|
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|Table 3: Comparison between the studied groups with respect to analgesia|
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|Table 4: Comparison between the studied groups with respect to patient and doctor satisfaction|
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|Table 5: Comparison between the studied groups with respect to visual analogue scale|
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| Discussion|| |
Our rationale for the inclusion of thoracic epidural anesthesia (TEA) and PVB in this study was based on clinical evidence suggesting that extradural anesthesia has been associated with fewer postsurgical recovery complications, shorter hospital stays, and consequently, decreased health care costs . In terms of the demographic variables (age, BMI, type of surgery, and duration of surgery) there was an insignificant statistical difference among the studied groups with respect to the HR. During surgery there was a significant statistical difference among the studied groups as in epidural group (B) showed a significant fall in HR leading to significant P value intra and 2 h postoperative. In PVB group A there was no significant fall in the HR leading to more stability in hemodynamics than group B. Giri et al.  compared combined general anesthesia with PVB group A versus general anesthesia alone group B in modified radical mastectomy and they found that intraoperative and postoperative tachycardia and hypertension were more common to a statistically significant extent in group B compared with group A . Also, Biswas et al.  who compared thoracic epidural block and thoracic PVB for post-thoracotomy pain relief, found that the HR decreased after activation of the epidural when compared with the baseline and then it remained stable after the initial fall (in first 20 min). In paravertebral group, no such decrease in HR was noticed after giving the bolus dose. In both groups the HR remained stable in the postoperative period . However; our results were not in accordance with Soni et al.  who compared thoracic epidural and PVB in patient undergoing breast surgery with sedation using 15 ml of 0.5% Ropivacaine. The HR of the two groups did not show any significant difference. With respect to the mean BP, during surgery there was a significant statistical difference among the studied groups as the patients receiving thoracic epidural (group B) showed a significant fall in BP intra and 2 h postoperative. In patients receiving ultrasound-guided thoracic PVB (group A) there was no significant fall in BP leading to more stability in hemodynamics than group B. The cardiovascular effects of a block above T4 are the result of a high sympathetic block. The cardiac sympathetic fibers (T1–T4) are blocked that may cause decrease in cardiac contractility, profound hypotension, and bradycardia. This can be detrimental to a patient with limited cardiac reserve because of profound hypotension and decreased contractility . The significant incidence of hypotension in thoracic epidural group compared with thoracic paravertebral group concurs with the study of Kumar  who compared thoracic epidural (group A) and PVB (group B) for post-thoracotomy pain relief using 0.25% bupivacaine and found that 50% of patients showed hypotension in group A and 8% in group B. Mean arterial pressure (MAP) readings at 10, 20, 30, 40, 50, 60 min were higher in group A than in group B to a statistically significant extent . Our study results are similar to the findings of Mukherjee et al. , Casati et al. , and Baidya et al. , who found that there were statistically significant MAP differences between thoracic PVB and thoracic epidural block, which were lower in the TEA group. Our study findings are contradictory to the findings of Dhole et al. , who found no significant differences with respect to HR and MAP. Systemic vascular resistance was lower in the TEA group throughout the study period, although there was no statistical difference. Our findings are also contradictory to the findings of Pintaric et al. , who found that both groups did not differ significantly in HR and MAP. This can be explained, as a greater volume of colloid infusion and phenylephrine is required in the epidural than in the paravertebral group to maintain the targeted oxygen delivery index. In terms of the total fentanyl required during surgery there was no statistically significant difference among the studied groups. Our study results are in accordance with Gautam et al.  who compared continuous thoracic PVB and thoracic epidural analgesia techniques for postoperative pain relief in patients undergoing open nephrectomy and found that fentanyl consumption were similar in the two groups. In our study the quality of analgesia immediately postoperative and till 6 h postoperatively was assessed using VAS. There was no statistical difference among the studied groups pertaining to VAS. The results are in accordance with the studies done by Soni et al.  and El-Hamid and Azab , which showed that the analgesic profile of the two regional technique were similar in both groups. However, our study findings are contradictory to the findings of Biswas et al. , in patients undergoing thoracotomy. In his study pain relief was significantly better with epidural. Also Debreceni et al.  found that thoracotomy pain management with continuous epidural analgesia was superior to that with continuous thoracic paravertebral analgesia (TPVA), in the early postoperative period. The statistically significant difference in the VAS scores between the two groups can be attributed to the large volume injected into the epidural space (0.2 ml/kg) compared with the lower volume given in our study (2 ml/segment). Our results are not in accordance with the findings of Richardson et al. , who found significantly lower VAS pain scores both at rest and on coughing in the PVB group compared with the TEA group. The statistically significant difference can be attributed to the fact that their studied population was heterogeneous in comparison with our study. They included patients undergoing esophagectomy and antireflux measures besides lung resection surgery, and this might be responsible for the greater difference between the two groups. With respect to the time to first dose of rescue analgesic, there was insignificant statistical difference among the studied groups. This shows similar analgesic profile of both the regional techniques. In a study conducted by Kairaluoma et al.  PVB with bupivacaine (1.5 mg/kg), performed before general anesthesia in patients scheduled for modified radical mastectomy (MRM), resulted in less need for postoperative opioid analgesics during the initial hours after surgery and less overall intensity of pain on the first postoperative day. In group B 20% (6/30) patients experienced nausea and vomiting whereas in group A the figure was 7% (2/30) showing that patients in paravertebral group suffered from less nausea and vomiting. The results match with Davies et al.  who found that nausea and vomiting occurred less often with PVB, odds ratio 0.47 (0.24, 0.53). Pertaining to patient satisfaction score, there was significant difference in the studied groups. It was better in paravertebral group. Whereas surgeon satisfaction was significantly higher in epidural group. The study done by Das et al.  compared thoracic PVB and general anesthesia for elective breast surgery and found that patients had higher satisfaction scores with paravertebral group than general anesthesia group. In the same study surgeon satisfaction was comparable. These differences may be attributed to the fact that epidural blockage leads to less bloody surgical field due to hypotension and consequently, better visualization of the anatomical structures and less blood loss. In this study, no patient in both groups had any complications due to technique like pneumothorax, epidural abscess or hematoma, skin site infection, spinal or nerve root injury, or urinary retention.
| Conclusion|| |
Ultrasound-guided thoracic PVB is an effective analgesic technique showing greater hemodynamics stability and less stress response to surgery compared with epidural.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kitowski NJ, Landercasper J, Gundrum JD, De Maiffe BM, Chestnut DH, Bottcher ML, et al
. Local and paravertebral block anesthesia for outpatient elective breast cancer surgery. Arch Surg 2010; 14
Riain SC, Donnell BO, Cuffe T, Harmon DC, Fraher JP, Shorten G. Thoracic paravertebral block using real-time ultrasound guidance. Anesth Analg 2010; 110
Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, Lyerly HK. Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases. Ann Surg 1998; 227
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia; their role in postoperative outcome. Anesthesiology 1995; 82
Giri M, Kumar S, Gautam R, Mishra LS, Vagyannavar R. Combined general anaesthesia with paravertebral block versus general anaesthesia alone in modified radical mastectomy: a stress response to surgery. Indian J Basic Appl Med Res 2015; 4
Biswas S, Verma R, Chandra G, Prakash R, Kumar A, Bhatia VK. Thoracic epidural block and thoracic paravertebral block for post thoracotomy pain relief. J Clin Diagn Res 2016; 10
Soni S, Soni A, Bapugol M. Comparison of thoracic epidural block vs paravertebral block in patients undergoing breast surgery. Indian J Clin Anaesth 2015; 2
Kumar SR. Thoracic epidural vs thoracic paravertebral block. Indian J Anaesth 2003; 47
Mukherjee M, Goswami A, Gupta SD, Sarbapalli D, Pal R, Kar S. Analgesia in post-thoracotomy patients: comparison between thoracic epidural and thoracic paravertebral blocks. Anesth Essays Res 2010; 4
Casati A, Alessandrini P, Nuzzi M, Tosi M, Iotti E, Ampollini L, et al
. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol 2006; 23
Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2014; 18
Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2001; 15
Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med 2011; 36
Gautam SK, Das PK, Agarwal A, Kumar S, Dhiraaj S, Keshari A, Patro A. Comparative evaluation of continuous thoracic paravertebral block and thoracic epidural analgesia techniques for post-operative pain relief in patients undergoing open nephrectomy: A prospective, randomized, single-blind study. Anesth Essays Res 2017; 11
El-Hamid AM, Azab AF. Intraoperative haemodynamic stability and stress response to surgery in patients undergoing thoracotomy: comparison between ultrasound-assisted thoracic paravertebral and epidural block. Egypt J Cardiothorac Anesth 2016; 10
Debreceni G, Molnar Z, Szelig L, Molnar TF. Continuous epidural or intercostal analgesia following thoracotomy: a prospective randomized double-blind clinical trial. Acta Anaesthesiol Scand 2003; 47
Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999; 83
Kairaluoma PM, Bachmann MS, Korpinen AK, Rosenberg PH, Pere PJ. Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy. Anesth Analg 2004; 99
Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006; 96
Das S, Bhattacharya P, Mandal MC, Mukhopadhyay S, Basu SR, Mandol BK. Multiple-injection thoracic paravertebral block as an alternative to general anesthesia for elective breast surgeries: a randomized controlled trial. Indian J Anesth 2012; 56
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]