Elsevier

Pain Management Nursing

Volume 18, Issue 4, August 2017, Pages 234-242
Pain Management Nursing

Original Article
The Trajectory of Postoperative Pain Following Mastectomy with and without Paravertebral Block

https://doi.org/10.1016/j.pmn.2017.03.003Get rights and content

Abstract

Evidence to support the argument that general anesthesia (GA) with paravertebral block (PVB) provides better pain relief for mastectomy patients than GA alone is contradictory. The aim of this study was to explore pain and analgesia after mastectomy with or without PVB during acute inpatient recovery. A retrospective study was conducted in a single hospital providing specialist cancer services in metropolitan Melbourne, Australia. We explored pain and concomitant analgesic administration in 80 consecutive women recovering from mastectomy who underwent GA with (n = 40) or without (n = 40) PVB. A pain management index (PMI) was derived to illustrate the efficacy of management from day of surgery (DOS) to postoperative day (POD) 3. Patients who reported no pain progressively increased from DOS (n = 12, 15%) to POD 3 (n = 54, 67.5%). Most patients were administered analgesics as a combination of acetaminophen and a strong opioid on DOS (n = 53, 66.2%), POD 1 (n = 45, 56.2%), POD 2 (n = 33, 41.2%), and POD 3 (n = 21, 26.2%). Less than 6% of patients on any POD were administered multimodal anlagesics. PMI scores indicate some pain in the context of receiving weak and strong opioids for GA patients and more frequent use of nonopioid analgesics in PVB patients during recovery. These findings highlight the need for data describing patterns of analgesic administration in addition to reports of postoperative pain to determine the most effective means of avoiding postoperative pain in patients who require mastectomy.

Section snippets

Literature Review

The evidence to support the argument that GA with PVB provides a better outcome for patients than GA alone when pain is the outcome of interest is contradictory. Pain is generally measured using a numerical rating or visual analogue scale at inconsistent time points in the trajectory of recovery. Reports include the assessment of pain at 1, 3, 6, 24, or 72 hours after surgery (Thavaneswaran et al., 2010). Few studies report the administration of analgesics other than those associated with the

Research Question and Design

The study was designed to answer the following: Does the trajectory of pain and pain management differ in women recovering from mastectomy with general anesthesia with or without paravertebral block? A retrospective review of the charts of a convenience sample of consecutive patients who underwent mastectomy was conducted. Retrospective chart audit was the most feasible approach to establish practice patterns at this institution. The hospital Human Research and Ethics Committee reviewed and

Demographic and Operative Characteristics

Mean age was 54.5 (SD = 12.4) years and mean body mass index 26.1 kg/m2 (SD = 5.8). At the time of surgery, there were 11 (13.7%) current smokers and 59 (73.8%) patients who had never smoked. Bilateral mastectomy was performed in 11 (13.7%) patients. Axillary node clearance was undertaken in 35 (43.8%) patients, lymph node biopsy in 29 (36.3%), and concomitant insertion of an expander or implant device in 19 (23.8%). Median duration of anesthesia was 135 minutes (Q1 102.5, Q3 168.5), and this

Discussion

In this study, the trajectory of pain, concomitant analgesic administration, and the effectiveness of analgesic administration were explored for women having mastectomy with GA or GA and PVB. The key findings were that the trajectory of patient reports of pain between groups was similar from POD 0 to POD 3; however, the effectiveness of analgesic administration (PMI) after surgery differed.

PVB is a well-established form of anesthesia thought to reduce postoperative pain for women undergoing

Conclusion

The findings from this study suggest that the effectiveness of analgesic administration is variable and potentially influenced by procedural bias even when patient reports of pain do not differ. Although multimodal options for analgesic administration were available in the postoperative setting, clinicians rarely used this approach to managing pain. Patient reports of pain intensity reduced during the trajectory of recovery, as did the administration of nonopioid analgesics. A relatively small

References (23)

  • C.S. Cleeland et al.

    Pain and its treatment in outpatients with metastatic cancer

    New England Journal of Medicine

    (1994)

    • Cited by (0)

    The authors have no conflicts of interest to declare.

    The study adheres to ethical principles and was granted Low and Negligible Risk Research approval by the institutional Human Research Ethics committee that approved the study (#2012.24).

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    © 2017 by the American Society for Pain Management Nursing