Preoperative Paravertebral Block and Chronic Pain after Breast Cancer Surgery: A Double-blind Randomized Trial.

BACKGROUND: The effectiveness of paravertebral block in preventing chronic pain after breast surgery remains controversial. The primary hypothesis of this study was that paravertebral block reduces the incidence of chronic pain 3 months after breast cancer surgery. METHODS: In this prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled study, 380 women undergoing partial or complete mastectomy with or without lymph node dissection were randomized to receive preoperative paravertebral block with either 0.35 ml/kg 0.75% ropivacaine (paravertebral group) or saline (control group). Systemic multimodal analgesia was administered in both groups. The primary endpoint was the incidence of chronic pain with a visual analogue scale (VAS) score greater than or equal to 3 out of 10, 3 months after surgery. The secondary outcomes were acute pain, analgesic consumption, nausea and vomiting, chronic pain at 6 and 12 months, neuropathic pain, pain interference, anxiety, and depression. RESULTS: Overall, 178 patients received ropivacaine, and 174 received saline. At 3 months, chronic pain was reported in 93 of 178 (52.2%) and 83 of 174 (47.7%) patients in the paravertebral and control groups, respectively (odds ratio, 1.20 [95% CI, 0.79 to 1.82], P = 0.394). At 6 and 12 months, chronic pain occurred in 104 of 178 (58.4%) versus 79 of 174 (45.4%) and 105 of 178 (59.0%) versus 93 of 174 (53.4%) patients in the paravertebral and control groups, respectively. Greater acute postoperative pain was observed in the control group 0 to 2 h (area under the receiver operating characteristics curve at rest, 4.3 ± 2.8 vs. 2.9 ± 2.8 VAS score units × hours, P < 0.001) and when maximal in this interval (3.8 ± 2.1 vs. 2.5 ± 2.5, P < 0.001) but not during any other interval. Postoperative morphine use was 73% less in the paravertebral group (odds ratio, 0.272 [95% CI, 0.171 to 0.429]; P < 0.001). CONCLUSIONS: Paravertebral block did not reduce the incidence of chronic pain after breast surgery. Paravertebral block did result in less immediate postoperative pain, but there were no other significant differences in postoperative outcomes.

[Analgesic treatment of cancer pain]. / Le traitement antalgique des douleurs cancéreuses.

Cancer pain can be nociceptive, neuropathic or mixed. It is linked to the tumour, to the metastases and to the treatments for the disease and is managed by multimodal analgesia corresponding to the pain relief drugs of the WHO's pain ladder, antidepressants, antiepileptic drugs and local anaesthetics.

Adducted vocal cords relieved by neuromuscular blocking drug: a cause of impaired mechanical ventilation when using a laryngeal mask airway: two photographically documented cases.

Two cases of vocal cord closure, which was responsible for acute intraoperative impairment of mechanical ventilation in two patients with entropy-controlled depth of anesthesia, are reported. Administration of low-dose neuromuscular blocking drug was associated with immediate vocal cord relaxation and restoration of efficient mechanical ventilation.

Acute postoperative glaucoma after nonocular surgery remains a diagnostic challenge.

IMPLICATIONS: Anesthesia may acutely reveal angle-closure glaucoma. This complication is an ophthalmologic emergency. However, symptoms of acute glaucoma may be overlooked or misinterpreted in a sedated or comatose patient, and this may result in delayed treatment. Immediate diagnosis and appropriate treatment should be done to prevent visual loss.