Sensory Assessment and Block Duration of Deep Parasternal Intercostal Plane Block in Patients Undergoing Cardiac Surgery: A Prospective Observational Study

INTRODUCTION

There has been increasing interest in using deep parasternal intercostal plane (PIP) block as a supplement to multimodal analgesia regimens in cardiac surgery. The aim of this study was to observe cutaneous sensory block distribution and its duration for deep PIP blocks in patients undergoing open cardiac surgery.

METHODS

This observational, prospective clinical study consisted of 113 participants. All patients received bilateral ultrasound-guided deep PIP block with 40 ml 0.33% ropivacaine. The primary study outcome was cutaneous sensory block distribution of deep PIP blocks in patients undergoing open cardiac surgery. Secondary outcome included block duration in all participants. The area of cutaneous sensory block was tested by using a cold stimulus (ice cube) 30 min after the end of deep PIP block administration. Cutaneous sensory testing was performed once every hour after extubation until the return of normal sensation.

RESULTS

Thirty minutes after bilateral deep PIP block administration, the successful block rate of dermatomes T4 to T6 was almost 100%. However, T2 (percentage of left T2 block: 64.6%; percentage of right T2 block: 42.5%) and T3 (percentage of left T3 block: 88.5%; percentage of right T3 block: 87.6%) had a lower percentage of success. A few patients had blocked dermatomes at T1 or T7 (percentage of left T1 block: 7.08%; percentage of right T1 block: 2.65%; percentage of left T7 block: 6.19%; percentage of right T7 block: 10.6%). The mean effective duration of the deep PIP block was 17 h.

CONCLUSION

Bilateral deep PIP blocks can produce a widespread cutaneous sensory blockade with variable dermatomal distribution in the mid-sternum for a considerable effective duration.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047755).

Randomized controlled trial to study the efficacy and safety of ultrasound-guided pectoral nerve block for superficial breast surgeries

BACKGROUND

Our study aimed to compare pectoral nerve (PEC) block with local anesthetic (LA) infiltration for providing analgesia in superficial breast surgeries.

MATERIALS AND METHODS

This prospective comparative randomized study included seventy American Society of Anesthesiologists I and II female patients undergoing excision of fibroadenoma. In Group 1, the LA mixture was infiltrated in the desired planes. In Group 2, PEC I and PEC II blocks were performed under ultrasound guidance. Patients were observed at regular time intervals for pain scores, time to first analgesic request, and the number of patients requiring rescue analgesia with the cumulative analgesic requirement, hemodynamic changes, and any adverse events.

RESULTS

The patients were comparable in demographic profile, duration of anesthesia, and hemodynamic parameters. NRS scores at all times after extubation were significantly lower in Group 2 as compared to Group 1 (P < 0.0001). All patients in Group 1 required additional analgesia, while only two in Group 2 received rescue analgesia (P < 0.0001). The time to first analgesic request was significantly longer in Group 1 as compared to group 2 (9.5 + 0.70 h vs. 1.35 + 0.83 h) (P < 0.0001). The cumulative requirement of tramadol in Group 1 (96.88 ± 16.45 mg) was significantly higher than in Group 2 (6.47 ± 26.38 mg) (P < 0.0001). No adverse event was reported in either group.

CONCLUSION

PEC block is a useful method for achieving effective and long-lasting analgesia. It is an efficient and safe alternative to LA infiltration in patients undergoing fibroadenoma excision.

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

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.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

PURPOSE OF REVIEW

Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important.

RECENT FINDINGS

With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve.  Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.

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

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.

Evaluation of the Analgesic Efficacy of Bilateral Ultrasound-Guided Transversus Thoracic Muscle Plane Block on Post-Sternotomy Pain: A Randomized Controlled Trial

PURPOSE

Transverse thoracic block is a new perioperative analgesic method for post-sternotomy discomfort. This study discusses the efficacy of an ultrasound-guided transversus thoracic muscle plane block (TTPB) in patients undergoing heart surgery, including sternotomy.

PATIENTS AND METHODS

In this prospective trial, 60 patients were randomly assigned to two groups: transversus (T) or general anesthesia (GA). Patients in the T group received TTPB with GA and 15 mL of 0.25% bupivacaine was administered on either side. Patients in the GA group received TTPB along with GA, but 15 mL saline was injected on either side instead. The patients were followed up postoperatively. The percentage of patients receiving additional opioids, extubation time, intensive care unit (ICU) length, postoperative morphine dose, and adverse events were documented.

RESULTS

The percentage of patients requiring additional morphine was significantly lower in the T group (p<0.015). Pain scores were comparable between the groups at extubation time and 18 h postoperatively. At 8, 12, and 24 h after surgery, pain scores in the T group were significantly lower (P<0.001). The total amount of morphine required after surgery was much lower in the T group (8±0.74 mg), and the duration to initial analgesic necessity was significantly greater in the GA group (P<0.001). Patients in the GA group had a considerably longer ventilation time (11.07±0.64) (P<0.001). The ICU stay in the T group was substantially shorter (P<0.001), and postoperative complications were comparable.

CONCLUSION

For patients undergoing heart surgery, TTPB offers sufficient postoperative pain control, resulting in lower pain scores, lower postoperative analgesic doses, shorter extubation times, and shorter ICU stay lengths.

Pectoral Nerve Blocks for Breast Augmentation Surgery: A Randomized, Double-blind, Dual-centered Controlled Trial

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

Ultrasound-guided parasternal injection in dogs: a cadaver study

OBJECTIVES

To describe the technique of performing an ultrasound-guided distal parasternal intercostal block and to determine the distribution of two volumes of methylene blue dye solution injected in canine cadavers.

STUDY DESIGN

Prospective cadaver study.

ANIMALS

A group of seven canine cadavers weighing 12-34 kg.

METHODS

The space between the transversus thoracic and the internal intercostal muscles is a virtual cavity. Ultrasound-guided injections in the distal (parasternal) intercostal space were performed using dye solution at 0.05 mL kg^-1 in each intercostal space from the second to seventh (LV, low volume, six injections per dog) in one hemithorax, and 0.1 mL kg^-1 in the third, fifth and seventh intercostal spaces (HV, high volume, three injections in each dog) on the contralateral side. Anatomical dissection was carried out to describe dye spread characteristics and staining of intercostal nerves.

RESULTS

The ultrasonographic landmarks for injection were identified in each cadaver. In the LV group the solution was found in every intercostal space (36/36), whereas the HV injection stained six intercostal spaces in two dogs, five in two, and in two dogs the solution was found in four and three spaces, respectively, demonstrating multisegmental distribution. Intrapleural staining was observed after two injections.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided injection of 0.05 mL kg^-1 at the distal intercostal space resulted in staining of the intercostal nerve in all dogs when performed in every space and may be an appropriate alternative to previously reported techniques. A single injection of 0.1 mL kg^-1 may anaesthetize more than one intercostal nerve, but not consistently. Clinical investigations are warranted to better characterize and to refine this locoregional technique.

Pectoral nerve blocks for breast surgery: A meta-analysis

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.

Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery

With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.

Combined transverse thoracis plane and pectoral nerve blocks for breast surgery under sedation

The pectoral nerves 2 (pecs 2) block is widely used as adjunct to general anaesthesia for breast surgery. There are a few case reports and a single case series that describe regional anaesthesia as a single technique or supplemented by light to moderate sedation. Here we describe the management of a 91-year-old ASA physical status 4 patient who presented with a T4 breast malignancy. She was considered unfit for general anaesthesia due to significant valvular heart disease. A wide local excision was successfully performed under a pecs 2 block and a transverse thoracis plane block, supplemented with light sedation. We consider this technique to be a good option for selected patients who are considered unfit for general anaesthesia.

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.

Comparison of pectoralis plane blocks with ketamine-dexmedetomidine adjuncts and opioid-based general anaesthesia in patients undergoing modified radical mastectomy

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.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

Parasternal Intercostal Block Complementation Contributes to Postoperative Pain Relief in Modified Radical Mastectomy Employing Pectoral Nerve Block I and Serratus-Intercostal Block: A Randomized Trial

Purpose

Pectoral nerve block I (PECS I) and serratus-intercostal plane block (SIPB) can anesthetize the majority mammary region, while parasternal intercostal block (PSI) targets the internal area during breast resection surgery. The aim of this study was to determine whether including PSI with PECS I and SIPB is more effective compared to PECS I and SIPB alone.

Patients and Methods

Sixty-two adult females undergoing unilateral modified radical mastectomy (MRM) were randomly assigned to receive either PECS I and SIPB (PS group, n=31) or a combination of PECS I, SIPB, and PSI (PSP group, n=31). The outcomes were measured with a numerical rating scale (NRS) score, and in terms of opioid consumption and anesthesia-related complications within 48 h after surgery.

Results

Although there were no differences in the NRS scores between the two groups during the inactive periods, the combination of three nerve blocks significantly reduced the NRS scores during movement. In addition, morphine equivalent consumption was lower in the PSP group compared to the PS group. Postoperative adverse events were similar in both groups in terms of regional anesthesia-related complications.

Conclusion

The combination of PECS I block, SIPB, and PSI block provides superior pain relief and postoperative recovery for patients undergoing MRM.

Comparison of pectoral Nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion - A pilot study

Background

Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone.

Materials and Methods

Thirty adult patients between the age group of 18-85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block (n = 15) or Group PT: PECS1 and TTM blocks (n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure.

Results

VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure (P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT (P= 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT (P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT (P = 0.0003).

Conclusion

Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

Comparison of pectoral Nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion - A pilot study

Background

Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone.

Materials and Methods

Thirty adult patients between the age group of 18-85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block (n = 15) or Group PT: PECS1 and TTM blocks (n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure.

Results

VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure (P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT (P= 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT (P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT (P = 0.0003).

Conclusion

Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

Transversus Thoracis Muscle Plane Block

The transversus thoracis muscle plane block (TTP) block is a newly developed regional anesthesia technique which provides analgesia to the anterior chest wall. Since its introduction, this technique has been utilized for a wide range of surgical procedures as well as nonsurgical indications. Current evidence suggests that the TTP block provides effective analgesia for breast and cardiac surgeries, cardiac device implantation, pericardiocentesis, and acute and chronic pain management. To date, no major complications have been reported. Currently there is an urgent need to standardize the nomenclature of this technique to facilitate accurate communication amongst care providers, researchers, and authors. In this review, we describe the TTP block technique, review the indications and available evidence in clinical practice, and discuss alternative blocks and future prospects.

Transversus thoracis muscle plane block in cardiac surgery: a pilot feasibility study

Introduction

Cardiac surgery patients often experience significant pain after median sternotomy. The transversus thoracis muscle plane (TTP) block is a newly developed, single-shot nerve block technique that provides analgesia for the anterior chest wall. In this double-blind pilot study, we assessed the feasibility of performing this novel block as an analgesic adjunct.

Methods

All patients aged 18–90 undergoing elective cardiac surgery were randomized to the block or standard care control group on admission to the intensive care unit after surgery. Under ultrasound guidance, patients in the block group received the TTP block with 20 mL of either 0.3% or 0.5% ropivacaine bilaterally, based on weight. The control group did not receive any injections. All blocks were performed by a single anesthesiologist, and data collection was performed by blinded assessors. The primary feasibility outcomes were rate of recruitment, adherence, and adverse events. The rate of recruitment was defined as the ratio of patients giving informed consent to the number of eligible patients who were approached to participate. Secondary outcomes included 12-hour and 24-hour Numeric Rating Scale (NRS) pain scores, 24-hour hydromorphone and acetaminophen requirements, time to extubation, time to first opioid administration, and patient satisfaction (on a yes/no questionnaire) at 24 hours.

Results

Twenty patients were approached for this study and 19 were enrolled. Eight patients received the intended intervention in each group. The recruitment rate was 95% of all approached eligible patients, and the adherence rate to treatment group was 94%. There were no block-related adverse events. The mean (SD) NRS pain scores at rest were 3.3 (3.2) in the block group vs 5.6 (3.2) in the control group at 12 hours. At 24 hours, the pain scores were 4.1 (3.9) vs 4.1 (3.3) in the block and control group, respectively. The mean (SD) 24-hour hydromorphone administration was 1.9 (1.1) mg in the block group vs 1.8 (0.9) mg in the control group.

Discussion

The TTP block is a novel pain management strategy poststernotomy. The results reveal a high patient recruitment, adherence, and satisfaction rate, and provide some preliminary data supporting safety.

Trial registration number

NCT03128346.

Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial

INTRODUCTION

Prosthetic breast surgery is a very common plastic surgery procedure, but its postoperative analgesic management is a challenge for the surgical team. The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty.

PATIENTS AND METHODS

A randomised, controlled, triple-blind, clinical trial was designed, and included 30 patients undergoing retropectoral augmentation mammoplasty. All of them had a modified PECII block and a serratus plane block with a total volume of 40ml per breast. In 15 of them bupivacaine 0.25% (GPEC) was injected and in the other 15 patients saline was used (GC). Standardised management of anaesthesia and postoperative analgesia was performed. Intra-operative haemodynamic parameters required for postoperative analgesia, and a numeric verbal scale on arrival in the recovery unit were measured and at 3, 6, and 24h. The quality perceived by patients and surgeons was also measured.

RESULTS

Post-operative pain was significantly better in GPEC (5.3±2.3 vs. 2.9±2.7; P=.018). No significant differences were observed at 3, 6, and 24h. The surgeons rated the anaesthetic-analgesic quality as very good in 80% of the cases in GPEC versus 33% in CG (P=.01).

CONCLUSIONS

The use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty.

Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome

INTRODUCTION

Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region.

METHODS

We describe a 60-year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine.

RESULTS

Pain disappeared and the result was maintained 3 months later.

DISCUSSION

This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region.

SIGNIFICANCE

The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.

Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study

Objectives

The pectoral nerve block type II (PECS II block) is widely used for postoperative analgesia after breast surgery. This study evaluated the analgesic efficacy of PECS II block in patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SNB).

Methods

Patients were randomized to the control group (n=40) and the PECS II group (n=40). An ultrasound-guided PECS II block was performed after induction of anesthesia. The primary outcome measure was opioid consumption, and the secondary outcome was pain at the breast and axillary measured using the Numerical Rating Scale (NRS) 24 hours after surgery. Opioid requirement was assessed according to tumor location.

Results

Opioid requirement was lower in the PECS II than in the control group (43.8 ± 28.5 µg versus 77.0 ± 41.9 µg, p < 0.001). However, the frequency of rescue analgesics did not differ between these groups. Opioid consumption in the PECS II group was significantly lower in patients with tumors in the outer area than that in patients with tumors in the inner area (32.5 ± 23.0 µg versus 58.0 ± 29.3 µg, p=0.007). The axillary NRS was consistently lower through 24 hr in the PECS II group.

Conclusion

Although the PECS II block seemed to reduce pain intensity and opioid requirements for 24 h after BCS and SNB, these reductions may not be clinically significant. This trial is registered with Clinical Research Information Service KCT0002509.