A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone

Abstract

AimTo test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics.MethodA prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n = 42) or 0.5% levobupivacaine with 2% lidocaine (n = 43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale.ResultsAlthough the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P < 0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P < 0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P = 0.006) and more episodes of hypotension (17.5%; P = 0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P < 0.001).ConclusionThe use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.Registration No.: NTC02004834

<p>A Randomized Controlled Trial Comparing Analgesic Efficacies of an Ultrasound-Guided Approach with and without a Combined Pressure Measurement Technique for Thoracic Paravertebral Blocks After Open Thoracotomy</p>

“… 6 A previous clinical study also revealed that the application of ultrasound-guided paravertebral block was unsuccessful in 5–10% of cases. 7 This failure rate is similar to the rate observed in paravertebral block using the classic landmark technique. 8 , 9 A substantial improvement in reliability is needed, and thus, we devised the pressure measurement method during needle advancement of TPVB.…”

“… 15 , 16 The studies in human cadavers and human patients also showed that the application of ultrasound-guided TPVB was unsuccessful in 4–7% of cases. 4 – 7 A potential explanation for the unsuccessful results is the technical difficulty, even under ultrasound guidance, that can occur with potential image loss when the needle tip is advanced to the adjacent transverse process. 4 , 5 Therefore, we tried to improve the accurate placement of the needle tip by combining a pressure measurement method with an ultrasound-guidance approach while also intending to assess the analgesic efficacy through this more delicate technique.…”

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

“…The time required to perform a single‐injection paravertebral block was shorter compared with the multiple‐injection group (5 min vs. 10 min; median difference 4 min; 95%CI ‐6 to ‐3 min; p < 0.001) . Ultrasound guidance was used to perform paravertebral injections or catheter positioning in eight studies , whereas 16 other studies did not use ultrasound . The results were not different depending on the use of ultrasound guidance or not.…”

The Role of Paravertebral Blocks in Ambulatory Surgery: Review of the Literature

“…Unilateral application can be conducted on one or more vertebral levels, with or without catheter insertion ( 5 , 8 , 10 , 12 , 24 ). Bilateral application is most commonly a single shot technique on two levels, depending on the type of surgery, in order to avoid potential complications (local anaesthetic toxicity and haemodynamic instability) ( 5 , 8 , 10 , 12 , 25 ). Unilateral application is used in breast surgery, thoracic surgery, cardiac pacemaker insertion, rib fractures, open cholecystectomy, liver resections, oesophageal and gastric surgery, partial or complete nephrectomies, inguinal herniorraphy ( 5 , 7 , 8 , 10 , 12 , 13 , 15 - 18 , 23 ).…”