Postoperative Pain
Conditions
Keywords
regional anesthesia, postoperative pain, mastectomy, erector spinae plane block, paravertebral block
Brief summary
In this randomized, controlled, observer-blinded study the investigators plan to evaluate ultrasound-guided thoracic paravertebral block (TPVB) and ultrasound-guided thoracic erector spinae plane (TESP) block for postoperative pain management after unilateral total mastectomy without immediate reconstruction.
Detailed description
Despite substantial advances in our understanding of the pathophysiology of pain and availability of newer analgesic techniques postoperative pain is not always effectively treated. Optimal pain management technique balances pain relief with concerns about safety and adverse effects associated with analgesic techniques. Currently, postoperative pain is commonly treated with systemic opioids, which are associated with numerous adverse effects including nausea and vomiting, dizziness, drowsiness, pruritus, urinary retention, and respiratory depression. Use of regional and local anesthesia has been shown to reduce opioid requirements and opioid-related side effects. Therefore, their use has been emphasized. The advent of ultrasound guided regional anesthesia has brought more precision to these techniques, including the ability to visualize the anatomy, perform real-time navigation, and direct observation of local anesthetic spread, as it allows a greater degree of sensory and motor blockade. Thoracic paravertebral block (TPVB) has been used for analgesia of the thoracic wall since it was first described in 1905. A relatively recent alternative to the TPVB is the thoracic erector spinae plane (TESP) block, which involves the ultrasound-guided injection of local anesthetic into the interfascial plane deep to the erector spinae muscle at the level of the transverse process. It results in a loss of somatic sensory sensation across multiple unilateral dermatomes due to local anesthetic mediated blockade of the dorsal and ventral rami of the spinal nerve roots. It is increasingly being used due to ease of placing the block and a perception of greater safety. It has been shown to provide pain relief from rib fractures, thoracotomy, and chronic neuropathic pain of the chest wall. However, to date, TESP block has not been compared with TPVB in regards to analgesia with mastectomy surgery, which has been extensively studied. The investigators hypothesize that TESP block will provide similar (i.e., non-inferior) analgesia compared to TPVB block while reducing the cumulative consumption of oral morphine equivalents during the 24h post-operative period. The two co-primary aims of the study are to compare a) pain scores at 2h post-operative period, and b) cumulative consumption of oral morphine equivalents during the 24h post-operative period. Secondary objectives include comparison between the group in terms of pain scores at 6, 12, 24, and 48 hours post-operatively, as well as block-related morbidity (e.g.- pneumothorax), time to perform each block, and opioid-related adverse effects (e.g.- postoperative nausea and vomiting).
Interventions
PROCEDUREErector Spinae Plane Block
A relatively recent alternative to the paravertebral block is the thoracic erector spinae plane block, which involves the ultrasound-guided injection of local anesthetic into the interfascial plane deep to the erector spinae muscle at the level of the transverse process. It results in a loss of somatic sensory sensation across multiple unilateral dermatomes due to local anesthetic mediated blockade of the dorsal and ventral rami of the spinal nerve roots. It is increasingly being used due to ease of placing the block and a perception of greater safety. It has been shown to provide pain relief from rib fractures, thoracotomy, and chronic neuropathic pain of the chest wall. However, to date, erector spinae plane block has not been compared with paravertebral block in regards to analgesia with mastectomy surgery, which has been extensively studied.
PROCEDUREParavertebral Block
Paravertebral block is a classic regional anesthesia technique that has been in use for over 100 years. It is performed by the injection of local anesthetic into the space between the costotransverse ligament and parietal pleura resulting in blockade of ipsilateral intercostal nerves. It results in a loss of somatic sensation over multiple unilateral dermatomes.
Sponsors
University of Texas Southwestern Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Masking description
The practitioner must know which block to perform, and the patient will be able to deduce which block was performed because paravertebral requires two injections, and erector spinae requires only one injection. The outcomes assessor will not know which group each patient is in.
Intervention model description
Two parallel arms. One group will receive erector spinae plane block, and the other will receive paravertebral block.
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
Yes
Inclusion criteria
Criteria for Inclusion of Subjects: * Female and male ASA physical status 1-3 scheduled for unilateral total mastectomy without immediate reconstruction * Age 18-80 years old * Able to participate personally or by legal representative in informed consent in English or Spanish Criteria for Exclusion of Subjects: * History of relevant drug allergy * Age less than 18 or greater than 80 years * Chronic opioid use or drug abuse * Significant psychiatric disturbance * Inability to understand the study protocol * Refusal to provide written consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Pain | 2 hours after surgery | Pain score via Numeric Rating Scale (0-10) |
| Opioid Use | 24 hours after surgery | Cumulative opioid consumption in oral morphine equivalents (mg) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Pain | 6, 12, 24, and 48 hours after surgery | Pain scores via Numeric Rating Scale (0-10) |
| Opioid morbidity | 2, 6, 12, 24, and 48 hours after surgery | Any evidence of opioid-related morbidity or adverse effects |
| Procedural morbidity | 2, 6, 12, 24, and 48 hours after surgery | Any evidence of procedure-related morbidity (i.e.- with paravertebral block and erector spinae plane block) |
| Time | preoperative | Total time (in minutes) needed to perform the block (paravertebral or erector spinae plane block) |
Outcome results
None listed