Breast Surgery Using Thoracic Paravertebral Blockade and Sedation Alone

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. 1. Introduction Acute postoperative pain occurs after breast cancer surgery in approximately 36% of patients [1] and is a key risk factor for the development of chronic pain [1, 2]. Thoracic paravertebral block (TPVB) provides superior analgesia for breast cancer surgery when used in conjunction with general anesthesia (GA) [3] and reduces the severity of chronic pain after mastectomy [4]. Although TPVB and GA are often combined [3], for some patients GA is either contraindicated or undesirable due to factors including frailty, comorbidities, anxiety and patient choice. TPVB alone has previously been compared with GA alone [3]. However, much of the literature is heterogeneous and includes landmark techniques at multiple thoracic levels [5] which are time consuming, uncomfortable, and expose the patient to risk with each needle pass. A block from T1–T6 is required for most breast cancer surgeries. TPVB has recently undergone resurgence with improvements in ultrasound technology, affording many benefits including direct visualisation of local anesthetic (LA) spread and the pleura [3, 6]. This enables larger volumes to be injected at fewer levels whilst still achieving adequate analgesia. We present a series of 28 patients who received an ultrasound guided TPVB with sedation alone at one,