Clinical Study Breast Surgery Using Thoracic Paravertebral Blockade and Sedation Alone James Simpson, 1,2 Arun Ariyarathenam, 2 Julie Dunn, 2 and Pete Ford 2 1 Department of Anaesthesia, South Devon Healthcare NHS Foundation Trust, Torbay Hospital, Lowes Bridge, Torquay TQ2 7AA, UK 2 Department of Anaesthesia, Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK Correspondence should be addressed to James Simpson; james.simpson2@nhs.net Received 18 June 2014; Accepted 12 August 2014; Published 21 August 2014 Academic Editor: Enrico Camporesi Copyright © 2014 James Simpson et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Toracic paravertebral block (TPVB) provides superior analgesia for breast surgery when used in conjunction with general anesthesia (GA). Although TPVB and GA are ofen combined, for some patients GA is either contraindicated or undesirable. We present a series of 28 patients who received a TPVB with sedation alone for breast cancer surgery. Methods. A target controlled infusion of propofol or remifentanil was used for conscious sedation. Ultrasound guided TPVB was performed at one, two, or three thoracic levels, using up to 30 mL of local anesthetic. If required, top-up local infltration analgesia with prilocaine 0.5% was performed by the surgeon. Results. Most patients were elderly with signifcant comorbidities and had TPVB injections at just one level (54%). Patient choice and anxiety about GA were indications for TVPB in 9 patients (32%). Prilocaine top-up was required in four (14%) cases and rescue opiate analgesia in six (21%). Conclusions. Based on our technique and the outcome of the 28 patients studied, TPVB with sedation and ultrasound guidance appears to be an efective and reliable form of anesthesia for breast surgery. TPVB with sedation is a useful anesthetic technique for patients in which GA is undesirable or poses an unacceptable risk. 1. Introduction Acute postoperative pain occurs afer breast cancer surgery in approximately 36% of patients [1] and is a key risk factor for the development of chronic pain [1, 2]. Toracic paravertebral block (TPVB) provides superior analgesia for breast cancer surgery when used in conjunction with general anesthesia (GA) [3] and reduces the severity of chronic pain afer mastectomy [4]. Although TPVB and GA are ofen combined [3], for some patients GA is either contraindicated or undesirable due to factors including frailty, comorbidities, anxiety and patient choice. TPVB alone has previously been compared with GA alone [3]. However, much of the literature is heterogeneous and includes landmark techniques at multiple thoracic levels [5] which are time consuming, uncomfortable, and expose the patient to risk with each needle pass. A block from T1–T6 is required for most breast cancer surgeries. TPVB has recently undergone resurgence with improvements in ultrasound technology, afording many benefts including direct visualisation of local anesthetic (LA) spread and the pleura [3, 6]. Tis enables larger volumes to be injected at fewer levels whilst still achieving adequate analgesia. We present a series of 28 patients who received an ultrasound guided TPVB with sedation alone at one, two, or three levels, for breast cancer surgery at a single UK centre between 2008 and 2012. 2. Methods Patients were identifed by retrospective database analysis followed by notes review for the period 2008 to 2012, at the Royal Devon and Exeter NHS Foundation Hospital, UK. Ethics committee approval was not obtained given the histor- ical nature of the data. In all cases the same anesthesiologist (author 4) performed the block and the same surgeon (author 3) either performed or supervised the surgery. Although propofol was initially used (4/28 cases) a target controlled infusion (TCI) of remifentanil was used from 2009 onwards (24/28 cases) for conscious sedation during block placement and surgery. Tis was delivered using Minto’s pharmacokinetic model [7] with efect site concentrations of Hindawi Publishing Corporation Anesthesiology Research and Practice Volume 2014, Article ID 127467, 4 pages http://dx.doi.org/10.1155/2014/127467