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Role of ultralow dose of naloxone as an adjuvant to fentanyl–bupivacaine in thoracic paravertebral block analgesia after modified radical mastectomy: Randomized controlled trial

Amany F. Omara, MD, Sameh A. Ahmed, MD, Motaz M. A. Abusabaa, MD


Objective: We evaluated the effect of the addition of 100 ng of naloxone to fentanyl–bupivacaine mixture used in thoracic paravertebral block (PVB) on the duration and the quality of post-mastectomy analgesia.

Design: A randomized double-blinded trial.

Setting: Oncology surgery unit.

Patients and participants: This study included 135 patients, aged 40-60 years of either sex presented for elective unilateral-modified radical mastectomy.

Interventions: Patients were divided randomly into three groups: group I, received 0.3 mL/kg of 0.25 percent bupivacaine; group II, received 0.3 mL/kg of 0.25 percent bupivacaine, fentanyl 50 μg, and naloxone 100 ng; group III, received 0.3 mL/kg of 0.25 percent bupivacaine and fentanyl 50 μg.

Main outcome measure(s): The visual analog scale was assessed immediately post-operative, every 2 hours till 12 hours, and then every 6 hours for 24 hours; the time of first and total amount of rescue analgesia and side effects during the first 24 hours were recorded.

Results: Group II showed a significant prolonged analgesia with a delayed first request of rescue analgesia and lower amount of morphine (592.1 ± 14.9 minutes and 7.28 ± 7.81 mg, respectively) than groups I (127.7 ± 35.1 minutes and 19.84 ± 2.56 mg, respectively) and III (232.2 ± 9.27 minutes and 13.52 ± 1.74 mg, respectively) as p < 0.001.

Conclusion: Using naloxone as additives in PVB has been promising and effective in controlling post-mastectomy pain.


naloxone, pain, paravertebral, post-mastectomy, antagonist

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Schnabel A, Reichl S, Kranke P, et al.: Efficacy and safety of paravertebral blocks in breast surgery: A meta-analysis of randomized controlled trials. Br J Anaesth. 2010; 105(6): 842-852.

Poleshuck EL, Katz J, Andrus CH, et al.: Risk factors for chronic pain following breast cancer surgery: A prospective study. J Pain. 2006; 7(9): 626-634.

Gotoda Y, Kambara N, Sakai T, et al.: The morbidity, time course and predictive factors for persistent post-thoracotomy pain. Eur J Pain. 2001; 5(1): 89-96.

Kairaluoma PM, Bachmann MS, Korpinen AK, et al.: Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy. Anesth Analg. 2004; 99(6): 1837-1843.

Hamann S, Sloan P, Witt W: Low-dose intrathecal naloxone to enhance intrathecal morphine analgesia: A case report. J Opioid Manag. 2008; 4(4): 251-254.

Gan TJ, Ginsberg B, Glass PS, et al.: Opioid-sparing effects of a low-dose infusion of naloxone in patient-administered morphine sulfate. Anesthesiology. 1997; 87(5): 1075-1081.

Marashi S, Sharifnia H, Azimaraghi O, et al.: Naloxone added to bupivacaine or bupivacaine–fentanyl prolongs motor and sensory block during supraclavicular brachial plexus blockade: A randomized clinical trial. Acta Anaesthesiol Scand. 2015; 59(7): 921-927

Ezz HAA, Elkala RS: Ultra-low-dose naloxone added to fentanyl and lidocaine for peribulbar anesthesia: A randomized controlled trial. Egypt J Anaesth. 2015; 31(2): 161-165.

Al-Khayat HS, Patwari A, El-Khatib MS, et al.: Intrapleural bupivacaine analgesia: Bolus versus continuous infusion technique for post-operative pain relief in children. Indian J Anaesth. 2008; 52(4): 404.

Crain SM, Shen KF: Ultra-low concentrations of naloxone selectively antagonize excitatory effects of morphine on sensory neurons, thereby increasing its antinociceptive potency and attenuating tolerance/dependence during chronic cotreatment. Proc Natl Acad Sci USA. 1995; 92(23): 10540-10544.

Wang H-Y, Burns LH: Naloxone's pentapeptide binding site on filamin a blocks Mu opioid receptor–Gs coupling and CREB activation of acute morphine. PLoS One. 2009; 4(1): e4282.

Levine JD, Gordon NC, Fields HL: Naloxone dose dependently produces analgesia and hyperalgesia in post-operative pain. Nature. 1979; 278(5706): 740-741.

Movafegh A, Nouralishahi B, Sadeghi M, et al.: An ultra-low dose of naloxone added to lidocaine or lidocaine-fentanyl mixture prolongs axillary brachial plexus blockade. Anesth Analg. 2009; 109(5): 1679-1683.

Al-Shukaili A, Al-Mandhari K, Younis B, et al.: Ultra-low dose naloxone added to 0.5% bupivacaine significantly prolongs the duration of analgesia following supraclavicular brachial plexus block. Am J Med Case Rep. 2016; 4(10): 336-338.

Greengrass R, O’Brien F, Lyerly K, et al.: Paravertebral block for breast cancer surgery. Can J Anaesth. 1996; 43(8): 858-861.

Coveney E, Weltz CR, Greengrass R, et al.: Use of paravertebral block anesthesia in the surgical management of breast cancer: Experience in 156 cases. Ann Surg. 1998; 227(4): 496-501.



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