Pangthipampai Pawinee, Karmakar Manoj K, Songthamwat Banchobporn, Pakpirom Jatuporn, Samy Winnie
Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region of the People's Republic of China.
J Pain Res. 2020 Jul 9;13:1713-1723. doi: 10.2147/JPR.S246406. eCollection 2020.
Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1-T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS.
Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1-0.5 µg.kg.h) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA.
The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia.
USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.
据报道，胸椎旁神经阻滞（TPVB）联合静脉镇静可为原发性乳腺癌手术（PBCS）提供手术麻醉。尽管已经描述了超声引导（USG）下的TPVB，但尚无关于USG下多级TPVB用于PBCS手术麻醉的报道。这项前瞻性观察性研究的目的是确定在T1 - T6椎体水平进行USG下多级TPVB（6m - TPVB）的可行性，并评估其为PBCS提供手术麻醉的效果。
25例接受PBCS的女性患者接受了USG下6m - TPVB用于手术麻醉。在每个椎体水平注射4毫升0.5%罗哌卡因（含1:200,000肾上腺素）。使用右美托咪定输注（0.1 - 0.5μg·kg·h）进行清醒镇静。手术麻醉阻滞成功定义为能够完成PBCS而无需采用补救镇痛或转为全身麻醉（GA）。
所有25例患者均成功实施了USG下6m - TPVB，但仅20%（5/25）的患者作为单一麻醉有效。其余80%（20/25）的患者在分离乳房与胸大肌及其筋膜时报告疼痛。使用小剂量静脉注射氯胺酮（平均总剂量38.0±20.5毫克）作为辅助镇痛，手术成功完成。
USG下6m - TPVB在技术上是可行的，但对于涉及胸大肌及其筋膜手术解剖的PBCS并不能始终提供完全的手术麻醉。我们的数据表明，不受6m - TPVB影响的胸神经参与了传入性伤害感受。
