Introduction. Thoracic paravertebral block (TPVB) provides superior analgesia for breast surgery when used in conjunction with general anesthesia (GA). Although TPVB and GA are often combined, for some patients GA is either contraindicated or undesirable. We present a series of 28 patients who received a TPVB with sedation alone for breast cancer surgery. Methods. A target controlled infusion of propofol or remifentanil was used for conscious sedation. Ultrasound guided TPVB was performed at one, two, or three thoracic levels, using up to 30 mL of local anesthetic. If required, top-up local infiltration analgesia with prilocaine 0.5% was performed by the surgeon. Results. Most patients were elderly with significant comorbidities and had TPVB injections at just one level (54%). Patient choice and anxiety about GA were indications for TVPB in 9 patients (32%). Prilocaine top-up was required in four (14%) cases and rescue opiate analgesia in six (21%). Conclusions. Based on our technique and the outcome of the 28 patients studied, TPVB with sedation and ultrasound guidance appears to be an effective and reliable form of anesthesia for breast surgery. TPVB with sedation is a useful anesthetic technique for patients in which GA is undesirable or poses an unacceptable risk.
Background: Debate regarding the benefit of radiotherapy after local excision of ductal carcinoma in situ (DCIS) continues. The Van Nuys Prognostic Index (VNPI) is thought to be a useful aid in deciding which patients are at increased risk of local recurrence and who may benefit from adjuvant radiotherapy (RT). Recently published interim data from the Sloane project has showed that the VNPI score did significantly affect the chances of getting planned radiotherapy in the UK, suggesting that British clinicians may already be using this scoring system to assist in decision making. This paper independently assesses the prognostic validity of the VNPI in a British population.
There is a risk of hypocalcaemia following total thyroidectomy and parathyroidectomy surgery, with the nadir being two to five days post operatively.[1] This project examined and improved the post-operative monitoring of serum calcium in patients undergoing these procedures at the Royal Devon and Exeter (RD&E) Hospital over a ten month period in 2013. A retrospective audit was undertaken, identifying whether serum calcium was monitored according to guideline; ie measured within the first 24 hours of surgery and daily thereafter until the patient was normocalcaemic.[2–3] The audit showed an overall compliance in 79% (n = 34) of cases. Of the non-compliant cases (n=9), seven also suffered hypocalcaemia.The current process was mapped by a flow chart and used as a basis for discussing experiences and identifying areas for improvement. Interventions implemented included a patient leaflet, a process flow chart displayed in the team office and in the weekend handover book, standard text for use in discharge summaries describing the process to GPs, the issuing of prescriptions or actual supplements for patients felt to be at high risk of hypocalcaemia, and finally education to the wider surgical junior doctor team. Percentage compliance with guidelines was compared before and after intervention with a re-audit undertaken in April 2014. Significant improvement was shown, with 100% of re-audit cases compliant (n=41), and all seven cases of hypocalcaemia were managed in full compliance with guideline.
This study highlights the impact of the 47-49 year age extension within the breast screening programme on the workload of the surgical department of a UK Breast Cancer Screening Unit offering non-randomized invitations. The study will inform other surgical units of expected workload when age extension is fully implemented.
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