Flinders University School of Medicine, Adelaide.
Anesth Analg. 2012 Nov;115(5):1053-9. doi: 10.1213/ANE.0b013e318264ba33. Epub 2012 Sep 13.
Bilateral breast augmentation is an increasingly popular day-case procedure. Local infiltration with sedation is routinely used for its ease of application compared with the more complex and potentially riskier paravertebral blockade (PVB). We hypothesized that ropivacaine injected by experienced anesthesia providers into the paravertebral space as a PVB was more effective than ropivacaine injected by the operating surgeon (plastic surgeon) directly into the zone of surgical dissection.
Forty female patients who were ASA physical status I or II and undergoing bilateral subpectoral cosmetic breast augmentation were recruited for participation in a prospective, randomized, single-blind study. Patients were randomized to 1 of 2 groups: ropivacaine via PVB, or surgical infiltration of ropivacaine. In both groups, the surgeon was asked to infiltrate the appropriate area with either saline (PVB group) or ropivacaine (local infiltration group). Both groups were sedated with propofol, titrated to effect. The plastic surgeon was blinded to the solution injected. Data collected included demographic characteristics, intraoperative cooperation scores, recovery room postoperative nausea and vomiting, analgesia use, and visual analog scale pain scores. All patients were asked to complete a preoperative anxiety and quality of recovery questionnaire and to record their pain scores and analgesia requirements on discharge. The outcome measures were (i) intraoperative patient cooperation as assessed by the plastic surgeon, (ii) propofol requirement, (iii) postoperative pain, and (iv) quality of recovery.
Forty patients completed the study. PVB improved intraoperative cooperation (significance of difference P < 0.001, WMWodds = 6.69 with 95% 1-sided confidence interval CI ≥2.85), reduced propofol requirement (significance of difference P = 0.005, WMWodds = 0.35, CI <0.69), and decreased average postoperative pain in the home environment (significance of difference P = 0.007, WMWodds = 0.38, CI <0.73). There were no PVB complications. Only patients from the surgical infiltration group required rescue analgesics (30%, significance of difference = 0.01).
In a limited number of patients, we found that PVB is superior to direct surgical infiltration of ropivacaine for bilateral breast augmentation in same-day surgery. These advantages need to be balanced against the potential risks of PVB, especially in an office setting.
双侧乳房增大是一种越来越受欢迎的日间手术。与更复杂且潜在风险更高的椎旁阻滞（PVB）相比，局部浸润镇静因其易于应用而被常规使用。我们假设，经验丰富的麻醉提供者在椎旁间隙注射罗哌卡因作为 PVB 比手术医生（整形外科医生）直接将罗哌卡因注射到手术区域更有效。
招募了 40 名 ASA 身体状况 I 或 II 级的女性患者，她们正在接受双侧胸下美容乳房增大手术。这些患者被随机分为 2 组之一：PVB 中的罗哌卡因，或罗哌卡因的手术浸润。在两组中，均要求外科医生用生理盐水（PVB 组）或罗哌卡因（局部浸润组）浸润适当区域。两组均用丙泊酚镇静，滴定至有效。整形外科医生对注射的溶液不知情。收集的数据包括人口统计学特征、术中合作评分、恢复室术后恶心和呕吐、镇痛使用情况以及视觉模拟评分疼痛。所有患者均被要求在术前完成焦虑和恢复质量问卷，并在出院时记录疼痛评分和镇痛需求。主要观察指标为：（i）整形外科医生评估的术中患者合作情况，（ii）丙泊酚需求，（iii）术后疼痛，和（iv）恢复质量。
40 名患者完成了研究。PVB 改善了术中合作（差异的统计学意义 P < 0.001，WMWodds = 6.69，95%单侧置信区间 CI ≥2.85），减少了丙泊酚的需求（差异的统计学意义 P = 0.005，WMWodds = 0.35，CI <0.69），并降低了在家环境中的平均术后疼痛（差异的统计学意义 P = 0.007，WMWodds = 0.38，CI <0.73）。没有发生 PVB 并发症。只有手术浸润组的患者需要使用急救镇痛药（30%，差异的统计学意义 = 0.01）。
在少数患者中，我们发现与双侧乳房增大的直接手术浸润罗哌卡因相比，PVB 用于日间手术具有优势。这些优势需要与 PVB 的潜在风险相平衡，特别是在办公室环境中。
