Plastic Surgery Research Council

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Decreasing Opiate Use in Plastic Surgery: Does Use of Preoperative Bilateral Thoracic Paravertebral Blocks for Breast Reduction Surgery Reduce Opiate Exposure?
Frank D. Lalezar, MD, Lyahn K. Hwang, MD, Amanda Rizzo, BS, Katie E. Weichman, MD.
Montefiore Medical Center, Bronx, NY, USA.

Purpose:
Decreasing total exposure to opioids in the operative and postoperative periods has become a focus of recent efforts to control the opioid crisis. Regional anesthesia, specifically, thoracic paravertebral blocks, have been shown in mastectomy to decrease pain and aid in early discharge; however, the use of this technique has not been explored in outpatient procedures such as breast reduction mammoplasty (BRM). Here we seek to determine the effects of thoracic paravertebral blocks on pain and opioid consumption in patients undergoing BRM.
Methods:
A retrospective review of all patients undergoing BRM by the senior author (KEW) between January 2016 and October 2018 was conducted. Patients were divided into two cohorts: Those who received bilateral paravertebral blocks pre-operatively in addition to general anesthesia and those who underwent general anesthesia alone. Patients were analyzed based on age, body mass index (BMI), total reduction weight, length of surgery, and medical comorbidities. The primary outcome measures were intra-operative and post-operative opioid consumption measured in morphine milligram equivalents (MME). Secondary outcome measures included postoperative pain, as rated on the numerical pain rating scale, immediately postoperatively and on postoperative day two, and duration of time spent in recovery prior to discharge.
Results:
One hundred and six patients were included for analysis (block n=58 (54.7%), no block n=48 (45.3%)). Age, BMI, reduction specimen weight, and co-morbidities did not differ between groups. Intraoperatively, opioid consumption was significantly lower in patients with paravertebral blocks (block 19.6 11.7 MME, no block 2410.4 MME; p<0.001). Furthermore, length of surgery was significantly longer in patients who did not receive a block (block 175.124.0 minutes, no block 185.825.2 minutes; p = 0.027). In the immediate postoperative period, there was no difference in opioid consumption between groups (block 5.94.4 MME, no block 5.24.2 MME; p=0.381). However, a significantly higher proportion of patients without blocks received any dose of non-opioid analgesic for pain management (block n= 16 (27.6%), no block n=24 (50.0%); p=0.018). Patient-reported pain scores did not differ between groups in the immediate postoperative period (block 5.03.6, no block 5.82.0; p=0.264). Time to discharge of patients from the PACU was significantly lower in patients with paravertebral blocks (block 253.694.5 min, no block 380209 min; p<0.001). The cost of the paravertebral block ($215.64) was less than the cost of increased time in the PACU ($556.16).
Conclusion:
Patients undergoing preoperative paravertebral block have decreased intraoperative opioid use as compared to those undergoing general anesthesia alone. In the postoperative period, patients having no block received more non-opioid pain medications but had similar postoperative pain
and use of opioids. Of interest, both length of surgery and time to discharge from recovery are shorter in patients who underwent block. Additionally, the use of the paravertebral block was economically beneficial due to cost savings from decreased time in the PACU. Therefore, use of preoperative paravertebral blocks in concert with postoperative non-opioid analgesia is suggested and necessary to decrease overall opioid exposure, to reduce both operative and recovery time, and decrease healthcare costs.


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