Paravertebral Blocks Provide Superior Same-Day Recovery over General Anesthesia for Patients Undergoing Inguinal Hernia Repair

Abstract

Inguinal herniorrhaphy is commonly performed on an outpatient basis under nerve blocks or local or general anesthesia (GA). Our hypothesis is that use of paravertebral blocks (PVB) as the sole anesthetic technique will result in shorter time to achieve home readiness and improved same-day recovery over a 'fast-track' GA. Fifty patients were randomly assigned to receive either PVB or GA under standardized protocols (PVB = 0.75% ropivacaine, followed by propofol sedation; GA = dolasetron 12.5 mg, propofol induction, rocuronium, endotracheal intubation; desflurane; bupivacaine 0.25% for field block). Eligibility for postanesthetic care unit (PACU) bypass and data on time-to-postoperative pain, ambulation, home readiness, and incidence of adverse events were collected. More patients in the PVB group (71%) met the criteria to bypass the postanesthetic care unit compared with patients in the GA group (8%; P < 0.001). Only 3 (13%) of patients in the PVB group requested treatment for pain while in the hospital, compared with 12 (50%) patients in the GA group, despite infiltration with local anesthetic (P = 0.005). Patients in the PVB group were able to ambulate earlier (102 +/- 55 minutes) than those in the GA group (213 +/- 108 minutes; P < 0.001). Time-to-home readiness and discharge times were shorter for patients in the PVB group (156 +/- 60 and 253 +/- 37 minutes) compared with those in the GA group (203 +/- 91 and 218 +/- 93 minutes) (P < 0.001). Adverse events (e.g., nausea, vomiting, sore throat) and pain requiring treatment in the first 24 hours occurred less frequently in patients who had received PVB than in those who had received GA. In outpatients undergoing inguinal herniorrhaphy, PVB resulted in faster time to home readiness and was associated with fewer adverse events and better analgesia before discharge than GA.

Thoracic Paravertebral Block, a Suitable and Safe Adjunct for General Anaesthesia, for Post-Operative Pain Relief in Modified Radical Mastectomies

“…1,7,13,14,15,16 Of these, three RCTs that compared PVB and GA for anaesthesia during breast surgery, showed that the pooled relative risk for PONV was 0.25 (95% CI: 0.13-0.50), significantly in favour of PVB. 7,13,15 Of the next three studies, one study reported that nausea occurred significantly less frequently after PVB compared with GA. 16 The 2 nd study reported significantly less PONV after PVB , 24 hours after surgery. 1 The 3 rd study reported a similar incidence of PONV in both the PVB & GA groups.…”

“…In a systematic review of eight randomized controlled trials (RCTs) (level II evidence) by Thavaneswaran et al, 17 seven RCTs 1,7,[13][14][15][16]18 reported on the failure rates of PVB which were between 0-13%. Wassefet al 18 reported that 100% of field blocks were effective.…”

Is Regional Anesthesia Associated With Reduced PACU Length of Stay?

“…Multiple randomized controlled trials and a recent metaanalysis confirm that regional anesthesia in the ambulatory setting decreases PACU LOS [6,7,14]. One of the few articles to show a benefit of regional anesthesia concerning PACU LOS in a large tertiary-care hospital demonstrated a decrease in LOS for 20% of the 340 patients receiving regional anesthetic [18].…”

“…Patients receiving regional anesthesia for rotator cuff surgery versus general anesthesia were shown to bypass the PACU more often, report less pain, ambulate earlier, meet discharge criteria sooner, and be more satisfied with their care [7]. Similarly, patients undergoing inguinal hernia repair in the outpatient setting with paravertebral blocks compared to general anesthesia demonstrated higher PACU bypass rates, earlier ambulation, less nausea and vomiting, and reduced need for supplemental analgesics [6]. A meta-analysis performed by Liu et al [14] in 2005 showed that peripheral regional anesthesia in the ambulatory setting was associated with decreased PACU use, nausea, and postoperative pain.…”

Is There a Role for Regional Anesthesia in the Obese Patient?

“…Although outcomes studies specific to the obese surgical population are limited, previously-published studies of surgical patients suggest that peripheral regional anesthesia may offer advantages over general anesthesia in terms of immediate postoperative pain control and anesthetic-induced side effects, possibly reducing the time required for discharge from the postanesthesia care unit in the ambulatory setting [5,6]. While neuraxial anesthesia may not offer the same advantages in terms of recovery time over general anesthesia, avoidance of general anesthesia may be preferred for other reasons [7].…”