Paravertebral Block

Paravertebral Block

PEP Topic 
Acute Pain
Description 

Paravertebral block is done by injection of a local anesthetic into the paravertebral space, adjectent to the vertebral bodies of the spine.  Paravertebral block has been examined for its effectiveness in managing acute postoperative pain and other symptoms in patients undergoing surgery for cancer.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146159/

Effectiveness Not Established

Research Evidence Summaries

Aufforth, R., Jain, J., Morreale, J., Baumgarten, R., Falk, J., & Wesen, C. (2012). Paravertebral blocks in breast cancer surgery: Is there a difference in postoperative pain, nausea, and vomiting? Annals of Surgical Oncology, 19(2), 548–552.

doi: 10.1245/s10434-011-1899-5
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Study Purpose:

To evaluate the effect of paravertebral blocks on the postoperative pain, nausea, and vomiting of patients undergoing breast cancer surgery with or without axillary staging

Intervention Characteristics/Basic Study Process:

Chart review

Sample Characteristics:

  • The sample was composed of 337 patients.   
  • Mean patient age was 59.5 years.
  • All patients were female.
  • All patients underwent breast cancer surgery and received paravertebral blocks (PVBs). Of all patients, 45.5% (110 patients) had mastectomy; in addition, 13.4% (45 patients) had tissue-expander reconstruction, 53.3% (129 patients) had a sentinel lymph node biopsy, and 33.5% (81 patients) had full axillary dissections.  
  • A study was excluded if patients had myocutaneous tissue-flap breast reconstruction simultaneous to mastectomy, had additional surgeries, used continuously delivered postoperative pain medication, had a history of chronic pain, or had a history of needing antiemetics prior to surgery.

Setting:

  • Single site
  • Inpatient
  • Hospital
     

Phase of Care and Clinical Applications:

  • Phase of care: active treatment
  • Clinical applications: late effects and survivorship

Study Design:

Retrospective chart review

Measurement Instruments/Methods:

  • Scores, 0–10, to measure pain
  • Opioid analgesic converter as presented on globalRPh.com

Results:

In patients who had undergone breast cancer surgery, PVB had no effect on postoperative pain, nausea, or vomiting.

Conclusions:

  • The pain, nausea, and vomiting scores of patients who had undergone breast cancer surgery with PVBs were similar to the scores of patients who had undergone breast cancer surgery without PVBs.
  • The study demonstrated that PVBs can be easily and safely administered. This study did not show any advantage to doing so.

Limitations:

  • The study had a risk of bias due to no appropriate control group.
  • The list that follows showed other study limitations.
    • The study was retrospective.
    • Not all charts contained consistently recorded postoperative pain scores; the timing or frequency of pain scores varied greatly.
    • Determining the relationship of pain score to administration of pain medication was difficult.
    • Some pain scores were gathered before administration of pain medication; some, after administration.
    • The study lacked a standard postoperative pain medication regimen.
    • Patients received different types of opioids.
    • Some patients received postoperative NSAIDs. Authors did not consider the effect of the NSAIDs on pain.
    • The study had no means of evaluating whether PVBs were successful in reducing pain.
    • Each cohort included significantly different types of breast and axillary surgeries.
       

Nursing Implications:

This study indicated that PVB might decrease postoperative pain in breast cancer surgery patients with immediate breast reconstruction with tissue expanders. PVB may have an important role in decreasing postoperative pain and opioid analgesic usage in patients electing to have immediate breast reconstruction with tissue expanders.


 

Fahy, A.S., Jakub, J.W., Dy, B.M., Eldin, N.S., Harmsen, S., Sviggum, H., & Boughey, J.C. (2014). Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Annals of Surgical Oncology, 21, 3284–3289. 

doi: 10.1245/s10434-014-3923-z
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Study Purpose:

To evaluate whether paravertebral block use affected opioid use, antiemetic use, and length of stay in patients receiving mastectomies

Intervention Characteristics/Basic Study Process:

Patient data were collected from medical records from the time periods before and after the use of paravertebral blocks (PVBs). Patients receiving unilateral mastectomies had unilateral PVBs, and those receiving bilateral mastectomies had bilateral PVBs. Blocks were placed preoperatively. All patients had general anesthesia. Prophylactic opioids and antiemetics were given intraoperatively at the discretion of the anesthesia team. Pain scores were documented with vital sign monitoring postoperatively. The results of those who had PVBs were compared to a cohort of patients who did not have PVBs.

Sample Characteristics:

  • N = 526  
  • MEAN AGE = 56.5 years (range = 20–97 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer, and slightly less than half had unilateral mastectomy; about half had immediate reconstruction
  • OTHER KEY SAMPLE CHARACTERISTICS: 75% did not have axillary lymph nodes removed

Setting:

  • SITE: Single site  
  • SETTING TYPE: Inpatient    
  • LOCATION: Rochester, NY

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Retrospective cohort comparison

Measurement Instruments/Methods:

  • Total postoperative opioid consumption
  • Length of stay less than or greater than 36 hours
  • Length of time in the postanesthesia care unit

Results:

In a multivariate analysis that was controlled for age and surgeon, there was no significant difference between groups in length of stay. The percentage of patients requiring antiemetics was higher in the no-PVB group (57 versus 39%, respectively, p < 0.00001). The amount of opioids required was higher in the no-PVB group on the day of surgery (47.6 versus 40.1 morphine equivalents, respectively, p < 0.0001). Despite differences in opioid consumption, there were no significant differences between groups in pain scores. The greatest difference in opioid consumption was seen in patients receiving immediate bilateral reconstructions.

Conclusions:

The use of PVBs in patients receiving mastectomies was associated with lower antiemetic and opioid consumption on the day of surgery.

Limitations:

  • Risk of bias (no random assignment)
  • Key sample group differences that could influence results 
  • Measurement/methods not well described 
  • Other limitations/explanation: The method of pain measurement and the actual timing of measurement was not described. It appeared that the analysis was done in terms of opioid consumption for only the day of surgery. The analysis did not take into account any prophylactic antiemetics or opioids given intraoperatively. No description or standardization of all relevant postoperative medications was given.

Nursing Implications:

The findings of this study suggested that among patients receiving mastectomies, PVBs may reduce the need for postoperative antiemetics and opioids. However, it was not clear that the procedure actually reduced postoperative pain. This procedure appeared to be most beneficial for women having the most extensive surgical procedures. Additional well-designed research is warranted to determine the clinical benefits of PVB and its role in improving perioperative pain control.

Li, N.L., Yu, B.L., Tseng, S.C., Hsu, C.C., Lai, W.J., Hsieh, P.F., . . . Chen, C.M. (2011). The effect on improvement of recovery and pain scores of paravertebral block immediately before breast surgery. Acta Anaesthesiologica Taiwanica: Official Journal of the Taiwan Society of Anesthesiologists, 49(3), 91–95.

doi: 10.1016/j.aat.2011.08.006
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Study Purpose:

To investigate whether paravertebral block (PVB) implemented immediately before breast cancer surgery can affect pain and emesis and improve the quality of life of patients after breast cancer surgery

Intervention Characteristics/Basic Study Process:

Consecutive patients received general anesthesia or PVB plus anesthesia before breast cancer surgery. Researchers compared the pain scores of both groups of patients at one hour and at six hours postoperatively and at midmorning of postoperative day 1 (POD1). At one hour, patients were observed in the postanesthesia care unit for one hour, where they were provided with analgesics to achieve a pain score of less than 4 on the Numeric Rating Scale (NRS). Choices of analgesic for patients with moderate to severe pain included intravenous morphine, 3–6 mg, and intravenous ketorolac, 30 mg. Patients with mild to moderate pain (a score of 4–7) received acetaminophen, 500–1000 mg, at the patient’s request. At six hours after surgery and on POD1, pain scores were recorded with patients at rest and during movement. Movement consisted of moving the arm until the arm and body were at a 90-degree angle. The amount of postoperative narcotics and the time to first request for pain medication was recorded.

Sample Characteristics:

  • The sample was composed of 40 patients; presurgery, 25 received general anesthesia only and 15 received general anesthesia and a PVB.
  • In the general anesthesia group, mean patient age was 50.4 years. In the group that received general anesthesia and PVB, mean patient age was 54.2.
  • All patients were female.
  • All patients had breast cancer. In the group that received general anesthesia only, four patients underwent modified radical mastectomy and 21 underwent a breast-conserving procedure. Of patients that received PVBs, one underwent modified radical mastectomy and 14 underwent a breast-conserving procedure.

Setting:

  • Single site
  • Inpatient
  • Taiwan
     

Phase of Care and Clinical Applications:

  • Phase of care: active treatment
  • Clinical applications: end of life and palliative care

Study Design:

Intervention study

Measurement Instruments/Methods:

  • Quality-of-recovery (QoR) tool, 0–18 scale
  • Numeric Rating Scale for pain, 0–10 scale
  • Apfel risk score for postoperative nausea and vomiting (PONV)
  • American Society of Anesthesiologists (ASA) physical status classification

Results:

  • Compared to pain scores in the general anesthesia (GA) group, pain scores were significantly lower in the GA + PVB group at one hour (p < 0.0001), six hours (p < 0.0001), and at midmorning on POD1 (p = 0.041). SImilarly, in the GA + PVB group, pain scores with movement were lower at all three time points: one hour and six hours, p < 0.0001; POD1, p = 0.0012.
  • The median QoR scores were higher in the GA + PVB group than in the GA group. At six hours, the median QoR score in the GA group was 12; in the GA + PVB group, 18, (p < 0.0001). At 10 a.m. on POD1 the mean QoR score in the GA group was 16; in the GA + PVB group, 18 (p = 0.0079).
  • In the GA group, median cumulative postoperative analgesic consumption was four doses; in the GA + PVG group, 1 dose (p < 0.0001).
  • In the GA group, median cumulative postoperative narcotic consumption was 1 dose; in the GA + PVB group, 0 dose (p = 0.001).
  • Median time from the end of the operation to the first request for analgesia differed significantly between the two groups. In the GA group, the median time was 30 minutes; in the GA + PVB group, 435 minutes (p = 0.0002).
  • Incidence of PONV was higher in the GA group (64%) than in the GA + PVB group (6.67%) (p < 0.001). 
  • Patients in the GA group had significantly greater (p < 0.00001) antiemetic use overall than did patients in the GA + PVB group.

Conclusions:

After breast cancer surgery, PVB plus GA may provide better pain relief than does GA alone. The researchers observed higher QoR scores and less antiemetic use in the GA + PVB than in the GA group.

Limitations:

  • The study had a small sample size, with fewer than 100 patients.
  • The study was conducted at a single site.
  • Only 15 patients received the intervention.
  • The study contained no randomization.
  • At baseline, patients in the GA group used more antiemetic than did patients in the other group, a fact that makes results difficult to interpret.
     

Nursing Implications:

PVB may be a useful tool to decrease pain after breast cancer surgery and to reduce PONV, but more research is needed before researchers can draw definitive conclusions.

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