Analgesic efficacy of PECS vs paravertebral blocks after radical mastectomy: A systematic review, meta-analysis and trial sequential analysis

Incidence and characteristics of chronic postsurgical pain at 6 months after total mastectomy under pectoserratus and interpectoral plane block combined with general anesthesia: a prospective cohort study

INTRODUCTION

Chronic postsurgical pain (CPSP) occurs in 20%-30% of patients who undergo total mastectomy (TM) performed under general anesthesia alone and significantly affects the quality of life. Pectoserratus and interpectoral plane block have been reportedly combined with general anesthesia to control immediate postoperative pain after TM. Our prospective cohort study aimed to evaluate the incidence of CPSP after TM when pectoserratus and interpectoral plane block were combined with general anesthesia.

METHODS

We recruited adult women scheduled to undergo TM for breast cancer. Patients planned for TM with flap surgery, those who underwent breast surgery in the past 5 years, or those presenting with residual chronic pain after prior breast surgery were excluded. After general anesthesia induction, an anesthesiologist performed pectoserratus and interpectoral plane block with a ropivacaine (3.75 mg/mL) and clonidine (3.75 µg/mL) in 40 mL of 0.9% sodium chloride. The primary endpoint was the occurrence of CPSP-defined as pain with a Numeric Rating Scale Score of ≥3, either at the breast surgical site and/or at axilla, without other identifiable causes-evaluated during a pain medicine consultation at 6 months post TM.

RESULTS

Overall, 43/164 study participants had CPSP (26.2%; 95% CI: 19.7 to 33.6); of these, 23 had neuropathic type of pain (53.5%), 19 had nociceptive (44.2%), and 1 had mixed (2.3%) type of pain.

CONCLUSION

Although postoperative analgesia has significantly improved in the last decade, there is still need for improvement to reduce CPSP after oncologic breast surgery.

TRIAL REGISTRATION NUMBER

NCT03023007.

Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article

Background

Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients.

Methods

An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation.

Results

A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain.

Conclusion

The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis.

MATERIALS AND METHODS

The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective.

RESULTS

The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6).

CONCLUSIONS

TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

Dexamethasone Does Not Provide Additional Clinical Analgesia Effect to Local Wound Infiltration: A Comprehensive Systematic Review and Meta-Analysis

Objective: Although the use of dexamethasone as an adjunct agent is associated with alleviating pain and prolonging analgesic duration in local wound infiltration (LWI), efficacy and safety of dexamethasone infiltration have not been fully explored. The study sought to quantify the pooled effects of dexamethasone infiltration on postoperative pain, analgesic consumption, and side effects through a review of randomized controlled trials (RCTs). Approach: RCTs comparing dexamethasone + LWI with LWI alone were retrieved from seven electronic databases. Co-primary outcomes were rest pain scores and cumulative morphine equivalent consumption within 24 h postoperatively. The study followed PRISMA, AMSTAR, and the Cochrane Collaboration. Results: Eight trials comprising 609 patients were included in the final analysis. Results indicated that dexamethasone infiltration effects were only statistical but not clinically significant at individual time points of rest pain and patient satisfaction scores. Notably, the effect of dexamethasone infiltration therapy on other pain-related parameters, including cumulative morphine consumption (mean difference, -9.05 mg; 95% CI: -22.47 to 4.37), was not significantly different compared with the control group. Analysis showed no significant differences in safety indicators between the two groups. The overall quality of evidence was high to very low. Innovation: Although statistically significant effects of dexamethasone infiltration were observed for some outcomes of postoperative wound pain, the overall benefits were below the expected minimal clinically important difference. Conclusions: In summary, the current evidence does not support routine clinical use of dexamethasone in LWI. However, further studies should explore the clinical value of preemptive analgesia and safety of a combination of dexamethasone with ropivacaine for LWI.

Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature

Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.

The analgesic efficacy of transversus abdominis plane block vs. wound infiltration after inguinal and infra-umbilical hernia repairs: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Both transversus abdominis plane (TAP) block and wound infiltration with local anaesthetic have been used to relieve pain after inguinal or infra-umbilical hernia repair.

OBJECTIVES

To determine whether TAP block or local anaesthetic infiltration is the best analgesic option after inguinal or infra-umbilical hernia repair.

DESIGN

Systematic review and meta-analysis with trial sequential analysis.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science, up to June, 2020.

ELIGIBILITY CRITERIA

We retrieved randomised controlled trials comparing TAP block with wound infiltration after inguinal or infra-umbilical hernia repair. Primary outcome was rest pain score (analogue scale 0 to 10) at 2 postoperative hours. Secondary pain-related outcomes included rest pain score at 12 and 24 h, and intravenous morphine consumption at 2, 12 and 24 h. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, haematoma, visceral injury and systemic toxicity of local anaesthetic.

RESULTS

Seven trials including 420 patients were identified. There was a significant difference in rest pain score at 2 postoperative hours in favour of TAP block compared with wound infiltration, with a mean (95% confidence interval) difference of -0.8 (-1.3 to -0.2); I2  = 85%; P   =  0.01. Most secondary pain-related outcomes were also significantly improved following TAP block. No complication was reported. The overall quality of evidence was moderate.

CONCLUSION

There is moderate level evidence that TAP block provides superior analgesia compared with wound infiltration following inguinal or infra-umbilical hernia repair.

TRIAL REGISTRY NUMBER

PROSPERO CRD42020208053.

Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy

BACKGROUND

As plastic surgeons continue to evaluate the utility of nonopioid analgesic alternatives, nerve block use in breast plastic surgery remains limited and unstandardized, with no syntheses of the available evidence to guide consensus on optimal approach.

METHODS

A systematic review was performed to evaluate the role of pectoralis nerve blocks, paravertebral nerve blocks, transversus abdominus plane blocks, and intercostal nerve blocks in flap-based breast reconstruction, prosthetic-based reconstruction, and aesthetic breast plastic surgery, independently.

RESULTS

Thirty-one articles reporting on a total of 2820 patients were included in the final analysis; 1500 patients (53 percent) received nerve blocks, and 1320 (47 percent) served as controls. Outcomes and complications were stratified according to procedures performed, blocks employed, techniques of administration, and anesthetic agents used. Overall, statistically significant reductions in opioid consumption were reported in 91 percent of studies evaluated, postoperative pain in 68 percent, postanesthesia care unit stay in 67 percent, postoperative nausea and vomiting in 53 percent, and duration of hospitalization in 50 percent. Nerve blocks did not significantly alter surgery and/or anesthesia time in 83 percent of studies assessed, whereas the overall, pooled complication rate was 1.6 percent.

CONCLUSIONS

Transversus abdominus plane blocks provided excellent outcomes in autologous breast reconstruction, whereas both paravertebral nerve blocks and pectoralis nerve blocks demonstrated notable efficacy and versatility in an array of reconstructive and aesthetic procedures. Ultrasound guidance may minimize block-related complications, whereas the efficacy of adjunctive postoperative infusions was proven to be limited. As newer anesthetic agents and adjuvants continue to emerge, nerve blocks are set to represent essential components of the multimodal analgesic approach in breast plastic surgery.

Transversus abdominis plane block versus local anaesthetic wound infiltration for analgesia after caesarean section: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Transversus abdominis plane (TAP) block and local anaesthetic wound infiltration are used to relieve pain after caesarean section.

OBJECTIVES

To determine whether TAP block or local anaesthetic wound infiltration is the better analgesic option after caesarean section.

DESIGN

Systematic review and meta-analysis with trial sequential analysis.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science up to June 2020.

ELIGIBILITY CRITERIA

We retrieved randomised controlled trials comparing TAP block with wound infiltration after caesarean section. Primary outcome was pain score during rest (analogue scale, 0 to 10) at 2 h postoperatively, analysed according to the TAP block technique (ultrasound-guided/landmark-guided), anaesthetic strategy (spinal/general), intrathecal fentanyl (yes/no) and multimodal analgesia (yes/no). Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, and total intravenous morphine consumption at 2, 12 and 24 h. We sought rates of block complications, including postoperative infection, haematoma, visceral injury and local anaesthetic systemic toxicity.

RESULTS

Seven trials, totalling 475 patients, were identified. There was no difference in pain score during rest at 2 h between groups. Subgroup analyses revealed no differences related to TAP block technique (P = 0.64), anaesthetic strategy (P = 0.53), administration of intrathecal fentanyl (P = 0.59) or presence of multimodal analgesia (P = 0.57). Pain score during rest at 12 h and intravenous morphine consumption at 2 and 12 h were identical in both groups. Data were insufficient to compare block complications. Overall quality of evidence was moderate.

CONCLUSION

There is moderate level evidence that TAP block and wound infiltration provide similar postoperative analgesia after caesarean section.

TRIAL REGISTRY NUMBER

PROSPERO CRD42020208046.

The Analgesic Benefits of Ketorolac to Local Anesthetic Wound Infiltration Is Statistically Significant But Clinically Unimportant: A Comprehensive Systematic Review and Meta-Analysis

Objective: Even though ketorolac-infiltration is said to provide superior postoperative analgesic benefits in different surgical procedures, its safety and efficacy remain to be validated because of the lack of high-quality evidence. We aimed to summarize the efficacy and safety of ketorolac-infiltration based on published randomized-controlled trials (RCTs). Approach: This work followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, assessing the methodological quality of systematic reviews and the Cochrane Collaboration recommendations. We searched for RCTs evaluating the efficacy of ketorolac-infiltration in adults in the PubMed, Web of Science, Embase, Cochrane Library, Chinese databases, and Google Scholar. The two co-primary outcomes of this meta-analysis were rescue analgesic consumption in the 24-h postoperative period and rest pain scores. Results: Twelve trials (761 patients) were analyzed. Ketorolac-infiltration provided a clinically unimportant benefit in morphine consumption (mean difference, -2.81 mg; 95% confidence interval [CI], -5.11 to -0.50; p = 0.02; moderate-quality evidence). Low-to-moderate quality evidence supported a brief (2-6 h), clinically subtle, but statistically consistent effect of surgical site ketorolac-infiltration in reducing wound pain at rest. High-quality evidence supported shorter hospital stays for surgical patients receiving local ketorolac-infiltration when compared to controls (mean difference, -0.12 days; 95% CI, -0.17 to -0.08; p < 0.00001). Further, ketorolac-infiltration does not improve any opioid-related side effects. Innovation: Ketorolac-infiltration provides statistically significant but clinically unimportant benefits for improving postoperative wound pain. Conclusion: Overall, despite the fact that current moderate-to-high quality of evidence does not support routine using of ketorolac as an adjuvant to local anesthetic for wound infiltration, these findings underscore the importance of optimizing agents and sustained delivery parameters in postoperative local anesthetic practice. Clinical Trials.gov ID: CRD42021229095.

Efficacy of different analgesia treatments for abdominal surgery: A network meta-analysis

OBJECTIVE

This study was designed to evaluate the efficacy of analgesia and incidence of postoperative nausea and vomiting (PONV) of several widely used clinical treatments for postoperative analgesia following abdominal surgery through network meta-analysis (NMA) based on published randomized controlled trials (RCTs).

METHODS

This NMA was registered on PROSPERO as CRD 42020169606. Primary outcomes were pain scores (visual analog scale) and accumulative opioid consumption, and secondary outcomes assessed the incidence of PONV at 24 h after surgery.

RESULTS

A total of 215 RCTs and 15,114 patients were identified in this NMA. In comparison with placebo, use of a preoperative paravertebral block (mean: -12.63, 95% CI: -21.12 to -4.13), continuous wound infiltration (mean: -9.68, 95%CI: -13.15 to -6.22) and postoperative wound infiltration (mean: -6.34, 95%CI: -10.59 to -2.08) had significantly lower pain scores, less opioid consumption (mean: -2.00, 95%CI: -3.52 to -0.48; mean: -1.34, 95%CI: -1.87 to -0.81; mean: -1.41, 95%CI: -2.07 to -0.74, respectively) and lower incidence of PONV (OR: 0.30, 95%CI: 0.13 to 0.67; OR: 0.49, 95%CI: 0.24 to 0.98; OR: 0.55, 95%CI: 0.34 to 0.89, respectively).

CONCLUSIONS

The findings from our work provide evidence that preoperative paravertebral block was superior to continuous or postoperative wound infiltration to provide postoperative analgesia, nausea and vomiting after abdominal surgery.

Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis

Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side‐effects. We undertook a systematic review, meta‐analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty‐nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high‐quality evidence), without sub‐group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high‐quality evidence). However, a sub‐group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub‐group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high‐quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.

Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Both transversus abdominis plane (TAP) block and local anesthetic wound infiltration have been used to relieve pain after laparoscopic cholecystectomy. We undertook this systematic review and meta-analysis with trial sequential analysis to determine the best analgesic technique.

METHODS

We systematically searched the literature for trials comparing TAP block with wound infiltration after laparoscopic cholecystectomy. The primary outcome was pain score during rest (analogue scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, pain scores during movement and intravenous morphine consumption at 2, 12 and 24 h, and postoperative nausea and vomiting. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, hematoma, visceral injury and local anesthetic systemic toxicity.

RESULTS

Ten trials including 668 patients were identified. There was a significant difference in pain score during rest at 2 postoperative hours in favour of TAP block when compared with wound infiltration (mean difference [95%CI]: -0.7 [-1.2, -0.2]; I2 = 71%; p = 0.008). Pain scores during rest at 12 and 24 h and pain scores during movement at 24 h were also significantly lower with TAP block than wound infiltration. Postoperative morphine consumption and the incidence of postoperative nausea and vomiting were significantly lower in patients who received a TAP block. Data were insufficient to compare block-related complications. The overall quality of evidence was moderate-to-high.

CONCLUSIONS

There is moderate-to-high level evidence that the TAP block provides superior analgesia when compared with wound infiltration in patients undergoing laparoscopic cholecystectomy. Trial registry number: PROSPERO CRD42020208057.

The analgesic efficacy of iPACK after knee surgery: A systematic review and meta-analysis with trial sequential analysis

STUDY OBJECTIVE

The novel infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to relieve posterior knee pain after knee surgery. The study objective is to determine whether iPACK provides analgesia after knee surgery when compared with a control group.

DESIGN

Systematic review, meta-analysis and trial sequential analysis.

SETTING

Operating room, postoperative recovery area and ward, up to 24 postoperative hours.

PATIENTS

Patients scheduled for knee surgery under general or spinal anaesthesia.

INTERVENTIONS

We searched five electronic databases for randomized controlled trials comparing iPACK with a control group.

MEASUREMENTS

The primary outcome was rest pain score scores on a visual analogue scale (VAS) of 0-10 at 12 h postoperatively, analysed according to the nature of surgery (total knee arthroplasty vs. anterior cruciate ligament reconstruction) and the use of multimodal analgesia. Secondary outcomes included rest and dynamic pain scores, intravenous morphine-equivalent consumption at 2 h and 24 h, and functional outcomes including ambulation distance and range of motion at discharge.

MAIN RESULTS

Six trials involving 687 patients were included, all of which received total knee arthroplasty only. When compared with a control group, iPACK significantly reduced rest pain scores at 12 h, with a mean difference (95% CI) of -1.0 (-1.5 to -0.5), I² = 93%, p = 0.0003, without subgroup differences for postoperative multimodal analgesia (p = 0.15). Secondary pain outcomes were inconsistently improved with iPACK. Functional outcomes were either similar between groups or had clinically unimportant differences. The overall quality of evidence was moderate.

CONCLUSIONS

There is moderate level evidence that iPACK might provide analgesia for posterior pain after total knee arthroplasty when compared with a control group at 12 h, but was not associated with any other meaningful benefits. Based on these results, there is currently limited evidence supporting the use of iPACK as a complement to adductor canal block for analgesia after total knee arthroplasty.

Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review

Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.