|Year : 2017 | Volume
| Issue : 2 | Page : 91-95
Thoracic epidural analgesia for breast oncological procedures: A better alternative to general anesthesia
Parli Raghavan Ravi1, Pradeep Jaiswal2
1 Department of Anaesthesiology, Command Hospital Air Force, Bengaluru, Karnataka, India
2 Department of Oncosurgery, Command Hospital Air Force, Bengaluru, Karnataka, India
|Date of Web Publication||13-Feb-2018|
Dr. Parli Raghavan Ravi
Department of Anaesthesiology, Command Hospital Air Force, Agram Post, Old Airport Road, Bengaluru - 560 007, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study was to compare the outcomes of the incidence of nausea/vomiting and other complications along with the time taken for discharged in patients undergoing Thoracic Epidural Analgesia (TEA) and General Anaesthesia (GA) for breast oncological surgeries. Background: GA with or without TEA or other postoperative pain-relieving strategies remains the traditional anesthetic technique used for breast oncological procedures. We initiated the use of high segmental TEA for patients undergoing these procedures in our hospital. Methods: Eighty patients undergoing breast oncological procedures performed by one surgical team were randomly allocated into two groups receiving TEA and GA. The Chi-square test and Fisher's exact test were used for categorical parameters, paired t-test and Student's t-test was used for continuous measurements. Results: In comparison with GA, TEA was associated with lesser incidence of complications of nausea/vomiting. In lumpectomy with axillary node dissection, 1 out of 18 patients (5.55%) in the TEA group had nausea/vomiting, while 11 out of 19 (57.8%) of the GA group had similar symptoms (P < 0.001). The discharge rate for the thoracic epidural group was 12 out of 18 by day 3 (66.6%) while all patients in the GA group required more than 3 days of hospitalization (P < 0.001). Conclusion: Thoracic epidural anesthesia is a safe technique and its use in breast oncological procedures could improve patients' recovery and facilitate their early discharge to home.
Keywords: Bupivacaine, general anesthesia, postoperative nausea and vomiting, regional anesthesia, ropivacaine
|How to cite this article:|
Ravi PR, Jaiswal P. Thoracic epidural analgesia for breast oncological procedures: A better alternative to general anesthesia. J Mar Med Soc 2017;19:91-5
| Introduction|| |
Breast cancer is one of the most commonly seen cancers among females in our country. In India, it accounts for 25%–32% of all female cancers. It requires various surgical interventions ranging from lumpectomy to mastectomy, along with axillary lymph node clearance. Conventionally general anesthesia (GA) is the most frequently used technique, but it is associated with inadequate pain control due to lack of residual analgesia and also with other complications such as nausea, vomiting, and depression of the immune system.
Various regional anesthesia techniques have been described for breast surgeries. These include wound infiltration, thoracic epidural anesthesia, thoracic paravertebral block, and ultrasound-guided interfascial plane blocks such as pectoral nerve (PACS) block Type 1 and 2. Beneficial effects of regional anesthesia include effective anesthesia and analgesia in the perioperative period, decreased need for opioids, decreased postoperative nausea and vomiting, fewer postoperative pulmonary complications, decreased duration of stay in hospital, and reduction in cancer progression.
However, none of them was proved to provide complete anesthesia. The present study was conducted to compare the efficacy of high Thoracic Epidural Analgesia (TEA) against the traditional GA approach.
| Methods|| |
This was a prospective, randomized controlled study undertaken at a tertiary care center between January 2014 and January 2016, after approval from Institutional ethical committee. Eighty patients aged 30–70 years, of American Society of Anesthesiologists Grade I or II, scheduled for oncological breast procedures were included. Patients with significant cardiovascular, renal, hepatic diseases and patients who refused to give consent were excluded from study. Since early discharge was an important aspect of the study, all the patients enrolled in the study were living at a distance of <50 km from the hospital and were adequately educated about wound care at the place of residence. All patients were visited on the day before the surgery and were explained in detail about the anesthetic procedure and written informed consent was obtained. Patients were kept nil orally from 12 o'clock midnight before the day of surgery.
Patients were randomly divided into two groups using computer-generated random numbers. Group A received TEA plus GA and Group B received TEA only. Inside the operation theater, the patient's peripheral oxygen saturation, surface temperature, electrocardiogram, end-tidal carbon dioxide, and intra-arterial blood pressures were monitored. Basal values were recorded. The patients were placed in sitting position, and thoracic epidural placement was attempted. Epidural space was identified with 18G Tuohy needle using loss of resistance technique for saline. An epidural catheter was placed in one of the spaces between first-second (T1–T2) and the second-third (T2–T3) thoracic vertebra in an attempt to achieve a segmental block from C5 to T8 level. A test dose of 2-3 ml of 2% lignocaine with 1:200,000 epinephrine was given to rule out intravascular or subarachnoid placement. The anesthetic dermatomal levels achieved were determined by the surgical procedure. In the majority of the breast surgical procedures, patients were given an initial dose of 10–14 ml 2% lignocaine given in incremental doses to achieve surgical plane of anesthesia quicker and faster. Patients were given dexmedetomidine 1 μ/kg bolus over 20 min followed by 0.2–0.3 μ/kg/min for sedation, which was discontinued at the end of surgery. The patients were given additional aliquots of 4 ml of 2% lignocaine as and when required to maintain the doses within safe range. Those who were exceeding safe range converted to GA and were excluded from the study. In Group B, thoracic epidural catheter was placed, and GA was induced with intravenous thiopentone after premedication with 0.02 mg/kg of midazolam, 10 mg of metoclopramide, 50 mg of ranitidine, and 50–100 μg of fentanyl. Succinylcholine or vecuronium was used to facilitate endotracheal intubation, and GA was maintained with 70% nitrous oxide, 30% oxygen, and 1.2%–1.6% (Vol) sevoflurane. Intra-operative analgesia was maintained with injection paracetamol 1 gm intravenous stat and injection fentanyl 50 μg intravenous repeated every 45 min. Patients of both the group received 3 ml of 0.125% bupivacaine hourly through their TEA catheter for a period consisting of the first 24 h, postoperatively. During the surgery, hemodynamic changes (tachycardia, represented by a heart rate >100 bpm; bradycardia, a heart rate below 60 bpm; hypotension, defined as a 20% drop in baseline blood pressure; and hypertension, a 20% increase in baseline blood pressure), local anesthesia supplementation, and other events such as pruritus, nausea, and vomiting were recorded. Postoperatively, the length of hospitalization was recorded. The quality of analgesia was evaluated using a visual analog scale.
Patients were discharged from the hospital based on the discharge criteria followed as per the laid out discharge criteria of the institute, which included no medical or surgical complications, an ability to tolerate fluids without nausea and vomiting and adequate pain control with oral medication.
The sample size estimation was based on a pilot study using the mean length of stay in the hospital for lumpectomy with TEA (60 ± 15 h) and GA plus TEA (82 ± 27). The minimum sample size was calculated as 78 patients, with a Type I error of 0.05 and statistical power of 0.95. We recruited 80 patients [Figure 1]. Chi-square test and Fisher's exact test were used for categorical parameters, and paired Student's t-test for continuous measurements, using a p < 0.05 as significant. The data are shown as mean ± standard deviation in absolute numbers or proportions. The statistical analysis was done using a Statistical Package for the Social Science version 16 (SPSS Inc., Chicago, IL, USA).
| Results|| |
A total of 80 patients were enrolled in the study. The two groups were similar regarding age [Table 1] and [Figure 1]. [Table 2] summarizes the number of patients who underwent each surgical procedure and anesthetic technique. During surgery, five patients needed supplementary sedation, (3 patients in Group B), but it was statistically nonsignificant. The anesthetic complications for the surgical procedure are shown in [Table 3]. For lumpectomy with Axillary Node Dissection (LAND) procedure in Group A patients, 11 of the 19 patients (57.8%) had vomiting/nausea which was statistically significant when compared to the Group B where only 1 out of the 18 (5.55) patients developed nausea/vomiting (P < 0.001). In Modified Radical Mastectomy (MRM), 6 out of 10 (60%) of the patients of Group A developed nausea and vomiting which were statistically significant in comparison to Group B where 3 out of 13 (23.07%) had postoperative nausea/vomiting (p < 0.001). [Table 4] shows the initiation of enteral feed for both the groups. Forty out of 42 (95.2%) patients of Group B tolerated oral feeds within 4 h after surgery which was statistically significant in comparison to Group A where no patients tolerated oral feeds within 4 h of surgery. The earliest that someone in Group B was able to tolerate oral feeds was after 12 h.
One patient of the Group B had intraoperative bradycardia, which responded to 0.6 mg of atropine intravenously and fluids. There was neither hypotension nor a loss of responsiveness. Two patients of group A too had bradycardia which responded to atropine. One patient in Group A undergoing MRM had severe hypotension in the postoperative period and was put on dopamine infusion for the maintenance of blood pressure for a duration of 12 h.
An analysis was made between the lengths of the stay of patients who underwent various breast surgeries with either technique of anesthesia. Day 1 was considered the day of the surgery. Statistical analysis was performed only for the LAND and MRM group as they provided the largest sample size. [Table 5] shows the day of the discharges for all the procedures. Twelve out of 18 (66%) patients of Group B undergoing LAND were discharged by day 3 of surgery, while in the MRM group, 10 of the 13 patients (76.9%) of Group B were discharged by day 6. A Chi-square analysis revealed that patients of Group B were discharged from hospital earlier than the patients from Group A (P < 0.001). [Figure 2] demonstrate the length of stay for patients undergoing LAND and MRM with both the techniques. Two attending anesthesiologists and one resident anesthesiologist were involved in administration of thoracic epidurals to all the patients in this study.
The intensity of pain and consumption of supplementary analgesics were lower in patients in Group B, and it was statistically significant in the first 12 h (P < 0.05) [Table 6].
| Discussion|| |
The incidence of breast cancer has been increasing, and currently, it is the most common cancer in females. Surgery is the main treatment, and the current tendency is toward less extensive procedures (sectorectomy, localized resections, etc.) with axillary dissections for removal of lymph nodes so as to guide further treatment. In this situation, the anesthetic technique used should provide adequate intraoperative anesthesia and good postoperative analgesia without collateral effects and with minimum hospitalization time.
TEA has been established as a cornerstone in perioperative care after thoracic and major abdominal surgeries. TEA has many advantages compared to GA which includes decreased incidence of nausea and vomiting, earlier discharge from hospital, and avoiding the hemodynamic changes associated with tracheal intubation. TEA has also been shown to decrease adverse perioperative cardiac events by decreasing stress associated with anesthesia and surgery.
TEA was instituted by our hospital to evaluate the differences in outcome compared to GA. For effective ablation of pain response in breast surgery, it is necessary to block sensory nerves from T2 to T7 dermatomes. We placed an epidural catheter in T1–T2 or T2–T3 level. Although slightly more difficult, upper thoracic placements of epidural analgesia do not produce adequate blockage of cardiac sympathetic fibers, which cause hypotension and bradycardia.
We found that TEA has multiple advantages over GA. Patients of LAND and MRM group who formed the bulk of our patients had a significant decrease in the incidence of nausea and vomiting. They had better pain control and also were discharged earlier from the hospital in comparison to the patients who received GA with TEA. Patients who underwent other breast oncological procedures were also discharged earlier in comparison to patients under GA, but the group size was too small to establish any statistical significance. Although no cost-effect analysis was done, due to the earlier discharge rates from the hospital and lesser complications, TEA appears to be more cost-effective in comparison to GA. There were no surgical complications in the study population. No neurological complication occurred during or after the TEA in both the groups.
One problem we encountered was inadequate analgesia in the axilla which was due to dual innervation of this area. Three patients had axillary sparing, which was managed with local infiltration.
Belzarena  conducted a study to compare the efficacy of TEA and GA for oncologic mastectomy. They found that patients who were operated on under TEA had better pain control, a reduced use of supplemental analgesic, and early discharge from the hospital. The incidences of bradycardia, hypotension, nausea, and vomiting were higher in patient who had GA compared to TEA group. The results of our study are comparable to theirs.
Shah et al. conducted a study to evaluate the efficacy of TEA in breast surgeries. They studied 20 patients; who were given thoracic epidural anesthesia. Twelve patients out of 20 had complete analgesia. Four patients complained of slight pain initially at the time of skin incision. Four patients showed discomfort toward the end of the operation. All these 8 patients received small additional doses of diazepam or midazolam. The postoperative pain score was <5 until the first 48 h after the surgery. The incidence of bradycardia, hypotension, and nausea were <10%. The results of the above study were comparable to those of our study in terms of better pain control, less incidences of nausea, bradycardia, and hypotension in TEA.
Vineetha et al. conducted a study on thoracic epidural anesthesia for mastectomy on postoperative pain, nausea, and vomiting. They found that surgical anesthesia was adequate in 89% of the patients who had taken TEA, and the postoperative analgesia was excellent in 98% of the patients with no major hemodynamic changes. The results of our study are comparable to their study in terms of better pain control and incidence of complications.
Limitations of the study
Special medical problems which were present among some of our patients made TEA more desirable; however, these patients were not included into the study as it would have created an observational bias. These were a 82 years old individual with interstitial pneumonia with reduced respiratory reserves, a 35-year-old female, who was the sole bread earner of the family and a teacher by profession who was scared of losing her voice after intubation. It also included a woman who was scared of being operated by male surgeons and refused to accept GA. These special situations make a more broad base reason for the use of the TEA in today's competitive health-care environment, in addition to reducing the cost of health care.
| Conclusion|| |
We conclude that TEA is a safe alternative to GA for breast oncological procedures including reconstructive surgeries and is associated with early discharge of patients to home and a lower rate of complications i.e nausea, vomiting, pain etc. The results are statistically significant.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]