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Mokhtar AT, Khan HR, Antiperovitch P. Letter to the editor: Re Intraoperative ultrasound-guided pectoral nerve blocks for cardiac implantable device procedures. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01834-7. [PMID: 38896191 DOI: 10.1007/s10840-024-01834-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Ahmed T Mokhtar
- Department of Medicine, London Health Sciences Center, University of Western Ontario, London, ON, Canada
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Habib Rehman Khan
- Department of Medicine, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Pavel Antiperovitch
- University Hospital, C6-115; 339 Windermere Road, London, ON, N6G5A5, Canada.
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Ní Eochagáin A, Carolan S, Buggy DJ. Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review. Br J Anaesth 2024; 132:1133-1145. [PMID: 38242803 DOI: 10.1016/j.bja.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 10/22/2023] [Accepted: 12/04/2023] [Indexed: 01/21/2024] Open
Abstract
Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.
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Affiliation(s)
- Aisling Ní Eochagáin
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Seán Carolan
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Euro-Periscope, The ESA-IC Oncoanaesthesiology Research Group, Europe
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3
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Lizarraga IM, Huang K, Yalamuru B, Mott SL, Sibenaller ZA, Keith JN, Sugg SL, Erdahl LM, Seering M. A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction. Ann Surg Oncol 2023; 30:6010-6021. [PMID: 37526752 DOI: 10.1245/s10434-023-13890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy. METHOD Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications. RESULT No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates. CONCLUSION Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks. TRIAL REGISTRATION This trial is registered with Clinical Research Information Service (NCT03653988).
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Affiliation(s)
- Ingrid M Lizarraga
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - K Huang
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - B Yalamuru
- Pain Division, Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - S L Mott
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Z A Sibenaller
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J N Keith
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - S L Sugg
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - L M Erdahl
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - M Seering
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Chan SM, Wang PK, Lin JA. Editorial: New trends in regional analgesia and anesthesia. Front Med (Lausanne) 2023; 10:1256371. [PMID: 37593407 PMCID: PMC10431956 DOI: 10.3389/fmed.2023.1256371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Shun-Ming Chan
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Po-Kai Wang
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jui-An Lin
- Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei City, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Wanfang Hospital, Taipei Medical University, Taipei City, Taiwan
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Diana K, Teh MS, Islam T, Lim WL, Beh ZY, Taib NAM. Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study. World J Surg 2023; 47:564-572. [PMID: 36599951 DOI: 10.1007/s00268-022-06881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia. MATERIAL AND METHODS A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII). RESULTS Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar. CONCLUSION This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.
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Affiliation(s)
- Kavinya Diana
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei-Sze Teh
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Tania Islam
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Woon-Lai Lim
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zhi-Yuan Beh
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Nur Aishah Mohd Taib
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Aggarwal AK, Ottestad E, Pfaff KE, Huai-Yu Li A, Xu L, Derby R, Hecht D, Hah J, Pritzlaff S, Prabhakar N, Krane E, D’Souza G, Hoydonckx Y. Review of Ultrasound-Guided Procedures in the Management of Chronic Pain. Anesthesiol Clin 2023; 41:395-470. [DOI: 10.1016/j.anclin.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Jindal R, Meena S, Bhati S, Patel P, Gulati C, Singh S. Postoperative Analgesic Efficacy of Intraoperative Pectoral Nerve Block for Modified Radical Mastectomy: a Double-Blind Prospective Randomised Interventional Study. Indian J Surg Oncol 2023; 14:215-221. [PMID: 36891452 PMCID: PMC9986367 DOI: 10.1007/s13193-022-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022] Open
Abstract
Severe acute postoperative pain following breast surgery increases the risk of persistent pain and affects the recovery of patients. Recently, pectoral nerve (PECs) block has gained significance as a regional fascial block that can provide adequate postoperative analgesia. This study aimed to evaluate the safety and efficacy of PECs II block, which was given intraoperative under direct vision after performing modified radical mastectomy for breast cancer patients. This prospective randomised study was comprised of a PECs II group (n = 30) and a control group (n = 30). Group A patients received 25 ml of 0.25% bupivacaine for PECs II block intraoperatively after the surgical resection was done. Both groups were compared with respect to the demographic and clinical parameters, total intraoperative fentanyl dose, total duration of surgery, postoperative pain score (Numerical Rating Scale) and the analgesic requirement, postoperative complications, postoperative duration of hospital stay, and the outcome. Intraoperative PECs II block was not associated with any increase in the duration of surgery. The postoperative pain scores were significantly higher in the control group till 24 h after the surgery, and so was the postoperative analgesic requirement. Patients in the PECs group were found to have rapid recovery and decreased postoperative complications. Intraoperative PECs II block is not only safe, time-saving procedure but also significantly reduces the postoperative pain and analgesic requirement in breast cancer surgeries. It is also associated with a faster recovery, decreased postoperative complications, and better patient satisfaction.
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Affiliation(s)
- Rohit Jindal
- Department of Surgical Oncology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
| | - Sushila Meena
- Department of Anaesthesiology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
| | - Sushil Bhati
- Department of Anaesthesiology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
| | - Pinakin Patel
- Department of Surgical Oncology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
| | - Chanchal Gulati
- Department of Anaesthesiology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
| | - Suresh Singh
- Department of Surgical Oncology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan India
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Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Pasek J, Fiorda-Diaz J, Palettas M, Skoracki RJ, Poteet SJ, Heard JA. Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study. Front Med (Lausanne) 2022; 9:975080. [PMID: 36045918 PMCID: PMC9420942 DOI: 10.3389/fmed.2022.975080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption. Methods We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups. Results Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group. Conclusion PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.
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Affiliation(s)
- Alberto A. Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | | | - Luis Periel
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Joshua Pasek
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Marilly Palettas
- Department of Biomedical Informatics, The Ohio State University, Center of Biostatistics, Columbus, OH, United States
| | - Roman J. Skoracki
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Stephen J. Poteet
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Jarrett A. Heard
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
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PEC block versus local anesthetic infiltration in breast implant augmentation surgery: a retrospective study. Plast Reconstr Surg 2022; 150:319e-328e. [PMID: 35666162 DOI: 10.1097/prs.0000000000009292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pectoral plane (PEC) blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration (LAI) is a simple alternative technique with the same aim. We evaluated both techniques. MM In this single-center retrospective study, patients received PEC block (ropivacaine 0.2%, 10 ml PEC I, 20 ml PEC II) or LAI. The primary outcome measure was pain, according to the visual analog scale (VAS), at 24h post-surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours post-surgery, total opioid consumption at 24h, and opioid side effects. RESULTS 81 were finally recruited: 37 in the PEC group and 44 in the LAI group. Patient characteristics were comparable between the two groups. At 24h post-surgery, the LAI group showed a decrease in pain, with a VAS score of 0.7 vs 1.5 in the PEC group (p = 0.007). There was no difference in VAS between the two groups at 1, 2, 6, or 12 hours post-surgery. The duration of anesthesia was increased in the PEC group with 153 minutes vs 120 minutes in the LAI group (p < 0.001). There was no difference in rescue morphine consumption between the two groups. CONCLUSIONS We found that LAI had a superior analgesic effect at 24h after surgery for dual-plane breast implant augmentation compared with PEC block. These findings are a good indication that the LAI technique is at least as effective as PEC block while being safe, fast, and easy to use.
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10
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Singh NP, Makkar JK, Kuberan A, Guffey R, Uppal V. Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:527-549. [PMID: 35102494 DOI: 10.1007/s12630-021-02183-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION PROSPERO (CRD42020198244); registered 19 October 2020.
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Affiliation(s)
- Narinder Pal Singh
- Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, Ambala, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ryan Guffey
- Department of Anesthesia, Washington University in St. Louis, St. Louis, MO, USA
| | - Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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Xu X, Chen X, Zhu W, Zhao J, Liu Y, Duan C, Qi Y. Efficacy and Safety of Ultrasound Guided-Deep Serratus Anterior Plane Blockade With Different Doses of Dexmedetomidine for Women Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial. Front Med (Lausanne) 2022; 9:819239. [PMID: 35198576 PMCID: PMC8860248 DOI: 10.3389/fmed.2022.819239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Ultrasound guided-deep serratus anterior plane block (USG-DSAPB) has been used for pain management of patients undergoing modified radical mastectomy (MRM), but evidence supporting their adjuvant analgesic benefits is limited. We explored the efficacy and safety of preemptive use of ropivacaine combined with different doses of dexmedetomidine (DEX) in USG-DSAPB for patients undergoing MRM. Methods Ninety-five female patients undergoing unilateral MRM were allocated randomly to two groups. Group RD1 had 20 mL of 0.5% ropivacaine with 5 mg of dexamethasone and 0.5 μg·kg−1 DEX in USG-DSAPB. Group RD2 had 20 mL of 0.5% ropivacaine with 5 mg of dexamethasone and 1 μg·kg−1 DEX in USG-DSAPB. The primary outcome was sufentanil consumption 72 h after USG-DSAPB. Secondary outcomes were: postoperative pain scores and level of sedation; intraoperative hemodynamics; duration of post-anesthesia care unit (PACU) stay; prevalence of moderate-to-severe pain; one-time puncture success; procedure time of blockade; time to first rescue analgesia; requirement of rescue analgesia; satisfaction scores of patients and surgeons; duration of hospital stay; adverse events; prevalence of chronic pain; quality of postoperative functional recovery. Results Compared with the RD1 group, the visual analog scale score for coughing was significantly lower at 4, 8, 12 h and sufentanil consumption was significantly lower at 4, 8, 12, 24, and 48 h after surgery in the RD2 group (P < 0.05). The time to first rescue analgesia was significantly longer in the RD2 group (P < 0.05). The requirement for rescue analgesia was significantly higher in the RD1 group (P < 0.05). The prevalence of moderate-to-severe pain, number of patients using vasoactive agents, duration of PACU stay, as well as consumption of propofol, remifentanil, and DEX were significantly lower in the RD2 group (P < 0.05). There were no significant differences between the two groups with respect to one-time puncture success, procedure time of blockade, total dermatomal spread, satisfaction scores of patients and surgeons, postoperative complications, duration of hospital stay, 40-item Quality of Recovery questionnaire (QoR-40) score, or prevalence of chronic pain (P > 0.05). Conclusions We discovered that 1 μg·kg−1 (not 0.5 μg·kg−1) DEX combined with 20 mL of 0.5% ropivacaine and 5 mg of dexamethasone in USG-DSAPB could provide superior postoperative analgesia for patients undergoing MRM. However, the quality of postoperative functional recovery and prevalence of chronic pain were similar. Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx?proj=54929, identifier: ChiCTR2000033685.
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Affiliation(s)
- Xia Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Xingfang Chen
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Wenchao Zhu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jing Zhao
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Yanchao Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Caiping Duan
- Department of Anesthesiology, Ordos Central Hospital, Ordos, China
| | - Yingying Qi
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
- *Correspondence: Yingying Qi
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Elshanbary AA, Zaazouee MS, Darwish YB, Omran MJ, Elkilany AY, Abdo MS, Saadeldin AM, Elkady S, Nourelden AZ, Ragab KM. Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis. Clin J Pain 2021; 37:925-939. [PMID: 34593675 DOI: 10.1097/ajp.0000000000000985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB). METHODS We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software. RESULTS We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006). CONCLUSION Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.
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Affiliation(s)
- Alaa Ahmed Elshanbary
- Faculty of Medicine, Alexandria University, Alexandria
- International Medical Research Association (IMedRA), Cairo
| | - Mohamed Sayed Zaazouee
- Faculty of Medicine, Al-Azhar University
- International Medical Research Association (IMedRA), Cairo
| | - Youssef Bahaaeldin Darwish
- Faculty of Pharmacy, Mansoura University, Mansoura
- International Medical Research Association (IMedRA), Cairo
| | - Maha Jabir Omran
- International Medical Research Association (IMedRA), Cairo
- Faculty of Pharmacy, Al-Azhar University-Gaza, Gaza, Palestine
| | - Alaa Yousry Elkilany
- Faculty of Medicine, Menoufia University, Menoufia
- International Medical Research Association (IMedRA), Cairo
| | - Mohamed Salah Abdo
- Faculty of Medicine
- International Medical Research Association (IMedRA), Cairo
| | - Ayat M Saadeldin
- Department of Radiation Oncology, El Hussein University Hospital
- International Medical Research Association (IMedRA), Cairo
| | - Sherouk Elkady
- Department of Medical Biochemistry, Faculty of Medicine, Assiut University, Assiut
- International Medical Research Association (IMedRA), Cairo
| | - Anas Zakarya Nourelden
- Faculty of Medicine, Al-Azhar University
- International Medical Research Association (IMedRA), Cairo
| | - Khaled Mohamed Ragab
- International Medical Research Association (IMedRA), Cairo
- Faculty of Medicine, Minia University, Minia, Egypt
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Pectoral Nerve Blocks for Breast Augmentation Surgery: A Randomized, Double-blind, Dual-centered Controlled Trial. Anesthesiology 2021; 135:442-453. [PMID: 34195767 DOI: 10.1097/aln.0000000000003855] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pectoral nerve blocks have been proposed for analgesia during and after breast cancer surgery, but data are conflicted in aesthetic breast surgery. This trial tested the primary hypothesis that adding a preincisional pectoral nerve block is superior to systemic multimodal analgesic regimen alone for pain control after breast augmentation surgery. A second hypothesis is that rescue opioid consumption would be decreased with a long-lasting effect for both outcomes during the following days. METHODS Seventy-three adult female patients undergoing aesthetic breast augmentation surgery under general anesthesia were randomly allocated to receive a pectoral nerve block versus no block. Both groups received standard care with protocolized multimodal analgesia alone including systematic acetaminophen and nonsteroidal anti-inflammatory drugs. The primary outcome measure was the maximal numerical rating scale in the first 6 h after extubation. Secondary outcomes included intraoperative remifentanil consumption and from extubation to day 5: maximal numerical rating scale, postoperative cumulative opioid consumption and postoperative opioid side effects, and patient satisfaction recorded at day 5. RESULTS The maximal numerical rating scale score in the first 6 h was lower in the pectoral nerve block group compared with the control group (3.9 ± 2.5 vs. 5.2 ± 2.2; difference: -1.2 [95% CI, -2.3 to -0.1]; P = 0.036). The pectoral nerve block group had a lower maximal numerical rating scale between days 1 and 5 (2.2 ± 1.9 vs. 3.2 ± 1.7; P = 0.032). The cumulative amount of overall opioids consumption (oral morphine equivalent) was lower for the pectoral nerve block group from hour 6 to day 1 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 31.5] mg, P = 0.006) and from days 1 to 5 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 51] mg, P = 0.002). CONCLUSIONS Pectoral nerve block in conjunction with multimodal analgesia provides effective perioperative pain relief after aesthetic breast surgery and is associated with reduced opioid consumption over the first 5 postoperative days. EDITOR’S PERSPECTIVE
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Abstract
BACKGROUND Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery. OBJECTIVE The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery. DESIGN We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment. DATA SOURCES The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched. ELIGIBILITY CRITERIA All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included. RESULTS A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference -1.14, 95% confidence interval (CI), -2.1 to -0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference -1.79, 95% CI, -3.5 to -0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference -0.83, 95% CI, -1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference -0.18, 95% CI, -1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference -0.56, 95% CI, -1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported. CONCLUSION There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted. PROTOCOL REGISTRATION CRD42019126733.
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Shah SB, Chawla R, Pahade A, Mittal A, Bhargava AK, Kumar R. Comparison of pectoralis plane blocks with ketamine-dexmedetomidine adjuncts and opioid-based general anaesthesia in patients undergoing modified radical mastectomy. Indian J Anaesth 2020; 64:1038-1046. [PMID: 33542567 PMCID: PMC7852431 DOI: 10.4103/ija.ija_8_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/14/2020] [Accepted: 10/19/2020] [Indexed: 01/21/2023] Open
Abstract
Background and Aims: Regional anaesthesia attenuates surgical stress-response, provides superior analgesia, reduces recovery time with early mobilisation and is opioid-sparing [addresses post-operative nausea vomiting (PONV), constipation, immunosuppression and cancer-progression concerns with opioids]. Hence, we studied pectoralis (PECS) blocks for modified radical mastectomy (MRM). Methods: A prospective, interventional, double-blind, randomised, parallel-arm, active-controlled study comparing two anaesthetic techniques for post-operative pain relief in70 adult American Society of Anesthesiologists grade I/II carcinoma breast patients undergoing MRM was conducted. Patients were randomised to Group-O (opioids, sevoflurane) and Group-P (PECS-block, pre-incisional intravenous (IV) ketamine (0.5 mg/kg), pre-incisional IVdexmedetomidine (1 μg/kg over 10 min, then 0.6 μg/kg/h). Data were subjected to statistical analysis using the Statistical Package for Social Sciences, version-23 and independent sample t-test/Welch test for equality of means and expressed as dotted box-whisker plots. Nominal categorical intergroup data was compared using Chi-squared test/Fisher's exact test. P<0.05 was considered statistically significant. Clinical significance was calculated. Results: Higher Visual Analogue Scale (VAS)-scores were recorded in Group-O versus Group-P, immediately post-extubation [mean (SD) 3.6 ± 1.5 and 0.76 ± 0.6] and at 1h (3.1 ± 1.2 and1.4 ± 0.5), 2h (2.5 ± 0.9 and 1.2 ± 0.6) and 4h (2.2 ± 0.5 and 1.7 ± 0.9) respectively. At 8h and 24h post-surgery VAS was comparable. Cumulative-VAS was lower in Group-P. Intraoperative haemodynamics were comparable. Incidence of PONV and constipation was higher in Group-O where each patient received average 27.46 mg morphine-equivalents of opioids. Time to discharge from surgical intensive care unit was 2h shorter in Group-P. Conclusion: Pre-emptive PECS-blocks supplemented with low-dose ketamine and dexmedetomidine comprise a practical and useful alternative technique to the standard opioid-based general anaesthetic technique for MRM.
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Affiliation(s)
- Shagun B Shah
- Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
| | - Rajiv Chawla
- Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
| | - Akhilesh Pahade
- Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
| | - Amit Mittal
- Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
| | - Ajay K Bhargava
- Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
| | - Rajeev Kumar
- Department of Breast Oncosurgery Unit, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
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Yamak Altinpulluk E, Turan A. Future in regional anesthesia: new techniques and technological advancements. Minerva Anestesiol 2020; 87:85-100. [PMID: 32959636 DOI: 10.23736/s0375-9393.20.14791-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Regional anesthesia has a very interesting long history, initially preferred over general anesthesia because of safety concerns, then for a period general anesthesia became safer and was preferred. The use of innovative technologies such as ultrasound technology has made the blocks safer and successful by directly visualizing targeted nerves and the location of local anesthetics. With the wide use of ultrasound in the regional anesthesia field success rate of peripheral nerve blocks increased and novel blocks techniques developed. Moreover, new extended-release local anesthetic agents have begun to be promising time-efficient and longer duration of analgesia with a single injection. In this article, we attempt to summarize some of the novel block techniques, pharmacological agents, and new technologies in the field of regional anesthesia.
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Affiliation(s)
- Ece Yamak Altinpulluk
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Anesthesiology and Reanimation, Faculty of Medicine, Istanbul University Cerrahpaşa, Instambul, Turkey
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA - .,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic OH, USA
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Regional Anesthetic Blocks in Plastic Surgery Using Portable Ultrasound: A Simplified Approach. Ann Plast Surg 2020; 82:S374-S379. [PMID: 30694847 DOI: 10.1097/sap.0000000000001805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND With the introduction of latest generation ultrasound technology and its easy availability and portability, regional anesthetic blocks, which were formally in the domain of anesthesiologists, have now become available to practicing plastic surgeons. Enhanced Recovery After Surgery protocols for other specialties such as orthopedics and colorectal surgery have incorporated regional anesthetic blocks. These regional blocks have been shown to be effective in improving the patient comfort and experience and decreasing reliance on opioid medications. METHODS Patients scheduled for elective plastic surgery received PEC-1, serratus anterior plane, or transversus abdominis plane blocks as indicated for the proposed procedure. All blocks were performed under ultrasound guidance using the Philips Lumify system with the linear array 12-4 probe by the operating surgeon. RESULTS A total of 83 patients received regional anesthetic blocks by the senior author. Thirty-three patients undergoing cosmetic breast augmentation or implant-based breast reconstruction received the PEC-1 and the serratus anterior plane blocks after the induction of anesthesia but before the prep and drape. Fifty patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction received intraoperative transversus abdominis plane blocks. Anatomic planes were clearly visualized with this new ultrasound technology. Patients experienced good to excellent analgesia with less reliance on opioid medications and decreased need for refills. For hospitalized patients, length of stay in some cases was decreased up to 1 day, and PCA pumps were eliminated. There were no complications or adverse sequelae observed in any of these patients related to the regional blocks. CONCLUSIONS Incorporation of these known regional anesthetic techniques in this single-surgeon experience seems to confirm reports of effectiveness in the anesthesia literature and may be of benefit to a wide range of plastic surgery patients.
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Analgesic efficacy of PECS and serratus plane blocks after breast surgery: A systematic review, meta-analysis and trial sequential analysis. J Clin Anesth 2020; 63:109744. [DOI: 10.1016/j.jclinane.2020.109744] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/07/2020] [Accepted: 02/15/2020] [Indexed: 01/13/2023]
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Robinson H, Mishra S, Davies L, Craigen F, Vilcina V, Parson S, Shahana S. Anatomical Evaluation of a Conventional Pectoralis II Versus a Subserratus Plane Block for Breast Surgery. Anesth Analg 2020; 131:928-934. [DOI: 10.1213/ane.0000000000005039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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The Effect of Pectoral Nerves Blocks on Narcotic Consumption and Pain Intensity in the Patients Undergoing Breast Cancer Surgery. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.98879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Improving Cost-efficiency in Bilateral Direct-to-Implant Reconstructions with Acellular Dermal Matrix. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2447. [PMID: 31942404 PMCID: PMC6908385 DOI: 10.1097/gox.0000000000002447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022]
Abstract
The use of acellular dermal matrix (ADM) for bilateral breast reconstruction has increased in recent years. Detection of BCRA mutation and therefore bilateral risk-reduction mastectomy is one of the main reasons for this increase. High cost of ADM is considered a major drawback for its use. The authors present a new technique which allows the use of only one unit of ADM for both breasts. After assessing the viability of the skin of mastectomy flaps, a musculofascial pocket formed superiorly by pectoralis major, laterally by serratus fascia and inferiorly by rectus fascia, is performed. Then, the ADM is divided in two halves. We propose two different ways to divide the matrix, cutting it vertically or diagonally in two. The way in which the matrix should be cut depends on the distensibility of the pocket. Afterwards, the implant is inserted and the exposed area of the implant is covered by the ADM sutured to the edges of the musculofascial pocket. Using only one ADM unit for bilateral reconstruction, the procedure becomes not only more cost-effective but also can reduce complications such as seroma, rippling, wrinkling, and visibility by means of a better coverage with lesser foreign body load. Furthermore, the lesser the matrix used, the faster the integration is achieved.
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Huang L, Zheng L, Wu B, Chen Z, Chen J, Xu X, Shi K. Effects of Ropivacaine Concentration on Analgesia After Ultrasound-Guided Serratus Anterior Plane Block: A Randomized Double-Blind Trial. J Pain Res 2020; 13:57-64. [PMID: 32021395 PMCID: PMC6959503 DOI: 10.2147/jpr.s229523] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/24/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose Serratus anterior plane (SAP) block is effective for analgesia after breast surgery. Whether a higher local anesthetic concentration prolongs sensory block duration and improves postoperative analgesia remains unclear. The aim of this study was to compare the analgesic effects of SAP block with different concentrations of ropivacaine. Patients and Methods Sixty patients scheduled for breast surgery were enrolled in this randomized double-blind trial. SAP block was induced with 20 mL of 0.375%, 0.5%, or 0.75% ropivacaine in Group R0.375, Group R0.5, and Group R0.75, respectively. The primary endpoint was the area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores at rest over time. The secondary endpoints were AUC of NRS pain intensity scores on movement over time, active sensory block duration, tramadol consumption, and the elapsed time between completion of surgery and the first administration of rescue analgesia. Results The AUC of NRS pain intensity scores at rest of Group R0.375 was significantly higher than that of Groups R0.5 and R0.75 (P=0.025, and P=0.001). The AUC of NRS pain intensity scores on movement of Group R0.375 was also significantly higher than that of Groups R0.5 and R0.75 (both P<0.001). At higher ropivacaine concentrations, the duration of SAP sensory block increased (P<0.001). Tramadol consumption and the elapsed time between completion of surgery and the first administration of rescue analgesia were similar in the three groups (P>0.05). Conclusion A comparison of 0.5% and 0.75% ropivacaine showed no significant difference in postoperative analgesia, but both were superior to 0.375% ropivacaine, although higher ropivacaine concentration lengthened the duration of SAP block. Therefore, SAP block with 0.5% ropivacaine is recommended for postoperative analgesia in breast surgery.
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Affiliation(s)
- Lvdan Huang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Liangyu Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Bingjing Wu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Zhengjie Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Jiali Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Xuzhong Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Kejian Shi
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
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Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression. Ann Vasc Surg 2019; 66:301-308. [PMID: 31857230 DOI: 10.1016/j.avsg.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD. MATERIALS AND METHODS We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting. RESULTS Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively). CONCLUSIONS There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.
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Urits I, Ostling PS, Novitch MB, Burns JC, Charipova K, Gress KL, Kaye RJ, Eng MR, Cornett EM, Kaye AD. Truncal regional nerve blocks in clinical anesthesia practice. Best Pract Res Clin Anaesthesiol 2019; 33:559-571. [DOI: 10.1016/j.bpa.2019.07.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
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Joshi GP, Kehlet H, Rawal N. Surgeon-administered regional analgesia to replace anaesthetist-administered regional analgesia: need for communication and collaboration. Br J Anaesth 2019; 123:707-709. [DOI: 10.1016/j.bja.2019.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 01/04/2023] Open
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Irwin R, Stanescu S, Buzaianu C, Rademan M, Roddy J, Gormley C, Tan T. Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial. Anaesthesia 2019; 75:89-95. [DOI: 10.1111/anae.14852] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Affiliation(s)
- R. Irwin
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - S. Stanescu
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - C. Buzaianu
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - M. Rademan
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - J. Roddy
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - C. Gormley
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - T. Tan
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery.
Methods
Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling.
Results
Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes.
Conclusions
We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.
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Lovett-Carter D, Kendall MC, McCormick ZL, Suh EI, Cohen AD, De Oliveira GS. Pectoral nerve blocks and postoperative pain outcomes after mastectomy: a meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2019; 44:rapm-2019-100658. [PMID: 31401620 DOI: 10.1136/rapm-2019-100658] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/24/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Several studies have evaluated the effect of pectoral nerve blocks to improve postoperative analgesia following breast cancer surgery resulting in contradictory findings. The aim of this study was to examine the effect of Pecs blocks on postoperative analgesia in women following mastectomies. METHODS We performed a quantitative systematic review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Articles of randomized controlled trials that compared Pecs block (types I and II) to a control group in patients undergoing mastectomy were included. The primary outcome was total opioid consumption 24 hours after surgery. Secondary outcomes included pain scores and side effects. Meta-analysis was performed using the random effect model. RESULTS 7 randomized controlled trials with 458 patients were included in the analysis. The effect of pectoral nerve blocks on postoperative opioid consumption compared with control revealed a significant effect, weighted mean difference (WMD) (95% CI) of --4.99 (-7.90 to -2.08) mg intravenous morphine equivalents (p=0.001). In addition, postoperative pain compared with control was reduced at 6 hours after surgery: WMD (95% CI) of -0.72 (-1.37 to -0.07), p=0.03, and at 24 hours after surgery: WMD (95% CI) of -0.91 (-1.81 to -0.02), p=0.04. DISCUSSION This quantitative analysis of randomized controlled trials demonstrates that the Pecs block is effective for reducing postoperative opioid consumption and pain in patients undergoing mastectomy. The Pecs block should be considered as an effective strategy to improve analgesic outcomes in patients undergoing mastectomies for breast cancer treatment.
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Affiliation(s)
| | - Mark C Kendall
- Division of Biology and Medicine, Brown University, Providence, Rhode Island, USA
| | - Zachary L McCormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Edward I Suh
- Division of Biology and Medicine, Brown University, Providence, Rhode Island, USA
| | - Alexander D Cohen
- Division of Biology and Medicine, Brown University, Providence, Rhode Island, USA
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Al Ja'bari A, Robertson M, El‐Boghdadly K, Albrecht E. A randomised controlled trial of the pectoral nerves‐2 (PECS‐2) block for radical mastectomy. Anaesthesia 2019; 74:1277-1281. [DOI: 10.1111/anae.14769] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 01/28/2023]
Affiliation(s)
- A. Al Ja'bari
- Department of Anaesthesia Lausanne University Hospital LausanneSwitzerland
| | - M. Robertson
- Department of Anaesthesia Lausanne University Hospital LausanneSwitzerland
| | - K. El‐Boghdadly
- Department of Anaesthesia Guy's and St. Thomas’ NHS Foundation Trust LondonUK
- King's College London UK
| | - E. Albrecht
- Department of Anaesthesia Lausanne University Hospital Lausanne Switzerland
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30
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Chin KJ. Thoracic wall blocks: From paravertebral to retrolaminar to serratus to erector spinae and back again – A review of evidence. Best Pract Res Clin Anaesthesiol 2019; 33:67-77. [DOI: 10.1016/j.bpa.2019.02.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 12/14/2022]
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31
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Sherwin A, Buggy DJ. Anaesthesia for breast surgery. BJA Educ 2018; 18:342-348. [PMID: 33456800 DOI: 10.1016/j.bjae.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 01/25/2023] Open
Affiliation(s)
- A Sherwin
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - D J Buggy
- Mater Misericordiae University Hospital, Dublin, Ireland.,University College Dublin, Dublin, Ireland
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