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Introduction: The ultrasound (US)-guided erector spinae plane (ESP) block is a new regional anesthetic technique that offers significant advantages over paravertebral block as it is easy and safe to perform. We aim to compare the efficacy of US-guided paravertebral block with ESP block for postoperative analgesia in modified radical mastectomy (MRM). Methods: Eighty female patients of age group 18–70 years, belonging to physical status American Society of Anesthesiologists (ASA) I and II, undergoing MRM were included in the study. In Group P, patients received paravertebral block and in Group E, patients received ESP block before induction of general anesthesia. Both the groups received 0.5% 20 mL ropivacaine. The time to first rescue analgesia and total doses of rescue analgesics were recorded in the postoperative period. Numeric Rating Scale (NRS) scores at 0 min, 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h were noted, and patient satisfaction was evaluated at 24 h. Unpaired t-test or the Mann–Whitney U test was used to compare quantitative variables while Chi-square test or Fisher's exact test was used to compare qualitative variables. Results: The time for the first analgesic request was 232.5 min (140-1200) in ESP group as compared to paravertebral group in which the duration was 205 min (135-1190) (P value = 0.29). The total dose of rescue analgesics and NRS scores in postoperative period were comparable. However, the time to perform ESP block was significantly shorter than that of paravertebral block. Conclusion: ESP block can be used as a safe and easy to perform alternative analgesic technique over paravertebral block in breast cancer surgeries.

Background: Thoracic paravertebral block (TPVB) has become the gold standard to provide postoperative analgesia in breast surgery. Recently, ultrasound-guided (USG) pectoralis (PECS) block and serratus anterior plane (SAP) block have been described as an alternative to TPVB. The objectives were to compare TPVB, PECS, and SAP block in terms of analgesic efficacy and the spread of local anesthetic by ultrasound imaging, correlating it with the sensory blockade. Materials and Methods: Prospective randomized interventional study conducted in 45 ASA grades I–II patients scheduled for the elective breast surgery. Patients were randomly allocated into three groups, i.e., Gr.1 (USG –TPVB) (ropivacaine 0.375% 20 ml), Gr.2 (USG-PECS II) block (ropivacaine 0.375% 30 ml), and Gr.3 (USG-SAP) (ropivacaine 0.375% 30 ml). Spread of the local anesthetics was seen with ultrasound imaging. Onset of sensory blockade, postoperative fentanyl consumption, and pain scores was measured. Results: TPVB and SAP group had comparatively higher spread and sensory block compared to PECS group. Postoperative fentanyl requirement (mean ± SD) was 428.33 ± 243.1 μg, 644.67 ± 260.15 μg, and 415 ± 182.44 μg in the TPVB group, PECS II group, and SAP group, respectively. SAP group had significantly lesser requirement than PECS II group (P = 0.028) but similar requirement as in TPVB group (P = 1.0). Pain scores were not significantly different among the group in the postoperative period. Conclusion: TPVB and SAP group result in a greater spread of the drug and provide equivalent analgesia and are superior to the PECS II block in providing analgesia for breast surgeries. SAP block is easier to perform than TPVB with lesser chances of complications and results in faster onset.

Background and Aims: Pectoral nerve (PecS II) block is the latest modality for providing postoperative analgesia after breast surgery. The present study was planned to compare the analgesic efficacy of thoracic paravertebral block (TPVB) and PecS II for postoperative analgesia after modified radical mastectomy (MRM). Methods: A total of 40 female patients undergoing radical mastectomy were randomly allocated into two groups (n = 20). Group T received ultrasound-guided TPVB, while group P received PecS II block using 0.25% levobupivacaine 24 ml + dexamethasone 1 ml (4 mg) before induction of anesthesia. The primary outcome was duration of analgesia (time to request first analgesic dose), while total rescue analgesic consumption in first 24 h, numeric rating score (NRS), and complication were secondary outcomes. The data were analyzed using IBM SPSS software version 22.0. Results: The duration of analgesia was significantly prolonged in the group P than group T (474.1 ± 84.93 versus 371.5 ± 51.53 min, respectively; P < 0.0001). Postoperative morphine consumed at 24 h was less in the group P than group T (11.25 ± 4.75 and 15.0 ± 4.86 mg, respectively; P = 0.018). NRS at movement and rest were lower in the group P as compared to group T at all time intervals (median 3 versus 4). No block-related complication was recorded in any group. Conclusions: The 0.25% levobupivacaine with dexamethasone 4 mg in PecS II block provided longer duration of analgesia than the TPVB in patients undergoing MRM without any adverse effects.

Context: Inadequate pain relief after thoracotomy may lead to postoperative respiratory complications. Aims: We have compared total morphine consumption in 24 hours following thoracotomy. Settings and Design: This prospective randomized pilot study involved 50 patients undergoing elective thoracotomy for lung surgery at AIIMS, New Delhi. Patients and Methods: Fifty patients undergoing elective thoracotomy were randomly allocated into two groups. In Group I patients, ultrasound (USG)-guided paravertebral catheter was inserted preoperatively and in Group II patients, serratus anterior plane (SAP) catheter was inserted by the surgeon before closure. Ropivacaine bolus (group I: 0.2% 0.1 ml/kg and group II: 0.375% 0.4 ml/kg) was given before extubation, followed by its continuous infusion for 24 hours. If the numerical rating scale (NRS) was >3, then patients were given intravenous (i.v.) morphine 3 mg. Total 24-hour morphine consumption, duration of effective analgesia, hemodynamic parameters, side effects, and overall patient satisfaction were recorded. Statistical Analysis Used: T-test was used to compare the parametric values in both the groups, whereas the Mann–Whitney U-test was performed to compare the nonparametric values. Results: Postoperative morphine requirement in the ParaVertebral Block (PVB) group (8.65 ± 4.27 mg) was less as compared to the SAP group (11.87 ± 6.22 mg) but that was not statistically significant (p 0.052). Postoperative pain scores at rest and on movement, patient satisfaction, and incidence of chronic post-thoracotomy pain were comparable in both the groups. Conclusion: SAP block with continuous catheter technique seems to be a safe and effective modality for the management of acute postoperative pain after thoracotomy.

Background: Thoracic interfascial plane blocks and modification (PECS) have recently gained popularity for analgesic potential during breast surgery. We evaluate/consolidate the evidence on opioid-sparing effect of PECS blocks in comparison with conventional intravenous analgesia (IVA) and paravertebral block (PVB). Materials and Methods: Prospective, randomized controlled trials comparing PECS block to conventional IVA or PVB in patients undergoing breast surgery published till June 2017 were searched in the medical database. Comparisons were made for 24-h postoperative morphine consumption and intraoperative fentanyl-equivalent consumption. Results: Final analysis included nine trials (PECS vs. IVA 4 trials and PECS vs. PVB 5 trials). PECS block showed a decreased intraoperative fentanyl consumption over IVA by 49.20 mcg (95% confidence interval [CI] =42.67–55.74) (I2 = 98.47%, P < 0.001) and PVB by 15.88 mcg (95% CI = 12.95–18.81) (I2 = 95.51%, P < 0.001). Postoperative, 24-h morphine consumption with PECS block was lower than IVA by 7.66 mg (95% CI being 6.23–9.10) (I2 = 63.15, P < 0.001) but was higher than PVB group by 1.26 mg (95% CI being 0.91–1.62) (I2 = 99.53%, P < 0.001). Two cases of pneumothorax were reported with PVB, and no complication was reported in any other group. Conclusions: Use of PECS block and its modifications with general anesthesia for breast surgery has significant opioid-sparing effect intraoperatively and during the first 24 h after surgery. It also has higher intraoperative opioid-sparing effect when compared to PVB. During the 1st postoperative day, PVB has slightly more morphine sparing potential that may however be associated with higher complication rates. The present PECS block techniques show marked interstudy variations and need standardization.

The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

Background: Local anesthetic infiltration for medical thoracoscopy has an analgesic properties for short duration. Single injection thoracic paravertebral block (PVB) provides limited analgesia. Purpose: Comparison between thoracic PVB performed at two or three levels with local infiltration for anesthetic adequacy in adult medical thoracoscopy as a primary outcome and postthoracoscopic analgesia and pulmonary function as secondary outcomes for adult medical thoracoscopy. Patients and Methods: Prospective randomized control study included 63 adult patients with exudative pleural effusion randomly divided into three groups of 21 patients: 3-level PVB, 2-level PVB group, and local infiltration group. Patients with contraindications to regional anesthesia or uncontrolled comorbidities were excluded from the study. Pain visual analog scale and spirometry were used for comparison as anesthetic adequacy in adult medical thoracoscopy as a primary outcome besides prolonged analgesia and improved pulmonary function as secondary outcomes. Results: The anesthetic adequacy was 95.3% in 3-level PVB group, 81% in 2-level PVB group, and 71.5% in local infiltration group. The mean sensory level was 1 ± 0.8 and 1 ± 0.6 segment above and 0.8 ± 0.6 and 0.7 ± 0.7 segment below the injected level in 3-level PVB group and 2-level PVB, respectively. VAS was statistically significant higher in local infiltration compared to the other two groups immediately postthoracoscopic and 1 h after. Two-hour postthoracoscopy, significant increase in forced vital capacity values in the three groups compared to their basal values whereas forced expiratory volume at 1 s (FEV1) only in both PVB groups. Conclusion: Unilateral 3-level TPVB was superior to 2-level TPVB and LA infiltration for anesthetic adequacy for patients undergoing medical thoracoscopy. Moreover, US-guided TPVB was followed by higher FEV1 values and lower pain scores during the next 12 h postthoracoscopy in comparison to local infiltration, so 3-level TPVB is an effective and relatively safe anesthetic technique for adult patients undergoing medical thoracoscopy which may replace local anesthesia.

Background: Acoustic puncture assist device (APAD™) is a pressure measurement combined with a related acoustic signal that has been successfully used to facilitate epidural punctures. The principal of loss of resistance (LOR) is similar when performing paravertebral block (PVB). We investigated the usefulness of APAD™ by comparing it with the conventional LOR techniques for identifying paravertebral space (PVS). Subjects and Methods: A total of 100 women who were scheduled for elective breast surgery under general anesthesia with PVB were randomized into two equal groups. The first group (APAD group) was scheduled for PVB using APAD™. The second group (C group) was scheduled for PVB using conventional LOR technique. We recorded the success rate assessed by clinical and ultrasound findings, the time required to identify the PVS, the depth of the PVS and the number of attempts. The attending anesthesiologist was also questioned about the usefulness of the acoustic signal for detection of the PVS. Results: The incidence of successful PVB was (49) in APAD group compared to (42) in C group P < 0.05. The time required to do PVB was significantly shorter in APAD group than in C group (3.5 ± 1.35 vs. 4.1 ± 1.42) minutes. Two patients in APAD group needed two or more attempts compared to four patients in C group. The attending anesthesiologist found the acoustic signal valuable in all patients in APAD group. Conclusion: Using APAD™ compared to the conventional LOR technique showed a lower failure rate and a shorter time to identify the PVS.

To avoid the complications related to thoracic epidural and paravertebral block, we performed mid-point transverse process to pleura (MTP) block in a patient with multiple rib fractures. A patient with 2nd--5th rib fractures came with complains of severe pain and difficulty in breathing. Ultrasound (US)-guided continuous MTP block was given at T4 level and 15 ml of 0.375% ropivacaine was deposited, followed by the catheter insertion at the same level. Patient reported decreased sensation from T2--T8 dermatomes and reduced VAS scores from 9/10 to 1/10 within 20 min of block insertion. Continuous MTP block is efficacious in providing thoracic analgesia and has higher safety margin as needle is inserted further away from pleura.

Background: Paravertebral block (PVB) has been an established technique for providing analgesia to the chest and abdomen. We conducted the current study to compare single-dose PVB versus single-dose epidural blockade (EP) for pain relief after renal surgery. Methods: Eighty patients scheduled for renal surgery were randomly assigned into two groups according to the analgesic technique, PVB group or EP group. General anesthesia was induced for all patients. Postoperative pain was assessed over 24 h using 10-cm visual analog scale (VAS). Postoperative total pethidine consumption was recorded. Any postoperative events, such as nausea, vomiting, shivering, or respiratory complications, were recorded. Hemodynamics and blood gasometry were also recorded. Results: EP group showed significant decrease of both heart rate and mean blood pressure at most of the operative periods when compared with PVB group. There was no difference in total rescue analgesic consumption. Postoperative VAS showed no significant difference between the studied groups. Postoperative events were comparable in both the groups. Conclusion: Single injection PVB resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients undergoing renal surgery, therefore this technique may be recommended for patients with coexisting circulatory disease.

Objectives : This study was designed to compare the intrathecal morphine and paravertebral block with bupivacaine given before induction of anesthesia for intra-operative and post-thoracotomy pain relief for 48 hours using patient controlled paravertebral analgesia in post-operative period. Methods : After taken an approval from the ethics committee of the University, 40 patients were randomly assigned to receive either preservative-free intrathecal morphine 0.3 mg in 3 ml normal saline together with paravertebral block (group I) or paravertebral block alone using bupivacaine (group II) before an induction of anesthesia. No continuous infusion of bupivacaine was started in both groups. Primary outcomes were Visual Analogue Score (VAS) at rest and on coughing. Hemodynamic and respiratory effects, bupivacaine consumption, patient's satisfaction, and side effects like nausea, vomiting, urinary retention, and itching were considered as secondary outcomes. All patients in both groups received paracetamol 1 gram (gm) IV every 6 hourly for the 1 st 24 hr. Amount of rescue analgesic (pethidine 0.5 mg/kg IV) in both groups and total bupivacaine cumulative doses in 48 hrs were calculated. Results : VAS at rest and on coughing did not differ significantly between the 2 groups at 0, 1, 6, 12, 18, 24, and 48 hours (P=>0.1). At 24 hours, VAS increased in both the groups, but the increase in VAS was comparable in both groups. There were insignificant incidences of nausea, purities, and urinary retention in intrathecal group compared with paravertebral group. The other side effects and patient satisfaction did not show any statistical significant difference between 2 groups. Conclusion : Intrathecal morphine 0.3 mg is safe and effective way to improves pain control for thoracic surgery and was comparable to paravertebral patient control analgesia (PPCA) with bupivacaine for the 1 st 48 hours post-thoracotomy.

Background: Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery. Methods: Fifty patients were included in this prospective randomized study and allocated to two groups: Group A (25 patients) receiving general anesthesia alone and Group B (25 patients) receiving nerve-stimulator–guided bilateral thoracic Paravertebral Block (PVB) at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl (0.5 μg/kg) based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia (PCA) morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups. Results: Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A (17.6 μg and 38.6 μg, respectively, P =0.001). PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A (4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P

Background: Postoperative pain after breast cancer surgery is not uncommon. Narcotic based analgesia is commonly used for postoperative pain management. However, the side-effects and complications of systemic narcotics is a significant disadvantage. Different locoregional anesthetic techniques have been tried including, single and multiple levels paravertebral block (PVB), which seems to have a significant reduction in immediate postoperative pain with fewer side-effects. The aim of this study was to compare unilateral multiple level PVB versus morphine patient-controlled analgesia (PCA) for pain relief after breast cancer surgery with unilateral lumpectomy and axillary lymph nodes dissection. Materials and Methods: Forty patients scheduled for breast cancer surgery were randomized to receive either preoperative unilateral multiple injections PVB at five thoracic dermatomes (group P, 20 patients) or postoperative intravenous PCA with morphine (group M, 20 patients) for postoperative pain control. Numerical pain scale, mean arterial pressure, heart rate, Time to first analgesic demand, 24-h morphine consumption side-effects and length of hospital stay were recorded. Results: PVB resulted in a significantly more postoperative analgesia, maintained hemodynamic, more significant reduction in nausea and vomiting, and shorter hospital stay compared with PCA patients. Conclusion: Multiple levels PVB is an effective regional anesthetic technique for postoperative pain management, it provides superior analgesia with less narcotics consumption, and fewer side-effects compared with PCA morphine for patients with breast cancer who undergo unilateral lumpectomy, with axillary lymph nodes dissection.