The Application Of Ultrasound-guided Thoracic Paravertebral Block Combined With Total Intravenous Anesthesia For Modified Radical Mastectomy

1. BackgroundAccording to the WHO/I ARC estimation, there were new diagnosed 1,380,000 cases of breast cancer in 2008, which account for 22.9% of all females new diagnosed tumor. In addition, nearly 460,000 women died due to breast cancer each year, accounting for 1.7% of female death caused by tumor. Currently, endocrine therapy, chemotherapy, radiotherapy and Chinese tradition therapy have been applied in treating breast cancer, mastectomy is still the most popular and basic therapy for breast cancer.There are several anesthesia methods applied in mastectomy, including regional block, general anesthesia and combining techniques with regional block and general anesthesia. Benefit from the improvement of the general anesthetics’ quality, general anesthesia has becoming the most popular anesthesia in mastectomy in recent decades. However, general anesthesia can only inhibit the limbic system of cerebral cortex and the projection system of thalamocortical projection system. Consequently, it cannot completely and effectively inhibit the noxious stimulus and stress response caused by perioperative nociceptive stimulus. With increasing demand to the perioperative comfort, the concept of combining different anesthesia techniques, which can make best use of the advantages and avoid the disadvantages of these techniques, has been widely accepted and applied in clinical practices. The combination of anesthesia techniques can not only effectively reduce the anesthetics consumptions and side effect, but also can increase anesthesia quality through improving the postoperative pain and recovery. Accordingly, how to choose and combine the anesthetic technique for different surgery is a meaningful and challenging research to exploration and discussion.With the development of ultrasound-guide regional block techniques in the recent years, thoracic paravertebral block is be applied as an alternative technique to replace or combine with general anesthesia in breast surgery by several anesthesiologists, which has achieved satisfactory outcome and can provide superior perioperative analgesia compared with other analgesic methods. The most important difference between ultrasound-guided thoracic paravertebral block and traditional methods is that the ultrasound-guided technique can not only provide a vivid image of the important structure surrounding paravertebral, it can also monitor the path of needle insertion and local anesthetics spread in target region, which can decreased a number of complications, such as pneumothorax, intrathecal injection, intravenous injection of local anesthetics, and so on.2. ObjectiveTo compare and evaluate the feasibility of thoracic paravertebral block combined with TIVA for modified radical mastectomy and the effect on perioperative pain and recovery.3. MethodsSixty female patients (18-85 years old), ASAⅠ-Ⅲ, undertaking modified radical mastectomy, were equally randomized into intravenous-inhalation general anesthesia (G) group and thoracic paravertebral block combined with TIVA (P) group. The heart rate, blood pressure, SpO2, PetCO2 and BIS were recorded during preoperative to discharge from PACU, and the heart rate, blood pressure and SpO2 were recorded from 2 hours to 7 days after operation. The resting and coughing VAS pain score were evaluated at 2,4,8,16,24 hours and 2,4,7 days after operation. The modified quality of recovery was assessed at 24 hours,2,4,7 days after operation. The consumption of sufentanil during operation, PACU stay time, PCIA sufentanil consumption, frequency of PCIA pressing and incidence of complication related to anesthesia and analgesia were also recorded.4. ResultsAt the beginning and ending of the operation, the HR of P group are respectively higher and lower than G group (P<0.05). At 4 hours after operation, the SBP of P group was obviously lower than G group, while the SBP and DBP of P Group was significantly lower than G group at 16 and 24 hours after operation. The SpO2, PETCO2 and BIS were similar between two groups during perioperative. The resting and coughing VAS pain score of P group is significantly less than G group at 2,4 and 8 hours after operation (P<0.05). The modified quality of recovery of P group was superior than G group from 8 hours to 2 days after operation. The consumption of sufentanil during operation and PCIA, PACU stay time, the frequency of PCIA pressing of P group were also lower than G group (P<0.05). The complications of P group are less than G group, but the incidence has no statistical significance (P> 0.05).5. ConclusionThe thoracic paravertebral block combined TIVA could be safely and effectively applied in modified radical mastectomy with less opioids consumption, shorter PACU stay time and more satisfactory in postoperative pain control.