Use of preoperative paravertebral block decreases length of stay in patients undergoing mastectomy plus immediate reconstruction.

BACKGROUND: A prior study in patients undergoing breast surgery with and without the use of paravertebral blocks (PVB) found no significant difference in patient length of stay (LOS). However, patients undergoing bilateral procedures and those undergoing immediate reconstructions were excluded. We sought to determine if the use of PVB in patients undergoing unilateral or bilateral mastectomy plus immediate reconstruction decreases patient LOS. METHODS: We undertook a retrospective review of patients who had mastectomies with immediate reconstructions with and without the use of preoperative PVB. Outcomes including LOS, postoperative nausea and vomiting, and time to oral narcotics were compared between groups. RESULTS: Mean LOS for the PVB group was 42 h. This was significantly less than the mean LOS of 47 h for the nonblock group (p = .0015). The significantly lower LOS for the PVB group was true for patients undergoing bilateral procedures (p = .045), unilateral procedures (p = .0031), tissue expander placement (p = .0114), and immediate implant placement (p = .037). Mean time to conversion to oral narcotics was significantly shorter in the PVB group (15 h) compared with the nonblock group (20 h) (p < .001). The incidence of postoperative nausea in the PVB group (42.8 %) was also significantly less than in the nonblock group (54.7 %) (p = .031). CONCLUSIONS: The routine use of preoperative PVB in patients undergoing mastectomy plus immediate reconstruction significantly decreased patient LOS. In addition to improved pain control from the block itself, quicker conversion to oral narcotics because of less postoperative nausea likely contributed to a decreased LOS.

Management of the sheared epidural catheter: is surgical extraction really necessary?

Trauma to epidural catheters on insertion or removal may result in shearing or breakage. Although there is no evidence of neurologic sequelae from a sheared catheter, many reports still advocate eventual surgical removal. The literature suggests the following options: (1) using slow continuous force at all times; (2) discontinuing application of force if the catheter begins to stretch and reapplying traction several hours later; (3) placing of the patient in the same position as insertion; (4) placing the patient in the lateral decubitus position if possible; (5) attempting to remove in extreme flexion if the previous interventions are not efficacious; (6) attempting extension if flexion fails; (7) attempting removal after injection of preservative-free normal saline through the catheter; (8) considering use of a convex surgical frame; (9) considering computed tomographic scan to identify the etiology of entrapment; (10) considering leaving a retained epidural catheter in place in adult patients; (11) providing patient education regarding "red flags" to watch out for; and (12) neurosurgical consultation for all cases in which the catheter fragment is in the spinal canal.

Harlequin Syndrome After Thoracic Paravertebral Block.

Harlequin syndrome is characterized by the sudden onset of unilateral facial flushing and sweating, often preceded by exercise, excessive heat, or, rarely, regional anesthesia. Although the exact mechanism remains unclear, it is often referred to as transient or permanent interruption of the sympathetic nervous system. We present a case of Harlequin syndrome without Horner syndrome in a patient with unilateral right-sided facial flushing that started shortly after a left-sided thoracic paravertebral nerve block for a mastectomy. We discuss the interruption of the sympathetic and parasympathetic nervous system and the levels of spinal nerve block associated with a thoracic paravertebral nerve block.